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THE 


MEDICAL  AND  SURGICAL  HISTORY 


OF  THE 


WAR  OF  THE  IIEBELLIO^. 


PART  III. 


VOLUME  I. 


MEDICAL  HISTORY. 


BEING   THE 

THIRD   MEDICAL  VOLUME. 


Prepared  under  the  direction  of  the  Surgeon  General,  United  States  Army. 
By  CHARLES  SMART,  Major  and  Surgeon,  United  States  Army. 


WASHINGTON: 

GOVERNMENT    PRINTING    OFFICE. 

1888. 


WAR  DEPARTMENT, 

Surgeon  General's  Office, 

Washington,  D.  C,  January  17,  1SS8. 

Brioadif.r  General  JOHN  MOORE, 

Surgeon  General,  U.  S.  Army. 
General: 

I  have  the  honor  herewith  to  submit  the  Third  and  concludinir  Part  of  the  Medical 
History  of  the  War  of  the  Rebelhon.  The  First  Part,  pubhshed  in  1870,  consisted  of  a 
consoUdation  by  departments  and  regions  of  tlie  muntldy  reports  of  sick  and  wounded  nf  tlie 
various  regimental  organizations,  with  appended  extracts  from  special  I'eports  of  nirdical 
officers,  giving  a  view  from  the  medical  standpoint,  of  the  movements  of  our  armies  and  the 
many  deadly  struggles  that  took  place  between  the  opposed  forces.  The  >Secon</  Parf.  [udi- 
lished  in  1879,  was  devoted  to  a  thorough  discussion  of  the  alviiie  lluxes  based  on  the  mate- 
rials, documentary  and  anatomical,  collected  l)y  our  medical  officers  during  the  war.  Sur- 
geon J.  J.  WoODWARP,  its  distinguislied  author,  brought  to  his  task  a  comprehensive  knowl- 
edge of  those  records  of  the  past,  which  form  the  historical  basis  of  the  professional  opinions 
of  the  present  day,  on  the  nature  and  causation  of  these  important  diseases.  Moreover,  his 
intimate  familiarity  with  the  materials  which  had  accumulated  in  the  Army  ^Medical  Museum, 
and  the  entliusiasm  with  which  he  prosecuted  their  study,  peculiarly  fitted  him  for  the  work 
of  laying  before  the  profession  the  results  of  that  study.  Unfortunately,  failing  health  and 
vdtimately  death,  prevented  the  iurthor  progress  of  the  work  by  the  mind  and  hand  tliat  had 
conducted  it  thus  far  witli  such  consummate  ability.  In  July,  1883,  the  late  Surgeon  Gen- 
eral Crane  expressed  to  me  his  desire  that  I  should  undertake  tiie  Third  Part  of  the  work; 
and,  in  view  of  my  reluctance  to  assume  this  heavy  responsibility,  he  gave  me  to  understand 
that  his  wish  in  this  instance  was  intended  to  carry  the  weight  of  an  order.  No  conditions 
were  imposed  as  to  the  matter  or  manner  of  the  volume  to  bo  written,  save  that  the  val- 
uable plates  which  Dr.  Woodward  had  prepared,  illustrative  of  the  pathological  changes 
in  the  intestinal  tunics,  should  be  embodied  in  the  work.  Since  that  time  I  have  given  my 
best  endeavor  to  the  fulfilment  of  this  duty;  and  in  presenting  the  completed  results  of 
these  years  of  labor,  I  beg  that  their  shortcomings  and  errors  may  be  attributed  to  lack  of 
judgment  rather  than  to  a  want  of  careful  and  earnest  consideration. 
I  have  the  honor  to  be.  General, 

Very  respectfully,  your  obedient  servant, 

CHARLES  SMART, 

Major  and  Surgeon,  U.  8.  A. 


TABLE   OP   CONTENTS 


A^OLTJn^v^E    III    OF    I=^I^T    I 


MEDICAL  AND  SURGICAL  HISTORY  OF  THE  REBELLION, 


HEING  THE 


THIRD  MEDICAL  VOLUME. 


LIST  OF  ILLUSTRATIOXS- - IX 

LIST  OF  STATISTICAL  TABLES  AXD  TARULATED  STATEMENTS —   XI 


CHAPTER  I.  ON  THE  MEDICAL  STATISTICS  OF  THE  WAR. 


I\liO 


ilp^. 


SECTION  I.    Sickness  and  mortality  among  the  U.  S. 
forces ' 

JMortiility,  actual  and  reported 

Mortality-rates 

Sickness,  absolute  and  reported 

Sick-rates 

Rates  of  fatality  in  speciflod  diseases 

General  and  annual  rates  of  sickness  and  mor- 
tality  

Sickness  and  mortality  as  caused  by  various 
diseases  and  classes  of  disease 

Sick  and  mortality-rates  of  V.  S.  white  troops, 
as  compared  with  those  of  other  bodies  ofmen 
of  the  military  ase 

Sickness  and  mortality  as  influenced  by  season, 
locality,  etc 

Discharges  on  account  of  disability  from  disease 

Transfers  to  the  Veteran  Reserve  Corps 

SECTION  II.  Medical  statistics  of  the  Confederate 
armies '" 


SECTION  III. 


SECTION  IV. 


s 
1 
1 

6 
10 

14 

17 
21 

28 

1-3-3 


Prevalence  and  mortality  of  disease  among 

U.  S.  troops  in  Confederate  prisons  .-Ji'.-l") 
Prevalence    and    mortality    of    disease 
among    Confederate    troops    in   U.  -S. 

prisons — IJ-TI 

rrison-i-amji  and   liospital  at  Camp  Douglas, 

near  Chicago,  111 4S 

Prison  and  hospital  at  Alton,  IIL— __ 50 

Prison-barracks  and  hosi)italat  Hock  Island,  III    .52 
Prison  and  hospital  at  Camp  Morton,  near  In- 
dianapolis, Ind 

Prison-camp  and  hospital  at  Johnson's  Island, 

Sandusky,  Ohio Hi 

Prison  and  hospital  at  Camp  Chase,  Columbus, 

Oliio — 

Pi-ison-camp  and  hospital  at  Elmira,  N.  Y 

Prison-cle^ot  at  Fort  Delaware,  Del 

I'rison-campand  hospital  at  Point  Lookout.  Md 
Prison-camp  near  Si)riugfield,  111 


.5.) 


CHAPTER  II.    INTRODUCTORY  TO  THE  PRESENTATION  OF  THE  CAMP  FEVERS. 


CHAPTER  III.    ON  THE 

SECTION  I.     The  statistics  of  the  malarial  fevers TT-lU 

Malarial  fevers  among  the  U.  S.  forces 77 

Prevalence  and  mortality ' ' 

Annual  variations  in  prevalence  and 

mortality *^ 

Relative     prevalence    and    mortality 
among  the  white  and  colored  troops..    84 

Seasonal  variations  in  prevalence S9 

Seasonal  variations  in  mortality 91 

Influence  of  region  on  prevalence 94 

Malarial     fevers     among     the     Confederate 

troops 1«-  ^ 

Prevalence " 

Mortality ^ ^^ 

Malarial  fevers  among  the  prisoners  of  war 

held  by  the  Rebel  authorities 108 

Malarial  fevers  among  the  prisoners  of  war 

lield  by  the  U.  S ^^ 

SECTION  n.    Clinical  records  of  malarial  disease 111-119 

SECTION  III.   Symptomatology  of  malarial  disease — 119-129 
Intermlttents  and  remittents 119 


PAROXYSMAL  FEVERS. 

SECTION  III.    Symptomatology,  etc.— [Continued.] 

The  pernicious  fevers lil 

Clironic  malarial  poisoning Ijy 

SECTION  IV.    Post-mortem   records   and   pathology  of 

malarial  disease rjy-i"a 

Post-mortem  records 129 

Pathological  anatomy  and  pathology 111 

SECTION  V.     Causation  of  malarial  disease 1.53-ir,) 

Causation  of  relapses hit 

SECTION  VI.     Prevention  of  malarial  disease Iti^-Hfi 

General  considerations Ift) 

Prophylactic  use  of  quinine W> 

Propliylaotic  use  of  other  medicinal  agents 175 

SECTION  vn.     Treatment  of  malarial  disease 176-190 

General  considerations 170 

Treatment  of  intermittentg l^^l 

Treatment  of  remittents l'>2 

Treatment  of  congestive  fevers 1*5 

Treatment  of  clironic  malarial  poisoning 183 

Untoward  eflTeets  of  quinine 1>>3 

Use  of  other  remedial  agents 1S4 

V 


TABLK    OF    CO^■TE^'T.■^. 


CHAPTER  IV.     ON  THE  CONTINUED  FEVERS. 


L'So 
L's.5 
•JS7 
•2>S 


SECTION  I.    The  statistics  of  the  continued  fevers  ^-Hh'-^jio 

In  the  U.  H.  armies imi 

rrevalcnco  aiul  MKiiiality luo 

I'rovalfnoeasri'latiMl  loscaMin  and  liicality.  lliil 
In  the  f 'onledt'i'iiti'  arniios L'lio 

Anions;  I'nion  sohlicrs,  jirisonci's  of  wai' lios 

Amiins;  Rel)el  sohlicrs,  prisonfrs  of  war liui* 

SECTION  II.     Clinical  records  of  the  continued  fevers^lfi-LlO 

Coniliioil  colltiniKM)  fcvci* -l[ 

T.vplio-inularial  and  typhoid  fevei'S 212 

l-'clirilc   casos    at   tlie   Seminary  IIosi>ital, 

^  (ieoriictown,  I).  C 215 

Fcbrilo  cnses  from  reirimental  records 2Iii 

Fi-brilo  cases  I'roni  various  records 257 

Typhus  fever 2(],S 

SECTION  III.    Symptomatology  of  the  continued  fevers-2T0-:m 

('oiiiiuoii  <'Oiitiniu'd  fever 270 

Typhoid  fever 273 

Temperature 279 

I'ulsc : 2S1 

P'.pistaxis 2s:5 

Condition  oftlie  skin 

Sudamin.-i 

Rose-colored  spots 

Tetechiie 

liedsores 

Herpetic  -poIs 

reculiar  odors 

Condition  of  tile  ih.rvous  systeiLi 2ss 

Heliriuni 2S.S 

Dilatation  of  the  pupils 2S1I 

Coiaiition  of  the  diirestive  system 2ld 

Anorexia,  tliirst  and  liastrie  irritatiility.  Ltd 

Ai>pearance oftlie  tontrue 2ii2 

Soriles 

Diarrliiea 

Hemorrhage  from  the  ho\vels 

Tenderness,  t.viniianites  and  trurfiliiiL'-- 

Piilmoiiai'V  sym)itonis 

Cither  elinieal  fe.itiires 

Jlieturition , 

Parol  ill  swelling 

Pain  ill  the  lower  extremities 

ModUieU  typhoid  fever 

Onset 

Pulse 

Epistaxis 

Condition  oftlie  sliin 

Kose-colored  spots 

Sndamina 

Petechial  and  ei-chyniotie  patelies 

Erysipelas 

liedsores 

Peculiar  odors 

Cerebral  symptoms 

Delirium 

Contraction  of  the  )iui)ils 

Prostration  and  muscular  tremors 

Condition  of  the  digestive  system 

Gastric  irritability 

Jaundice 

Apjiearance  of  the  tongue,  mouth  and 

throat _ 

Diarrhrea 

Hemorrhage  from  the  bowels 

Jleteorisiii,  abdominal  tenderness  and 

gurgling .107 

Splenic  enlar<:emeiit :iii7 

Chest  complications :{ii7 

Cough :m 

Other  clinical  features lliiS 

Jlieturitioii 3)8 

Parotid  swellimr ."MS 


2!i2 
2)12 
2:u 
2!  15 
2(17 
2!  17 
2117 
2!W 
2!K 
:!0J 
;i(H 
3(11 

■■;ii2 

:in2 
;!!« 
:;0i 
:l(li 
.■11  li 
:!01 
;i01 
.">(ll 
■Mi 

■.m 

:i05 
.■>05 
;iii5 
.■W5 

;!(n; 
.'11 II I 
.'!  17 


Page. 
sECTIi.iN  III.    8ymi'Toii.\tology,  ktc— [Continued.  1 

Pain  in  the  Joints  and  muscles iJiiS 

Ciangrciie :{ii.s 

Uelapses :ios 

Fatality "us 

Typhoid,  modified  and  uiitiiodifietl ;HI1) 

Sequehe :m) 

Relapses -iri 

Second  attacks 'ifJ 

Extracts  IVoni  rejiorts  of  medical  odieers  ■112 
Typhus  fever :>23 

SECTION  IV.     Post-mortem    records   of   the    continued 

fevers Sii-ilO 

Cases  in  which  the  diagnosis,  t.vphoid,  is  more 
or  less  sustaineil  b,v  the  clinical  history 33.5 

Ca.ses  entered  as  typho-malarial  with  or  with- 
out a  record  of  syni|itomR  to  substantiate  the 
diagnosis 315 

Cases  entered  as  typlioid,  but  with  clinical  his- 
tories suggestive  of  malarial  eomiilieations__  .351 

Ca.ses  reported  as  typhoid,  the  clinical  iiistory 
absen\  or  defective ".77 

Cases  variousl.v  registered,  but  typlmid  lever 
considered  present  from  tlii>  symptoms  or 
post-mortem  aiijiearances |n3 

Crises   illustrative  of  conipll<'at  iolls  ol    se-|llel;e_     111) 

Cases  re]»irled  .-is  typhus lis 

SECTION  V.     Pathological  anatomy  and  pathology  of  the 

continued  fevers illi-|s5 

The  aases  and  their  anai.vsis UIJ 

The  alimentary  tract  and  abdominal  viseera__  131 

.'Salivary  glands -1:'>I 

Pharyn.x  and  (esophagus 131 

Btomach 135 

Duodenum -135 

■Ti'juniim l".5 

Intussusception 135 

liUmbricoid  wtirms 13ii 

Patches  ofPeyer I3() 

Large  intestine 111 

Solitary  glands 112 

Erosion  of  the  intestinal  mucous  membrane  1.5i) 
Hemorrhage,   perforation    and    peritoneal 

in  Ma  111  mat  ion l.)i' 

Reparation  of  the  intesliiinl  ulceratioiis___   153 

Pigmentation  oftlie  intestinal  lining 1-55 

Jli'senterie  glands l.'iS 

.Spleen 1.5!l 

Liver HiO 

Emiihysema  of lid 

Ciall-bladder fii3 

Pancreas l(i3 

Kidneys 103 

The  organs  of  respiration  and  circulation Jii3 

Larynx  and  trachea AKi 

Bronchial  tubes lid 

Lungs ltd 

Pleura' 1(15 

Pericardium lil5 

Heart in', 

The  blood 171 

The  lirain  and  its  membranes 47s 

Age  of  patient;  state  of  nutrition,  etc 4S1 

Cieneral  eonelusi,ons 4^3 

SECTION  VI.     Etiology  of  the  continued  fevers is.5-.53i 

Couiiiion  continued  fever Is5 

Tyi>U(dd  fever (sii 

Continued  malarial  fever .5IK 

Typlio. malarial  fever 'MA 

Typhus  fever. .5l'i> 

SECTION  VII.     Treatment  of  the  continued  fevers .331-.551 


VI 


TABLE    OF    CONTENTS. 

CHAPTER  V.    ON  THE  DISEASES  ALLIED  TO  OR  ASSOCIATED  WITH  THE  PAROXYSMAL 

AND  CONTINUED  FEVERS. 


rage. 

SECTION  I.     Cerebro-spinal  fever- o.y2-o'M 

Clinical  and  post-mortem  records 50'- 

Among  the  colored  troops— -- 5)S6 

Anions;  the  Confederate  troops 587 

Among  the  prisoners oiii 

Symptomatology     and      patliologieal      anat- 
omy   590-610 

Pathology 001 


Tape. 

Section  I.    Cerebrospinal  fever— [Continued.; 

Prevention  and  treatment OliKil:! 

Prevention 010 

Treatment _  611 

SECTION  II.    Pneumonic  fever oi3-tii5 

SECTION  III.     Diarrhoea  and  dysentery oi.Vh;22 

SECTION  IV.      Scurvy 022- 024 


CHAPTER  VI.     ON  THE  ERUPTIVE  FEVERS. 


SECTION  I.     Small-pox Oi>-Ols 

Statist  ics 02o 

Cliniciil  and  post-mortem  records 020 

Treatment O-i;! 

Untoward  results  of  attempted  vaccination O-'il 

SECTION  II.     Measles oio-iii;! 

Prevalence  and  fatality 0111 

Clinical  records OkV) 

Post-mortem  records 0)S 


CHAPTER  VII.     OTHER 


SECTION  I.     Mumps- 


Section  II.    Me.vslks— [Continued.] 

Treatment - 0")9 

SECTION  III.     Scarlet  fever o<;2 

SECTION  IV.     Erysipelas-— a\2-i-r, 

Prevalence  and  fatality 002 

Symptoms —  <it!| 

Clinical  records —  -  0''0 

Post-iiU)rtem  ri'cords 'l*'0 

Treatment OT'i 

MIASMATIC  DISEASES. 

SECTION  II.     Yellow  fever --  '"> 


CHAPTER  VIM.     ON  SCURVY. 


Prevalence,  etc ''~~  ■ 

Clinical  records i»"' 

Post-mortem  observations '"" 


Symptoms 

Nyctalopia 

Morliid  anatomy - 

Pathology,  causal  ion  and  treatment. 


TOO 
71  IS 
7tl!> 


CHAPTER  IX.     ON  DISEASES  ATTRIBUTED  TO  NON-MIASMATIC  EXPOSURES. 


SECTION  I.     Disease  of  the  respiratory  organs 71ii-s 

Catarrh " 

Kpidemic  catariU ' 

.Vcute  l)r*nichitis ' 

Chronic  bronchitis " 

Asthma ' 

IiiHaniniation  of  the  larynx 'i 

Iiinainniation  of  the  tonsils '• 

Diphtheritic  iutlanimatioii  of  the  fauces,  etc    " 

Clinical  records ' 

Post-mortem  records '' 

Treatment ' 

Pneumonia ' 

Clinical  records ' 

Post-mortem  oljservations: • 

with  ante-mortem  notes ' 

in  cases  complicated  with  laryuiiitis : 

in  patients  afft-eted  with  delirium  tre- 
mens   

in  cases  in  wliich  cerebral  lesions  were 
not  associated  vvitli  recognized  cere- 
bral symptoms 

in    cases   unmarlied   by  characteristic 

pneumonic  symptoms 

in  cases  of  relapse  or  recurrence 

in  cases  complicated  by  mtilarial  mani- 
festations  

in  cases  possibly  iissociatcd  witli   the 

poison  of  typhoid  fever 

In  eases  showing  disease  of  tlie  solitary 

follicles 

in  cases  having  typhoid  symptoms  but 

no  typhoid  lesion 

in  cases  sliowing  tlie  maximum  weight 

of  the  consolidated  lungs 

in  cases  associated  with  pericarditis 

in  cases  complicated  with  peritonitis— 

in  cases  complicated  with  erysipelas — 

In  cases  complicated  with  inflammation 

of  the  parotids 


SECTION  I. 


rc-'i 

701 
7iil 

70.) 

700 

760 


70.S 
70S 


SECTION  II. 


SECTION  III. 


In.si:.\.si:soF  itKsi'iit.VToKV  oit(;.\Ns— [Conl'd.J 
Post-mortem  ol>scrvalions: 

in  cases  fatal  by  hemorrliage  into  tin- 

jileural  cavity "• 

in   cases   tern\inated   in  absci'ss  or  cir- 
cumscribed disintegration --  771 

in  cases  ending  in  gangrene .--  770 

in  cases  ending  in  liqucfacliiin  of  the 

lungs "~ 

in  cases  with  coexisting  tubercle 777 

in  cases  complicated  with  cercbrul   le- 
sions   "^ 

Analysis  of  the  post-mortem  appearances 

in  three  liundred  lobar  cases 77!) 

Post-mortem  records  of  catarrlial  cases 7S'i 

Analysis  of  the  post-mortem  aiipearam-cs 
in  one  hundred  and  thirty-five  catarrhal 

cases '''^ 

Pathology  of piuumonia —  >>01 

Treatment **00 

Consumption sis-sa 

Prevalence ^H 

Clinical  records f"!'' 

Post-mortem  records >-2"> 

Treatment 82S 

Kheumatic  affections S2<i-sn 

Acute  rlieuuiatisui --  ^-^ 

Statistics '-^» 

Clinical  and  post-mortem  records s-20 

Chronic  rheumatism ■'^>- 


Character  of  the  cases ^-f- 

Treatment ^l-' 

SECTION  IV.     Other  diseases  attributed  to  exposure-SJt-SCO 
Congestion  and  inllammation  of  the  spinal 

membranes ^'^ 

Ophthalmia '''^■* 

Sunstroke ^^^ 

VII 


TAI:LE    of     CO^'TENTS. 

CHAPTER  X.     ON  CERTAIN   LOCAL  DISEASES. 


ra,:;v. 

SECTION  I.     Cardiac  diseases Mi" 

Orj^aiiir  iilVcrtions "^'i" 

Functional  dislurbances n')2 

IdiopatliUi  Itei-irartlitis Miti 

Kiil>tur(r  <>t  the  Heart NlT 

Aneurism >-*JS 

SECTION  II.     Morbid  conditions  attributed  to  the  weight 

of  the  accoutrements  w;ft 

Haemoptysis ^^'0 


Par.' 


SECTION  ir.     MriKBID  CONDITIONS,  KTf'.— ^('oiitiiuicd.] 

Hernia .^71 

Lumbar  pains,  et<' S7J 

SECTION  III.     Constipation,  headache  and  neuralgia —  *T'i 

SECTION  IV.     Jaundice S74 

Aeute  iiiiianiination  of  tlie  liver ^77 

SECTION  V.     Idiopathic  peritonitis S7& 

SECTION  VI.    Diseases  of  the  kidneys ^?i 


CHAPTER  XI.     ON  CERTAIN  DISEASES  NOT  HERETOFORE  DISCUSSED. 


Nostalgia 884 

Army  iteU 88ti 

Poisoning 890 


Alcoliolism 

^'enel■eal  diseases 

Systematized  elTorts  at  prevention. 


MM 


CHAPTER  XII.     ON  THE  GENERAL  HOSPITALS. 


Exteiiiporized  hosiiitnls Sfi!) 

Barrack-buildinfis  converti'il  to  hospital  uses..  !hi8 

Pavilion  wards ItDs 

I'avilion  liospitals iU7 


Remarks  on  constraotion, personnel  and  man- 
agement  !i"i'i 

List  of  liospitals  in  active  serviee  in  December, 
I8I1I   illW 

Medic;il  and  hospital  supplies Wit 


LIST  OF  JIEDICAL  OFFICERS  CITKD  OR  MENTIONED 

LLST  OF  MEDICAL  AUTHORS  AND  OTHERS  CITED  OR  MENTIONED^ 
INDEX - 

VIII 


967 
972 
97J 


LIST  OI^   ILLXJSTI^^TIOiTS- 


A  comparison  of  the  annual  mortality-rates  caused  by  certain  specideil  diseases  In  various  bodies  of  men  of  tlie  military 

age,— facing  page 11 

Montlily  deatli-rates  among  wliito  troojis  from  all  diseases  and  from  oerlain  spedlled  diseases,— faeing  page a) 

Tlie  prevalence  of  disease  and  the  mortality  caused  thereliy  among  the  while  and  the  CDlnred  troojis  oftlie  V.  S.  armies  during 
the  years  of  tlie  war  and  tiie  year  following  tlie  war,  expressed  in  moiilhly  rates  p<'r  thousand  of  strength  present,— facing 

page - 2i 

Ciiromo-plate  sliowinglthe  prison-liarraclis  and  liospital  at  Roelj  IslaiKl,  111.— facing  page V.' 

Tlie  monthly  prevalence  of  malarial  fevers  among  the  white  troops,— facing  page ',» 

Average  annual  curvesof  prevalence  of  tlie  malarial  fevers  among  tlie  wiiite  and  tlie  colored  troops  during  tlie  war  in  monthly 

I'ates  per  tliousand  of  strengtii,— facing  page ill 

Seasonal  prevalence  of  malarial  fevers  in  the  Atlantic,  Central  and  Pacifli'  regions _. _ ini 

Map  of  tlie  United  States,  showing  tile  prevalence  of  imiiariai  fevers  in  tlie  various  military  deiiartments  during  the  Ueliel- 

i ion,— facing  page — ..  llKl 

Lines  indicating  tlie  prevalence  of  tlie  continued  fevers  among  tlie  white  troojis, —facing  page I!i!) 

Lines  indicating  tiio  prevalence  and  mortality  of  tiic  continued  fevers  among  the  colored  troops,— facing  page 2iK) 

Seasonal  variations  in  tlie  mortality  and  prevalence  of  typhoid  fever  among  a  I'.  S.  civil  population  of  eight  millions 200 

Seasonal  variations  in  tlie  mortality  and  prevalence  of  tlie  continued  fevers  among  the  white  and  the  colored  troojis 201 

Lines  indicating  the  prevalence  of  the  continued  fevers  iii  tlie  Atlantic,  Central  and  Pacific  regions,- facing  page 202 

rerforating  ulcers  of  tlie  ileum,— facing  pages 3i:{,  3S2,  :ii)l 

Tiiickened  patclies  of  Peyer  and  enlarged  solitary  follicles,— facing  pages 3S0,  111),  112, 1.'IO 

Slougiiing  patches  of  Peyer,— facing  ]iages USS.  IIS 

Cicatrices  of  typlioid  ulceration,— facing  pages ^ 101,101,  ir)l,l.")((,l.")S 

Vlceration  of  tlie  patclies  of  Peyer,— facing  pages l.'V-,  HO 

Perpendicular  section  of  tlie  ileum  sli  owing  enlargement,  softening  and  ulceral  ion  of  the  solitar\"  glands,- facing  page 111 

Perpendicular  section  of  the  ileum  showing  a  follicular  ulcer  which  has  iiciietraled  nearly  to  the  muscular  coat,— facing  page  116 

Section  of  a  typhoid  patch  ulcerated  superticially 117 

Section  ofa  typlioid  patch  showing  the  lymphoid  elements  in  the  glaiuis  and  stroma IIS 

Perpendicular  section  of  tlie  ileum  showing  typhoid  ihickening  ofa  Peyer's  patcli,— iiiciiig  page Hs 

Section  ofa  typhoid  patcli  with  the  lymphoid  elements  aggregated  mainly  in  the  glands 119 

Perpendicular  section  of  tlie  ileum  througli  an  ulcerated  patcii  from  wliich  the  softened  contents  of  several  follicles  liave 

escaped, — facing  page 150 

Microscopic  appearance  of  matter  from  the  superflcial  part  ofa  typhoid  patch l.'iO 

Microscopic  appearance  of  matter  from  tlie  deeper  parts  of  a  typlioid  patcli I'lO 

Pigmentation  of  the  ileum  in  continued  malarial  fever,— facing  page 1()0 

Sliowiiig  the  relation  between  the  height  of  the  subsoil  water-level  and  the  prevalence  of  typlioid  fever  in  the  State  of  Michi- 
gan during  the  j  ear  1882 .WJ 

Hilliard's  temperature  chart  of  typlio-malarial  fever 518 

Town's  teniperature  charts  of  typlio-raalarial  fever 518, oiO 

Comegy's  temperature  charts  of  typho-malarial  fever 520 

Hoff's  temperature  charts  of  mountain  fever 52:1,521 

Sliowing  tlie  monthly  rates  of  prevalence  of  small-pox  and  erysipelas  among  tiie  white  and  tlie  colored  troops,— facing  page—  (121 

Sliowing  tlie  monthly  rates  of  prevalence  of  measles  among  the  white  and  the  colored  troops,— facing  page (>jO 

Showing  tlie  iirevalence  of  scurvy  among  the  white  and  the  colored  troops  of  the  L".  S.  during  the  war  of  tlie  Rebellion,  and  in 

the  Englisli  and  French  armies  during  tlie  Crimean  war,— facing  page 691 

Showing  that  in  tlie  civil  population  of  the  United  .States  pneumonia  has  seasonal  waves  of  prevalence  similar  to  those  of 

acute  broncliial  inflammation 722 

Showing  tiie  monthly  rates  of  prevalence,  per  thousand  men  of  mean  strength  among  the  whites,  of  catarrli,  epidemic  catarrh, 

acute  bronchitis,  pneumonia  and  pleurisy,— facing  page 722 

Sliowing  tlie  monthly  prevalence  of  tonsillitis  and  diphtheria  among  tlie  white  and  the  colored  troops,— facing  page 738 

Showing  f  lie  monthly  variations  in  the  prevalence  of  acute  and  chronic  rlieumatism  and  consumption  among  tlie  white  and 

the  colored  troops,— facing  page S2S 

Sliowing  tlio  regulation  weights  carried  by  the  soldier  and  tlie  belts  and  braces  whicli  supported  them;  also,  the  method  of 

carrying  them  generally  adopted  by  veteran  troops,— fticing  page S70 

Sliowing  the  monthly  rates  of  prevalence  of  constipation,  headache  and  neuralgia  among  tlie  white  and  the  colored  troops,— 

facing  page 871 

Showing  the  variations  in  the  monthlj'  prevalence  of  jaundice  among  the  white  and  the  colored  troops  in  the  Atlantic  and 

the  Central  regions,— facing  page 876 

Lines  indicating  the  monthly  prevalence  of  venereal  diseases  and  of  alcoholism  among  tlie  white  and  tlie  colored  troops, — 

facing  page 890 

2  JX 


X  LIST    OF    ILLUSTrvATIOXS. 

PLAN'S,  ETC.,  OF  HOSPITALS: 

Seminary  Hospital,  Georgetown,  P.  C fKX> 

Old  Ilallowell  liou.se,  Alexandria,  ^■a 'J02,i»i« 

Broad  and  C'lierry  street.*,  rhiladelphia,  Ta (101 

Good  Samaritan,  St.  Louis,  5Io !(0.5,!Wii 

Marino  Hospital,  St.  Louis,  JIo il07 

Clarysville,  Md.,  pavilions  at 'JOS 

ilcKim's  Mansion,  Baltiinore,  Md Oil 

Patterson  Park  Hospital,  r)altiniore,  Md 912 

C'ampl)en  Hospital,  Wasliin^'tou,  1).  L" 913 

Carver  Hospital,  Washington,  D.  C 914 

Emory  Hospital,  Washington,  D.  C 915 

Hilton  Head  Hospital,  S.  C OIK 

Details  of  wards  at  Mount  Pleasant  and  Judi<'iary  S(iuare  hospitals,  Washington,  D.  C 917 

Judiciary  Square  Hospital,  Washington,  T>.  C— ground  plan 918 

Judiciary  Hospital, — side,  front  and  rear  elevations 919 

Chester  Hospital,  Chester,  Pa 921 

Dc  Camp  Hospital,  David's  Island,  X.  Y.  Harlii>r,— lacing  page 922 

Summit  House,  Delaware  Co.,  Pa 923 

Tilton  Hospital,  Wilmington,  Del 92.5 

C'uyler  Hospital,  Germantown,  Pa . 927 

Satterloo  Hospital,  West  Philadelphia,  Pa.— ground  plan 92-9 

Ventilation  of  the  wards  of  tlie  Satterlee  Hospital 9ol 

Mower  Hospital,  Chestnut  Hill,  Pa 933 

Stanton  Hospital,  Washington,  D.  C 030 

Armory  Square  Hospital,  Washington,  D.  C 937 

Hampton  Hospital  near  Fort  Monroe,  Va 9.3H 

Lovell  Hospital,  Portsmouth  Grove,  R.  I 010 

Harewood  Hospital,  Washington,  D.  C 911 

Hammond  Hospital,  Point  Loolvout,  Md. — facing  paiie  Hli 

.Sections  of  wards  and  covered-ways  of  the  Hammimd  Hospital 012 

Plan  of  wards  as  given  in  orders  from  the  War  Department 911 

Ventilation  and  licating  of  wards  as  directed  tiy  orders  from  the  War  Department 91.> 

.Sedgwick  Hospital,  Greenville,  La 910 

Kitchen  of  the  Sedgwick  Hospital 917 

■  Wards,  ventilation  and  heating  of  the  Sedgwick  Hospital 918 

Hick's  Hospital,  P.altimoro,  Md Or,() 

Cross- ventilation  of  water-closets  of  pavilion-wards Ojl 


LIST  OF  STATISTICAL  TABLES  AXD  TABULATED  STATEMENTS. 


Page, 
Mortality  of  the  U.  S.  Armies  from  May,  ISfil,  to  June  30,  ISOti - 1 

Table  I,  showing  the  annual  movement  of  sickness  and  deatli  among  tlie  white  and  tlie  colored  troops,  expressed  in  ratios 

per  tlioiisand  of  mean  strength 6 

Statement  of  the  mortality  from  disease  in  the  German  army  during  the  war  of  l.ST(l-'7l 7 

Rates  of  mortality  from  disease  in  llie  U.  S.  Army  during  the  years  ISI0-'.")II S 

Rates  of  mortality  from  disease  among  the  wliile  troops  of  tlie  V.  S,  Army  during  the  years  1S(~-'S.'! !t 

Table  II,  showing  the  comparative  freciuency  of,  and  mortality  from,  tlie  diseases  that  prevailed  among  the  white  troops  of 
the  U.  S.  Army  during  the  period  from  May  1,  ISOl,  to  June  130,  ISiiii,  and  among  the  colored  troops  during  the  period  from 
July  1,  ISti'i,  to  June  30, 1S06 U 

Table  III,  showing,  by  average  annual  rates  per  1,000  of  mean  strength,  the  comparative  frequency  of,  and  mortality  from,  the 

diseases  that  prevailed  among  the  white  and  thecolored  troops  of  the  I".  S.  Army 13 

Table  IV.  Average  annual  sick  and  death-rates  per  thousand  of  mean  strength  in  tlie  U.  S.  Army  before,  during  and  since  the 
war,  and  In  the  German  and  French  armies,  with  the  annual  death-rate  for  males  of  the  military  age  In  the  United 
States,  as  calculated  from  the  returns  of  the  census  year  1880 ^ 16 

Table  V,  showing  tlie  annual  prevalence  of  sickness  and  the  mortality  from  disease  in  the  several  regions,  expressed  In  ratios 

per  thousand  of  mean  strengtli 18 

Table  VI,  showing  tlie  annual  prevalence  of  sickness  from  all  diseases  in  the  several  military  departments,  expressed  in 

ratios  per  tiiousand  of  strength lit 

Table  VII.  Monthly  ratio  of  sickness  jier  tiiousand  of  mean  strength  among  the  white  troojis  of  tlic  l'.  S.  Army,  by  regions, 

for  the  period  from  June  30,  IStil,  to  June  30,  IHiiO 21 

Table  VIII.  Monthly  ratio  of  cases  of  sickness  per  tiiousand  of  mean  strengtli  among  the  colored  troojis,  by  regions,  for  the 

period  from  June  30,  1SB3,  to  June  3ii,  im> - 21 

Table  IX.  Monthly  ratio  of  deaths  from  disease  per  tiiousand  of  mean  strength  among  the  white  troops  of  tlic  I'.  S.  Army,  by 

regions,  for  tiie  period  from  June  30,  1801,  to  June  30,  1800 22 

Table  X.  Monthly  ratio  of  deaths  from  sickness  per  thousand  of  mean  strength  among  the  colored  troojis,  by  regions,  for  tlie 

period  from  June  30,  isij:!,  to  June  30,  18<)B 22 

Table  XI.  Discharges  for  disability  from  disease  in  the  U.  S.  Army  from  May  1,  IHtil,  to  June  30, 1800,  with  ratio  per  thousand 
of  mean  strength  in  the  Held,  garrisons  and  general  hospitals,  ratio  per  thousand  of  total  discharges,  and  mean  annual 
ratio  per  tiiousand  of  strength 27 

Table  XII.  Abstractor  the  cases  of  specified  diseases  with  recorded  terminations,  and  of  deaths  .among  such  cases  at  the  I'll  Im- 

borazo  hospital,  Riclimond,  Va 30 

Statement  of  the  sickness,  wounds  and  mortality  in  the  C.  S.  army,  exclusive  of  the  troops  in  the  Trans-Mlsslsslppl  Depart- 
ment, from  the  beginning  of  the  war  to  December  31, 1802 30 

Table  XIII.  A  comparison  of  the  prevalence  and  fatality  of  disease  in  the  opposing  armies  from  tlie  commencement  of  the 

war  to  December  31, 1802 - 31 

Table  XIV.  Ca.ses  of  sickness  and  wounds  reported  from  certain  of  the  Confederate  armies  during  portions  of  the  years  1801, 
1802  and  1803,  with  the  strengtli  present  during  tlie  periods  covered  by  tlie  statistics,  and  the  calculated  annual  rates  per 
thousand  of  strengtli  in  juxtaposition  with  the  corresponding  rates  of  the  U.  S.  Army  for  the  year  ending  June  30, 180.3.-    32 

Table  XV,  summarizing  the  records  of  the  hospital  at  Camp  Sumter,  Andersonville,  Ga 31 

Table  XVI,  giving  a  general  view  of  the  sick  and  death-rates  from  prominent  diseases  and  classes  of  diseases  among  the  Feel- 
eral  prisoners  at  Andersonville,  Ga.,  for  tlie  period  extending  from  Marcli  I  to  August  31, 1804.  Average  present,  19,t.")3 
prisoners 35 

Table  XVII,  summarizing  the  records  of  the  prison  hospital  at  Danville,  Va.,  Xovemlicr  21,  IStvi,  to  March  27,  180-5 u 

Table  XVIII,  showing  the  number  of  cases  of  certain  specified  diseases  and  classesof  disease,  and  of  deaths  attributed  to  them, 
among  the  Confederate  prisoners  of  ^var  at  tlie  principal  prison  depots,  for  the  period  covered  by  the  records  of  eacli 

prison 10 

Table  XIX,  in  which  the  facts  of  Table  XVIII  are  consolidated  and  expressed  in  average'annual  rates  per  thousand  of  strength, 
with  tlie  ratio  of  cases  of  specified  diseases  to  cases  of  all  diseases,  of  deaths  from  specified  diseases  to  deaths  from  all  dis- 
eases, and  the  percentage  of  fatal  cases  of  specified  disease.    Average  strength  present,  40,815  men 47 

Table  XX,  contrasting  the  mortality  rates,  per  thousand  of  strength,  among  tlie  white  and  the  colored  troops  of  the  U.  S. 

.\rmy  and  the  Union  and  the  Confederate  prisoners  of  war 18 

Barrack  occupancy  of  the  Union  troops  as  compared  with  that  of  the  Confederate  prisoners  at  Camp  Chase,  Ohio 55 

Table  XXI,  comparing  the  annual  sickness  and  mortality  from  certain  specified  diseases  at  the  principal  depots  for  Rebel 

prisoners 61 

Tabular  statement  of  the  ration  in  kind  allowed  to  Rebel  prisoners  of  war,  with  the  full  ration  of  the  U.  S.  troops  at  tlie  same 

dates,  and  the  ditt'erence  in  the  value  of  tlie  two  rations  credited  to  the  prison-fund 69 

XI 


XII  l:>t  uf  statistical  tap.lks 

Paga 

Table  XXII.  statPiilont  of  llio  rreqiwncy  ami  iiiortaliiy  of  ilic  several  I'onii-^  of  malarial  fever,  friviii!,'  the  lotals  reported  from 
Jlay  I,  Isiil,  to  June  Mil,  isiiii,  with  llie  ratio  ofi-ascs  to  >truni.'th  and  tn  cases  of  till  diseases,  ami  the  I'utio  of  deaths  to 
strength,  to  deaths  from  all  diseases,  and  to  oases  of  nudarial  fever:  White  troops 79 

Table  XXIII.  statement  of  t lie  freiniem-y  ami  mortality  of  the  si-veral  forms  of  malarial  irvrr,  .uivimr  ihe  ii>i;ils  re|iortc'd  from 
July  I,  l^tl'!,  to  June  .ia,  istlil,  willi  tin'  I'alins  of  cases  to  strcni^'th  and  to  ea*es  i if  all  diseases,  and  the  i-al  ios  nf  deal  lis  to 
strenuth,  to  deaths  from  all  diseases,  and  to  cases  of  malarial  fever:  Colored  troo]is SO 

Table  XXIV.  Relative  freipieney  of  eases  of  malarial  fi^vers  and  deatlis  caused  by  them,  dui'in.ir  the  several  years  of  the  war 

and  the  year  following'  tiie  war,  expressed  in  annnal  rates  per  l,fHiO  of  mean  strength :  White  troops S2 

Table  XXV.  Uelative  frcquene.v  of  cases  of  malarial  fevers  and  of  deaths  caused  by  them  among  the  colored  trncips  iluiiiit;  two 

years  of  the  war  and  the  year  following  the  war,  expressed  in  annual  rates  per  1,(HK)  of  mean  strength 83 

Table  XXVI.  Relative  freciiieney  among  the  white  and  the  colored  troops  of  cases  of  malarial  fever.?  and  of  d<'aths  caused  by 

them,  as  shown  by  the  average  number  annuall.v  recorded,  reduced  to  ratios  per  1,M)  of  strength SI 

Table  XXVII.  A  comparison  of  the  prevalence  of  malarial  fevers  among  the  ^vhite  and  the  colored  troops  serving  in  the  same 
localities  during  the  two  years  from  July  1,  ISiB,  to  June  ;!(l,  ISiio,  the  ligures  given  being  the  average  annual  ratios  jier 
l,iXK)  of  strength _ 88 

Tabular  statement  of  the  death-rate  from  nialarial  fevers  among  the  white  and  the  colored  population  of  certain  sectiiais  of 

the  Tnited  States 87 

Comparison  of  the  death-rate  from  malarial  disease  among  the  white  and  the  colored  population  of  certain  cities  of  the  I'nited 

States -    87 

Statement  of  the  prevalence  of  periodic  fevers  among  the  white  and  colored  troops  serving,  since  the  war,  at  certain  posts  in 

the  Department  of  Texas : 8S 

Table  XXVIII,  showing  the  seasonal  variations  in  the  prevalence  of  malarial  fevers  among  the  w'hite  troops  In  the  several 
regions  during  the  years  of  the  war  and  the  year  following  the  war,  expressed  in  monthly  ratios  per  l,0()u  of  mean 
strength  80 

Table  XXIX.  Average  monthly  number  of  cases  of  the  several  v.arieties  of  malarial  fever  among  the  white  troops  from  July  1, 

istd.  to  June  SO,  1800,  expressed  as  ratios  per  1,(XW  of  mean  strength 0:i 

Table  XXX.  Average  monthly  number  of  cases  of  the  several  varieties  of  malarial  fever  ainong  the  colored  troops  from  July 

1,  IsiK,  to  June  liO,  ISOO,  expressed  in  ratios  per  1,0(W  of  strength 01 

Table  XXXI.  Average  monthly  number  of  cases  of  the  several  forms  of  malarial  fever  among  the  white  troops  in  the  sevei'al 

regions,  expressed  in  ratios  per  l,OiKi  of  strength,  calculatedfrom  the  cases  which  occurred  from  July  1,  ISOI,  to  June:!ii,  isiio^    05 

Table  XXXII,  showing  the  in-e  valence  of  malarial  fevers  in  the  departments  on  the  Blaster  n  and  Southern  coasts  of  the  I'nited 
States,  and  in  those  of  the  high  and  low  grounds  of  the  Central  Regk>n,  expressed  in  annual  ratios  per  I,(X)0  of  strength, 
calculated  from  the  statistics  of  the  four  years  ending  Juno. '30, 180) 07 

Table  XXXIII,  showing— 1,  the  relative  prevalence  of  the  malarial  fevers  among  the  white  troops  in  the  several  departments 
and  regions  during  the  four  years  ending  June  30, 180.5,  expressed  as  ratios  per  1,(KXJ  of  strength ;  2,  the  relative  frecjueney 
of  the  forms  of  these  fevers,  expressed  in  ])ercentages  of  the  total  number  of  cases;  and  3,  the  relative  frequency  of  the 
varieties  of  intermittent  fever,  expressed  as  percentages  of  the  total  number  of  intermittent  cases OS 

Tabular  statement  of  the  death-rates  from  malarial  disea.se  in  the  States  and  Territories  of  the  United  States  from  the  census 

returns  of  1870  and  1880 102 

Table  XXXIV.  A  comparison  of  the  prevalence  of  intermittent  and  remittent  fevers  in  the  Confederate  and  Federal  Armies 

of  the  Potomac  from  July  1, 1801,  to  March  31, 1802 103 

Table  XXXV.  A  comparison  of  tlie  prevalence  of  intermittent  and  remittent  fevers  in  the  Confederate  and  United  States 

Armies  of  the  Tennessee  from  June  1, 1802,  to  JIa.v  31,  1803 101 

Tabulateil  comparison  of  the  prevalence  of  intermittent  and  remittent  fevers  in  the  Confederate  Army  of  the  Valley  of  Vir- 
ginia and  the  U.  S.  Middle  Department  of  the  Atlantic  Region  from  July  1  to  October  31, 1802 105 

Table  XXXVI.  A  comparison  of  the  prevalence  of  intermittent  and  remittent  fevers  in  the  Confederate  Army  of  the  Valley  of 

Virginia  anil  the  U.  S.  Department  of  the  Shenandoah  from  January  1, 1802,  to  June  30,  1802 100 

Table  XXXVII,  showing— 1,  the  relative  frequency  of  the  forms  of  malarial  fever  among  the  Confederate  troops  as  compared 
with  their  frequency  among  the  troops  of  the  United  Statc-s,  expressed  in  percentages  of  the  total  number  of  malarial 
cases;  and  2,  the  frequency  of  the  varieties  of  the  intermittents  expressed  in  percentages  of  tlieir  totals 107 

Tabular  statement  of  the  relative  frequency  of  the  various  types  of  malarial  fever  among  the  U.  S.  and  the  C.  S.  troops,  with 

an  approximative  comparison  of  the  mortality  occasioned  h.v  them 108 

Table  XXXVIII.  Cases  of  malarial  fever  with  resulting  mortality,  reported  from  the  principal  prison  depots  as  liaving 

occurred  among  the  Confederate  prisoners  of  war;  with  the  annual  ratios  per  thousand  of  strength  present 110 

Table  XXXIX.  Statement  of  tlie  fre(iuency  and  fatality  of  the  continued  fevers,  giving  the  totals  reported  from  May  1, 1801,  to 
June. 30,  ISGO,  among  the  wliite  troojis,  and  from  .July  1,  1803,  to  June  .30,  I8<30,  among  the  colored  troops;  «itli  the  ratio  of 
cases  to  strength  and  to  cases  of  all  diseases,  and  tlie  ratio  of  deaths  to  strength,  to  deaths  from  all  diseases,  and  to  cases 
of  the  continued  fevers 191 

Table  XL.  Expressing  the  frequency  of  and  mortality  from  the  reported  forms  of  the  continued  fevers  as  percentages  of  the 

total  cases  and  deaths  caused  by  such  fevers 192 

Table  XLI.  Relative  frequency  of  cases  of  the  continued  fevers,  and  of  deaths  occasioned  by  them,  during  the  several  years  of 

the  war  and  the  year  following  the  war,  expressed  in  annual  rates  per  thousand  of  strength  present 193 

Table  XLII,  showing  the  annual  percentages  of  latality  of  the  continued  fevers 191 

Table  XLIII.  Comparison  of  the  frequency  of  eases  of  tlie  continued  fevers,  and  of  the  deaths  occasioned  by  them,  among  the 
white  and  the  colored  troops,  as  shown  by  the  average  numbers  annually  recorded,  reduced  to  ratios  per  thousand  of 
strength ;  the  figures  for  the  white  troops  based  on  the  statistics  of  the  period  May  1, 1801,  to  June  30,  1800,  and  those  for 
the  colored  troops  on  the  statistics  of  the  three  years  July  1,  180.3,  to  June  30,  1860 195 

Table  XLIV,  showing  the  variations  in  the  prevalence  of  the  continued  fevers  among  white  troops  in  the  various  regions 

during  the  years  of  the  war  and  the  year  following  the  war,  expressed  in  monthly  ratios  per  thousand  of  mean  strength.  196 

Table  XL\'.  Seasonal  variations  in  the  prevalence  and  inortalit.v  of  the  continued  fevers  among  tlie  white  troops,  expressed 
in  average  monthly  rates  per  thousand  of  strength,  obtained  by  tlie  consolidation  of  the  figures  for  the  corresponding 
month  of  each  of  the  years  covered  by  the  statistics 201 

Table  XLVI.  Seasonal  variations  in  the  prevalence  and  mortality  of  the  continued  fevers  among  the  colored  troops,  expressed 
as  average  monthly  rates  per  thousand  of  strength,  obtained  by  the  consolidation  of  the  figures  for  the  corresponding 
months  of  each  of  the  years  covered  by  the  statistics 202 

Table  XLVII,  showing  the  relative  freiiuency  of  the  reported  forms  of  the  continued  fevers  among  the  white  troops  in  the 

several  departments  and  regions  during  the  four  years  of  war  service  from  July  1,  ISOl,  to  June  30, 1805 203 


A^D    TABULATED    STATEMENTS.  XIII 

Tnl-ilo  XLVIII.  Number  of  cnses  of  the  continued  fevers  in  tlio  Confeilcnite  ami  Federal  Armies  of  the  Potoiuiic  from  July  1, 

Hill,  to  JIareli  .'U,  lSii2,  witli  the  ratio  per  tliousand  of  mean  strength  for  each  month Jflt> 

Talde  XLIX    Aeomiiarison  of  the  prevaleneenf  tlie  continued  fevers  in  tlie  I'nion  and  Coul'ederateforcesduring  tlio  nineteen 

moullis,  January,  lS(j2,  to  July,  ISii:'.,  Inclusive,  expressed  in  montlily  ratios  per  liiousand  of  strengtli iM7 

Tabular  statement  ofthe  continued  fcversat  the  liospital  at  Camp  Sumter,  Andersonvillc,  Ga iXiS 

Tabular  statement  of  the  fatality  of  tlic  continued  levers  in  certain  of  theConfederale  general  liosiiitals „  20S 

Tal)le  L.  Number  of  cases  of  tlie  continued  fevers,  witli  the  resulting  mortality,  reiiorted  from  llie  princijial  prison  dei>ots  ns 

having  occurred  among  Conl'ederate  prisoners  of  war,  with  the  annual  rates  per  tiiousaiul  of  strcngtii iJW 

rercentagi'  of  men  of  various  stated  ages  in  tlie  ranks  of  tlie  army 481 

Table  LI,  showing  the  ages  of  four  hundred  and  tliirty-one  cases  of  continued  fever,  and  comparing  tlie  freiiuency  of  these 

fevers  at  certain  ages  witli  the  relative  number  of  men  of  those  ages  in  the  ranks  of  the  army 4S'2 

Tabular  statement  of  the  relations  of  diarrliceal  diseases  to  the  malarial  fevers  as  shown  by  the  mortality  tables  of  tlie  Tentli 

U.  S.  Census,  ISSO _  017 

Table  LII,  showing  the  prevalence  and  mortality  of  the  eruptive  fevers  among  the  U.  S.  forces  during  the  years  of  the  war 

and  the  year  following  tlie  war (1-1 

Table  LIII,  sliowing  tlie  numlier  of  cases  of  tlie  eruptive  fevers  and  of  deaths  caused  by  them  among  the  Confederate  prisoners 

of  war  at  the  principal  prison  depots  for  the  period  covered  by  tlie  records  of  each  prison 629 

Tabic  I, IV,  showing  the  annual  and  average  annual  rates  of  sickness  and  deatli  from  diseases  of  the  rcspirator.v  organs,  as 
also  the  percentage  of  fatality  of  these  diseases  among  the  U.S.  troops  for  stated  periwls,  expressed  in  ratios  per  tlnaisand 

of  strength 71!> 

Table  LV,  contrasting  tlie  mortality  from  pneumonia  in  rales  per  tliousand  of  strengtli  in  certain  of  the  Confederate  armies 

and  the  white  commamls  »-)f  tlie  I'nion  army 720 

Table  LVI,  showing  the  prevalence  and  mortality  from  certain  diseases  atlribntcil  to  atmospheric  exposures  among  tlie  Con- 
federate prisoners  held  at  the  principal  jirison  depots  in  tlio  United  States.    Average  period  covered  by  tlie  oliservations, 

two  years;  average  strengtli  present,  4(i,si.3  men 72! 

Tabular  statement  ofthe  seasonal  prevalence  of  pneumonia  in  tlie  Southern  armies. 72:5 

Table  LVII,  showing,  liy  ratios  per  thousand  of  strength,  the  relative  I'reiinency  of  catarrh  of  the  rcspirator.v  iiukmiis  mem- 
brane and  pneumonia  among  the  white  troops  of  tlie  several  departments  and  regions  during  the  four  years  of  war  serv- 
ice, July  1,  ISOl,  to  June  OO,  18(15 _ 721 

Table  LVIII.  Localization  and  specification  ofthe  morbid  conditions  found  in  tin'  lungs  in  ;;iK)  cases  of  acute  lobar  pneumonia.  780 

Tabular  statement  of  the  pleuritic  complications  in  ?M  cases  of  lobar  pneumonia 781 

Tabulation  ofthe  stated  cf>nditions  ofthe  lungs  in  K!-)  cases  of  lobular  piii'unionia 79S 

Tabulation  of  tlie  jileuritlc  complieations  in  l:i)  cases  of  lobular  imeumonia 79!) 

Tabulation  comparing  the  death-rates  from  malarial  fevers  and  consiiniptioii  in  some  large  cities  of  tlu'  V.  S._ 824 

Mean  of  temperature  observations  taken  during  tlie  hot  months  of  the  years  of  the  war R.jl 

List  of  general  hospitals  in  active  service  in  DecemluT,  18(11 9(l() 

Quantity  of  certain  medical  and  hospital  supplies,  etc.,  issued  by  the  Medical  Purveying  Ilureau  during  the  war... _.  !Hk( 

Aljiliabetical  list  of  medical  olTicers  <'ited  or  mentioned,- (H" 

Alphabetical  list  of  medical  antliors  and  others  cited  or  mentioned 972 

Index _ - __ ()7i 


THE 


MEDICAL   AND   SURGICAL   HISTORY 


OF  TlIK 


WAll  OF  THE  ItEr.ELLIOX  (ISiil-Tu). 


PART  III,  VOLUME  I. 

BEINGr    Tlil^:    XHIKD    IMKIJIC^VI.    A'OIjXJMK. 


CHAPTER  I.— OX  THE  ^lEDICAL  »^TATIHT1CS  uV  Til  I'.  WAK. 


L— SICKNESS  AND  MORTALITY  AMONG  THE  U.  S.  FORCES. 


The  First  Pari  of  this  Medical  Volume  of  the  History  of  the  War  is  mainly  com- 
posed of  a  series  of  Taljlcs  giviiis^  tlie  fii^ures  repoi-ted  by  various  commands  as  cxprcssintj; 
the  facts  connected  witli  the  occurrence  of  sickness  and  deaths  from  certain  s]H>cifK'd 
diseases  among  the  troops  composing  tliem.  To  derive  anv  information  from  thcsi'  Tallies 
otlier  tlian  that  borne  upon  their  face,  as  fur  instance,  to  compare  their  items  one  with 
another,  or  with  similar  statistics  from  (jther  soui'cc'^,  it  is  necessary  to  convert  their  ligures 
into  others  expressive  of  their  relation  to  some  common  standard.  l)Ut  l)ef()re  deducing 
ratios  of  sickness  and  mortalitv  in  designated  diseases  from  the  figures  tabulated,  it  may 
be  well  to  recall  some  })oints  connected  with  them  that  detlnite  ideas  may  be  olitaiiied  oi 
their  probable  value. 

1st.  As  to  mortality  actual  and  kki'oktkd. — On  page  xxxvir  of  the  Intnuluc- 
tion  to  the  First  Part,  it  is  shown  by  a  comparison  of  data  drawn  from  varimis  sources  (hat 
the  actual  mortality  of  our  armies  from  May,  1S61,  to  June  30,  LS(56.  may  b(>  assumed  to 
be  closely  approximated  by  the  following  figures: 


MORTAUTY. 


Killed  ill  liattlo 

Uiod  <it'  wounds,  etc 

Died  of  disease 

Died,  unknown  causes. 


White.       Culoiskd 


I'm  A  I.. 


42, 724 

l.r.lt 

41,238 

47,9U 

1,S17 

1>,>,731 

1.57, 004 

2!l,  212 

lsn,21i) 

23,347 

><37 

21,1SI 

Total. 


270,li8tl 


33, 3S0 


3(11, 3(i9* 


•According  to  Dr.  JOSEI'II  JOXES  (see  Richmond  and  Lnnisvillf.  Med.  Jour..  Vol.  IX,  1870,  p.  259t,  the  lieaths  in  the  Confederate  annifs  during 
the  war  dirt  not  fall  short  of  200,000,  throe-fourths  of  whii-li  number  were  due  to  disease  and  one-fourlh  to  the  casualties  ftf  battle.  The  data  from  wliieU 
these  eoiielusiiins  were  derived  are  saiil  to  have  been  critically  examined  and  considered  correct  by  ihe  former  Adjutant  C^eneral  of  the  Confederate  States, 
,S.  Cooi'EK,  of  .Alexandria.  Mrginia. 

Meu.  Hist.  Pt.  Ill— 1 


Z  SICKNESS    AND    MORTALITY 

If  tlie  deatlis  from  unknown  causes  in  tins  statement  be  distributed  auiono;  the  three 
causes  specified  in  tlic  proportion  which  tlie  figures  of  each  bear  to  their  totah  the  deaths 
from  disease  will  be  found  to  amount  to  171,806  among  the  white  troops,  and  to  29,963 
among  the  colored  troops,  giving  a  total  of  201,769  deaths  irom  disease. 

Looking  now  at  Table  C,'''  which  gives  a  general  summary  of  the  sickness  and  mor- 
tality among  the  white  troops  during  the  war,  it  will  be  found  that,  excluding  37,237 
deaths  attributed  to  wounds,  accidents  and  injuries,  there  were  reported  128,937  deaths 
from  diseases  that  are  specified  and  449  from  diseases  that  are  not  specified,  making  a  total 
of  129,386  deaths  reported  as  from  disease. 

But  since  the  total  mortality  from  disease  was  171,806,  it  is  evident  that  42,420 
deaths,  or  24.7  per  cent,  of  the  total,  were  not  reported,  and  that  42,869  deaths,  or  24.9 
per  cent,  of  the  total,  were  not  attributed  to  their  special  causes.  Hence,  if  it  be  desired 
to  obtain  from  the  Tables  in  the  First  Part  of  this  work  an  approximation  to  the  absolute 
mortality  Irom  any  specified  disease,  we  may  assume,  in  the  absence  of  other  and  accurate 
data,  a  j/>ro  rata  distribution  of  the  42,869  deaths  from  unspecified  diseases  and  multiply 
the  number  in  the  tables  by  1.33,  since  the  number  of  deatlis  tabulated  and  reported  as 
due  to  specified  causes,  to  wit,  128,937,  is  to  the  whole  number  of  deaths  attributed  to 
disease,  171,806,  as  1  :  1.33.  Thus,  taking  acute  and  chronic  diarrhea  and  dysentery  by 
way  of  illustration,  it  is  found  that  the  deaths  reported  as  from  these  diseases  numbered 
37,794;  but  the  actual  mortality  caused  by  them  must  have  been  considerably  greater, 
to-wit,  about  50,226.t 

Again,  looking  at  Table  CXI,!  which  gives  a  general  summary  of  the  sickness  and 
mortality  of  colored  troops  during  the  war,  it  will  be  found  that  in  the  strength  represented, 
27,499  deaths  were  reported  from  specified  diseases.  This  number  is  less  by  2,464  than 
the  actual  mortality,  29,963,  in  the  strength  present  and  absent.  The  tables,  therefore, 
embrace  91.8  per  cent,  of  the  mortality  statistics  of  the  colored  troops.  If  an  approxima- 
tion to  the  actual  mortality  be  desired  in  the  case  of  any  given  disease,  it  may  be  obtained 
from  the  figures  in  the  statistical  tables  by  the  use  of  the  factor  1.09.  Thus,  in  the  case 
of  the  alvine  fluxes,  the  tables  give  a  mortality  of  6,764,  but  the  actual  mortality  was 
probably  about  7,373.|| 

2d.  As  to  mortality  rates. — Although  the  figures  given  in  the  tables  constitute 
but  75.3  and  91.8  per  cent,  of  the  total  mortality  among  the  white  and  colored  troops 
respectively,  it  is  to  be  remembered  that  the  strength  in  winch  this  tabulated  mortality 
occurred  was  only  a  part  of  that  which  furnished  the  total.  The  tabulated  deaths  took 
place  among  the  men  in  the  field  and  garrisons,  and  among  the  floating  population  of  the 
general  hospitals  in  which  the  sick  from  the  field  and  garrisons  were  treated,  when,  for 
military  or  medical  reasons,  it  was  deemed  expedient  to  send  them  to  a  distance  from  their 
commands.  The  untabulated  deaths  of  white  and  colored  soldiers,  42,420  and  2,464, 
respectively,  occurred  firstly,  in  commands  the  reports  of  which  were  not  received,  or  if 
received  were  not  embodied  in  the  tables  on  account  of  some  defect  which  rendered  them 
valueless  for  the  computation  of  rates ;  secondly,  among  men  separated  from  their  com- 
mands by  the  fortune  of  war  and  held  as  prisoners  by  the  enemy;  and  thirdly,  among 
those  not  borne  as  present  numerically  in  the  strength  of  their  commands  on  account  of 
temporarv  absence  on  furlough  or  various  special  duties. 

*  I'ait  First,  p.  (141.  \  See  Dr.  'Wooiuvakd's  oalciilation,  p.  3  t>l  Part  II,  wliero  tlie  actual  mortality  in  this  iustance  is  figured  as  49,88.5. 

,  Part  First,  p.  712.  |1  Dr.  WoomvAUIi's  calculation  puts  tlie  luiiiiber  at  7.380. 


AMONG    THK    U.    S.    FORCES.  6 

With  regard  to  untabulated  deaths  due  to  unrendered  or  rejected  reports,  the  assump- 
tion seems  warranted  that,  had  these  reports  been  received  in  a  condition  to  admit  of  tlieir 
incorporation  in  the  tables,  it  is  not  likely  that  the  rates  calculated  from  the  latter  would 
have  been  materially  altered,  since  the  numbers  tabulated  were  in  themselves  so  large,  and 
constituted  so  large  a  percentage  of  the  deaths  that  occurred  in  the  field,  garrisons,  and 
general  hospitals.  Dr.  Woodward  estimated  that,  in  a  general  way,  the  tables  covered 
about  nine-tenths  of  the  class  of  facts  which  they  were  intended  to  embrace. 

With  respect  to  the  deaths  that  occurred  among  prisoners  of  war,  they  are  with  pro- 
priety excluded  from  data  forming  the  basis  of  an  inquiry  into  the  mortality  rates  affecting 
our  armies  in  the  field,  since,  as  is  well  known,  the  circumstances  surrounding  these 
unfortunate  men  were  such  as  predisposed  to  a  higher  rate  of  mortality.  Had  full  returns  of 
the  deaths  among  them,  with  a  knowledge  of  tJie  numerical  strength  present  in  the  prisons 
during  the  war,  been  preserved,  they  would  have  served  as  materials  for  an  interesting 
study;  but  it  would  not  have  been  advisable  to  consolidate  them  with  the  mortality 
statistics  of  men  under  wholly  different  conditions. 

Similarly,  it  seems  proper  to  exclude  from  consideration  the  deaths  tliat  occurred 
among  the  large  number  of  men  absent  from  their  commands  on  furlough  and  by  reason 
of  other  causes,  as  this  class  was  for  the  time  being  removed  from  the  infiucnce  of  the 
causes  and  conditions  which  favored  mortality  among  the  men  on  active  service.  It  is 
highly  improbable  that  the  deaths  among  them  were  relatively  as  numerous  as  among  n:en 
on  field  duty.  Although  many  men  were  furloughed  because  they  were  sick,  and  undoubt- 
edly many  deaths  occurred  among  such  cases,  the  majority  of  those  thus  furloughed  were 
convalescents  looking  for  improvement  and  return  to  health  during  their  temporarv  sojourn 
at  home.  The  number  of  these  absent  from  their  commands  cannot  be  obtained;  but  had 
it  been  possible  to  have  ascertained  all  the  facts,  their  consolidation  with  the  matter  of  the 
statistical  tables  of  Part  First  would  have  introduced  an  element  which  would  have 
required  elimination  before  the  rates  affecting  the  troops  on  active  service  could  have  been 
deduced. 

We  may  therefore  accept  the  conclusion  that  death  rates  based  on  the  tabulated 
figures,  notwithstanding  the  incompleteness  of  the  latter,  will  furnish  a  fair  index  to  the 
n:iortality  caused  by  the  morbific  influences  to  which  the  array  was  subjected  during  the 
years  of  the  war. 

3d.  As  to  the  cases  of  sickness,  absolute  and  eepokted. — The  tabulated  statis- 
tics show  the  occurrence  among  white  troops  of  5,417,360  cases  in  which  the  disease  is 
specified  and  7,187  cases  of  unspecified  disease,  making  a  total  of  5,424,5-47  cases  of  dis- 
ease, exclusive  of  400,933  cases  of  wounds,  accidents  and  injuries  comprised  in  Class  V 
of  the  oflBcial  reports.  This  number  of  cases  of  disease  is  far  from  including  the  whole  of 
those  furnished  by  the  army  during  the  war.  The  tabulated  mortality  among  the  white 
troops  has  been  shown  to  be  deficient  by  24.7  per  cent.  The  deficiency  in  the  tabulation 
of  the  cases  is  even  greater,  as  it  includes  not  only  cases  among  prisoners  of  war  and 
others  absent  from  their  commands  as  well  as  those  in  commands  Avhich  failed  to  make  the 
required  reports,  but  also  the  many  cases  that  occurred  among  the  floating  population  of 
the  general  hospitals.  The  strength  of  these  hospitals  was  reported  regularly ;  but  it  was 
found  impossible,  as  already  explained,*  to  ascertain  the  number  of  cases  of  sickness  that 

*  Introduction,  Part  First,  p.  .XXIV. 


SICKNESS    AND    MORTALITY 


e 


origin!itc'<l  in  tliom  or  tlie  number  of  cases  tliat  \v(>ro  received  without  having  been  pre- 
vious! v  reported  on  i'(»giinenfal  returns. 

The  same  remarks  are  ajipHcablc  to  tlie  005,017  cases  of  specified  diseases  which  are 
repnrted  in  the  tabh'S  as  liaving  occurred  among  tlie  cohered  troops. 

4th.  As  to  sick  katks. — But  althougli  tlic  statistical  tables  give  only  an  unknown 
percentage  of  the  sickness  which  aflected  our  armies,  their  application  to  the  calculation 
of  correct  rates  is  not  impaired  thereby.  They  give,  we  may  assume,  a  fairly  accurate 
representation  of  the  attacks  of  sickness  that  occurred  in  those  commands  in  "field  and 
garrison"  from  which  reports  were  received.  The  large  number  of  men,  a  mean  strength 
of  431,237  white  and  61,132  colored  troops,  under  observation,  warrants  the  belief  that 
the  rates  deduced  from  the  reports  would  not  be  materially  altered  if  to  these  reports  had 
been  added  the  mean  strength  and  total  cases  of  sickness  of  commands  which  failed  to 
report,  or  sent  in  reports  which  were  valueless  in  this  connection  by  the  omission  of  needful 
data.  The  remarks  already  made  with  regard  to  mortality  rates  among  prisoners  of  war 
and  others  absent  from  their  commands  are  equally  applicable  here.  Supposing  the  neces- 
sary figures  for  calculating  the  ratio  of  cases  to  strength  among  them  to  be  available,  the 
propriety  of  consolidating  these  rates  with  those  from  troops  in  active  service  would  b 
subject  to  question,  as  tending  to  complicate  the  point  at  issue  by  the  introduction  of  results 
due  to  other  conditions.  For  similar  reasons  it  would  Lave  been  proper  to  have  excluded 
from  the  tabulated  reports  the  cases  originating  in  the  general  hospitals,  as  the  conditions 
aflfecting  the  inmates  of  these  hospitals  were  certainly  very  different  from  those  which 
determined  attacks  of  sickness  in  the  field.  As  it  is,  those  cases  were  not  reported.  A 
complete  medical  history  of  any  war  necessarily  involves  the  separate  presentation  of  the 
facts  reported  from  the  various  classes  of  men  and  their  comparison  with  those  gathered 
from  the  men  present  for  duty  with  the  Hag;  but  the  difficulties  in  the  way  of  obtaining 
the  necessary  data  are  so  great  that  it  is  doubtful  if  such  a  history  will  ever  be  written. 
While  regretting  the  want  of  records  covering  the  attacks  of  sickness  in  the  whole  number 
of  men  who  were  enrolled  for  service,  it  suffices  at  present  to  point  out  that  this  want  does 
not  affect  the  value  of  the  sick  rates  deduced  from  tlie  reports  which  form  the  main  part 
of  the  First  Part  of  this  work. 

5th.  The  rates  of  fatality  in  specified  diseases. — In  comparing  the  number 
of  deaths  from  a  given  disease  with  the  number  of  cases  of  the  same  disease  to  ascertain 
the  percentage  of  fatal  cases  caused  by  it,  a  point  of  importance  comes  up  for  appreciation. 
It  has  been  shown  that  neither  the  deaths  nor  the  attacks  tabulated  form  the  respective 
totals  of  these  occurrences,  but  only  an  uncertain  though  comparatively  large  portion  of 
them,  and  it  has  been  argued  that  this  want  of  absolute  figures  does  not  detract  from  the 
value  of  the  death  rates  and  sick  rates  as  deduced  respectively  from  the  strength  given  in 
connection  with  the  figures  of  each,  to  wit:  the  strength  present  in  the  field  and  garrison 
in  connection  with  the  cases,  and  the  strength  present  in  the  field,  garrisons,  and  general 
hospitals  in  connection  with  the  deaths.  But  in  considering  the  ratio  of  deaths  to  cases 
their  abnormal  relationship,  consequent  on  their  derivation  from  different  numbers  of  men, 
must  not  be  forgotten.  The  cases  occurred  in  the  strength  present  in  the  field  and  garri- 
sons; the  deaths  in  the  strength  present  in  the  field,  garrisons,  and  general  hospitals. 
The  strength,  wliii-li  furnished  the  cases,  431,237,  in  the  instance  of  the  white  troops, 
was  smaller  than  the  strength,  468, 275,  which  furnished  the  deaths.     If  the  cases  which 


AMONG   THE    U.    S.    FORCES.      .  0 

originated  in  the  hospitals  were  known,  their  addition  to  the  others  would  establish  a 
normal  ratio  between  the  cases  and  deaths.  Or,  if  the  deaths  which  occurred  among 
such  cases  were  known,  a  similar  result  would  be  obtainable  by  deducting  them  from  the 
tabulated  deaths.  But,  as  it  was  found  impossible  to  rectify  this  matter  by  either  of  these 
methods,  there  exists  this  want  of  relationship  between  the  deatlis  and  cases. 

In  calculating  from  the  tabulated  figures  the  rate  of  fatality  of  a  given  disease,  a 
figure  of  unknown  and  prob^ibly  different  value  for  each  disease,  caused  by  the  unrecorded 
cases  among  the  hospital  population,  tends  to  increase  the  percentage  of  fatal  cases. 

The  fatality  of  cases  originating  in  the  general  hospitals  was  probably  greater  than 
that  of  those  occurring  among  men  in  active  service,  for  although  the  latter  had  a  greater 
exposure  to  many  of  the  causes  of  disease,  they  had  at  the  same  time  a  greater  power  of 
resistance  against  these  morbific  influences.  The  exposures  of  the  field  may  be  regarded 
also  as  having  tended  to  multiply  cases  and  to  correspondingly  lessen  the  fatality  of  disease 
among  the  troops  as  compared  with  the  rates  affecting  a  hospital  population.  If,  therefore, 
we  assume  that  the  same  rates  prevailed  among  the  floating  population  of  the  hospitals  as 
in  the  commands  from  which  tlieir  population  was  derived,  we  shall  ascertain  a  portion  of 
the  error  whicli  is  involved  in  a  calculation  of  rates  from  the  deaths  and  cases  in  the  tables 
already  published. 

On  this  assumption  the  deaths  attributable  to  diseases  originating  in  the  hospitals  and 
those  attributable  to  diseases  originating  in  the  field  and  garrisons  would  be  respectively 
proportioned  to  the  number  of  men  present  in  each;  and  the  factor  .921,  obtained  by 
dividing  the  strength  present  in  the  field  and  garrison  by  the  total  strength  in  the  field, 
garrison,  and  general  hospitals,  when  applied  to  the  rates  of  fatality  calculated  from  the 
cases  and  deaths  recorded  in  the  First  Part  of  this  work,  would  reduce  these  rates  bv  the 
elimination  of  the  deaths  assumed  to  have  taken  place  among  cases  that  originated  in  the 
hospitals.  In  this  way  a  part  of  the  error  is  indicated,  the  ti*ue  rate  of  fatality  being 
lower  even  than  tliis  corrected  rate.  Thus,  in  the  case  of  typhoid  fever  among  the  white 
ti'oops,*  where  75,368  cases  in  the  field  and  garrison  are  associated  with  27,056  deaths  in 
the  field,  garrison,  and  general  hospitals  a  mortality  of  35.9  per  cent,  is  obtained;  but  this, 
for  the  reason  given,  is  certainly  higher  than  the  true  rate  of  fatality.  Multiplied  by  the 
factor  .921  the  percentage  becomes  reduced  to  33.0,  and  this  probably  expresses  the  very 
highest  figure  at  which  we  may  put  the  mortality  from  typhoid  fever  as  deduced  from  the 
tabulated  statistics.  When  we  come  to  consider  the  continued  fevers  it  will  be  found  that 
this  corrected  percentage  is  open  to  question;  but  the  present  object  is  merely  an  illustra- 
tion of  an  inaccuracy  which  affects  the  rates  of  fatality  when  deduced  from  the  published 
figures."!" 

The  factor  .921,  based  on  the  mean  strength  for  the  whole  period  of  the  war,  has 
necessarily  a  generic  character.  The  error  which  it  is  intended  to  define  varied  month  by 
month  and  year  by  year  in  the  same  command,  and  differed  in  different  commands  during 
the  same  periods  in  proportion  to  the  number  of  men  constituting  the  hospital  population. 
In  tlio  following  pages  the  rates  of  fatality  will  be  calculated  from  the  figures  as  reported 
in  the  First  Part  of  this  work.     Those  who  desire  greater  precision  in  individual  cases 


*  Table  C,  p.  636,  First  Part. 

f  Dr.  GEOHiiE  L.  PEAiiOliv,  in  an  article  on  the  Treatment  nf  T;ijihiiiil  Fever,  in  the  Phihulelphia  Medical  News,  March  2ii,  18S4,  tabulates  the 
typhoid  fever  cases  as  reported  in  the  First  I*art  of  tliis  work,  and  calcnlaTes  tlic  tatality  aniunp  whiie  troops  at  35.9  per  cent,  of  the  cases,  without  observ- 
ing that  the  cases  and  deaths  did  not  occur  ainonj^r  tlie  same  number  of  men. 


6 


SICKNESS    AND    MORTALITY 


may  make  use  of  the  average  factor  above  stated,  or  calculate  the  factor  specially  ajipli- 
cahle  to  the  case  in  point  in  aci'ordance  with  the  statement  given  of  the  principle  involved. 

General  and  annual  rates  of  sickness  and  mortality. — The  number  of  cases 
of  disease  reported  among  the  white  troops  during  the  period,  May  1,  1861,  to  June  30, 
1866,  was  5,424,517,  and  the  number  among  the  colored  troops  during  the  three  years 
ending  with  the  latter  date  was  605,017,  making  a  total  of  6,029,564  reported  cases  of 
disease. 

During  the  same  period  the  deaths  I'eported  as  from  disease  numbered  129,386  among 
the  white  and  27,499  among  the  colored  troops,  making  a  total  of  156,885;  but,  as  has 
been  already  explained,  if  it  be  desired  to  obtain  numbers  which  will  express  the  absolute 
mortality  from  disease  in  our  armies,  the  factor  1.33  must  be  used  in  the  case  of  the  white, 
and  1.09  in  the  case  of  the  colored  troops,  to  provide  for  the  addition  of  42,420  deaths 
among  the  former  and  2,464  deaths  among  the  latter,  as  the  proportion  of  deaths  from 
unknown  causes  which  may  with  propriety  be  ascribed  to  disease.  There  were,  therefore, 
during  the  war  and  the  year  that  followed  it  171,806  deaths  among  the  white  and  29,963 
deaths  among  the  colored  troops,  making  a  total  in  the  United  States  Armies  of  201,769 
deaths  which  were  attributed  to  disease. 

The  cases  and  deaths  available  for  the  calculation  of  rates  of  sickness  and  mortality 
"are  equivalent  to  12,579  cases  and  276  deaths  in  every  1,000  of  the  white  troops  during 
the  five  and  one-sixth  years  covered  by  the  reports,  and  9,897  cases  and  430  deaths  in 
every  1,000  of  the  colored  troops  during  the  three  years  similarly  covered.  Disease  among 
the  latter  is  thus  seen  to  have  been  not  only  of  more  frequent  occurrence  but  considerably 
more  fatal  than  among  the  former.  This  may  be  better  seen  by  presenting  the  statistics 
of  the  colored  troops  on  a  basis  of  five  and  one-sixth  years  of  service,  when  the  numbers 
are  found  to  be  17,044  cases  and  740.6  deaths,  equivalent  to  135.5  cases  and  268.4  deaths 
respectively  for  every  109  cases  and  every  100  deaths  among  the  white  troops.  The  greater 
liability  of  the  colored  troops  to  disease  and  death  is  also  clearly  shown  by  the  presentation 
of  the  statistics  in  the  form  of  annual  rates.  The  average  annual  numbers  among  wdiite 
soldiers  per  1,000  of  mean  strength  were  2,435  cases  and  53.4  deaths;  in  the  colored 
command  the  corresponding  numbers  were  3,299  and  143.4. 

Table  I.  -.    • 

Showing  the  Annual  Movement  of  Sickness  and  Death  among  the  While  and  the  Colored  Troops,  expressed 

in  ratios  per  J, 000  of  mean  strength. 


1 

j 

For  THE  YEAR  ENDING  JUNE  30TII — 

AVEUAOE 

Annual  Rate 

X'EK  a.OOO. 

i 

1 

1861.                       1862. 

1863. 

1864. 

1865. 

1866. 

Cases,  i  Deaths. 

Cases.  1  Deaths. 

Cases. 
2,  69fi 

Deaths. 
63. 

Cases,  j  Deaths. 

Cases. 

Deaths. 

Cases. 

Deaths. 

Cases. 
2, 433 

Deaths. 

3  t'Si       10.  8 

o  QSri           40. 

2  210         4H. 

9  97r! 

56. 
140. 

2  362 

42. 

r,r<  4 

Colort'il  Tniops 

1 
4,0!)2  ,     ail.      1     3. 20.^ 

2,  797 

94. 

3,  299      1 43  4 

i                                   i 

1 

It  may  be  inquired  how  these  figures  compare  with  the  records  of  other  armies.  To 
institute  a  satisfactory  comparison  between  the  sickness  and  mortality  of  armies  of  difter- 
ent  nationalities  is  difficult,  especially  in  dealing  with  the  records  of  war  service.  Besides 
diftercnces  in  riumenclature  and  in  methoils  of  reporting,  which  interfere  with  just  com- 


AMOKG   THE   U.    S.    FORCES. 


parisons  in  time  of  peace,  the  war  records  are  usually  more  or  less  indefinite  in  certain 
items  of  information,  as  of  strength  present,  needful  to  the  calculation  of  comparative 
rates. 

There  is,  however,  little  to  be  gained  by  comparing  the  statistics  of  one  campaign 
with  those  of  others  conducted  under  wholly  different  conditions.  Each  may  be  advan- 
tageously studied  for  the  special  lessons  inculcated,  but  unless  similar  general  conditions 
coincided  with  particular  conditions  which  were  not  similar,  there  is  no  profit  in  the  com- 
parison. The  medical  histories  of  the  French  and  English  armies  before  Sevastopol  present 
many  fruitful  comparisons,  but  it  is  of  little  moment  to  place  the  94.9  deaths*  per  1,000 
of  strength  which  occurred  from  disease  in  the  English  raidvs  in  January,  1855,  by  the 
side  of  our  average  annual  rate  of  53.4,  or  to  note  that  during  that  one  month  diseases  of 
the  stomach  and  bowels,  chiefly  diarrhoea  and  dysentery,  caused  among  the  British  troops 
as  many  deaths,  62.7  per  1,000  strength,f  as  were  occasioned  by  all  diseases  in  our  armies 
during  1862-3,  the  year  of  their  highest  mortality,  63  per  1,000.  For  similar  reasons  it 
is  needless  to  enter  into  detailed  comparisons  between  the  rates  above  mentioned  and  the 
14.30J  deaths  per  1,000  of  strength,  equalling  an  annual  rate  of  24.51,  which  occurred 
from  disease  during  the  seven  months  of  war,  August,  187.0,  to  February,  1871,  inclusive, 
in  the  Prussian  army. 

The  standard  of  comparison  for  each  army  should  be  its  own  average  sick  and  death 
rates  derived  from  the  records  of  a  series  of  years  during  which  it  was  exposed  to  no 
specially  unfavorable  conditions,  or,  preferably,  the  best  annual  record  furnished  by  its 
history,  as  all  deviations  from  that  record  indicate,  when  their  causes  are  investigated,  not 
only  liow  they  may  be  avoided  in  the  future,  but  how  the  standard  itself  may  be  improved. 

The  difference  between  such  a  standard  and  the  disastrous  experience  of  the  English 
during  the  first  half  of  the  Crimean  war  was  a  measure  of  the  virulence  of  the  unusual 
morbific  agencies  to  which  their  army  was  exposed. 

*  Medical  and  Surgical  History  of  the  British  Army  which  served  in  Turkey  and  the  Crimea  during  the  War  against  Russia  in  the  years  lt?34-^i. 
Ofticial  imblicatioii,  London,  IffiH,  Vol.  II,  p.  44. 

t  OJK  cit.,  last  note.     Table  B. 

^  Caleulateil  from  the  figures  given  by  Dr.  E.NiiEL  in  the  Zeitschri/t  des  Kim  Preussichen  Statiateschen  liureaus  Jahrgung  12.  Berlin,  lh7^,  p.  2.50. 
The  mortality  from  disease  in  the  German  army  during  the  war  of  1870-71  was  as  follows : 


MOUTAI-ITY. 


Deaths  from  acute  internal  diseases  : 

Dysentery 

Typhus 

Gastric  Fever , 

Small-pox *. 

Intlammation  of  the  air-passagcs  and  lungs. 

Other  diseases 

Deaths  from  chronic  intenml  diseases  : 

Consumption 

Other  internal  diseases  (chronic) 

.Sndtlen  death  (from  disease) 

Cases  in  which  the  disease  was  not  given 

Cases  in  which  the  cause  of  death  was  not  given 


Total. 


NlMUEU. 

.MKAX   HTUK.\(illl. 

0 

1,971 

2.31 

6,93.5 

8.14 

158 

0.18 

24!) 

0.29 

491 

0.  .57 

515 

C.  (11 

521 

n.  til 

24(1 

0.  29 

S':i 

0.10 

553 

0.C4 

415 

0.56 

12, 147 

14.30 

The  streiig-th  ('li'OOj.Vr))  from  whioh  tbt-se  rates  were  ciilculated  was  obtained  fnim  Dr.  Kn"i.;?:l'3  statement  of  tbe  total  number  of  deaths  from 
disease  aud  iujiiry  (40,74^)  and  of  the  rate  (47.90)  per  thousand  of  mean  strength,  to  which  this  total  ourresi>ouded. 


i 


SICKNESS    AKD    MORTALITY 


The  difference  between  the  ordinary  death  rate  from  disea.se  in  the  German  army, 
5.64  in  1808  and  4.76  in  1869/''  and  the  war  rate  of  1870,  ah-eady  instanced,  shows 
tlie  operation  of  insanitary  causes  wliicli  might  be  specified  with  more  or  less  accuracy  by 
detailed  comparisons.  The  German  record  during  this  war  is  noteworthy  as  having  pre- 
sented a  death  rate  from  disease  considerably  smaller  than  that  resulting  from  the  casualties 
of  battle.  The  total  death  rate,  47.90  per  thousand  strength,  in  the  seven  months  of  active 
operations  consisted  of  33.60  from  violence  and  14.30  from  disease,  the  latter  being  equal 
to  an  annual  rate  of  24.51  per  thousand.  But  when  this  record  is  compared  with  its 
proper  standard,  tlie  mortality  of  the  German  army  in  time  of  peace,  it  wull  be  observed  that 
a  very  notable  increase  took  place  in  the  deaths  from  disease  on  account  of  the  exposures 
incident  to  the  seven  months  of  war.     The  death  rate,  in  fact,  became  quadrupled. 

When  our  own  war  statistics,  as  given  above  in  annual  rates  per  1,000  of  strength,  are 
comjDared  with  similar  figures  derived  from  reports  covering  eighteen  years  of  the  history 
of  tlie  army,f  it  will  be  found  that  the  morbific  influences  to  which  our  troops  were  subjected 
were  sucli  as  to  increase  the  annual  death  rate  from  disease  by  34.50  per  1,000  of  mean 
strength.  The  peace  rate,  18.98  per  1,000,  became  nearly  tripled  by  the  war  influences. 
Our  war  rate  does  not  appear  great  when  viewed  in  relation  to  the  mortality  rates  of 
previous  years  and  to  the  English  and  German  figures  instanced  as  expressing  the  mortality 

*  These  rates  were  obtained  from  tlie  StuutdU  licricht  ii.  (h  Piritss.  Annee,  1868-69,  pp.  40,  142-145,  203,  and  298-301.  The  mean  strengrth  during 
1868  was  250,376  and  tlie  mortality  from  diseu.se  1,413;  the  strerigtli  during  1869  was  248,246  and  the  mortality  1,183. 

t  The  records  of  the  Surgeon  General's  *)lfice  show  that,  excluding  deaths  from  wounds,  accidents  and  injuries,  and  also  those  from  Asiatic  oholern 
and  yellow  fever,  the  annual  m<irtality  rate  (,f  the  I'nited  States  army  during  eighteen  years  of  peace  which  preceded  the  outbreak  of  the  civil  war 
averaged  18.98  per  1,000  of  strength,  the  extremes  being  8.4  in  1845  aiul  39.6  in  1849.  The  deaths  in  excess  of  the  minimum  were  due  for  the  most  part 
to  diarrhcea  and  dysenterj-,  continued  and  remittent  fevers.  The  following  table  has  been  compiled  to  show  the  death  rates  from  disease  that  prevailed  in 
the  army  before  the  war.     The  years  1847-48  are  not  included,  as  the  troops  were  then  on  active  service  in  Mexico. 


Ye.vr. 

STIlEN'GTll. 

Deaths  from — 

) 
Death  Kate  fkom— 

All  Diseases. 

Cholera. 

Yellow  Fever. 

All  Diseases. 

Exclusive  of  that 
from  Cholera  and 
Yellow  Fever. 

1840 

10,116 

9,  748 

10,600 

9,863 

8,570 

8,590 

9,083 

9,148 

8,970 

9,  242 

9,203 

9,994 

8,  095 

9,367 

14,  434 

12,  roi 

14,510 

15,510 

241 
367 
291 
156 
95 
72 
175 
721 
268 
280 
208 
266 
224 
305 
353 
1C7 
202 
240 

10 
6 

28 
12 
11 

23.8 
37.6 
29.1 
16.2 
11.1 
8.4 
19.3 
78.8 
29.9 
30.  3 
22.0 
26.  G 
27.7 
32.6 
24.7 
13.1 
13.9 
1.5.5 

22.8 
37.0 
26.3 
14.  6 

9.8 

8.4 
19.3 
39.6 
22.  9 
20.5 
19.8 
16.8 

15.2              ! 
19.3 

20.5              . 
12.0 
13.5 
10.8 

1841 

1842 

1843 

1844   

1845 

1846           ..                  .... 

! 

1849 

307 
60 
91 
26 
94 
18 

104 
58 

52 
3 

1850   

1851 

1852 

Ig,'i3            

4 
83 
20 

o 

14 

1854 

1855           

1 8.56     

Ig37                           

1858           

0 

1859 

72 

10,  397 

257 

24.72 

18.  98 

The  figures  of  this  table  mn.y  be  compared  with  those  lor  the  years  18t>6--83,  given  in  note      upon  page        ,  as  well  as  with  those  in  Table  1  i.f 
thf  text. 


AMO^'G    THE    U.    S.    FORCES.  y 

intluceJ  by  war  conditions.  It  is  the  mortality  rate  of  our  army  in  the  years  of  peace 
preceding  the  war  that  compares  unfavorably  with  the  analogous  German  rate,  and  gives 
the  high  rate  of  death  from  disease  when  that  consequent  on  the  aggregation  of  our  troops 
in  large  masses  and  the  exposures  incident  to  field  service  are  superadded.  Our  army  was 
scattered  at  posts  in  all  parts  of  the  country  which  afterwards  became  the  theatre  of  war, 
and  was  exposed  to  the  same  miasmatic  agencies  which  subsequently  attracted  more  notice 
on  account  of  the  large  number  of  men  constituting  the  commands.  The  peace  rate  of 
18.98  shows  the  insanitary  conditions  to  which  our  troops  were  subjected  during  those 
eighteen  years.  The  increase  to  53.48  during  the  war  is  the  measure  of  the  mortality 
directly  referable  to  its  morbific  influences. 

But  when,  instead  of  the  average  of  many  years,  the  best  annual  record  furnished  by 
the  history  of  our  army  is  accepted  as  a  standard,  the  influence  of  the  war  in  giving  potency 
to  the  causes  of  disease  becomes  very  manifest.  The  rates  8.4  in  1845,  9.8  in  1844,  and 
10.8  in  1859  are  much  below  the  average  of  the  eighteen  years.  Favorable  conditions 
conduced  to  this  relatively  light  mortality.  But  these  favorable  conditions  were,  as  will  be 
shown  directly,  in  great  part  susceptible  of  attainment  in  other  years.  The  average  of 
these  ]-ates,  9.33,  may  therefore  be  acce])ted  as  indicating  the  unavoidable  mortality  from 
disease  in  a  body  of  men  constituted  and  circumstanced  as  was  our  army  before  the  war; 
and  the  large  increase  of  44.15  deaths  per  1,000  of  strength  annually  is  necessarily 
referred  for  causation  to  the  war  influences. 

The  war  rates  assume  a  larger  relative  magnitude  when  the  rates  which  have  prevailed 
among  our  troops  since  the  war  is  made  the  basis  of  comparison.*     The  average  annual 


*  The  following  table  exhibits  the  mortality  rates,  exclusive  (jf  tliose  from  wounds,  accidents  and  injuries  and  also  those  from  Asiatic  Cholera  and 
Wlluw  Fever  iu  tlie  army  since  the  war,  and  may  be  compared  with  that  jjiveu  in  the  note  to  page  H,  supra. 

Table  showiny  the  Annual  Death  Rates  among  the  White  Troops  of  the  United  States  Army  since  the  close  of  the  War  of  the  Rebellion, 


Yeah. 

MEA.N  Stue.nc^th. 

All  Diseases. 

DEATHS  FROM— 

Yellow  Fever. 

DE.vnr  Uate  from— 

Cholera. 

AU  Diseases. 

Exclusive  of  that 
from  Choleni  and 
Yellow  Fever. 

18G6-7 

40, 183 
45,  022 
37, 197 
28,  6fiO 
29,373 
24,  lie 

24,  897 

25,  78(i 
21,939 
21,718 
23,  383 
20,813 
21,848 
22,  09fi 
21, 174 
20, 723 
20, 922 

1,529 
1,188 
376 
249 
355 
263 
247 
218 
158 
169 
179 
122 
162 
126 
131 
141 
146 

747 

139 

2 

7 

427 
1 

19 
46 
20 

38.05 

26.  39 

10.11 

8.69 

12.09 

10.91 

9.92 

8.45 

7.20 

7.  "8 

19.  a<) 

13.82 

10.03 

8.03 

10.  .12 

10.  eg 

9.84 

7.60 

7.11 

6  40 

1807-8 

18G8-9 

]8fi9-T0 

1870  1       . .        . 

1871-2                        

1872-3     ...               

2 
6 

1873  4       .    .               .... 

16 
o 

30 
2 

1874-5                .                   

18T5-6 

1676-7  ...                       

1 
7. 66                              7  .W             1 

1877  8 

5.86 
7.41 
5.70 
6.19 
6  80 

5.86 

6.96             1 

.5.  TO 

6.09 

R   SO 

1678  9 

10 

1879-80 

1880-) 

2 

1881  2 

1682  3 

3 
34.4 

6.  W                            6.  83 

2{!,  462 

338.7 

52.7 

12.80                            3-51 

! 

>Iki).  Hist.  Ft.  111—2 


10  SICKNESS    AKD     MORTALITY 

mortalit}'  Trom  disease  for  the  seventeen  years,  1866-7 — 1882-3,  was  but  9.51  per  1,000, 
altliougli  the  country  occupied  by  tlie  troops  and  the  imayoidable  causes  of  disease  to 
Avlucli.  tliey  were  exposed  were  the  same  as  in  the  years  preceding  the  war.  This  rate, 
taken  as  a  standard,  refers  tlie  large  annual  niortality  of  43.9  directly  to  the  exposures 
incident  to  the  war.  Eut  if  the  ayerage  rate  of  the  ten  years,  1873-1 — 1882-3,  be  made 
the  basis  of  comparison,  the  war  influences  become  correspondingly  magnified.  Tliis  rate, 
6.71.  is  but  slightly  in  excess  of  the  minimum,  5.70,  in  1879-80.  The  causation  of  this 
great  diminution  in  the  death  rate  of  our  soldiers  of  late  years  is  readdy  appreciated. 
After  the  war  the  regular  troops  were  distributed  maiidy  oyer  the  undeyeloped  West  to 
hold  the  Indians  in  cheek  and  |)romotc  the  settlement  of  the  country.  The  old  posts 
which  had  been  occupied  before  the  war  were  in  ruins,  and  the  new  conditions  deyeloped 
by  the  adyance  of  civilization  westward  required  the  establishment  of  garrisons  in  positions 
which  had  formerly  been  unoccupied.  Military  policy  rather  than  hygienic  considerations 
usually  dictated  the  selection  of  the  site,  and  in  many  instances  the  stations  were  estab- 
lished in  unhealthy  river  bottoms  for  the  sake  of  being  near  to  a  Avater  supply.  The 
quarters  built  by  tlie  troops  were  of  the  most  primitive  character,  the  materials  at  com- 
mand being  only  such  as  the  country  afforded.  Practically,  our  soldiers  during  the  years 
1867  and  1868  were  in  the  field,  and  hence  the  high  death  rate.  But  in  the  years  that 
followed,  posts  wddch  experience  had  shown  to  be  unhealthy  were  abandoned,  and  money 
was  appropriated  for  the  construction  of  barracks  at  such  stations  as  appeared  likely  to 
require  permanent  occupation.  The  conditions  became  gradually  changed  from  those 
attending  a  state  of  war  or  active  field  service  to  those  of  garrison  duty  in  time  of  peace, 
although  occasional  campaigns  against  hostile  Indians  kept  the  mortality  rate  higher  than 
a  purely  peace  rate  should  be.  The  average  rate  of  the  past  ten  years  testifies  to  the 
efforts  of  the  Medical  Department  on  Ijehalf  of  the  soldier,  and  the  earnest  and  intelligent 
co-operative  action  of  military  commanders. 

Tlie  popular  idea  that  our  armies  suffered  severely  from  disease  during  the  campaigns 
of  the  civil  war  is  tlius  well  sustained  by  the  fdatistics,  in  view  of  the  fact  that  no  notable 
epidemic  of  impoi'ted  pestilence,  as  of  typhus,  cljolera,  or  yellow  fever,  contributed  to  their 
mortality.  Had  our  camps  been  unhappily  visited  by  these  scourges,  our  annual  mortality 
of  53  per  1,000  of  strength  would  have  appeared  light  in  comparison  with  the  terrible 
record  which  would  have  formed  the  text  of  a  medical  history  of  the  period. 

Sickness  and  moetality  as  cai'sed  by  various  diseases  and  classes  of  disease. — ■ 
It  has  been  already  stated  that  among  the  white  troops  the  cases  of  disease  reported  during 
the  five  and  one-sixth  years  embraced  in  the  statistical  records  numbered  12,579  and  the 
deaths  276  in  every  1,000  men  of  mean  strength,  these  figures  being  equivalent  to  tlie 
annual  rates  of  21.34  and  53.48  respectively.  It  has  also  been  stated  that  among  tlie 
colored  troops  during  three  years  of  service  there  were  recorded  9.897  cases  of  sickness 
and  430  deaths  from  disease  in  every  1,000  men  of  mean  strength,  figures  equal  to  the 
annual  rates  of  3,299  and  143.4  rpspectively.  The  following  table  is  designed  to  give  a 
general  view  of  the  distribution  of  these  cases  and  deaths  under  specific  and  generic  head- 
ino-s.  The  first  two  columns  of  each  division  of  the  table  re[)resent  the  sickness  and  deaths 
that  occurred  during:  the  whole  period,  the  figures  being  ratios  per  1,000  men  of  mean 
stremctli;  the  last  two  columns  show  to  what  extent  the  specified  diseases  contributed  to 
the  totals  of  the  cases  and  deaths  that  were  reported  as  from  disease. 


AMONG    THE    U. 


FORCES. 


11 


Table  IL 
Shoiving  the  Comparative  Frequency  of,  and  Mortality  from,  the  Diseases  that  prevailed  among  the  White 
Troops  of  the  U.  8,  Army  during  the  period  from  May  1,  1861,  to  June  30,  1866,  and  aw.ong  the 
Colored  Troops  during  the  period  from  July  1,  1863,  to  June  30,  1866, 


Dif-EASKS. 


AVniTE  Troops. 


COLOUED  Titoors. 


Continued  Fevers 

Typho-malarial  Fevers  (a) 

Malarial  Fevers 

Diarrhoea  and  Dysentery 

Diphtheria  (a) 

Eruptive  Fevers 

Other  Jliasinatio  diseases  {b) 

Total  Miasniatio  diseases 

Syphilis,  Gonorrlicea  and  Orohitis 

Scurvy 

Rheumatism,  acute  and  chronic  . . 

Citnsuraption 

Itch 


Diseases  of  Nervous  System 

Diseases  of  Eye  and  Ear 

Diseases  of  Circulatory  Organs 

Acute  Bronchitis  and  Catarrh  (h) 

Inflammation  of  Lungs  and  Pleura 

Other  diseases  of  Respirator}-  Organs . 

Total  Respiratory-  Organs 

Diseases  of  the  Digestive  Organs 

Urino-genital  disease 

Diseases  of  Bones  and  Joints 


Cases 

Deatlis 

per  1,000  of 

per  1.000  of 

mean 

mean 

strength. 

strength. 

208.1(1 

59.91 

11.1.  C5 

8.67 

2,  B98.  78 

17.38 

,3,  m:x  9.3 

80,71 

16.87 

1.53 

240.  82 

23.20 

4C4.  60 

5.  33 

7,  3C6.  84 

196.79  ; 

42!!.  8.) 

.29 

71.22 

.82 

500.71 

1.01 

31.30 

11.29  ', 

74.  39 

394.  29 

9.  49 

272.  75 

.02 

58.  22 

3.  54  , 

901.57 

2.  .53 

215.78 

32.  73 

235.  02 

2.  «7 

1,352.67 

38.  23 

Cases  per      Deaths  per 

l.OOOoftotal  l,OI)0..ft.it;il 

oases  deatlis  from 
of  disease.        disease. 


Cases       '      Deaths      '    Cases  per  Deaths  per 

per  1,000  of    per  1,000  of   l.OOOoftotal  1.01 10  of  total 

niean                mean                eases  deatlis  from 

strength,    i     strength.        of  disease.  disease. 


Boils,  Abscesses  and  other  Integiimentarj- 
diseases. 


Rij.wD  Total  . 


1 ,  306. 10 

69.28 

18.73 

440.  17 


.  10 
.46 


276.  30 


16.  55 

9.  19 

214.55 

292.  23 

1.34 

14.  85 

32.  16 
,-.80.  87 

33.  Oil 
5.  6ti 

46.  9li 

2.49 

5.91 

31.34 

21.68 

4.63 

71.  67 

17.15 

18.71 

107.53 

103.  83 

5.51 

1.49 

C4.  99 


216.82 
31.  37 
62.91 

292. 10 

5.  53 

84. 19 


19. 

1 
28 

712. 

21 

1. 

05 

o_ 

9(i 

3. 

<"7 

40.  85 

34 

33 

00 

12 

81 

9 

Hi 

118 

47 

10 

74 

138.36 

32.04 

3.  32 

.36 

1.67 


C8.  98 

123.  10 

2,  488.  73 

2,  518.  14 

12.  (i9 

27>;.  80 

390.  90 

!),  R85.  4(i 

233.  22 

205.  28 

525.50 

21.77 

51.03 

391.53 

158.33 

25.50 

531.91 

381.27  I 

151.03  ! 

1,  064.  22 

687.  77 

49.  34 

15.  .54 

192,  37 


37.30 
20.35 

30.  (;s 

10.5.81 

.  95 

55.  C8 

8.98 

218.  02 

.50 

0.07 

3.67 

18.94 


12.75 

.03 

7.31 

4.07 

86.  62 

6.35 

£7.04 

15.19 

2.05 

.23 

.42 


0.97 

12.44 

251.  47 

2.>1.  40 

1.28 

40.  13 

.5.)4.  68 

23.  5li 

20.  80 

53,  10 

2.20 

5.22 

39.50 

l(i.  CO 

2.58 

.53.  7,-. 

38.  52 

15.26 

107.53 

85.70 

4.  98 

1.  57 

19.44 


80.84 

47.31 

69.93 

245.  97 

2.  22 

128.  C4 

20. 88 

601.  19 

1.  16 

14.  11 

8.  55 

44.  04 


£9.  04 

.07 

10.98 

9.  40 

201.35 

14.  73 

S25.  57 

3.-..  31  ! 

1 
4.70  i 

I 

•  *'  I 
.98  ' 


1,000.00  ,        0,890.89 


1,000.00 


1,000.00 


(a)  Cases  were  reported  under  this  heading  only  during  the  period  from  June  30,  1862. 

(6)  In  the  composition  of  this  table  the  figures  reported  under  the  heading  Epidemic  Catarrh  have  been  dropped  from  tlie  class  of  miasmatic  diseases 
and  consolidated  with  the  diseases  of  the  respiratory  organs,  as  there  seems  good  reason  for  believing  that  influenza  was  at  no  time  prevalent  among  the 
troops.    See  infra,  page  725. 

Amono-  the  white  troops  diarrlicea  and  dysentery  occurred  with  great  frequency  and 
occasioned  a  laro-e  mortality.  These  intestinal  affections  were  the  cause  of  more  than  one- 
fourth  of  all  the  entries  upon  the  sick  reports  ;  and  it  is  a  singular  coincidence  that  their 
reported  cases  hear  to  the  reported  cases  of  all  diseases  the  same  ratio,  292  per  thousand, 
that  the  deaths  occasioned  by  thern  bear  to  the  total  deatlis  from  disease.  Malarial  fevers 
followed  in  order  of  frequency,  having  constituted,  if  typho-malarial  cases  are  included, 
about  one-fourth  of  the  whole  number  of  cases  of  disease.  These  caused  nearly  one-tenth 
of  the  total  deaths,  a  mortality  almost  reached  by  the  eruptive  fevers,  which,  however, 
occasioned  only  14.8  of  every  thousand  of  the  cases.  But  in  order  of  gravity  the  continued 
fevers,  consisting  mainly  of  typhoid  cases,  took  the  second  place,  having  caused  216  deaths 
in  every  thousand  from  disease,  although  contributing  only  16.5  cases  to  every  thuusand 


12  SICKNESS    AND    MORTALITY 

cases  of  all  diseases.  To  tlie  miasmatic  diseases  as  a  class  were  attributed  considerably 
more  than  one-half,  581  cases  per  thousand  of  all  diseases,  of  the  entries  on  sick  reports,  and 
nearly  three-fourths  of  the  mortality,  712  deaths  in  every  thousand.  The  only  other  classes 
of  disease  which  furnished  high  rates  of  prevalence,  diseases  of  the  digestive  and  of  the 
respiratory  organs,  agreed  closely  in  their  number  of  cases,  103.8  of  the  former  and  107.5 
of  the  latter,  contributed  to  every  thousand  of  all  diseases  ;  but  the  deaths  caused  by  the 
diseases  of  the  respiratory  organs  assumed  a  higher  proportion,  138.4  per  thousand,  on 
account  of  the  gravity  of  the  pneumonic  cases.  Scurvy  as  an  individualized  disease  caused 
less  than  6  in  every  thousand  of  the  cases  and  less  than  3  in  every  thousand  of  the  deaths. 

The  second  joart  of  the  table  presents  the  parallel  facts  deduced  from  the  medical 
statistics  of  the  colored  troops.  Among  the  colored,  as  among  the  white  troops,  diarrhoea 
and  dysentery  occurred  with  great  frequency  and  fatality.  The  ratio  of  cases  of  these 
intestinal  aftections  to  the  total  number  of  cases  of  disease  was  254.4,  and  of  deaths  caused 
by  them  to  the  deaths  caused  by  all  diseases,  245.97  in  every  thousand  of  each  respectively. 
Malarial  fevers  constituted  one-fourth  of  the  whole  number  of  cases  of  disease,  and  caused, 
if  typho-malarial  fevers  are  included,  somewhat  more  than  one-tenth  of  the  deaths.  But 
inflammation  of  the  lungs  occupied  the  second  place  in  tlie  order  of  gravity,  the  deaths 
from  this  cause  having  formed  201.3  of  every  thousand  from  all  diseases.  The  eruptive 
fevers  occasioned  128  of  every  thousand  deaths.  The  continued  fevers  did  not  occupy  so 
prominent  a  place  in  the  medical,  records  of  the  colored  troops  as  in  those  of  the  white 
regiments  ;  the  cases  formed  only  6.97  of  every  thousand  cases  of  all  diseases,  and  the 
deaths  86.84  of  every  thousand  deaths  from  disease,  as  compared  with  16.55  and  216.82, 
the  corresponding  numbers  from  the  records  of  the  white  troops.  Miasmatic  diseases  as 
a  class  caused  594.68  of  every  thousand  cases  and  601.19  of  every  thousand  deaths. 
Scurvy  attained  a  decided  prominence  among  the  colored  troops  as  compared  with  its 
prevalence  among  the  whites.  It  was  nearly  as  frequent  as  the  eruptive  fevers,  26.80 
cases  having  been  recorded  in  every  thousand  cases  of  disease ;  and  a  comparatively  large 
number  of  deaths  were  attributed  to  it,  14.11  of  every  thousand  fronr  all  cases,  as  against 
2.96  among  the  white  troops. 

Incidentally  a  comparison  may  be  instituted  between  the  sickness  and  mortality  of 
the  white  and  the  colored  troo2:)s  by  noting  the  figures  in  the  third  and  fourth  columns  of 
Table  II,  in  connection  with  the  corresponding  figures  in  its  seventh  and  eighth  columns. 
The  first  two  columns  of  each  division  of  this  table  are  insusceptible  of  comparison,  as  they 
do  not  refer  to  equal  periods  of  time,  but  in  the  following  table  the  average  annual  rates 
of  sickness  and  death  in  the  white  and  the  colored  commands  are  strictly  comparable. 

From  this  table  the  greater  sickness  and  the  very  much  larger  death  rate  among  the 
colored  troops  may  be  appreciated  and  referred  to  the  disease  or  classes  of  disease  that 
occasioned  them.  There  occurred  on  the  average  annually  in  every  thousand  of  the  colored 
men  143.4  deaths  from  disease  as  compared  with  53.48  among  the  white  troops ;  and  as 
the  sickness  of  the  former,  although  large,  was  not  proportionally  increased,  the  greater 
fatality  of  disease  among  them  is  manifested. 

Malarial  diseases  caused  829.58  cases  as  against  522.34  among  the  white  troops,  and 
10.03  deaths  as  against  3.36,  whilst  at  the  same  time  cases  reported  as  typho-malarial 
were  more  numerous  and  very  much  more  fatal  among  the  colored  commands.  Evidently, 
from  these  figures,  the  latter  did  not  possess  that  insusceptibility  to  the  malarial  influence  that 


AMONG    THE    U.    S.    FORCES. 


13 


has  been  sometimes  claimed  for  them.'^'     Indeed,  an  insusceptibility  to  tlie  typhoid  poison 
rather  than  to  the  malarial  influence  appears  suggested,  for  the  average  annual  number  of 

Table  III. 

Showing  by  Average  Annual  Rates  per  1,000  of  mean  strength  the  Comparative  Frequency  of,  and 
Mortality  from,  the  Diseases  that  prevailed  among  the  White  and  Colored  Troops  of  the  U.  S.  Army. 


Diseases. 


AVhite  Titoors. 


COLOUEii  Tiioors. 


Cases. 


Deaths. 


AveraRe  annual  rate  for  all  diseases i  2, 434. 64  i 

I I 

Continued  Fevers i  41).  29  ' 

Typlio-inalarial  Fevers 'J2.  38 

Malarial  Fevers '  522.  34 

Diarrhoea  and  Dysentery '  711.  4(> 

Diphtheria '. 3.  B2 

Eruptive  Fevers : 4ti.  (il 

Other  Miasmatio  diseases , :  78.  31 

Total  Miasmatic  diseases 1,  414.  22 

Syphilis,  Gonorrha.'.l  and  Orchitis H2.  04 

Scurvy 1 3.  78 

Rheumatism,  acute  and  chronic ;  114.  .33 

Consumption ti.  (Hi 

Itch 14.40 

Diseases  of  Nervous  .System 71).  31 

Diseases  of  Eye  and  Ear 52.  7'J  ! 

Diseases  of  Circulation I  1 1.  27 

Acute  Bronchitis 174.  40 

Inflammation  of  Lun^s  and  Pleura 41.  7*1 

Other  diseases  of  Respiratory  Organs i  45.  ."5 

Total  diseases  of  Respiratory  Organs I  2(51.  80 

Diseases  of  Digestive  .System S.W.  7!) 

irrino-genital  diseases 13.  41 

Diseases  of  Bones  and  Joints 3.C3 

Boils,  .\bscesses  and  other  Integumentary  diseases 85. 10 


53.48 


Cases. 


Deaths. 


11.  BO 

1.  r8 

3.  3(i 

1 .".  02 
.34 

4.  .-.0 
1.03 

38.  on 

.06 
.16 
.20 

2.18 


3,298.96 

14a  4 

22.99 
41.05 

12.45 

6.78 

1.84 

.004, 

.09 

.49 
(i.34 

■"t 
7.40  ! 

1.71 

.18 

.02  ' 

I 

.09  ; 


829.  5^ 
839.38 
4.23 
92.  29 
132.  30 
1,961.82 
77.74  I 
88.43 
178.54  j 
7.26  j 
17.21 
130.51 
52.78 

8.  .50  j 
177.30 
127.  09 
.'^0.34 
354.74  ; 
29.5.  92  I 
16.  45 
5.18 
64.  12 


10.03 

3.-..  27 
.32 

18.36 
2.  99 

86. 21 

.17 

2.02 

1.23 

6.31 


4.25 

.01 

2.44 

1.36 

£8.87 

2.  12 

32.35 

5.06 

.68 

.08 

.14 


cases  of  the  continued  fevers  was  only  22.99  among  the  colored  men,  while  it  reached  40.29 
among  the  white  troops.  Nevertheless,  the  annual  death  rate  from -these  fevers,  typhoid 
mainly,  was  somewhat  larger  among  the  colored  men,  12.45,  than  the  white  commands, 
11.60;  thus  indicating  the  unlikely  coincidence  of  a  diminished  prevalence  and  a  largely 
augmented  virulence.  This  anomaly  is  probably  due  to  the  aggregation  of  a  larger  propor- 
tion of  true  typhoid  cases  in  the  41.05  cases  reported  as  typho-malarial  from  the  colored 
commands  than  in  the  22.38  cases  similarly  reported  from  the  white  regiments.  Diarrhcea 
and  dysentery,  the  eruptive  fevers,  diseases  of  the  lungs — in  fact,  with  the  partial  e^cception 
of  the  continued  fevers,  all  the  diseases  that  were  specially  prevalent  in  our  camps  occasioned 
more  sickness  and  more  deaths  among  the  colored  troops  than  among  corresponding  numbers 
of  the  white  troops.  Miasmatic  diseases  as  a  class  caused  1,961.82  cases  and  86.21  deaths, 
as  compared  with  1,414.22  cases  and  38.09  deaths  among  the  whites.     Even  those,  such  as 


*  See  infra,  page  84,  in  enntimmtitm  nf  this  subject. 


14  SICKNESS    AND    MORTALITY 

sypliilii^,  gonorrluiea  and  orchitiri,  coiiHumption,  diseases  of  the  eye  and  ear,  diseases  of  the 
circulation  and  acute  bronchitic  attacks,  which  were  not  of  more  frequent  occurrence 
among  the  colored  troops  were,  nevertheless,  attended  with  a  higher  niortality  than  among 
the  wliites/^" 

8lCK-  AKD  MORTALITY-RATES  OF  U.  S.  WHITK  TROORS  DURING  TIIK  AVAR  AS  COMPARED 
WITH  THOSE  OF  OTHER  BODIES  OF  MEN  OF  THE  MILITARY  AOE. Table  IV  and  tjie  platc  which 

faces  this  page  have  been  designed  to  illustrate  the  various  points  that  appear  of  interest 
under  this  heading.    Special  attention  may  be  invited  to  some  of  the  more  prominent  of  these. 

Five  of  the  red  lines  representing  annual  mortality  rates  among  our  white  troops 
during  the  war  are  projected  into  the  closed-up  divisions  of  the  plate.  Evidently  the  dis- 
eases indicated  by  them  caused  the  main  portion  of  the  total  mortality.  The  length  of 
these  lines  as  compared  with  that  of  the  correlated  lines  of  other  colors,  gives  expression 
to  the  influences  which  the  conditions  of  war  impressed  on  the  mortality  from  these  affec- 
tions. The  diseases  thus  prominently  brought  into  notice  are  those  already  recognized 
in  Table  II  as  having  occasioned  so  many  of  the  deaths  among  our  soldiers.  Of  the  53.48 
deaths  that  occurred  annually  in  every  thousand  men  of  the  average  strength  present, 
diarrhoea  and  dysentery  caused  15.62;  the  continued  fevers,  not  including  tliose  reported 
as  typho-malarial,  11.60;  diseases  of  the  respiration,  pneumonia  chiefly,  7.40;  the  erup- 
tive fevers,  4.50;  and  the  malarial  fevers,  3.B6.  The  only  other  lines  that  are  projected 
into  the  denser  portion  of  the  plate  are  the  black  line  indicating  the  mortality,  5.32,  from 
diarrhoea  and  dysentery  among  our  troops  before  the  war,  and  the  green  line  representing 
that  from  the  continued  fevers,  3.39,  among  the  French  troops.  The  former  was  due  to 
that  want  of  sanitary  supervision  and  care  for  the  health  of  the  troops  which  permitted 
scurvy  to  show  as  a  well-defined  cause  of  death  among  them,  while  it  scarcely  appears 
among  the  other  bodies  of  men  tabulated,  except  in  our  own  armies  during  the  war,  when 
the  unusual  nature  of  the  conditions  suffice  to  explain,  and  in  a  measure  to  condone,  its 
appearance.  The  latter  was  due  to  the  influence  of  local  epidemics  during  the  years  taken 
for  comparison,  and  especially  to  the  prevalence  of  continued  fevers  among  the  troops  in 
Algeria. 

The  increased  mortality  during  the  war  from  what  has  been  called  typho-malarial 
fever  is  well  marked  by  comparison  with  the  death  rate  from  the  same  disease  since  the 
war;  but,  as  will  be  shown  hereafter,  febrile  cases  presenting  essential  differences  were 
aggregated  under  this  heading. 

The  large  death  rate,  11.60  per  thousand  of  sti'ength,  from  the  continued  fevers  during 
the  war  period,  when  compared  with  their  relatively  insignificant  mortality  in  -our  army 
since  the  war,  0.61,  in  the  German  army,  0.98,  or  among  our  civil  population  of  the 
military  age,  0.49,  implies  of  necessity  a  vastly  increased  prevalence  as  well  as  fatality. 
Both  of  these  facts  may  be  verified  from  the  data  in  Table  IV.  A  precisely  analogous 
series  of  facts  delineated  under  the  heading  of  the  eruptive  fevers  is  suggestive  of  one  of 
the  probable  causes  of  the  increased  prevalence  and  fatality  of  the  continued  fevers.  The 
main  factor  in  the  development  of  an  epidemic  of  the  eruptive  fevers  is  not  so  much  the 
introduction  of  the  contagion,  although  this  of  course  is  essential,  but  the  accumulation  in 
the  population  of  a  sufficient  number  of  susceptible  individuals  to  afford  material  for  the 

*  This  tendency  of  the  colored  troops  to  succumb  to  inorbitic  influences  was  brought  forcibly  to  the  notice  of  the  writer  in  18fi4  by  Assistant  Surgeon 
J.  T.  Caijioun,  U.  S.  Army,  then  iu  cliarge  of  a  field  hospital  f(jr  their  treatment  at  City  Point,  Virginia.  ''  I  do  not  know  what  to  do  with  these  colored 
men,"  he  said,  *'I  cannot  keep  them  up.     They  do  not  have  the  stamina  of  our  white  men.     Tiiey  just  go  to  their  beds  and  die.*' 


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AMONG    THE    U.    S.    FORCES.  ^  15 

operation  of  the  morbid  agency.  This  is  well  recognized  by  the  recurrence  of  the  epidemic 
visitation  after  a  certain  lapse  of  time  has  permitted  the  community  to  accumulate  a  large 
proportion  of  persons  hitherto  unaffected ;  and  in  the  case  of  small-pox,  by  the  institution 
of  effective  preventive  measures  based  on  tlie  destruction  of  the  susceptibility  rather  than 
on  the  exclusion  of  the  contagion.  Regiments  recruited  in  country  districts  that  had  been 
unvisited  by  these  fevers  for  a  number  of  years,  presented  material  for  their  rapid  spread 
on  the  introduction  of  the  contagious  principle.  Similarly,  regiments  from  localities  that 
had  been  free  from  typlioid,  were  liable  to  suffer  severely  from  this  disease  on  account  of 
the  susceptibility  of  the  men  composing  them. 

The  mortality  lines  of  our  armies  during  the  war  period  are  exceeded  by  those  of  other 
bodies  of  men  in  the  two  instances,  consumption  and  scurvy.  The  males  of  our  civil 
population  have  a  higher  death  rate  from  the  first-mentioned  disease  as  a  result  of  the 
selection  for  service  and  discharges  for  disability  that  tended  to  free  the  army  from  such 
cases.  Our  own  troops,  before  the  war,  had  a  higher  rate  from  scurvy,  owing  to  deficient 
supplies  and  their  isolation  at  stations  at  and  beyond  the  frontier  of  civilization. 

Diseases  of  the  digestive  system  gave  a  larger  mortality  among  our  troops  during  the 
war  than  among  other  bodies  of  men.  The  records  show  this  to  have  been  mainly  due  to 
the  fatality  of  cholera  morbus  and  dropsy  from  hepatic  disease. 

Diseases  of  the  nervous  system  liad  also  a  comparatively  large  mortality,  which,  how- 
ever, was  equalled  in  our  own  army  before  the  war. 

Active  service  during  the  war  slightly  increased  the  mortality  from  diseases  of  the 
circulatory  system;  but  the  records  of  the  French  army  ascribe  to  these  diseases  a  nearly 
similar  death  rate. 

Rheumatism  contributed  but  little  to  the  mortality  in  our  camps,  scarcely  more  than 
was  the  result  of  the  conditions  existing  at  the  military  posts  of  earlier  times. 

From  Table  IV,  on  the  next  page,  may  be  gathered  some  interesting  points  regarding 
prevalence  not  shown  by  the  mortality  lines. 

Thus,  according  to  the  figures,  the  number  of  cases  of  sickness  among  our  troops  was 
relatively  greater  before  the  war  than  during  its  progress.  Certainly,  in  its  early  service 
in  the  Indian  country,  our  small  army  was  exposed  to  many  of  the  influences  that  subse- 
quently contributed  to  the  war  rates  of  sickness.  It  will  be  observed,  however,  that  the 
number  of  serious  cases,  i.  e.,  of  diseases  yielding  a  high  mortality,  was  invariably  greater 
during  the  war  than  before  it;  hence  the  smaller  figures  of  which  our  war  rates  consists, 
2,4:34.64  cases  annually  per  thousand  of  strength  as  against  2,886.01  in  earlier  years, 
must  be  attributed  to  the  failure  of  our  medical  officers  during  the  active  progress  of  a 
campaign  to  record  cases  of  trivial  ailments  rather  than  to  an  actual  diminution  in  their 
number. 

Again,  the  frequency  of  cases  of  disease  in  our  army  since  the  war  appears  to  have 
been  more  than  double  that  of  the  German  army  during  corresponding  years  of  peace, 
1,474.26  per  thousand  of  strength  as  compared  with  660.78.  Here  the  gravity  of  the 
affection  recorded  as  a  case  of  sickness  forms  an  element  of  difference.  In  our  service 
every  man  excused  from  military  duty  on  account  of  sickness,  however  trivial,  counts  as 
one  case  upon  the  record;  but  since  the  mortality  rate  of  the  Gernian  army  is  not  decreased 
in  proportion  to  its  sickness,  as  compared  with  our  rates,  it  may  be  inferred  that  in  their 
service  the  trivial  cases  are  not  recorded. 


16 


SICKNESS    AND    MORTALITY 


Ta1!LE    IV. 
Averar/e  Annual  Sick  and  Death  Hates  jier  thousand  of  mean  strength  in  the  U.  S.  Army  before,  during 
and  shicc  the  tear,  and  in  the  German  and  French  armies,  v:ith  the  Annual  Death  Rate  for  mcdes 
of  the  military  age  in  the  United^  States,  as  calculated  from  the  returns  of  the  census  year  1S80. 


=  ii=       I  .S  i"w 

KjS  I  III  I 

5^  =  0! 

P  S  .£  - 


I'.  S.  Army, 

White  'I'rtxips 

fi»r  .')i  j-ears  of 

War. 


Strcngtli  representeil 1,S06,  276   8,  S87,  358 


431,237 


Deaths.       Deaths. 


Avcra:;*'  annual  rale  for  all  iliseases  . . . 


6.97 


Cases.    Deaths. 


Continued  Fevers 

I'yplio-inalaria!  fevers 

Malarial  Fevers 

Diarrlicea  antl  Dyseiiter}- 

Diphtheria 

Eruptive  Fevers 

Other  Miasmatic  Diseases 

Total  Miasmatic  Diseases 

•Sypliilis,  fionorrlitea  and  Orchitis 

Scurvy 

Klun'.inatism,  acute  antl  chronic  . . 

Consumption 

Itch 


.49 


fi.  87   2,434.641    53.48 


:54 


.04 
.09 


.aii 

.27 
.05 
.06 


.02 


.02 


.04 
.94 


.04 
2.33 


Diseases  of  Nervous  .System 

Diseases  of  Ej-e  and  Ear 

Diseases  of  Circulation 

Acute  Bronchitis 

Inflammation  of  Lungs  and  Pleura 

Other  Diseases  of  Respiratory  Organs 

Total  Di.seases  of  Respiratory  Organs  . 

Diseases  of  Digestive  System 

Uriuo-genital  Diseases 

Diseases  (tf  B<mes  and  Joints 


.64 


..56 


Boils.    .Abscesses    and    other    Integumentary 
Diseases. 


.46 

.08 

■"! 

.13 

.98 
.35 
..3;! 
.04 
.04 


.33 
.05 

.97 
.13 
1.  H 
.32 
.18 
.03 
.05 


40.29 

22.38 

5i2.  34 

711.  4ti| 

a  92: 

46.61 

78.  31 1 

1,414.22| 

89.04] 

13.  78| 

114.  33 

6.06 

14.40 

76.31 

52.79 

11. 

174.49 

41.76 

45.  .55 

261.  80 

252.  79; 

13.41 

3.63 

85.  19 


11.60 

1.68 

3,  36 

15.  (i2 

.34 

4.50 

1.03 

38.09 

.06 

.16 

.20 

2.18 


T*.  S.  .Army,  I'.  S.  Army,  German  .Vrni\ 

"White  Troops  Wliiti?  Tri)oj)s  lor   four   year> 

for  I?^  \-cars  lie-  lur  10  years  since          1874-'5    to 

fore  the  War  (c)  tlie  War.                1877-'8.((/) 


10,  397 


324, 195  4.59,  420 


Cases.  I  Deaths.     Cases.    Deaths.     Cases.     Deaths.    Deatlrs. 


2,886.01      18.98    1,474.26 


1.84 
.004 
.69 
.49 

6.34 
.57 

7.40 

1.71 
.18 
.02 
.09 


21.30j       1.29  I  3.23 

1 j  2..58 

.'iUfi.  63,       1.76  j  226.68 

4:7.34,      5.32  224.56 

i \  .55 

7. 48j        .19  1  2.61 
..  (/).-■..  (/)..;(/)8.48 

1,112.74,      8.50  I  468.89 

87.86,        .08  '  87.62 

] 

26.37         .28  I  .42 

114.33'        .18  116.54 

3.53,       1.84  I  4.08 

I i  .29 

82.261       1.77  111.52 

,59.04!        .01  '  34.42 

3.04         .23  7.70 

299.59,        .19  208.83 

27.281       1.36  '  10.54 

j                i 
I i  11.42 

326.  87       1.  .55  230. 79 

i  J 

128.46'        .04  191.20 
I 

' i  15.44 

1 
' 1  .3.92 

129.91;        .10  I  118.09 


6.74  '  660.78 


.61 
.34 

.32 

.47 
.02 

.06  j 

(/).  13  j 

1.96  j 

.05  I 
.  005 
.06 


14.  35 


4.38 


.98 


3.39 


24.  79 

21.88 

1.18 

4.86 


,  009 
.  ID 
.04 
.07 


.38 
.2il 
.05 
.39 


.79 

.005 

.67 

.06  i 

1 
.84 

.20 

1.10 

.69  1 

.24 

.03 


07.07 

41.56 

.10 

26.  21 

3.77 

7.75 

4.17 

41.08 

2.10 

43.  64 

17.01 


1.20 
.006 
.009 
.05 
.74    . 


4.48 

.004 

I 
.004 

.09 


.21 
.02 
.06 
.03 


01.25 

30.82 

6.34 

7.  13 

42.78 


.48 
.004' 

.is! 

.18  I 
1.02  I 

.32 
1.51 


.009 

.29 

.08 

.04 

.06 

.09 

.006 

(</)  Tlie  mortality  returns  <if  the  Tenth  I'.  S.  Census,  1880,  were  not  published  at  the  time  this  table  was  calculated;  but  by  the  courtesy  of  the 
Superintendent  tlie  writer  was  furnished  with  page  proofs  (if  Table  XT,  Statistics  of  MnrtaHty,  giving-  the  deaths  in  certain  grand  groups  by  age  and  sex, 
with  distinction  of  coli>r  and  specification  <)f  cause,  fnun  whicli  he  calculated  the  rates  fur  his  compiirative  table  of  annual  rates  in  men  of  the  military  ag-e. 
Tlie  grand  groups,  Nos.  2,  8  and  11  of  the  topographical  divisions  made  V>y  the  Census  Office,  have  a  population  of  ].00(^276  white  males  between  and 
in<;Iuding  the  ages  of  20  and  44  years.  They  are :  2,  the  Middle  Atlantic  Coast,  comprising  the  District  of  Columbia,  the  State  of  Delaware,  and  part  of 
New  York,  Xew  Jersey,  Maryland  and  ^'i^ginia:  8.  the  Interior  Plateau,  embracing  parts  of  Kew  York,  Pennsylvania,  Virginia  and  North  Carolina; 
and  11.  the  Southern  Interior  Plateau,  including  parts  of  Simth  Carolina,  Cfeorgia,  Alabama,  Mississippi  and  Tennessee. 

{h)  The  figures  in  this  column  were  calculated  from  page  proofs  of  Table  VII  of  the  Statistics  of  Mortality  of  the  Tenth  Census,  which  gives  the 
mortality  »  f  the  I'nited  States  from  each  8i>eciiied  disease  and  class  of  diseases,  with  distinction  of  age  and  sex  but  not  of  color. 

{<■)  The  average  rates  in  this  column  are  from  the  statistics  of  the  years  1840  to  1859  inclusive,  but  not  including  the  years  1847  and  1848,  during  which 
the  troops  were  on  active  service  in  Mexico.  Yellow  fever  and  chcdera  prevailed  during  certain  of  these  years,  but  the  influence  of  these  epidemics 
has  been  excluded  in  calculating  the  rates.  There  were  317  deaths  from  yellow  fever  and  764  from  cholera,  which,  if  included,  would  raise  the  average 
annual  death  rate  from  18.98  to  24.72. 

((/)  These  rates  were  calculated  from  the  Statistischen  Sanitdlsberichf  iihf.r  fJie  Koni<jlivh  I'niissische  Anuce.  Care  was  taken  in  the  computation  to 
so  aggrngate  the  figures  given  under  S|>efified  diseases  as  to  render  them  strictly  comparable  with  the  I'nited  States  statistics, 

('■)  As  the  French  Statistiijiies  Mcdicales  de  l'Arm''e.  do  not  report  the  number  of  men  excused  from  duty  and  treated  in  quarters,  their  recorded  cases 
are  not  susceptible  of  comparison  with  those  of  the  United  States  or  German  army.  (/)  Not  including  yellow  fever. 


AMONG    THK    r.    f^.    FORCES.  17 

Notwitlistaiidiiig  the  great  fivijuciu-v  of  malaiial  attacks  during  the  war,  522.34  cases 
annually  per  tli<iusanil  of  streuglh,  it  \vill  lio  oljscrvcil  that  these  avito  rveii  of  greater 
frequency  uinniig  cjur  troups  during  the  v.ai's  ihat  pi'eeeded  it,  598.6:)  per  thousand.  IIk' 
material  reduetidu  o(  late  years  in  malarial  sickness,  226.68  per  thousand,  is  due  tu  the 
abandonment  of  unhealthy  stations.* 

Venereal  diseases  and  those  aiTeeting  the  urino-genital  organs  were  nearly  as  frcipicnt 
in  our  arni}^  during  the  war  as  in  earlier  years. 

Scurvy  during  the  war  gave  annually  per  thousand  of  strength  \'.^.7>^  cases,  c>r  only 
about  onedialf  of  the  number,  26.37,  recorded  bv  our  medical  officers  before  the  wai'. 

Tlie  war  records,  compared  with  those  of  our  army  before  and  since  the  war,  do  not 
show  an  increased  prevalence  of  rheumatism,  nor  of  tliseases  of  the  nervous  svstrni,  nor  of 
bronchitic  attacks;  pneumonic  cases,  however,  were  more  frequent  and  bv  far  more  fital. 

Diseases  of  the  circulation  were  somewhat  increased,  and  those  of  the  digestive  system 
considerably  augmented  in  number  during  the  period  of  the  war. 

Sickness  and  mortality  as  influence])  by  season,  locality,  etc. — The  regimental 
monthly  reports,  conqiiled  from  the  morning  reports  of  the  medical  officers  on  dutv,  are  the 
ultimate  elements  of  which  the  statistics  of  sickness  and  death  in  our  armies  were  couqutsed; 
but  these  lost  their  individuality  when  thev  were  converted  into  deoarlimMital  returns.  The 
data  in  these  departmental  tables  were  intended  to  show,  when  converted  into  comparative 
figures,  the  influence  of  season,  locality  and  military  operations  as  affecting  the  prevalence 
and  fatality  of  the  diseases  specified.  The  influence  of  season  can  be  determined  with 
accuracy,  but  that  exercised  liy  locality  and  military  operations  is  not  so  well  defined. 

A  series  of  regimental  histories  giving  in  parallel  sentences  an  account  of  the  condi- 
tions affecting  the  health  of  the  men  dui'ing  the  [trogress  of  their  service,  an<l  the  i>reva- 
lence  of  disease  and  death  among  them,  would  have  been  a  desirable  addition  to  the 
materials  for  a  medical  history  of  the  war.  The  want  of  these  has  been  in  part  replaced 
by  the  special  reports  rendered  by  medical  officei's,  although  generally  in  these  more  atten- 
tion was  given  to  the  details  of  hostile  movements,  battle  scenes  and  surgical  service,  than 
to  the  less  exciting  contests  with  the  more  deadly  enemy,  disease.  By  the  consolidation 
of  the  regimental  into  departmental  returns  the  numerical  statements  lost  a  great  ]>art  of 
their  value.  Certain  sections  of  the  de})artments  were  healthy,  others  unhealthy,  and  the 
consolidation  of  the  regimental  reports  obliterated  the  records  of  special  localities  and  gave 
results  for  each  department  depending  on  the  character  of  that  section  of  it  in  wdiich  the 
majority  of  the  regiments  were  concentrated.  Besides  this,  even  the  boundary  lines  of 
departments  were  subject  to  constant  variation  consequent  on  changes  in  the  military  policy, 
the  assignment  of  new  commanders,  etc.  Departmental  reports  must  therefore  be  consid- 
ered in  connection  with  the  localities  which  were  the  theatre  of  military  operations,  rather 
than  as  figures  applying  generally  to  the  section  of  country  included. in  the  department. 
This  renders  it  difficult  to  attain  to  an  accurate  estimate  of  the  relative  value  of  region  as 
influencing  disease  and  mortality. 

Moreover,  military  operations  carried  the  troops  from  one  part  of  a  department  to 
another,  and  frequently  to  some  other  depai'tment.  They  entailed  upon  the  soldier  fatigues, 
exposures  and  privations  which  tended  to  sickness  and  death.  The  pernicious  influences  of 
service  in  one  department  came  thus  in  many  instances  to  be  credited  to  a  wholly  different 
locality.     A  synopsis  of  the  history  of  the  operations  in  each  department  precedes  the  annual 

*  See  suirra,  p.  10. 

Med.  Hist.  Pt.  Ill— 3 


18 


PTCKNESR    AND    MORTALITY 


statistical  tables  in  the  First  Part  of  this  work,  and  many  of  the  movements  and  the  influ- 
ences exercised  hy  them  have  already  l)een  given  in  free  extracts  from  the  reports  of  the 
medical  oBicers  who  served  witli  tlie  commands.  Nevertheless,  it  will  readily  be  appreciated 
tliat  the  ratios  of  disease  and  death  calculated  from  the  figures  in  the  departmental  tables 
ex])ress  (July  in  a  general  way  tlie  conjoint  influence  of  locality  and  military  operations. 

The  following  table  presents  a  general  view  of  the  annual  movement  of  sickness  and 
death  among  the  white  and  the  colored  troops  in  the  several  regions: 

Table  V. 

Showhif/  the  Anm^d  Frevalciu;e  of  Sickness  and  the  Mortality  from  Disease  in  the  several  Regions, 

expressed  in  ratios  per  1,000  of  mean  strength. 


For  the  year  ENiiisft  Junp:  aoiii- 

- 

18fil. 

]8(>2. 

1863. 

18R4. 

1865. 

1866. 

Cases. 

Deaths. 

Cases. 

Deaths. 

(Jases. 

Deaths. 

Cases. 

Deaths. 

Cases. 

Deaths. 

Cases. 

2,  292 
2,549 
1,749 

Deaths. 

42 

48 
14 

42 

While  Troops, 

AtlariH)!  Rcffion 

Onlral  Kf^ioli 

a,  ;i:»i 
a,  4:t2 

11.4 
7.2 

2,71!l 
3,4;i5 
2,  171 

2,  »m 

81 
10 

40 

2,  .v>a 

2,8-11 
2,  VXi 

2,  (m 

42 

8.1 

11 

63 

2,  1:17' 
2,  21  y 
l,81ti 

33 

11 

2,221 
2,  :& 
1,864 

2,  273 

r,3 

61 
12 

."it! 

a,  822 

10.8 

2,210 

48 

2,362 

Colored  Troops. 
Atlantic  Re^on 

3,  461 
4,373 

4,  092 

83 
269 

211 

3,122 
a,  248 

3,205 

Ill 
156 

140 

2,  ,574 
2,842 

2,797 

100 
93 





T.itiil  i-i.Uirc rt 

94 

The  commencement  of  service  was  in  all  instances  characterized  by  the  highest  ratio 
of  sickness. 

Among  the  white  troops  the  flrst  year  gave  a  mortality  rate  as  low  as  10.8  per  thou- 
sand of  strength;  but  this  rate  is  calculated  on  observations  covering  only  the  months  of 
May  and  June,  as  the  troops  were  being  hastily  called  into  service.  The  thinl  year,  ending 
June  30,  1863,  gave  the  highest  death  rate,  63  per  1,000.  The  rate  fell  to  48  in  the  fourth 
year,  and  rose  to  56  in  the  fifth  year.  In  the  year  following  the  war  the  sick  rate  pre- 
served its  war  height,  but  the  mortality  fell  to  42. 

Among  the  colored  troops  the  sick  rate  fell  from  4,092  during  the  first  year  of  their 
service  to  2,797  during  the  last,  and  the  death  rate  from  211  to  94. 

The  rates  in  the  Pacific  region  corresponded  with  those  in  the  army  as  a  whole  since 
the  war.  The  troops  in  that  region  were,  in  fiict,  during  the  war  exposed  to  no  greater 
fatigues  or  privations  than  the  army  encountered  when  at  the  close  of  the  war  it  was 
distributed  over  the  west. 

The  high  death  rate  of  the  troops  in  the  Central  region  is  one  of  the  chief  points 
developed  by  this  table.  In  this  region  during  the  year  of  greatest  prevalence  the  deaths 
were  to  the  cases  as  1  :  43,  and  dui-ing  the  year  of  least  prevalence  as  1  :  39.  In  the  Atlantic 
region,  omitting  the  figures  for  LS(U  as  re])resenting  only  a  part  of  a  year,  the  correspond- 
ing 2)ro])ortions  were  1  :  85  and  1  :  60.  The  fatality  rates  or  the  deaths  in  a  given  number 
of  cases,  as  well  as  the  mortality  rates  or  the  deaths  in  a  given  number  of  men,  were 
greater  in  the  Central  than  in  the  Atlantic  region.  Unfortunately  it  is  impossible  to  learn 
precisely  in  which  of  the  departments  of  the  Central  region  this  large  excess  of  deaths 


AMONG    THB    V.    S.    KURCE8. 


19 


took  place.  Tlie  statistical  tables  in  tln'  Fir^^t  I'art  of  tins  wofk  record  the  deaths  which 
occurred  among  the  troops  serving  in  each  department;  Imt  the  dt'aths  that  occurred  in  the 
general  hospitals  among  soldiers  of  one  de[>urtnient  are  consolidated  with  those  of  men 
belonging  to  other  departments  in  a  series  of  tables  giving  the  deaths  in  tlio  general 
hospitals  of  the  region.  We  must,  therefore,  endeavor  to  appreciate  the  influence  of 
locality  on  the  mortality  by  an  examination  of  its  influence  on  the  ])revalence  of  disease. 
The  following  table  was  constructed  to  facilitate  this  examination: 

Table  VI. 

/Showing  the  Annual  Prevalence  of  SicknesH  from  all  Diseases  in  the  several  Military  Departments, 

ea^ressed  in  ratios  of  1,000  strength. 


WIUTK  TKOOI'S. 


Middle  Department , 

Department  uf  ttie  Shenandoah 

Army  of  tlie  Ptitiiinac 

Department  of  tlie  Kappaliannock  , 

Department  of  Virginia 

Department  of  North  Carolina . 

Department  <)f  tlie  Smith 

Department  i>f  the  East 

Department  of  Washington 

Middle  Division 

Atlantic  Kegion  


Tntal  in  At-Uinh'r  /iq/ioti.. 


l>epartmeiit  uf  ^Vestern  Virginia 

Department  tif  the  ('iiintM*rland 

Department  of  Tennessee 

Department  of  ttie  tlulf 

Department  of  the  Northwest 

Department  of  Missouri 

Northern  Department 

Department  of  the  Ohio 

Department  of  A  rkansas 

Mihtary  Division  of  the  Mississippi,  Part  ' 
Military  Division  of  the  Mississippi,  Part  I 
Cent  ral  Regit  m 


Total  in  i'entral  Rfyion. 


Department  of  New  Mexico  . 
Department  of  the  Pacitic... 
Pacific  Region 


Total  in  t'arijir  Region - 
Army  of  the  Umlfil  Slates 


Foil  THK   YKAK   KNIUNG   JlINK   [WlW — 


1861.  1862.  1863.  1864.  1865.  1866 


Cases. 


:i,  iwi 


3, 4:w 


;i,  4■^^i 


Cases. 

3,  09!) 

2,  ai)i 

2,844 
2,304 
2,432 
2, 410 

3,  O'J.'i 


2,  7 111 

2,  802 

3,  41o 
3,  !W1 
3,  855 
2,  88'.t 
3,301 


3,  495 

1 ,  738 

2,  57.i 


,171 


Cases. 


2,  6(19 


2,583 
2,  ',185 
2,  349 
2,  335 
2,  .524 


2,  .553 

2,1105 
2,  936 

2,  8.58 

3,  996 

2,  394 
2,296 

3,  383 
2,202 


2,  Ml 


2,218 
2,  076 


2,  983  2,  696 


Cases. 


1,563 


2,823 
4,  012 

2,  796 
2,  217 
2,  401 


1,293 
J,  747 
2,614 
2,  923 
2,  035 

2,  249 

3,  029 
1,931 
2,  829 


1,693 
1,9(K) 


1,816 


Cases. 


2,  363 


l,9(i3 


2,729 
3,110 
2,  3',I5 
2,  219 
2,  273 
1,788 


2,  7113 
2,  109 
2,  494 
2,  .508 


3,  428 
2,  361 
1,688 


2,  328 

1 , 6.58 
1,964 


1,864 


2,210  2,273 


Cases. 


2,  .549 


1,749 


I,  362 


20  SICKNKSS    AND    MORTALITY 

I'crlia[is  tlitj  (Irst  poiiil,  tluit  will  uttract  utteiitioii  iti  thiK  taljle  i.s  the  grailual  (liininu- 
tmii  ill  llii;  sick  rates  as  lliu  war  pnigressod.  Tho  years  (if  tlie  wai',  lliuugli  iK)iiiiiially  live, 
were  ill  reality  but  tour,  that  eiulino;  June  30,  1861,  having  embraced  only  two  moutlis  of 
service.  In  a  general  way,  as  may  bo  seen  by  the  regionic  or  army  totals,  the  rate  of  sick- 
ness ilecreased  during  the  first  three  years  and  became  somewhat  increased  during  the  fourth 
year.  Locality  had  nothing  to  do  with  this  except  in  so  far  as  in  some  instances  to  occasion 
an  exce{)tion  to  the  general  rule,  as  in  tho  Departments  of  Virginia  and  North  Carolina, 
where  the  sickness  increased  }»rogressively  during  the  three  years  on  account  of  continued 
exposures  in  malarious  sections.  The  diminished  sick  rate  must  bo  attributed  to  the 
weeding  out  by  death  and  discharge  for  disability  of  the  inferior  material  necessarily  present 
in  all  new  levies.  The  term  of  service  of  many  of  the  regiments  expired  during  the  third 
year  of  the  war,  when  the  hardy  veterans  composing  them  were  in  many  instances  replaced 
by  raw  troops  who,  in  becoming  inured  to  active  service,  swelled  the  sick  rates  during  the 
fourth  year. 

The  lowest  rate,  1,293,  was  furnished  during  the  third  year  by  the  high  grounds  of 
Western  Virginia.  The  low  rate  of  1,563  was  given  during  the  same  year  by  the  veterans 
of  the  Army  of  the  Potomac.  The  battle  of  Gettysburg  began  the  year,  and  the  desperate 
struggle  that  led  from  tho  Wilderness  to  Petersburg  during  May  and  June,  1864,  ended  it; 
but  the  greater  portion  of  this  period  was  spent  in  what  was  regarded  by  the  troops  as  a 
picnic  in  summer  quarters  on  the  Rapidan,  or  hutted  during  the  succeeding  winter  and 
spring  in  a  healthy  locality.  All  the  conditions  were  favorable  to  a  light  sick  report. 
Many  of  the  men  were  anticipating  a  sojourn  at  home  on  the  expiration  of  their  term  of 
service.  Even  the  exhausting  movements  which  closed  the  year,  the  constant  skirmishing, 
and  the  battles  fought  in  quick  succession  at  the  Wilderness,  Spottsylvania,  the  North 
Anna,  Cold  Arbor  and  Petersburg,  while  undoubtedly  the  cause  of  much  sickness,  tended 
to  reduce  tho  sick  rate  as  preserved  on  the  records  which  medical  oificers  made  up  at 
intervals  from  memory  or  pencilled  notes,  overlooking  tho  slighter  ailments  that  would 
have  been  recorded  in  quieter  times  and  noting  only  those  more  serious  cases  that  had  been 
des])atched  with  the  wounded  to  the  general  hosjiitals. 

The  highest  rate,  -1,<U2,  was  furnished  during  the  third  year  by  the  continued  ex[iosure 
of  the  troops  in  the  malarious  regions  of  the  Department  of  North  Carolina. 

The  high  mortality  rates  in  the  Ct'iitral  region  corresponded  with  high  sick  rates  which 
are  jiarticularly  displayed  in  the  re|)orts  from  the  Departments  of  the  Tennessee  and  the 
Gulf.  The  prevalence  as  well  as  the  virulence  of  the  morbific  influences  was  greater  in  the 
Central  than  in  the  Atlantic  region.  The  influence  of  locality  on  the  prevalence  of 
particular  diseases  will  })e  discussed  in  the  chapters  relating  to  the  diseases  in  question. 

To  express  the  relation  of  season  to  sickness  and  mortality  in  the  various  regions,  and  in 
the  army  as  a  wlioh>,  Tables  VIl,  VIIl,  IX  and  X  have  been  constructed;  but,  as  it  is  a  work 
of  suine  labor  to  gatlu'r  from  siieli  tables  the  relative  value  of  the  figures  contained  iii  them, 
the  diagram  facing  page  24  has  been  prepared,  and  to  it  accordingly  attention  is  invitt.'d. 

The  sickness  is  expressed  in  monthly  rates  per  thousand  of  strength  on  the  left  side  o 
plate  and  the  moi'tality  on  the  right;  but  the  scales  have  been  so  proportioned  that  the  sick 
rate  may  be  read  as  well  on  the  right  by  ap[)ending  a  cipher  to  the  printed  numbers.  The 
narrow  red  line  represents  the  siek  rate  among  the  white  troops  of  the  army,  the  broader  lin 
the  death  rate,  while  the  yelhnv  lines  indicate  the  correlated  figures  for  the  colored  troops. 


e 


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AMONG    THE    U.    P.    FORCES. 


21 


Table  VTT. 

3Iontlily  nttio  of  f^ichtess  per  1,000  of  mean  strength  amonff  the  White  Troops,  LI.  'S'.  Anni/,  />i/  j-er/ionfi, 

for  the  period  from  June  30,  ISGl,  to  June  SO,  JS06. 


:iu:! 


i-to 
a  a 

IHI 


i7i; 
iii'.i 

UNI 


IHll 

i(;ii 
I. "hi 


u: 

>- 

U 

X 

J 

ai 

V, 

■= 

< 

^ 

^, 

< 

■j:i' 

5111 

IM 

IfiT 

so*; 

11. "i 

■MS 

ar.:) 

a;i 

2!  14 

1 :.  1 

U'H 

a).') 

im 

HI 

2;i9  ;    20-2 


l.-i!) 

1 4;) 

1  r,H 


Kit' 
174 
144 


n->        171 


IH.-. 
154 


Ml 

1411 


2.ih 
I7J 


14^• 
iri:i 

140 


icr,  I 

I 

IfiO 

ifia 
11:) 

i:!f 
l!:t 


195 

18(1 
240 


181 
2311 

141;  I    ir.2 

•JDil        21  I 


24". 

14!l 
210 
l«l 

182 


i;).-> 
i:!8 
ii;i 


140 
14fi 

ir>3 

144 

124 
i:i4 


l.-i8 

1<I,1 

Ifi'.l 

1118 

142 

i.-w 

li;4 

1(17 

141 

]3li 

17il 

17(i 

1511 

189 

1(12 

158 

142 

14!) 

:    ir>4 

137 

Kill 

141 

123        14(i 


I'.ia 

2(111 
22(1 

233 

1(13 
192 
154 


147 
190 
134 


170 
183 
1B2 

177 

188 
170 
155 


1 

U 

c 

<i 

1 

53 

< 

u 

H  tr 

K 

•-5 

r-. 

-in 

2--7 

252 

291 

187 

ISI 

239  1 

249 

158 

213 

219 

237 

2(Hi  \\       178 


327 

124 

218 

181 
190 
160 

185 

207 
224 

14(1 


188  \ 
151     ] 

184    I 

185-  I 
194  I 
155    I 

189 

191 
212 

14(1 

197 


Table  VTII. 

Monliihj  ratio  of  easeti  of  Sich^ess  per  1,000  of  mean  strength  among  the  Colored  Troopx,  hy  regions, 

for  the  period  from  June  30,  18G3,  to  June  30, 1866. 


VK.Ait  ExniNn- 


UF.r.lON. 


June  30,  18(14 


Atlantic 

Central 

T,>lill 


292 

494 


517 
441 


5fi9 

4111 


403 
430 


294 

388 


274 

342 


333 


247 
301 


286 
347 


228 
3(13 


253 

34(1 


278 
377 


288 
364 


-..      459       458        451        422       3(11 


323  ,     31(9  I     282 


JlluelUI,  1865 


Atlantic 

C.Mitral 


341        349        298        293        234        --"id        289        219 


328  I     319       317  ;    343  ;,      341 


208        177        290       264 


260 


356        264        343        284        255        249        S;iT        206        234        241         259        261  271 

Total i    351       :!59       328       287'    248'    241        252       211       224       216       271       262 


June  30,  1866  . 


Atlantin 
Central 


259        231         264        25 


l:'8        151        168  I     152  ;     161   ■     122  92  I     1.54 


311         316        286        280        2113        ll'5        165        158   ,     141         129        125        1.57 

l  ,1 


267 

215 
237 


Tdtal  .300       298'     282]     275       202       181   l     165  I     1.57        145        127'     120  I     1.57 


II 


22 


SICKNESS    AND    MORTALITY 


Tablk  TX. 

Monthly  ratio  of  Deaths  from  disease  i^er  1,000  of  mean  strength  among  the  White  Troops,  U.  S. 
by  regions,  for  the  period  from  June  SO,  186 1,  to  June  30,  1S6G. 


A 


rmy, 


YK.AK    ENDINC;— 

KKtilON. 

l.ii5 
.97 
i.3i 

1.49 

a8o 

6.  62 
.  72 

4.96 

a  45 

6.trr 
.3:1 

4.97 

5.  .54 

6.82 

.65 

X 

< 

a.w 

2.  82 
.89 

2.15 

.5.19 

5.  .55 

.  .55 

5.25 

2.74 

7.53 

.6.5 

.5.  IM 

6.75 

6.10 

.65 

s 

5 

1.78 
3.49 
1.26 

2.  21 

4.06 

5.36 

.56 

4.  .58 

si 

.  5 
r 

2.01 
4.55 
1.21 

2.82 

4.  .52 
.5.  60 

.79 

5.  01 

3.02 
4.18 
.94 

a  71 

5.76 
5.35 
1.08 

5.46 

2^ 

2.66 
6.  20 
1.60 

3.79 

4.76 

7.48 
1.02 

6.  09 

2.  51 
4.06 
1.00 

3  44 

s 
s 
?■■ 

a 

3. 23 

6.58 
1.00 

4.29 

4.69 
8.00 

.81 

6.21 

2.  46 
3  50 
1.28 

a  10 

i 
■< 

s 
< 

2.90 

8.84 

.19 

4.  .52 

a88 

8.09 
.49 

.5.  93 

3.03 
3.94 
1.25 

a  .58 

3  80 
5.00 

.88 

X 

< 
1 

2.40 

8.82 

.41 

4.11 

3  08 
9.67 

1.02 

6.  39 

2.63 
4.  25 

1.28 

3.  61 

a  51 
4.75 
1.30 

X 

a 
-< 
S 

2.  52 
10.  24 

4.79 
2.74 

9.  a5 

.32 

6.11 

3  51 
5.51 
1.01 

4.71 

4.38 
5  89 
1.11 

a  12 

6.  37 
.49 

4..5S 

2.04 
7.09 
1. 15 

4.  76 

2.  95 
4.98 
1.08 

4.13 

3  33 
.5.04 
l.li3 

4.15 

1.14 

1.31 

.95 

< 

2.  85 
7.  18 

.51 

4.  93 

1.44 
.5.  17 

.70 

3.  .52 

1.87 

a  92 

.71 
3  12 

a  08 

3  48 
1.17 

a  24 

1.05 
l.iMi 

.77 

.99 

*^ 

3  00 

6.42 

.  77 

4.61 

1.65 

4.79 
1.03 

a  56 

2.93 

4.41 

.81 

a  82 

3.95 

a  28 

•91 

a53 

H 

o 

<  -j 

J  H 

is 

2.  (i7 

6.  7(i 
.88 

4.11 

a  47 

7.07 

.76 

.5.  27 

2.73 

4.87 

.93 

4.02 

4.44 

r>.  06 

.9'.t 
4.71 

a52 

4.01 
1.13 

a  51 

June  30,  1862 

Atlantic 

Central 

Paoitic 

June  30.  1863 

Atlantic 

Central   

Paoifiii 

June  30   1864 

Athuitif 

2.  63 
5.  84 
.63 

4.51 

5.16 

6.05 

.53 

5.58 

4.26 
5.42 
1.39 

4.62 

Central 

Pad  tie 

Total 

Atlantic 

3.87 

3  96 

.58 

4.90 
4.41 
1.41 

Pacific            , 

Total 

0.17 

6.25 

3  62 

4.72 

.99 

3  86 

4.57 

4.41 

4.11 

5.11 

1.84 
1.66 

.85 

1..54 

Jtine^)   IStHi 

Atlantic 

.5.06 

5  07 

4.42 
4.46 
1.09 

3  05 
3  44 
1.98 

3.07 

1.84 
2.66 
1.49 

2.15 

1.24 

1.79 

.93 

1.43 

l.OC 

1.38 
1.11 

1.22 

.90 
.82 
.70 

.82 

Pacific 

.98 
4.92 

Total 

4.10 

4.07 

1.19 

Table  X. 

Montldy  ratio  of  Deaths  from  sickness  per  1,000  of  mean  strength  among  the  Colored  Troops,  by  regions, 

for  the  period  from  June  30,  1803,  to  June  30,  1866. 


Yeak  ENIiINn— 

Region. 

.Tiin*-:W,  IHM 

Central 

Total 

June  :«i,  ij^r.r. 

Central 

Total 

Jnnt'  'JO    iHtHI 

Atlantic    ... 

Total 

>• 

*-A 

< 

o 

H 
U 
O 


I 


7.  .54  I    9.  03 


2!t.l931.40    31.02    32.63    16.84,  15.40;  18. 48   20.24 

24. 15!  25.  31  '24.91 


25.06 


8.  62 
13  39 


la  22 


lais 


6.  67 


6.  76 


10.  Ul  1 10.  93 


15.09 


9.08 
1.5.24 


16.41 

11.75 
12.14 


I 


8.611     7.38      8.89 

20.70  l!^.  .TO    16.87 

1 

16.71  I  14.  79    14.14 

I  I       _ 

11.11  '    7.24      8.59 

i         ! 

9.  50  :    9.  .52  I    7.  90     7.  92      6.  02  ,    7.  26  '    6.  74  I    6.  62  I 

I       I       i       :       '       I       I       I 


9.41 
22.16 


18.07 


10.  .■|5 
12.11 


6.32 
25.52 


19.25 


8.36 
10.33 


11.63     8.81,    9.33    12.77    11.99    11.45     9.55 


12.091    7.15     5.18  1    8.16'    6.73' 


7.4: 
8.07 


4.64 


.5.77 
21.38 


16.54 


11.23 
10.70 


10.89 


57     a  00 


9.851    9.01'    8. 021    8.«B     6.23'    6.96     0.91      6.63     7.97      6.99      3.18 


•A 

j  Monthly  Average 

1    FOK  THE  YEAR. 

5.77 

6.90 

20.75 

22.44 

15.40 

17.60 

lasi 

9.  2:1 

9.  (11 

12.99 

10.04 

n.<i6 

2.91 

8.  30 

3.51 

7.72 

a4i 

1 

7.82 

AMONG    THE    U.    S.    FORCES.  23 

The  largest  monthly  ratio  of  cases  among  tlie  white  troops  occurred  in  August,  1861, 
shortly  after  tlie  enlargement  of  the  army  to  meet  tlio  military  necessities  of  the  time. 
This  ratio  amounted  to  364  cases  per  thousand  of  strength.  The  exposures,  fatigues,  altered 
diet  and  other  changes  in  the  conditions  affecting  the  men  incident  to  their  new  mode  of 
life  as  soldiers,  coincided  at  this  time  with  the  jieriod  of  greatest  annual  prevalence  of 
malarial  disease,  and  the  large  amount  of  sickness  indicat<xl  by  tliis  ratio  was  the  result. 
A  reference  to  the  diagram  showing  tiie  pi'evalence  of  diarrhea  and  dysentery*  will  mani- 
fest the  great  influence  tliat  this  class  of  camp  diseases  exercised  on  the  general  sick  rate  of 
the  army  at  this  time.  Their  extensive  prevalence  in  the  Atlantic  and  Central  regions,  in 
whicli  most  of  the  troops  were  massed,  contributed  much  U>  tlie  lieight  of  the  general  sick 
wave  as  shown  on  the  diagram  under  present  consideration,  or  more  especially  on  Table 
VII,  which  it  ilkistrates. 

The  irregular  prominence  of  the  line  in  April,  July  and  October,  1862,  appears  due 
to  excess  of  diarrhoeal  cases, — in  the  Central  region  during  the  first-mentioned  month,  and  in 
the  Atlantic  region  dui-ing  the  others.  As  diarrhoea,  dysentery  and  the  malarial  fevers 
occasioned  more  than  oncdialf  d'  all  th<^  cases  of  disease,  507  of  every  thousand  cases*}"  that 
were  reported  from  the  whih;  commands,  the  concui'rencc  of  tlieir  |)eriods  of  maximum 
prevalence  gives  prominence  in  the  autumnal  months  of  subsequent  years  to  the  line 
indicating  the  ])revalence  of  disease  in  general.  But  in  none  of  these  years  did  the 
monthly  ratio  at  all  apjiroach  the  lieight  reached  during  the  autumn  of  the  year  1861 :  thus 
the  highest  ratio  recorded  in  1862  was  that  of  .Tuly,  279,  while  August,  in  the  three  ioUow- 
ing  years,  gave  the  highest  monthly  I'ates,  respectively  256,  265  and  233  ])er  thousand  of 
strength. 

The  minimum  as  Wfll  as  the  maximum  of  j)revalence  in  the  year  ending  .ruin'  30, 
1862,  was  higluM-  than  in  the  subsequent  years.  This  is  attributable  maiidy  to  the 
frequency  of  diseases  of  the  respiratory  organs  and  to  dian-ho^as,  which  continued  to  affect 
the  troops  in  the  Central  region,  and  but  little  b^  th(^  malai'ial  influence  which  in  this  year, 
as  will  be  seen  hereafter, |  was  at  its  mininnmi.  The  minima  of  the  several  years  were  as 
follows:  195  in  Marcli  of  1862,  179  in  May  of  1863,  and  137,  144  and  123  respectively 
in  February  of  the  tliree  following  years. 

Speaking  generally,  the  amount  of  sickness  among  the  white  troops  was  much  less  in 
the  last  year  than  in  the  first,  the  average  monthly  rate  of  the  latter,  249,  being  greater 
than  the  highest  monthly  rate  of  the  former,  233  per  thousand.  A  glance  at  the  diagram 
will,  however,  show  these  variations  in  the  level  of  the  rates  more  satisfactorily  than  a 
lengthened  description.  It  may  be  added  that  the  narrow  red  line,  the  subject  of  the  fore- 
going remarks,  corresponds  closely  in  its  course  with  that  indicating  the  prevalence  of 
disease  among  the  white  troops  in  the  Atlantic  region.  The  rates  of  the  Central  region, 
when  plotted  diagrammatically,  give  a  line  which  i-uns  parallel  to  the  red  line  but  on  a 
somewhat  higher  level.  The  rates  of  the  Pacific  region,  when  delineated  in  this  manner, 
occupy  a  lower  level,  and  fail  to  manifest  in  their  irregularities  the  existence  of  the  marked 
autumnal  elevations  which  form  so  strikino;  a  feature  of  the  lines  for  the  other  regions. 

The  mortality  from  all  diseases  among  the  white  troops,  represented  on  the  diagram 
by  the  thicker  red  line,  increased  from  a  low  rate  during  the  first  month  to  its  maxinmm, 
6.39,  in  February,  1863.     After  this  it   fell  during  March  and  April  to  3.5  in  May  and 

*  Kaciug-  \ni^f  'J*,'  til'  the  Serntnl  I'art  ot  this  vvnrk.  t  See  Table  II.  supra.  J  See  diagraui  faciiig^  pa^e  i«l,  infra. 


24  SU'KNKSS    AND    MORTALITY. 

June.  The  line  is  very  irregular  in  the  remainder  of  its  course;  but  in  each  of  the  subse- 
quent years  there  riiay  be  distinguished  a  large  autumnal  and  a  smaller  spring  elevation, 
the  latter  usually  occurring  during  the  month  of  March.  The  plate  facing  page  20  affords 
a  satisfactory  explanation  of  most  of  these  irregularities  in  the  level  of  the  mortality  line. 
The  sudden  rise  in  tlie  rate  during  the  autumn  of  1861  was  due  almost  wholly  to  typhoid 
fever,  but  in  November  and  December  of  that  year  and  January,  1862,  pneumonia  and  the 
eruptive  fevers  aided  considerably  in  its  elevation.  The  mortality  from  typhoid  fever 
continued  to  augment  and  uphold  the  general  death  rate,  although  the  former  allies  of  this 
disease  declined  in  virulence  as  the  spring  advanced.  Meanwhile  diarrhoea,  and  a  little 
later  the  malarial  fevers,  began  to  contribute  materially  to  the  rate.  During  the  period 
from  November,  1862,  to  March,  1863,  when  the  monthly  death  rate  amounted  to  about  6 
per  thousand  of  strength,  all  the  diseases  delineated  formed  notable  percentages  of  the  total. 
In  the  subsequent  years  the  autumnal  increase  corresponded  with  larger  rates  from  diarrhoea, 
typhoid  and  malarial  fevers,  while  the  smaller  prominences  in  tlie  spring  months  were 
caused  by  a  maximum  rate  among  the  pneumonic  cases  and  eruptive  fevei's,  with  a  large 
minimum  rate  among  tlie  diarrh(jeal  diseases  and  typhoid  fever. 

\h\t  to  return  to  the  diagram  on  the  opposite  page :  The  sick  rate  of  the  colored  troops, 
indicated  by  the  thin  yellow  line,  was  highest  immediately  after  their  enrollment  in  1863, 
when  nearly  one-half  of  the  command  was  reported  as  having  been  taken  sick  during  each 
of  the  months  July,  August  and  September.  Autumnal  exacerbations  were  encountered 
during  each  of  the  subsequent  years;  but  on  the  whole  the  health  of  these  troops  improved 
so  remarkably  that  during  the  last  quarter  of  the  year  ending  June  30,  1866,  their  sick 
rates  were  somewhat  lower  than  those  of  the  white  troops. 

Their  death  rates,  indicated  by  the  heavier  yellow  line,  followed  a  generally  parallel 
course — high  at  first,  about  25  per  thousand  of  strength  monthly  during  the  first  four  months 
of  service,  and  afterwards  declining  to  the  minimum  of  3.18  per  thousand  in  May,  1866; 
but  at  no  period  of  their  service  did  the  death  rate  of  these  troops  fall  below  that  of  the 
white  commands. 

DiscHARQKS  ON  ACCOUNT  OF  DISABILITY  FROM  DISEASE. — The  sick  and  mortality  rates 
by  no  means  express  the  whole  of  the  loss  to  the  army  occasioned  by  disease.  Large 
numbers  of  men  were  discharged  as  unfit  for  military  service  on  account  of  disease  that  in 
a  majority  of  instances  originated  in  the  line  of  duty. 

The  records  of  tlie  Adjutant  General's  Office  are  understood  to  embrace  certificates  of 
disability  on  which  275,738  white  soldiers  of  the  regular  and  volunteer  array  were  dis- 
charged, but  the  Hurgeon  General's  Office  has  reports  of  only  215,312  such  cases.  Of  these, 
48,374  were  based  on  wounds,  accidents  and  injuries;  4,439  on  deformities,  immaturity 
and  senility,  disabilities  which  existed  prior  to  enlisthient;  and  25,915  on  causes  that  were 
not  specified.  Dropping  these,  there  remain  136,584  certificates  in  which  the  disease  is 
stated.  But  if  the  cases  in  which  the  disease  was  not  stated  and  those  reported  to  the 
Adjutant  General,  but  not  to  the  Hurg(M:)n  General  of  the  Army,  were  distributed  |:>ro  rata 
among  the  discharges  occasioned  by  wounds,  by  conditions  which  should  have  prevented 
enlistment,  and  by  disease,  the  number  referred  to  the  last  cause  would  be  increased  to 
198,849,  equal  to  an  annual  loss  of  82.2  men  in  every  thousand  of  strength. 

Thi^  files  of  the  Adjutant  G^nrnd's  C)Hlco  include  cei-tificates  pertaining  to  9,807 
colored  men,  while  those  in  the  Surgeon  General's  Office  number  only  8,223;  and  of  these 


$  s 

^       "^ 


1  I 


5?.   5 


<•    -i 

■^     ^ 


1 


5» 


5' 


I 


A^rONCT    THE    U.    8.    FORCES.  29- 

1,479  are  based  on  wounds,  687  on  causes  wliit-h  sIkjuLI  liavo  ivjcctiMl  llio  riH-ruit,  and 
1,226  on  unspecifiod  causes.  Dropping  tliese,  tlieic  ri'maiii  I.SiM  ciTtiticatrs  in  which  the 
disease  is  specified.  But  if  these  fiuures  were  trcateii  as  in  ihc  case  dI'  thi'  wiiite  trnops. 
tlie  number  of  discliarges  due  to  disease  would  lie  augincnttMl  to  (),771.  eijiial  to  an  annual 
loss  of  35.3  men  in  every  thousand  of  strength. 

These  lieavy  losses  were  not  wholly  due  to  the  diseases  incident  to  military  service. 
Many  of  the  disabilities  existed  prior  to  enlistment;  for  instance,  not  all  of  the  men  dis- 
charged for  consumption  contracted  the  disease  in  the  service,  uov  did  all  of  those  discharged 
for  hernia  become  ruptured  in  the  performance  of  military  duty.  Ignorance,  carelessness 
and  intentional  fraud  at  the  recruiting  depots  were  at  first  responsible  lor  the  enrollment 
of  this  worse  than  valueless  material;  afterwards  liberal  bounties  induced  men  to  conceal 
infirmities  in  order  to  secure  acceptance.  In  garrison  or  winter  quarters  their  disabilities 
were  in  many  instances  not  manifested;  Init  when  exposed  to  the  hai'dships  of  a  cani|iaign 
they  swelled  the  sick  list,  crowded  the  hospitals,  and  were  eventuallv  ilischarged.  \h\ 
Tripler  reported  that  of  3,939  discharges  for  disability  from  the  Armv  of  the  Potomac 
during  the  last  quarter  of  the  year  1861,  2.881  were  ior  disaliilities  that  e.xisti'd  at  the 
time  the  men  were  enlisted.'''  j\[(!dical  (ifiicers  serving  in  the  lirld  iiad  their  duties 
materially  increased  by  the  presence  of  cases  of  this  character.  Some  adverted  lo  tli(»  fact 
apparently  to  explain  the  large  number  of  discharges  reported  fi'om  their  commands;  others 
entered  a  vigorous  protest  against  the  gross  negligence  of  the  recruiting  authorities.  A  few 
extracts  are  herewith  submitted,  and  as  these  are  by  no  means  excej^tional  cases,  it  will  be 
appreciated  that  a  considerable  percentage  of  the  disabilities  were  not  fairly  attributable 
to  the  service  of  the  soldier: 

I  consider  the  careful  inspeetioii  of  the  volunteers  before  accejjtanc'e  a  matter  of  the  f^reatest  iiii])ortanee. 
The  great  number  of  discliarges  for  disqualifying  defects  among  tiie  three-montlis  men  that  have  come  under  my  own 
notice,  convinces  me  either  that  the  men  were  not  inspected  at  all,  or  else  that  the  duty  must  have  been  performed 
by  inexperienced  otlicers.  The  incumbrance  and  dead  weight  of  the  men  of  tliis  (h'scrii)tion  witii  our  columns  has 
been  a  serious  and  constantly  accumulating  impediment  to  its  nuitions. — Hiirnroii  Ciiaiu.ks  S.  Tkiim.kij,  f.  S.  .Iniii/, 
AledUal  Dirtdor,  Departmint  of  I'tnnxj/hun'ui,  Charlextdwii,  I'li.,  Jiili/  IS,  18()1. 

The  number  of  men  discharged  from  service  witliin  the  last  mouth  or  two  is  very  large,  owing  chielly  to  the 
fact  that  a  great  many  were  sent  here  without  undergoing  a  proper  pliysical  examination  at  the  time  of  their  enlist- 
ment. For  example,  some  thirty  or  forty  cases  of  hernia  have  been  sent  away,  and  in  almost  every  instance  the 
disability  existed  previous  to  enlistment.  I  observe,  al.so,  that  a  large  number  of  boys  maybe  found  among  the 
troops  who  are  physically  incapable  of  enduring  tlie  liardshijjs  of  a  soldier's  life  in  the  field. — .s'hiv/coh  .1.  M.  Ccvi.kk, 
U.  S-Jniiy,  Medical  J)irntor,  Fortrens  Monroe,  Jo.,  .tiii/iixl  3,1861. 

In  regard  to  the  condition  of  tlie  companies,  tliey  are,  with  one  or  two  exceptions,  composed  chiefly  of  men 
who  hold  respectable  positions  at  home  as  farmers,  mechanics,  Ac,  and  who  possess  some  degree  of  jiride  concerning 
cleanliness  and  proper  behavior.  It  is  to  be  regretted,  however,  that  in  the  haste  of  preparation  and  dei)arturi', 
<liiite  a  number  were  enlisted  whose  physical  condition  was  such  that  they  ought  to  have  been  rejected.  A  large 
proiiortion  were  examined  in  the  country  towns  by  pliysicians  not  regularly  appointed,  and  some  were  not  examined 
at  all.  This  may  help  to  account  for  the  fact  that,  while  the  number  of  sick  in  the  hospital  is  not  very  great,  the 
list  of  those  in  quarters  is  larger  than  it  should  be. — Asxisiant  Surgeon  J.  Fo.steu  H.wen,  jr.,  I'.  S.  VoIk.,  Camp 
Foxier,  I'oolesrille,  Md.,  tSe2>tember  30,  1861. 

The  28th  Pennsylvania  A'olunteers,  numbering  ten  comjianies,  left  Philadelphia  .July  26,  1861,  witli  orders  to 
jiroceed  to  Harper's  Ferry.  They  had  never  been  regularly  examined  by  a  surgeon,  and  a  numl>er  of  diseased  men 
had  been  enrolled.  The.se  have  constantly  made  the  sick  list  larger  than  it  otherwise  would  have  been.  Eleven 
of  these  men  have  been  discharged,  and  certificates  of  disability  made  out  for  tifteen  others. — Surijeon  H.  E.\kn'Kst 
(JiKiNMAN,  28//t  I'a.  f'uh.,  Xoremher  11,1861. 

I  joined  the  regiment  after  it  was  mustered  into  service  and  found  over  one  hundred  enlisted  men  that  should 
have,  l>een  rejected  by  the  Medical  Insjiector  before  their  enlistment.  As  a  con.se(|iienee  of  this  I  have  been  com- 
pelled to  recommend  a  large  number  of  men  for  discharge  on  certificate  of  disability.  There  yet  remain  a  few  ca-ses 
that  1  doubt  not  before  long  w  ill  be  decided  unfit  for  tlie  duties  of  a  soldier. — Snrijeini  Wm.  K.  Tiikai.i.,  '21lh  Ohio 
;■(</«.,  Deeember  111,  1S61. 

*  See  page  47,  Appeiulix  to  \\w  First  I*art  i)f  this  work. 

Med.  Hist.  Pt.  HI— 4 


26  STOKNERS    AND    MORTALITY 

'J'he  men  in  Home  of  the  battffrics  were  not  properly  examined  when  enlisted,  and  I  have  found  it  necessary  to 
recommend  some  for  discharge  on  account  of  liernia,  tuberculosis,  ununited  fractures,  &c.—.ls^H  .Suryeon  Wii.mam 
A.  I'.itAKl.KY,  Jr.,  r.  ,S'.  ./.,  Camj)  Diipoiit,  I'd.,  Demiihir  'M,  IHVA. 

(Jkxku.m,:  An  <ivil  too  great  to  jiass  unnoticed  I  now  liring  to  your  attention. 

Vest erday  and  to-day  I  examined  eighteen  recruits  Just  sent  on  from  New  Jersey,  and  all  mustered  into  .service 
beftire  their  arrival.  I  have  unconditionally  rejected  eight.  Of  the  remainder,  one,  a  butcher,  miglit  l>e  made 
useful  as  such,  although,  owing  to  an  old  iiijuiy,  he  is  utterly  unlit  for  the  ordinary  duties  of  a  soldier.  His  case  is, 
therefore,  under  advisement  and  awaiting  your  decision. 

One  half  of  thi'se  recruits  \ver<^  thus  uualdt^  to  stand  the  test  of  a  ]>hyslcal  examination,  while  among  the 
w  bole  there  were  but  threi-  or  four  w  i-11-formed  and  able-bodied  nii'U. 

In  this  examination  nice  distinctions  regar<llng  (uirns,  flat  feet,  unsymmetrical  form,  Ac.,  were  not  made. 
Indeed,  I  approved  of  one  uum  lui  account  of  )(revious  service  whose  left,  elliow-Joint  has  not  i)erfect  treedom  of 
motion  on  account  of  a  former  fracture. 

Most  culpable  negligence  seems  to  i)revail  at  the  recruiting  stations.  'I'he  medical  examination  at  Trenton  or 
elsewhere  can  scarcely  be  better  than  a  farce;  at  least  m>-  ex])erience  within  the  past  two  days  seems  to  authorize 

such  an  opinion.     Theexjiense  to  thetJover eiit,  and  the  injury  to  our  cause,  resulting  from  such  shameful  neglect 

require  no  formal  exjiressiou. 

1  would  suggest  that  the  attention  of  the  authorities  of  youi'  State  be  Invited  to  this  matter,  advising  that 
medical  examiners  be  instructed  In  their  business  by  spending  a  week  in  the  otbce  of  the  medical  otticer  of  the 
regular  army  who  Ins|)ect8  recruits  in  New  York  City. 

I  a|>]ieiid  a  list  of  the  causes  re(|uirlng  the  rejection  of  the  eight  recruits  in  i|uestion: 

1.  Over  age  an<l  listula  111  ano  of  hmg  standing.  2.  Dislocation  of  the  clavicle.  :!.  Hernia.  4.  Large  scrotal 
hernia,  r..  Movement  of  right  shoulder  limited  by  previous  dislocation,  knock-knees  and  laige  vaijocele  on  left 
side.  (i.  Tdtal  blindness  of  right  <  ye  anil  lmj>erfeet  vision  of  left  eye.  7.  Left  slioulder  irippled  from  an  old  injury. 
8.  Syphilis  and  iinlnionary  trouble;  chest  badly  formed  and  geneial  contiguratlon  wnperfect.  To  these  are  added 
tlie  two  men  disapi)roved,  but  ictaincd  for  the  decision  of  thi'  commandiug  general:  1.  Louis  Loeb,  the  butcher,  who 
is  too  fat  and  heavy  for  a  soldier;  his  feet  an<l  legs  are  (edematous,  and  he  sutfers  from  an  old  and  severe  injury  of  the 
right  side.  2.  Samuel  Williams,  a  trained  soldier,  but  with  imperfect  motion  of  the  left  elbow,  resulting  from  a 
jirevions  fracture. — Litlir  tlatrd  October  tl,  1861, //•»)«  linijaili'  Siiryioii  (iKOKiiK  SllCKI.KY,  la  BrUjadiir  (liii'l  P.  Kkakney, 
commiiHilhii/  !»/  Uriyadf  yiw  Jertry  \'oU.,  mar  Alexandria,  fa. 

Tlic  tnljle  Oil  tlu^  opposilo  pfig<^  sliows  many  points  of  intorest  connected  with  the 
diseases  wliicli  were  the  rliief  eanses  of  disahiHtA'.  The  iirst  column  of  each  of  its  diYisions 
trives  for  th(^  wliite  and  tli(!  colored  troops  respectively  the  total  numher  of  discharges  for 
the  specified  diseases  during  the  periods  covered  hy  the  statistics,  [lyo  and  one-sixth  years 
in  the  oiii'  (•as((  sind  three  years  in  the  other.  The  second  columii  expresses  these  facts  in 
ratios  per  thousand  of  strength.  Tlu;  third  column  shows  to  what  extent  each  disease 
contributed  to  the  totality  of  the  dischai-ges  for  specitied  diseases,  while  the  hist  column, 
giving  the  mean  annual  ratio  of  discharges  per  thousiind  of  strength,  enables  a  comp;irisou 
to  be  made  between  the  disabilities  of  the  white  and  the  colored  troops  and  the  frequency 
of  the  consequent  discharges. 

The  prominent  causes  of  discharge  among  the  white  troops  were  consumption,  diar- 
rhcBa  and  dj'sentery,  and  debility,  which  respectively  occasioned  149.4,  127.3  and  106.2 
of  every  thousand  discharges  for  disease.  Typhoid  and  malarial  fevers  are  directly  credited 
with  but  few  discharges;  but  the  disability  in  a  large  proportion  of  the  14,500  debilitated 
and  the  2,224  dropsical  men  was  no  doubt  due  to  these  morbific  agencies.  Rheumatism 
and  heart  disease,  which  together  caused  scarcely  one  death  per  thousand  of  strength 
annually,  contributed  largely  in  diminishing  the  effective  force  of  the  army,  the  former 
having  constituted  80. 2  and  the  latter  77.9  of  every  thousand  discharges  on  account  of 
disetise. 

The  relations  between  death  and  discharge,  as  the  result  of  disease,  may  be  ascer- 
tained by  an  examination  of  Tables  U  and  III  in  connection  with  that  now  under  consid- 
eration. The  white  troops  lost  annuidly  1)y  death  from  disease  53.48,  the  colored  tirjops 
143.4  in  every  thousand  men;   but  these   rates,  while  correctly  expressing  the  facts  of  the 


AMONG    THE   U.    S.    FORCES. 

Table  XT. 


27 


Disvlian/es  for  Disahilily  from  Disease  in  the  United  States  A mif/ from  }fay  1,  ISO  1,  to  June  30,  1S66\ 
vith  ratio  per  IpOO  of  mean  strength  in  Field,  Garrison,  and  (Uneral  Hospitals,  ratio  per  I fiOO 
of  total  discharges  and  mean  annual  ratio  per  1,000  of  strength. 


All  diseafiefl 


,Spt^4^iHe<l  (liseases  only  . 


Typhoid  Fever 

Malariiil  I'Vvers 

1  >iarrlicea  and  Dysentery  . 

Kiiiptive  Fevers 

IMtility 

Syphilis 

Klieuniatisiii 

Drnpsy 

Cunsuiuption 

.S.-n.fula 

Kpilepsy 

Iii><aiiity 

Paralysis 

Ophthalmia 

Deafness 

Hi-art  disease 

Varicose  Veins 

Vario(jceIe 

Asthma 

Bronchitis 

TnHainmatioa  of  Ltmgs 

InHanunation  of  rienra. . . 
Ilapninrrha^e  fnini  Lungs 

Hernia 

Intlamniution  of  Liver 

Piles 

luHarnniation  of  Kidneys  . 

Anchylosis 

Disejises  of  Sjiine 

n.-ers 


White  T 

KOOI'.S. 

.    — 

COI.ORKK 

TllOOl'S. 

2 

M 

-  btS 

1^1 

£  S 

i_ 

t^  t:  ^ 

t*.  ±1 

,~  — 

S  1 

^■c  ^ 

■^  S 

';:  bij       i 

5  z 

S^^ 

H    1 

•Z  4 

C  en  -^ 

s- 

il 

I.  ^ 

i.z 

^  -  9; 

3S 

"   St 

H. 

s 

c 

c 

s 

5  ».  a 

s  <-  «• 

C3    «■    « 

s    -   * 

y. 

CS 

a 

P, 

y. 

ce 

» 

K 

l:t(i,  .V4 

4-J4.  7 
291.7 

83.2 

(t,  771 
4,f3l 

10.5.  !l 
75.  (» 

l.(H)0.  0 

3.-..  3 
2.").  2 

I.IKHI.  1) 

t«M> 

1.9 

|].7 

.n? 

10 

.2 

2.1 

.05 

H;".:! 

I.M 

C.  2 

.35 

30 

.5 

(1.  2 

.  16 

17,  H«l 

37.  1 

127.  3 

7.19 

359 

.5.  ti 

74.3 

1.87 

4->7 

M 

3.  1 

.  18 

3 

.6 

.  t)2 

14,  am 

31.1) 

1(11'..  2 

fi.  99 

.540 

8.4 

111.8 

2.82 

1,77!) 

3.  R 

13.0 

.74 

8(1 

1.3 

17.8 

.45 

11,77!) 

S.l.  1 

(j*;.  2 

4.87 

874 

13.7 

180.9 

4.56 

o  224 

4.7 

k;.  3 

.92 

HI!) 

1.7 

22.6 

.57 

■Jl),  403 

43.  r, 

149.4 

8.43 

592 

9.  3 

122.5 

3.  09 

907 

1.9 

(i.  ti 

.37  ' 

147 

2.3 

;ui.4 

.77 

3,1*72 

P.  3 

28.  3 

i.co 

174 

2.  7 

;!«.  0 

.91 

Hl;i 

1.7 

fi.d 

.34 

34 

r 

7.0 

.  18 

•J,  838 

i;.  1 

2(1.  H 

1.17 

(;<) 

1.  1 

14.3 

.;i6 

l,4f;3 

3.  1 

10.7 

.00 

'•5 

.4 

5.2 

.13 

1,1.^7 

2  ."> 

f.r, 

.48 

38 

.6 

7.9 

.20 

10,  ii3i; 

22.7 

77.9 

4.4(1 

KM 

2.  5 

33.3 

.84 

i,i)6;i 

4.2 

14.4 

.81 

(i!) 

1.1 

14.3 

.:ifi 

1,390 

3.0 

10.2 

.57 

25 

.4 

5.2 

.13 

1,220 

2.1! 

8.9 

.50 

42 

.  7 

8.7 

22 

;i,  72<) 

f.O 

S7.3 

1..54 

96 

1.5 

19.9 

.30 

1,092 

2.3 

8.0 

.43 

a.i 

.4 

5.2 

.13 

495 

1.1 

3.6 

.20 

18 

.3 

3.7 

.09 

(134 

1.3 

4.(1 

.26 

4 

.1 

.8 

.02 

II,  (102 

19.2 

fi5.9 

3.72 

358 

:>.  n 

74.  1 

1.87 

1,354 

2.9 

!).9 

.56 

29 

.4 

6.0 

.15 

l,5.-.5 

3.3 

11.4 

.B4 

!           43 

.7 

8.9 

.  22 

l,nfi<) 

2.3 

7.  H 

.44 

!           27 

.4 

.5.  « 

.14 

l,e38 

3.9 

:           13.3 

.7(1 

105 

1.6 

21.7 

..55 

1,547 

3.3 

1           11.3 

.(i4 

31 

.  5 

6.4 

.16 

I.KIH 

2.4 

1             H.  3 

1 

.47 

46 

i: 

.7 

9.5 

.24 

official  records,  do  not  convey  with  accuracy  the  relations  of  death  to  disease.  In  view  of 
tlie  number  of  men  discharged  for  diarrlioea  and  dysentery  it  is  evident  tliat  the  mortahty 
rates  for  these  intestinal  afi'ections  woukl  liave  been  greatly  increased  had  the  undoubtedly 


28  STCKNKSS    AND    MOKTALTTY    AMOKG    THE    U.    S.    FORCES. 

serious  casos  that  led  to  the  issue  of  these  certificates  been  followed  up  to  their  termination. 
Tn  viow  also  of  tlu'  disproportion  hetween  the  discharges  tVoiu  the  white  and  tlie  colored 
commands,  tln^  mortality  IVom  disoase,  as  above  expressed,  nxpiirt's  moditication.  Among 
the  former  82.2,  amontr  the  latter  only  .')5.3  men  were  dis('hargc(l  aumially  from. every 
thousand  present.  No  doubt  many  of  these  went  home  to  dif.  W  it  bo  assumed  that 
more  deaths  occunvd  among  the  82.2  discharged  white  men  than  among  the  3o.3  colored 
men,  the  ditfeivnce  between  th(^  mortality  rates  of  the  two  will  be  lessened.  But  even  il 
tht^  whohi  nundxn-  of  cases  in  each  instance  died  idtimately  of  the  disease  which  occasioned 
the  disability,  the  greater  mortality  among  the  colored  troops  would  still  be  (n'ident,  for  the 
sum  of  the  deaths  and  discharges  among  them  numbers  178.7  animally  per  thousand  ot 
strength  as  against  135.68  among  the  white  troops. 

The  infrequency  of  dischai-ge  among  the  colored  troops  inay  be  attributed  chiefly  to 
their  peculiar  condition  at  that  disturbed  period  of  their  history,  and  to  the  more  rapidly 
fatal  course  which  disease  certainly  ran  when  these  men  became  its  subjects.  While  7.1  y 
whites  were  annually  discharged  on  account  of  diarrhoea  and  dysentery,  5.99  on  account  of 
debility  and  8.43  on  account  of  consumption  from  eveiy  thousand  men,  in  the  hope  that 
the  change  of  climate,  scene  and  surroundings  consecpient  on  a  return  to  their  north(>rn 
homes  would  tend  to  prolong  existence,  the  corj-esponding  figures  for  tlie  coloi-ed  troops 
were  only  1.87,  2.82  and  3.09.  The  cases  representt?d  by  the  ditference  li.dween  these 
figures  were  retained  in  hospital  until  the  occurrence  of  the  fixtal  event,  in  some  instances 
because  of  the  imminence  of  that  event,  in  others  because  of  the  homeless  condition  of  the 
colored  soldier. 

Transfers  to  the  veteran  reserve  corps. — The  list  of  men  discharged  for  disa- 
bility would  have  been  considerably  larger  but  for  the  establishment  of  the  Veteran 
lieserve  Corps.  This  command  absorbed  a  lar^e  number  of  men  who  would  otherwise 
have  been  discharged.  From  certain  tables  appended  to  a  report  of  Surgeon  J.  H.  Baxtkm, 
U.  H.  Volunteers,  Chief  Medical  Officer,  Provost  Marshal  General's  Bureau,  dated  April 
28,  1864,  it  is  found  that  among  officers  the  principal  disabling  cause  was  wounds  received 
in  battle.  Of  636  officers  transferred,  426,  or  two-thirds  of  tlu;  whole  immber,  were  the 
subjects  of  gunshot  wounds  which  prevented  their  participation  in  active  or  field  service. 
Among  the  enlisted  men,  however,  disablement  by  disease  was  more  extensive  than  by 
wounds.  Of  a  total  of  25,031  transferred  in  1863,  6,067,  or  242.3  per  thousand,  were 
occasioned  by  gunshot  wounds,  and  2,037,  or  81.4  per  thousand,  by  injuries  mainly  also, 
perhaps,  caused  by  gunshot.  Deducting  these  cases  from  the  total  it  is  found  that  16,927 
were  transferred  on  account  of  disease.  Chronic  diarrhoea  and  general  debility  were  the 
chief  causes  of  disablement  in  these  cases,  the  former  having  occasioned  the  transfer  of 
2,292  men,  or  135.4  per  thousand  of  the  total  from  disease,  and  the  latter  1,916,  or  115.0 
])er  thousand.  Consumption,  which  figured  so  largely  in  discharges,  was  found  in  only 
217  of  the  transfers,  or  in  12.8  per  thousand  of  those  ior  disease.  But  disease  of  the 
heai-t,  i-heumatism  and  hernia  contributed  as  largely  to  the  constitution  of  the  Invalid 
Coi-ps  as  to  the  list  of  discharges.  Heart  disease  occas-ioned  1,735  transfers,  or  102.5  per 
thou.sand  of  the  total  from  disease,  rheumatism  1,363,  and  lumbago  427,  a  total  of  1.790 
cases,  or  105.7  i)er  thousand,  and  hernia  1,017,  or  60.1  per  thousand. 


29 


n.— MEDICAL  STATISTICS  OF  THE  CONFEDERATE  ARMIES. 


The  sources  of"  the  httle  iiiforinution  we  possess  concerning  the  prevalence  and  fatality 
of  disease  in  the  Confederate  armies  have  already  been  noted  in  connection  with  the  subject 
of  diarrhoea  and  dysentery.*  They  consist  of  the  monthly  returns  of  sick  and  wounded  of 
the  Army  of  the  Potomac  for  the  nine  months  from  July,  1861,  to  March,  1862,  the  reports 
of  certain  general  hospitals  in  Virginia  for  the  four  months,  September  to  December,  1862, 
the  original  registers  of  the  Chimborazo  Hospital,  Richmond,  Va.,  extending  from  October 
17,  1861,  to  March  31,  1865,  and  the  figures  published  by  Dr.  Joseph  Jones,  of  New 
Orleans,  La.,  as  compiled  from  the  records  of  the  Surgeon  General  of  the  Confederate 
States  Army. 

The  Returns  of  the  Army  of  the  Potomac  give  151,237  as  the  number  taken  sick 
and  wounded  during  the  nine  months  in  an  average  strength  of  49,394  inen.  The  cases 
of  sickness  numbered  148,149,  equiv^alent  to  three  entries  per  man,  3,019  jier  thousand, 
during  the  nine  months,  or  to  four  entries  per  man,  4,025  per  thousand,  for  the  year.  The 
United  States  Army  of  the  Potomac  during  the  same  nine  montJis  had  2,136  cases  per 
thousand  of  strength,  equivalent  U)  an  annual  rate  of  2,848  cases.  The  deaths  on  the 
Confederate  returns  number  2,016,  but  they  are  given  only  as  the  total  number  that 
occurred  among  the  sick  and  wounded;  their  distribution  among  the  specified  diseases  and 
wounds  is  not  known. 

The  hospital  reports  show  48,544  admissions,  of  which  34,890  were  lor  specified 
diseases;  but  the  deaths,  1,899,  are  not  distributed. 

The  registers  of  the  Chimborazo  Hospital,  Richmond,  Va.,t  which  have  been  carefully 
examined  and  freed  from  duplication  of  cases  originating  in  transfers  from  ward  to  ward, 
show  a  total  of  77,889  admissions;  14,661  of  these  are  recorded  under  the  headings  of 
Class  V  of  the  U.  S.  sick  reports,  comprising  wounds,  accidents  and  injuries,  12,057  have 
no  entry  in  the  column  of  diagnosis,  50  are  reported  as  malingerers  and  771  as  conva- 
lescents, without  specification  *of  the  disease  or  injury.  There  remain  50,350  cases  of 
specified  sickness,  but  the  result  in  26,501  of  these  cases  is  unknown,  as  14,464  were 
transferred  to  other  hospitals,  5,537  were  furloughed,  while  in  6,500  no  disposition  is 
recorded.  Of  the  cases  with  known  results,  23,849  in  number,  19,457  were  returned  to 
duty,  and  to  these  may  be  added  998  terminated  by  desertion;  2,717  died  and  677  were 
discharged.  The  mortality  was  therefore  11.39  per  cent.,  equivalent  to  one  death  in  every 
8.8  terminated  cases.  An  abstract  of  the  cases  in  this  hospital  is  given  on  the  following 
page. 

Some  interesting  data  bearing  on  the  mortality  of  disease  in  general,  and  of  some 
specified  diseases,  may  be  gathered  from  the  various  [Miblieations  of  Dr.  Joseph  Jones. J 

*  Ta^p  2<),  Prtrt  St-cnnil  of  tliis  work. 

I  KcfiTfiuM!  \viis  iiijwlf  in  It  foitt-notc  on  ynixf  "H  of  tlit*  Second   Part   of  this  work  to  a  partial  stat«'int'nt  of"  tlo'  statistirs  of  this  liospital  by  Or. 

JohKI'll  .JtiNkh  (Hii-hvtinifl  ami  J.nitiavillf  Mt>l.  Jour.,  .hint*.  IH70.  p.  (I.'iO).  anti  roasons  wt'rp  assi^nfil  for  prfft-rriiiif  to  tt tlip  iiiorf  t'oiiiplFt<>  statistii'.s 

rtimpilftl  from  tiip  liospilal  n'^'i.-.tors.  Aiiothor  partial  st;tlfnit>nt  of  tin?  statistirs  tif  this  hospital  was  pnbiisjit'd  l>y  .S.  K.  llAltKltsltAM  —  'tfix.  on  fhr 
slatislirs  o/"  Chimhorazn  limpilal,  trith  rt'imirkx  uiunt  Uir  trrttlinrnt  of  rurious  iti.<fiiKf,i  <lttrimj  ftii-  irirtit  rii'it  irnr.  —  Xashrittf-  Jour,  nf  MfL  and 
Siir;/.,  N.  .S.,  Vol.  I,  ICtKI,  |i.  4lfi— hut  Itr.  II.MlEliKl{.».M's  tabip  t-overs  only  the  |wriotl  from  littol»T.  IHi;l.  to  Xovi'inlH-r.  IHK.1.  tvhiltt  thp  rpjfistcrs  iinlmle 
the  facts  tip  to  Marcli  31,  186.5.  The  fttrmer  ftnits  ilj*  only  :t(i.H47  Htiinissions  for  all  tliseasfs.  with 'J.;Hi:i  tleaths,  while  the  hitter  ^ive  TT.Ht^il  eases  atni 
3,'Mi  ileaths. 

t  Jt>-NEt> — Obnfreatioiig  on  thf  Umux  nf  tin-  Cim/t'fttralf  armies  ffoiii  lUi/llf,  tfr. — Kirhtnowl  and  LottiaviUr  Mr<l.  Jnnr..  ttettjber  ami  Noveniln-r, 
JHtilt.  ami  .Mareh  antl  .lune,  IH70.  Esttai/  on  tfir  prfaitenrr  of  J'nfunionia  anil  Tiiphoiit  Fever  in  the  Confe'frratr  fnrcex,  ami  t)n  The.  dismxes  of  the  Ferkral 
}trisonfrx  vonjined  at  AndermnvUle,  publislietl  in  the  Medtral  Vofiinu  of  thr  Memoirx  of  the  United  States  St.ini:ary  Commiision,  New  York,  18ti7.  I'titu- 
mania  in  the  Confederate  Army,  in  Vol.  1  t.f  his  Medical  and  Sunjival  Memoirs.  New  Orleans.  1876. 


30 


SIOKJNlKtiS    ANI>    MORTALITY 


Taiile  XII. 

An  Abdract  of  the  cosch  of  Specified  DmxiHCH,  with,  recorded  terminations,  and  of  the  Deaths  among  such 

cases  at  the  Chimborazo  Hospital,  Richmond,  Va. 


SrECIFIEli   DIBEASE8. 

3 

•a 

i  ^  9 
2  °  S 

0 

•3 
& 

o 

a" 

o 
I.J 

S  J  3j 
III 

2,153 
1,988 

760 
4,644 
5,780 

189 
1,984 

119 
1,  099 
l,.'j«8 
3,565 

885 
125 
166 
455 

117 
52 
80 

e 

89 
583 
1.57 

41.11 
6.29 

21.84 
9.80 
S.02 

27.51 
4.03 
6.  72 
8.  10 

37.  18 
4.40 

11.39 

32.5.  7 
46.0 
61.1 

167.5 
43.1 
19.1 
29.4 
2.9 
32.  8 

214.6 
57.8 

23,  849 

2,717 

1,000 

He  states  that  the  reports  of  sick  and  wounded  filed  in  the  Office  of  the  Surgeon  General 
of  the  0.  B.  A.,  e.x;clu.siv(i  of  those  from  the  Trans-Mississipjii  department,  gave  the  follow- 
ing figures  up  to  December  81,  1S62: 


On  Field  Returns. 


All  dls<'a.'*p.'i  and  uoiithIh. 
fJun.'*lin(  wnimd.s 


All  iliKi>a,ses  and  wound.s  except  ^tinslint  wuimdi. 


84^,  .W5 
29,  569 

818,  986 


16,220 
1 ,  623 


14,  597 


ON  Hosriw 
Cases. 

L  KErORTS. 
Deaths. 

Total 
Deaths. 

441,689 

19,  359 

35,  .579 

47,  724 

2,618 

4,241 

393,  965 

16,741 

31,3.38 

Dr.  JoNKs  has,  Jiowevei',  pointt'd  (Mit  that,  on  account  of  tlie  repeated  transfers  of 
patients  from  one  lios|iital  to  another,  the  number  of  cases  shown  by  the  hospital  reports 
as  admitted  for  treatment  bears  no  ascertainable  relation  to  the  actual  numljer  of  patients 
admitted  fnjiu  tlie  field.  This  will  readily  be  acknowledged,  in  view  of  the  fact  that 
while  a  total  of  oul\'  10<S,()68  cases  wei'e  sent  from  the  field  to  general  hospitals,  no  less 
than    Ili.tiSU  cases  were  i-epoi'ted  a.s  admitted  on  the  hospital  registers. 

ISiit  since  tilt,'  s\'stem  of  i'e|iorts  in  the  ( 'oiilederate  army  was  similai'  to  that  employed 
in  oU!'  own  service,  and  since  the  liospital  cast's  in  both  sei'vices  were  derived  ti'om  similar 
soun-e.s,  I'onsistiiig  of  those  frt.aii  the  Hi/ld,  those  originating  m  the  hospital  |)opulation,  and 
an  indefinite  nunibef  fi'oiii  men  and  commands  on  detached  or  sjiecial  duties,  the  number 
of  cases  borne  on  the  field  reports  of  each  sei'vice  maybe  compared  with  the  corresponding 
number  of  deaths  in  field  and  lios]>ital,  with  the  view  of  contrasting  the  relative  nioilality 
from  disease  in  the  two  armies.      In  accordance  with  Dr.  JoXEs'  figures,  31,338'='  deaths  in 


*  'I'liesf  iiiinibers  slmuld  imiliubly  he  :11.238  and  819,286;  see  the  totals  ill  Table  -XIII  nf  the  text.     Dr.  JO-VES'  statistics  are  full  of  inaociiracies, 
the  result  ajti^arently  of  careless  preparation  and  proof-reading. 


AMONG    THK    CONFEDERATK    TROOPS. 


31 


field  and  hospital  corresponded  with  818,986  cases  of  disease  and  injury  other  than  gunshot 
wounds.  The  deaths  constituted  3.82  per  cent,  of  tlie  cases,  or  in  other  words,  were  to  the 
cases  as  1  :  26.  In  recasting  our  statistics*  to  conform  to  the  classification  adopted  by  Dr. 
Jones  in  his  statement  tabulated  above,  it  is  found  that  from  the  commencement  of  the 
war  to  December  31,  1862,  the  total  number  taken  on  sick  report  for  all  causes  except 
gunshot  wounds  was  1,709,416  cases,  of  which  34,326  died,  the  deaths  constituting  2  oer 
cent,  of  the  cases,  or  being  to  them  in  the  proportion  of  1  :  50. 

The  following  table  contrasts  the  ratios  calculated  from  Dr.  Jones'  figures  with  those 
obtained  from  the  statistics  of  our  army  for  the  same  })eriod: 

Table  XIII. 

A  Comparison  of  the  Prevalence  and  Fatality  of  Disease  in  the  Opposing  Armies  from  the  Commcnecme7it 

of  the  War  to  Decemhe)-  31,  1862. 


Continued  Fevers 

Malarial  Fevers 

Eruptive  Fevers 

Piarrhcea  ariit  Dysentery 
Pulmtinary  afTeetinns  ... 

Kheumatism 

AU  otlier  diseases 


Total  diseases  anil   injuries  exclusive 
shot  wounds. 


in!y  of  g-nn- 


CONFEDKRATE  FORCES. 


3(!,746 
ll.'),4l.'i 
44,  41)8 

aao,  Has 

4'J,  204 

S.»l,  .Tt4 

324,  ;i--'l 

sill, -JWi 


12,225 
1,333 
2,274 
3,354 

7,  H72 


4,(180 


in  « 
^  cs  o5 


45 
141 

.54 
277 

5! 

Wi 


1.1 


o*  a  2 

■«|s 

-  3E^ 
.£5- 


391 
43 
73 

107 


33.  27 
1.  15 
5.12 
1.4H 

IH.  H!) 


I.2ii 


U.  S.  Foui'HK. 


51,923 
274, 053 

38,  888 
482, 7tv4 
I9i;,  5117 

8H,  -175 
.Wil,  74(i 


U,  .Wl 
2,  Ii03 
2,050 
(i,  040 
■I,  (107 
12:.' 
7,  333 


l,7(iil,llll  ,  3t,32U 


•n  **-  I 

*  rt  i 


E  '^ 

30 

337 

1(10 

76 

23 

(iO 

283 

I7(; 

115 

134 

.12 

3 

337 

214 

1,0(X) 

1 

000 

2->.  2H 

.05 

S.i.*? 

L'.  \\\ 

.14 
','.  01 


It  is  greatly  to  be  regretted  thai  Dr.  Jonks  lias  not  publi.slu'(.l  the  mean  strength  Ibi- 
the  period  corresponding  to  his  sick  reports,  lie  has  given,  it  is  trne,  the  mean  strength 
represented  by  the  fiehi  reports  of  the  Confederate  Army  for  caeli  month  Kii  185:^  and  for 
the  tirst  six  months  of  ISli'^-j*  bnt  as  no  mean  strength  for  18*^1  is  tabnhited,  and  as  there 
is  no  way  of  ascertaining  what  portion  of  the  figures  given  in  his  text  belongs  to  that  year 
and  what  portion  to  1862,  it  is  impossible  to  comjmte  trustworthy  ratios  of  cases  to  strengtli 
for  either  year. J     Nevertheless,  by  rtiaking  use  of  the  sick  report  of  the  Confederate  Army 

*  Published  in  Tables  HI.  XXIV  and  XLVn,  Part  First  of  this  work.  t  Richmmid  aud  L'mi.^rilfe  Medknl  Juitruni.  WA.  VIH.  IHtiit.  p.  Xil. 

JNor  can  any  assistance  be  obtaint-d  in  this  cunnprtion  IVntn  an  intereslirif^  article  published  ori^finally  in  the  Xtw  York  Trihiinf.  and  subsequently 
reprinted  in  the  Historical  Magazinf — Mit.stt'r-rolls  of  thf  Confrderafe  Army  for  I8t)2,  18(13  a  nfi  1864.  Th»'  Historical  Matjaziiiv  and  Xotcsand  Qnfrirsron- 
ffrniiig  the  Antif/itities.  History  ami  Hioyraphii  of  Amt  rira.  Mdrrisania.  New  York,  Vol.  II,  N.  S.,  iHtiT,  pa^e  Kilt,  Mr.  Hkxkv  H.  OAWtsoN,  the  editor  of 
this  magazine,  invited  the  attention  of  tlie  Sur|rc(iii  (Jeneral  to  the  article  cited,  as  likely  to  prove  useful  in  conneetion  with  the  data  collected  by  I>r.  Jo\es. 
Unfortunately  the  statements  in  this  article  referring  to  the  year  IH<)]  are  too  frajfnientary  to  l)e  used  in  conipiulii^  ratitis.  Indeed  they  cnnid  not  be  safely 
so  used  were  they  as  complete  as  the  fijifures  for  IHtii',  contained  in  the  same  article.  This  will  Iw  readily  understood  on  c<»mparin^  the  stren^'-ths  re|H)rted 
for  18ti-J  with  those  given  by  Dr.  tloXKS.  'i'hus.  the  article  in  ijuestion  contains  a  table  pur|N»rting  to  give  "approximately  and  in  nunul  numbi>rs  the 
strength  and  di'*iH>sition  of  the  difl^'erent  Confederate  armies  at  s*'veral  important  peiinds  during  the  war."  Two  of  these  perioils  fall  within  the  year  IHti'J. 
The  first,  for  July  'JO,  IHti'J,  does  not  include  the  Trans-Mississippi  department,  anti  gives  the  total  strength  of  the  "Armies  4»f  Kast  and  West"  at  'JH!),(K>0 
present,  of  whom  lJ17.(KM)  are  reported  "for  tbity.''  Now  the  tabic  of  l>r.  .loNK:^,  referred  to  at  the  couuneni'cment  of  this  note,  which  also  does  not  include 
the  Trans-Mississippi  department,  gives  the  "  mean  strengtli,  oflicers  and  men."  for  July,  186-J,  at  79.y'j!(.  The  .se<u)nd  period  for  which  the  total  strength  of 
the  "Annies  of  East  and  West"  are  given  in  the  Historical  Magmine  is  September,  18tm;  this  includes  the  Trans-Mississippi  4lepartuient.  Deducting 
the  force  rejtorted  for  that  dei>artment  there  still  remains,  accoriiing  to  the  nmgazine  article,  a  force  of  •JJ8.0(M)  [»resent,  of  whom  Ut.'j,000  are  reported  for 
duty.  But  Dr.  Jones  gives  the  "mean  strength,  officers  and  men."  for  Se|>teniber,  18l>*J,  at  125,408.  N<»r  does  this  enormous  discrepancy  indicate  any 
unfaithfulness  on  the  part  of  either  autlioriiy.  The  magazine  writer  atternpte*!  to  give  a  correct  notion  of  (he  wlnde  Confederate  force :  Dr.  JtiNErt  ne<:e,s- 
sarily  intended  <mly  to  give  the  actual  nu'an  strength  of  that  part  itf  the  Confederate  force  represented  by  the  sick  reports  to  which  he  had  access.  Ratios 
computed  from  the  cases  and  deaths  derived  from  the  latter,  and  the  strengths  derived  fn>m  the  former  source,  would  understate  the  sickness  and  mortality 
of  the  Confederate  armies  to  an  indefinite  extent. 


32 


SICK.Ni>S    .\]S'D    MORTALITY 


of  tile  PiAuiiuic,  [ifoKt'rved  by  Dr.  Wll.LlAMS,  iiiid  of  ccrtiiiii  figures  [Uiljlished  by  Dr.  JoNES,* 
it  is  possible  to  calculate  siek  I'ate.s  for  a  jiart  of  the  CuiifeJerate  forces  diiriiig  certain  periods 
prior  to  July,  1868,  the  aL;ii:rei;;ate  monthly  strength  represented  being  123,257  men.  In 
Table  XIV  the  information  gathered  concerning  these  forces  is  presented  and  calcidaled  into 
ratios  pt'r  thousand  sti'engtli,  which  are  [>hiced  for  comparison  in  juxtaposition  with  the  rates 
lui'iiished  by  the  white  troops  of  the  United  States  Army  during  the  year  1863. 

Tablk  XIV. 

Catics  of  SicJcncss  and  Wouiidti  reported  from  certain  of  the  Confederate  Ar^nies  during  portions  of  the 
years  ISfJJ.  1<SG,'J  and  1S63,  ivith  the  strength  present  during  the  periods  corered  bij  the  statistics, 
and  the  calculated  animal  rates  per  thousand  of  strength,  in  juxtaposition  icith  the  corresponding 
rates  of  the  United  States  Army  for  the  year  ending  June  30,  1863. 


■ 

a 

£  - 

c  — 

f  .^ 

i 
< 

ifl 

Q 

a;  — 

g<;22 

1— ' 

Army  of  tlie  Valley   of  Vir- 
ginia, January,  lHti2,  to 
S           October,  1862. 

1 

r 

Annual  Rates  pkb  tiious- 

AX1>  OF  MEAN  AcnKEGATE 
STRENGTH. 

9 

19 

19 

12 

Confeder- 
ate Army. 

U..S. 
Ariny. 

49,394 

25,732 

6,752 

40,282 

15,582 

123, 257 

Cast's  of  disease  and  wounds 

151,237 

157,  113 

58,  4.'>3 

226,  721 

53, 198 

646,722 

4,563 
159(a) 

2,861 
93 

4,404 

2,768 

10, 197 
112, 788 

10,  li)7 

16,781 

36,  5T;.> 

3,  233 

734 

231 

31.", 

1,312 

19,  455 

275 

796 

987 

103 

19 

7 

12 

32 

415 

16 

7 

90 

87 

l-J.-.('.) 
4611 

41,526 

13,  940 

36,  665 



3,876 

fi43(/.) 

2,220 
445 
373 
184 

1,428 

18,862 

373 

251 

1,953 

2,047 

1,161 

135 

45 

191 

408 

3,500 
176 

ni 

1,189 

9'A 

6,974 

1,138 

221 

902 

858 

11,575 

855 

290 

4,732 

.'i,  195 

J,  0.34 

211 

101 

85 

514 

.5,  408 

235 

36 

1,518 

1,040 

14,  622 
2, 683  ■ 

971 
1,677 
4,520 

58,800 

1,639 

688 

9,392 

9,136 

34 

1 
17      1 

Laryngitis 

Phthisis            

10 
il 

30 
192 

16 
6 

76 

76 

Acute  BrtmchitisandCatarrh,  including  rases  rpported  as  epidemic 
Cbroiiie  Bronchitis        

.  _      

(rt)  See  the  text  for  tlie  derivation  of  tliis  rat<*. 

{b)  To  effect  an  allowable  ei>niparist»n  between  tin*  I'nion  and  Confederate  fit^^nres  indicatitifj  i)reva!enee,  this  annual  rate  is  b;ised  on  the  rei>ortrt  of 
the  I'nion  .Army  of  the  I'otonuie  for  the  nine  months.  July.  1^61.  to  Mareh.  I^62.  inelusive. 

Tlie  imperfection  of  the  data  here  presented  is  obvious;  only  in  the  figures  of  the 
Confederate  Army  of  the  Potomac  are  the  cases  of  disease  se[)arated  from  thosti  of  wounds 
received  in  battle.  But  as  the  gunshot  casnalties  in  this  army  during  the  nine  months 
covered  by  the  records  do  not  fairly  represent  thi/  iVeipiency  of  thest.'  injuries,  thi'  I'ate 
derived  from  them  cannot  with  |>roprietv  be  applied  to  the  consolidated  Hgui'es  tVoin  the 

*.Sec  pages  571-589  of  tlie  Mnliull  \'hlume.  ufthe  I'.  S.  Sanitnnj  Vummisiioti  Memoirs,  New  York,  1867. 


AMONG    THE    CONFEDEKATH    TRUOPt?.  3B 

otlitT  Jupartiiient^;.  Fortiuiatoly,  Hf.  JoNES  lias  put  oil  record  figures  which  sliow  the  reUi- 
tiou  of  gunshot  wouiu.ls  to  cases  nf  (Hsease  iu  the  greater  part  of  the  Confederate  forces 
during  tlie  first  year  and  a,  halt  of  the  war.  The  total  munber  of  cases  of  wounds  and 
(Hsease  reported  by  him  was  848,555,  of  gunsliot  wounds  29,56*).  These  figures  authorize 
the  statement  that  the  tabulated  annual  rate  of  disease  and  wounds,  4,563  per  thousand 
strength,  included  about  159  injuries  received  in  battle.  The  annual  rate  for  disease  alone 
is  thus  seen  to  have  been  4,404,  which  may  be  compared  with  the  corresponding  rate  of 
2,768  among  the  Union  forces.  Continued  and  malarial  fevers,  diarrhiea  and  dysentery, 
bronchitis  and  i)neumonia,  were  apparently  th(,'  chief  causes  of  the  increased  rate  among 
tlie  southern  troops.  An  expression  of  the  mortality  rate  per  thousand  of  strength  cannot 
be  directly  obtained  from  the  data  presented.  I3ut  since  the  sick  rate  has  been  found  to 
number  4,404  cases  annually  per  thousand  of  strength,  while  the  fatality  rate  was  3.8  per 
cent.,  the  annual  number  of  deaths  per  thousand  strength  must  have  been  167.3,  a  rate 
larger  even  than  the  average  annual  mortality  among  oui'  colui'i'd  troops.  l";Xce[ition  may 
be  taken  to  this  calculation  as  the  sick  and  fatality  rates  used  ai>!  derived  from  different 
sources,  but  it  serves  to  indicate  in  a  general  way  the  greater  relative  mortality  among  the 
smaller  number  of  combatants  on  the  soutliern  side. 

In  brief,  so  far  as  com}>ansou  can  be  made  with  the  statistics  at  command,  disease  was 
not  only  more  fatal  among  the  Confederate  forces,  but  the  number  of  cases  in  proportion 
to  the  strength  present  was  considerably  greater  among  them  than  among  the  United  Btates 
troops. 


III.— PREVALENCE  AND  MORTALITY  OP  DISEASE  AMONG  THE  UNION  TROOPS  IN 

CONFEDERATE  PRISONS. 

The  fragmentary  character  of  the  evidence  relating  to  tin;  diseases  of  the  Federal 
prisoners  in  the  hands  of  the  Confederates  has  already  been  indicated."^'  The  statistics  at 
command  are  derived  from  the  original  registers  of  the  hosjiitals  attached  to  the  Anderson- 
ville  and  Danville  prisons  and  certain  tables  prepared  by  Dr.  .Foseph  .Joxes  from  official 
records,  and  published  in  his  article  on  the  diseases  of  the  Andersonville  prisoners. f  The 
records  of  the  Adjutant  Greneral's  Office,  U.  S.  Army,  according  to  a  communication  from 
that  office  dated  .June  22,  1878,  include  the  cases  of  30,564  Federal  soldiers  who  died 
while  prisoners  of  w^ar. 

The  Andersonville  register,  extending  from  February  24,  1864,  to  April  17,  1865, 
inclusive,  shows  the  number  of  admissions  from  the  stockaded  prison  to  have  been  17,875, 
but  as  458  of  these  are  reported  as  having  been  cases  of  wounds  and  injuries,  and  1,430 
have  no  diagnosis  entered  against  their  names,  the  cases  of  specified  diseases  number  only 
15,987.  The  result  in  946  of  these  cases  is  not  recorded,  so  that  the  number  of  cases  of 
specified  disease  that  may  be  traced  to  their  tennination  is  reduced  to  15,041.  Cf  these 
11,086  died,  or  73.7  per  cent,  of  the  whole  number.      This  enormous  mortality  is  an  index 

""  Soe  i>iige  31,  Second  Piirt  nf  this  woik. 

t  Tliero  are  also  iu  tlio  Otiice  of  tlie  Adjutant  flciieral  u  list  of  Uxi  deaths  that  oei-uned  aiiionj^  siek  and  wounded  prisoner  at  Cahawba,  Ala.,  anil  two 
hospital  re^istei'S,  one  from  Hospital  Xo.  13,  and  the  otlier  from  a  ward  of  Hospital  No.  "Jl.  Kiehinond.  \'a.  But  these  retristers  are  valueless  for  statistical 
imriMfses,  as  so  many  of  the  patients  received  were  speedily  sent  e'sewhere;  and  in  the  ease  of  tlie  register  f>f  Hospital  No,  21,  the  disposition  of  so  many 
of  the  eases  is  uiireeorded.  'i'he  register  (if  Hospital  No.  13  extemls  from  .htne  2,  1863,  to  February  14,  IS*)."*,  and  contains  a  record  of  ti95  aduiissiona 
disposed  of  by  transfer  in  *)"J1  eases,  by  death  in  t)7,  and  by  desertion,  ete.,  in  7  eases.  The  register  of  Hospital  'Jl  extends  from  November,  18t»3,  to 
February,  18ti.'>.  Of  l,:i;j8  adini.ssions  it  is  not  stated  wlitit  beraiiio  of  llie  p:itifnts  in  olIH  instanees:  *J3t'  were  transferred,  '^2fi  paroled.  173  returned  to 
'(Uarters  and  3  detailed  :  one  is  said  to  have  esea|KMl  and  217  to  have  ili*d. 

Mkd.  Hlst.  I'T.  Ill— 5 


34 


SICKNESS    AND    MORTALITY 


of  the  condition  to  which  the  unfortunate  men  became  reduced  before  they  were  admitted 
to  tliis  so  called  hospital.  The  professional  mind  is  shocked  in  endeavoring  to  realize  the 
scenes  presented  in  an  establishment  the  wards  of  which  formed  the  portals  of  the  grave  to 
three  out  of  every  four  soldiers  wdio  had  the  misfortune  to  enter  them.  Indeed,  it  appears 
that  large  numbers  died  uucared  for  in  the  prison  and  were  removed  to  hospital  simply  for 
record  and  interment.  Hometimes  the  deaths  in  the  -prison  outnumbered  those  in  the  hos- 
pital. The  reports  for  the  week  ending  September  20,  1864,  show  the  occurrence  of  336 
deaths  in  the  former  and  334  in  the  latter  establishment.  At  this  particular  time  onedialf 
of  the  fatal  cases  were  already  terminated  when  taken  up  on  the  hospital  register.  The 
average  number  of  deaths  that  occurred  daily  during  the  occupation  of  the  depot  was 
thirty;  but  as  many  as  a  hundred  deaths  ^vere  recorded  in  a  single  day.  Certainly  the 
most  fatal  field  of  the  war  was  that  enclosed  within  the  stockade  at  Andersonville,  Georgia. 
Ratios  calculated  from  the  hospital  register  have  a  melancholy  interest  as  indicating 
the  manner  in  which  these  men  were  cut  down  in  the  flower  of  their  manhood.  They 
have  no  bearing  on  the  fatality  of  tlie  specified  diseases  as  the  number  of  those  sick  within 
the  stockade  is  not  known;  but  the  iidbrmation  yielded  concerning  tlie  relative  prevalence 
of  certain  grave  diseases  is  as  definite  as  if  complete  records  of  the  sickness  were  at  com- 
mand.    The  accompanying  table  gives  a  sunmiary  of  the  facts  gathered  from  the  register: 

Table  XV. 
Summarizing  the  Records  of  the  Hospital  at  Camp  Sumter,  Andersonville,  Georgia. 


All  diseases  mid  injuries. 


Woiiiuls  ami  iiijiiripy  . 
Not  specified 


Specified  diseases  . 


Continued  Fevers 

Malarial  Fevers 

Eruptive  Fevers 

Diarrhcea  and  Dysentery 

Debility 

Dropsy 

Consumption 

Kheumatism 

Scurvy 

Bronchitis 

Pneumonia  and  Pleurisy  . 
Other  diseases 


■d 


17,87.5 


45H 
1,430 

15,  mi 


283 

aM 

1(14 

;t:!:i 

498 
20^> 

I,  m-i 

S05 

.').-.:! 

446 


■£  S 


1,  001 


1«,  874 


411 
1,428 


15,  041 


2 

i;) 

o 

37 1! 

3ti 

ll» 


Total  specified  diseases i.'i,  987 


30 

377 

4 

64 

23 

946 


281 
241 
162 

6,  ;i7(J 

297 

479 

35 

172 

5,  285 
201 
489 
423 

1 5,  041 


12,541 


163 
1,292 


241 

163 

82 

5,  605 

192 

383 

26 

83 

3,  614 

141 

322 

234 


■2  5^ 

?3   ??  ~r 


d  3  £  S 


11,  086 


17.7 
15.9 
10.3 

459.9 

20.8 

31.2 

2.  2 

12  6 

354.2 
12  8 
34.6 
27.9 

1,000 


1,(X)() 

21.7 

14.7 

7.4 

505.  6 

17.3 

34.5 

2.3 

7.5 

326.  0 

12  7 

29.0 

21.0 


1,(XI0 


73.7 

85.8 
67.6 
50.6 
80.3 
64.6 
80.0 
74.3 
48.2 
68.4 
70.  1 
65.  8 
55.  3 


Diarrhoea  and  dysentery  caused  somewhat  less  than  onedialf,  and  scurvy  somewhat 
more  than  one-third  of  the  total  number  of  cases.     Under  these  two  headings  were  entered 


AMOWa    U^^ION    TKOOPS    IN    CONFKDEKATE    riUSONS. 


35 


Sl'i.l  of  every  thousand  cases,  leaving  only  185.9  cases  in  the  thousand  for  distribution 
among  all  other  diseases.  These  cases  also  occasioned  the  greater  part  of  the  mortality. 
Diarrhoea  and  dysentery  caused  505. 6  and  scur^•y  326.0  deaths  in  every  thousand  deaths  from 
all  diseases,  leaving  only  168.4  in  the  thousand  i'or  distribution  among  other  fatal  diseases. 
Dr.  Jones  has  fortunately  preserved  a  nionthlv  return  of  the  cases  and  deaths  in  the 
stockade  and  hospital  for  the  six  months  from  March  1  to  August  31,  1864,  giving  also 
the  mean  monthly  strength  during  the  period.'-'  From  this  paper  annual  rates  of  sickness 
and  mortality  per  thousand  of  strength  may  he  calculated.  Some  idea  of  the  relative 
prevalence  of  specified  diseases  an<l  of  the  mortality  caused  by  them  may  likewise  be 
obtained  from  the  information  thus  preserved.  In  the  following  table  the  facts  gathered 
from  the  paper  in  question  are  so  arranged  as  to  admit  of  comparison  with  the  analogous 
facts  from  the  records  of  our  troojts  in  the  field,  the  Confederate  forces  and  other  bodies  of 
men  already  submitted  in  Tables  11,  111,  IV,  XllI  and  XIV. 

Table  XVI. 

Oiling  a  genei-al  view  of  the  Sick  and  Death  Rate)^  from  prominent  diseases  and  classes  of  diseases  among 
the  Federal  prisoners  at  Anderso7iville  for  the  period  extending  from  March  1  to  August  SI,  186 1^. 
Average  present  19,Jf.53  prisoners. 


All  diseases  and  injuries 


"Wounds  and  injuries. 
Not  specified 


Specified  iliseases. 


42,  (i86 

238 
474 


eontinued  Kcvers 

Malarial  Fevers 

Eruptive  Fevers 

Diarriicea  and  Dysentery 

Debility 

Dropsy 

Consumption 

Kheumatism 

Scurvy  

Bronchitis 

Pneumonia  and  Pleurisy . 
Other  diseases 


Total  specified  diseases  . 


41,  974 

7.'.:) 
2,066 

236 
16,  772 

95.T 
1,556 

114 

S66 
9,501 
2,  808 

979 
4,  468 

41,  974 


s 

ce 

2§ 

•s 

'^r^ 

cC 

l« 

^ 

<  " 

7,712 

4,  388.  6 

21 

24.4 

.565 

48.8 

7,126 

4,315.4 

199 

77.4 

119 

:»,").  0 

80 

24.2 

4,529 

1,724.4 

170 

98.2 

319 

IfiO.O 

33 

11.8 

20 

89.0 

999 

976.8 

90 

288.  6 

266 

100.6 

302 

459.4 

7,126 

4,  aw.  4 

•Si 

■S  E 


c  9; 


792.8 

2.  2 
58.0 

7;k.  6 


20.  S 
12.  2 

8.2 

465.6 

17.5 

32.8 

3.4 

2.0 
102.8 

9.2 
27.4 
31.0 

732.6 


C.  0.  \ 

IS; 


1,000 


17.9 
70.7 
5.6 

399.6 

2-3.8 

37.1 

2.7 

20.6 

226.4 
66.9 
23.3 

106.4 


*■     "a 
ci.  •- 

IH 

9  to* 

*  S  «     . 

ft 


1,000 


27.9 
16.7 


17.2 


26.4 
4.0 


11.2  !  3,^9 


635.6 

23.9 

44.8 

4.6 

2.8 


27.0 
17.8 
20.5 
28.9 
2.3 


140.  2  I  10.  5 

12.  6  !  3.  2 

37.3  27.2 

42.4  '  6.8 

1,0(X)  I  17.2 


The  annual  sick  rate  per  thousand  of  prisoners  was  4,388.6,  or  nearly  double  that  of 
our  white  troops.     Xevertheless,  it  was  not  so  high  as  the  rate  which,  according  to  Table 

*  Memoirs  of  I'nited  States  Sanitary  Ormmission,  p.  524.  Dr.  JONRS.  op.  cit..  p.  r)67,  specifies  the  strength  for  eacii  of  the  six  months  and  gfives 
the  average  strenia^th  as  21,120  men.  Tliere  is  an  error  either  in  the  items  or  in  the  cul(Mdate<l  average.  liut  as  the  items  are  cxpresseil  hy  the  .same 
numbers  in  another  part  of  his  article,  p.  502,  it  seems  probable  that  the  error  is  in  the  <^ah'ulation.  the  correct  stren^h  for  the  six  months  being  19,453. 


36  SICKNESS    AND     MORTALITY 

XTV,  pivvailfcl  ill  ccriiiiii  poiiiuiis  of  tin;  Coiil'oclcr.ito  forces.  Tlii.s  demonstrates  merely 
that  tlie  methods  adopted  in  reporting  sick  men  in  the  Confedei'ate  ranks  was  not  observed 
in  the  case  of  the  xXndersonville  prisoners.  The  number  of  sick  was  certainly  vastly  in 
excess  of  the  number  of  recorded  cases.  When  Dr.  Jones  inspected  the  stockade  in  Sep- 
tember, ]864,  he  found  two  thousand  sick  exclusive  of  those  admitted  into  the  priscjn 
hospital,  and  as  there  was  but  one  medical  officer  to  attend  to  this  enormous  number  of 
patients,''' and  to  the  cases  brought  daily  to  his  notice  among  the  mass  of  the  prisoners,  the 
impossibility  of  preserving  an  accurate  record  of  the  cases  is  manifest.  Large  numbers  of 
the  prisoners  who  liad  never  been  entered  on  the  sick  list  were  suffering  from  severe  and 
incurable  diarrhoea,  dysentery  and  scurvy.  Slighter  ailments,  such  as  dictated  the  relief 
of  a  soldier  on  active  service  from  military  duty  and  his  entry  on  sick  report,  were  of 
necessity  unnoticed.  Hence  the  annual  ratio  of  sick  per  thousand  persons  present,  and 
the  ratio  of  deaths  to  cases,  as  represented  in  the  table,  are  certainly  far  from  accurate, 
and  arc  not  admissible  for  comparison  with  the  records  of  the  Confederate  troops  on  active 
service.  Nevertheless  Dr.  Jones  instituted  the  comparison  and  concluded  that  the  diseases 
referable  to  exposure  without  proper  clothing  and  shelter  were  as  prevalent  among  tbe 
Confederate  troops  as  among  the  Federal  prisoners.  The  following  liy  Dr.  J.  G.  Bates, 
who  was  on  duty  at  the  prison  hospital  from  April  22,  1864,  to  March  26,  1865,  is  of 
interest  in  this  connection: 

"  I  regret  to  say  that  the  supply  of  wood  was  not  sufficient  to  keep  the  prisoners  from  what  we  term  freezing 
to  death.  They  would  not,  perhaps,  actually  freeze  to  death,  but  a  patient  whose  blood  is  thin,  and  his  systeiu  worn 
down,  is  very  susceptible  to  the  influence  of  cold.  In  the  absence  of  sufficient  food,  sufficient  stimulus,  and  especially 
in  flio  absence  of  fuel,  numy  of  the  patients  (I  speak  now  of  what  I  saw  in  my  own  ward)  would,  during  the  night, 
become  so  chilled  that  in  the  morning,  passing  round,  I  would  remark  to  my  steward,  '  Last  night  did  the  work  for 
that  poor  fellow — he  will  die;'  or  'This  one  will  die;  I  cannot  resuscitate  him  with  the  means  in  my  hands,  his  sys- 
tem is  so  reduced.'  Lying  upon  the  ground  during  those  chilly  nights  (the  weather  was  not  freezing,  but  sufficient 
to  thoroughly  chill  the  whole  systeui),  the  i)atient  would  reach  a  condition  in  which  resuscitation  was  a  matter  of 
impossibility  after  he  commeuct^d  going  down  hill  from  this  exposure.  I  have  seen  a  number  die  in  that  way." — 
Report  on  the  Trculmtiit  of  I'rinoyicrs  of  i\'<ir  hy  the  Relel  Authorities,  2d  Sess.,  iOth  Cong.,  p.  118. 

The  figures  expressing  the  relations  of  individual  diseases  to  the  total  cases  of  specified 
diseases  are  modified  by  the  exclusion  of  the  many  cases  of  slight  ailments  which  were 
unnoted,  and  by  the  errors  in  diagnosis  consequent  on  the  disposition  of  so  many  cases  by 
one  medical  officer.  On  September  18,  1864,  906  new  cases  were  reported  as  taken  on 
sick  report;  but  as  none  were  so  reported  on  the  two  following  days,  it  may  be  assumed 
that  these  three  days  were  spent  in  the  transfer  of  the  men  in  question  to  the  sick  report. 
Ten  hours  daily  of  uninterrupted  labor  on  the  part  of  the  medical  officer  would  have 
afforded  about  two  minutes  for  the  diagnosis  and  treatment  of  each  case;  but  this  officer 
was  not  at  liberty  to  allow  so  much  time  to  the  new  cases,  for  the  1,102  cases  carried 
forward  from  the  previous  day  claimed  some  share  of  his  attention.  Naturally,  under  such 
conditions,  the  diagnosis  and  management  of  a  majority  of  the  cases  devolved  upon  the 
intelligence  of  the  probably  unskilled  men  who,  having  given  their  parole,  were  granted 
the  freedom  of  the  post  and  filled  subordinate  offices  in  its  domestic  economy. 

Overlooking  the  influence  of  inaccurate  diagnosis,  the  annual  death  rate  tabulated 
mav  be  accepted  as  a  close  approximation  to  the  actual  mortality.  In  this  consists  the 
chief  value  of  the  extracts  made  by  Dr.  Jones  from  the  records.  During  the  six  months 
7,712  deaths  occurred  in  the  average  strength  of  19,453  prisoners  present,  equaling  an 

*  "At  this  time  uiily  one  medical  ollicer  was  in  attentlaiioe,  whereas  at  least  twenty  medieal  otlioers  should  have  been  employed. " — Jones,  o/>.  ct't.^  p.  51ti. 


AMONG    UNION    TROOPS    IN    CONFEDERATE    PRISONS.  37 

annual  rate  of  792.8  }>er  thousand,  or  the  exlmction  ul'  tlic  whole  19,453  in  about  Hfteen 
months.  By  comparing  those  columns  of  Tables  XV  and  XVI  which  give  expression  to 
the  total  number  of  deaths,  it  will  be  found  tliat  the  mortality  was  much  greater  during 
tlie  first  six  months  than  during  the  last  eight  months,  7,712  deaths  having  been  recordeil 
during  the  former  period,  which  number  was  increased  to  but  12,541  by  the  addition  of 
those  that  occurred  later.  This  might  indicate  that  disease  became  less  prevalent  or  less 
fatal  as  time  progressed,  or  that  the  number  of  men  in  confinement  became  considerably 
reduced.  In  the  absence  of  a  knowledge  of  the  strength  present  this  point  cannot  be 
settled;  but  it  is  of  interest  to  observe  that  while  the  greater  number  of  the  specified 
diseases  participated  in. this  diminished  mortality  there  was  one  very  marked  exception. 
Thus:  deaths  from  continued  fevers,  numbering  199  in  the  first  six  montlis,  became 
increased  to  241  during  the  whole  perioil,  an  addition  of  oidy  42  fatal  cases  I'or  the  kist 
eight  months.  Malarial  fevers,  numbering  119,  became  correspondingly  increased  by  44. 
Only  2  deaths  from  the  eruptive  fevers  occurriMl  in  the  last  eight  months,  as  against  80  in 
the  earlier  period.  Diarrluea  and  dysentery  ended  fatally  in  4,529  cases  during  tlie  first 
six  months,  and  in  5,605  cases  during  the  whole  period,  an  addition  of  only  1 ,07()  deaths 
for  the  last  eight  months.  And  so  of  most  of  the  diseases  specifiiKl.  P>ut  siun-vy,  which 
occasioned  999  deaths  in  the  first  period,  had  by  the  end  of  the  second  period  increased 
the  number  of  its  victims  to  3,614  by  an  addition  of  2,613  cases. 

The  aggravation  of  the  scorbutic  element,  as  time  progressed,  is  manifested  by  these 
figure^.  Of  the  7,712  deaths  that  took  place  in  the  first  period,  diarrhoea  and  dysentery 
caused  4,529,  or  636  of  every  thousand,  and  scurvy  999,  or  140  of  every  thousand.  Of 
the  4,829  deaths  that  occurred  during  the  second  period,  diarrhoea  and  dysentery  caused 
1,076,  or  223  in  every  thousand,  while  scurvy  caused  2,613,  or  541  in  every  thousand. 
At  first  more  than  one-half  of  the  victims  fell  before  the  causes  of  diarrhoea  and  dysentery, 
but  later  scurvy  assumed  the  role  of  chief  executioner.  Together  tliey  occasioned  more 
than  three-fourths  of  the  total  mortality. 

Dr.  JoxES  says:  Tlie  efiect  of  scurvy  was  manifest  on  every  hand,  and  in  all  its  various  stages,  from  the 
muddy  pale  complexion,  pale  gums,  feeble,  languid,  muscular  motions,  lowness  of  spirits,  and  fetid  breath,  to  the 
dusky,  dirty,  leaden  complexion,  swollen  features,  spongy,  puri)le,  livid,  fungoid,  bleeding  gums,  loose  teeth,  (ede- 
matous limbs,  covered  with  livid  vibices  and  petechia^,  spasmodically  flexed,  painful  and  hardened  extremities, 
spontaneou.s  Incniorrhages  from  mucous  canals,  and  large,  ill-conditioned,  spreading  ulcers  covered  with  a  dark 
purplish  fungous  growth. 

In  some  of  the  cases  of  scurvy  the  parotid  glands  were  greatly  swollen,  and  in  some  instances  to  such  an 
extent  as  to  preclude  entirely  the  power  of  articulation.  In  several  cases  of  dropsy  of  the  abdomen  and  lower 
extremities  supervening  upon  scurvy,  the  patients  affirmed  that  previous  to  the  appearance  of  the  dropsy  they  had 
suffered  with  profuse  and  obstinate  diarrhoea;  and  that  when  this  was  checked  by  a  change  of  diet  from  Indian-corn 
bread,  cooked  with  the  husk,  to  rice,  the  dropsy  appeared.  The  severe  pains  and  livid  patches  were  fre(iuently 
associated  with  swellings  in  various  parts,  and  especially  in  the  lower  extremities,  accompanied  with  stifi'ness  and 
contractions  of  the  knee-joints  and  ankles,  and  often  with  a  brawny  feel  of  the  parts,  as  if  lymph  had  been  eflused 
between  the  integuments  and  aponeurosis,  preventing  the  motion  of  the  skin  over  the  swollen  parts.     »     »     » 

The  scorbutic  ulcers  presented  a  dark,  purple,  fungoid,  elevated  surface,  with  livid,  swollen  edges,  and  exuded 
a  thin,  fetid,  sanious  fluid  instead  of  pus.  Many  ulcer.s  which  originated  from  the  scorbutic  condition  of  the  system 
appeared  to  become  truly  gangrenous,  assuming  all  the  characteristics  of  liospital  gangrene. 

From  the  crowded  condition,  filthy  habits,  bad  diet,  dejecred  and  depressed  condition  of  the  prisoners,  their 
systems  had  become  so  disordered  that  the  smallest  abrasion  of  the  skin,  from  the  rubbing  of  a  shoe,  or  from  the 
effects  of  the  hot  sun,  or  from  the  prick  of  a  splinter,  or  from  scratching  a  mosquito's  bite,  in  some  cases  took  on  a 
rapid  and  frightful  ulceration  and  gangrene. 

Dr.  Jones  was  surprised  at  the  comparative  absence  of  typhoid  and  typhus  fevers, 
notwithstanding  the  prevalence  of  the  conditions  that  are  supposed  to  produce  them,  and 
attributes  this  to  the  immunity  derived  from  a  previous  attack,  or  to  an  insusceptibility 


38  SICKNESS   AND    MORTALITY 

resultlMg  from  continued  exposure.  According  to  tlie  records  continued  fevers  constituted 
only  17.9  of  every  thousand  cases.  They  were  thus  comparatively  rare,  but  this  arose 
from  the  increased  prevalence  of  diarrhoeal  and  scorbutic  cases  rather  than  from  the  actual 
infrequency  of  typhoid.  An  annual  rate  of  77.4  cases  of  the  continued  fevers  per  thousand 
of  strength  was  recorded;  and,  as  has  been  already  shown,  tlie  figures  representing  the 
prevalence  of  disease  within  the  stockade  greatly  understate  the  facts.  This  rate  is  con- 
siderably higher  than  the  average  annual  rate  among  our  white  or  colored  troops;  although, 
as  might  be  expected,  it  falls  below  that  shown  on  Table  XIV,  as  prevailing  in  the  camps 
of  the  Federal  and  Confederate  Armies  of  the  Potomac  when  typhoid  was  epidemic  in 
many  of  the  new  regiments.  Continued  fevers  caused  26.4  deaths  annually  in  every 
thousand  prisoners,  as  compared  with  11.6  deaths  among  our  white  troops. 

Malarial  fevers  were  infrequent  among  the  prisoners;  but  as  their  percentage  of  fatal 
cases  was  much  larger  than  among  the  United  States  or  Confederate  troops,  4  per  cent,  as 
against  1.15  and  .95  respectively,*  it  is  probable  that  numbers  of  intermittent  and  remittent 
attacks  were  not  recorded."]" 

The  other  diseases  specified  were  presumably  of  more  common  occurrence  among  the 
prisoners  than  among  our  troops  in  active  service;   certainly  they  were  more  fatal. 

Bronchitis,  which  in  the  field  gave  an  annual  death  rate  of  .49  per  thousand  of 
strength,  caused  a  rate  of  9.2  among  the  prisoners,  while  the  corresponding  rates  for  inflam- 
mation of  the  lungs  and  pleura  were  6.3  and  27.4. 

This  extensive  prevalence  and  terrible  fatality  of  disease  among  the  Andersonville 
prisoners  creates  no  surprise  when  the  unsanitary  conditions  affecting  them  are  taken  into 
consideration.  These  were  officially  investigated  by  Dr.  Jones,  and  are  fully  developed  in 
the  report  of  the  Committee  of  the  House  of  Representatives  on  the  treatment  of  prisoners 
of  war  by  the  rebel  authorities  during  the  War  of  the  Rebellion. J 

The  Andersonville  stockade  and  prison  hospital  were  established  on  a  naturally  healthy 
site  in  the  highlands  of  Suinter  County,  Ga.  Tlie  former  enclosed  twenty-seven  acres, 
consisting  of  the  northern  and  southern  exposures  of  two  rising  grounds,  between  which  lay 
some  swampy  bottom  and  a  stream  running  from  west  to  east.  In  August,  1864,  nearly 
33,000  prisoners  were  crowded  together  on  this  area,  which  afforded  but  little  more  than 
35  square  feet  for  each.  But  even  this  limited  space  was  not  wholly  available,  as  six  acres 
of  the  bottom  land  had  by  this  time  become  unfit  for  occupation.  Each  prisoner  had  there- 
fore scarcely  28  square  feet  of  surface  on  which  to  conduct  all  the  operations  of  nature. 
The  Confederate  guard  occupied  the  fortified  exterior  of  the  stockade. 

No  shelter  from  the  sun,  wind  or  rain,  the  dews  of  night  or  the  frosts  of  winter,  was 
furnished  by  the  Confederate  government.  Fresh  arrivals  of  prisoners  were  driven  into  the 
stockade  and  left  to  find  so  many  feet  of  foul  surface  for  their  occupancy  among  the  army 
of  ragged,  vermin-covered,  emaciated  and  dying  men  already  there.  The  pines  and  other 
small  trees  that  had  originally  sparsely  covered  tlie  enclosure  had  been  cut  down.  Frag- 
ments of  tent-canvas,  blankets,  oil-cloth  and  clothing  were  stretched  upon  sticks  as  a 
protection  from  the  hot  sun.  Some  of  the  men  burrowed  in  the  ground  and  others  built 
huts  of  the  mud  removed  from  these  burrows. 

The  sinks  were  built  over  the  lower  portion  of  the  stream,  but  the  volume  and  flow  of 
the  water  was  insufficient  to  carry  off  the  excreta.     Heavy  rainfalls  causing  the  stream  to 

*  See  Table  XIII  xu^a  p.  31.  t.See  t'n/ra,  note  *,  liagi' lliu, 

IReport  i\rt.  i'tj  House  nf  Reprexfjtiniiri'Sy  3//  Seas.,  40th  Cnnffress,  Oovenimetit  I'nTiting  Ortine.  Washingrton,  D.  C,  1869. 


AMONG    UNION    TROOPS    IN    CONFEDERATE    PRISONS.  39 

overflow  spread  the  foul  accumulations  over  the  adjoining  bottom  lands,  converting  them 
into  a  quagmire  of  fermenting  filth  the  stench  from  which  has  been  represented  as  horrible, 
sickening  and  indescribable.     Speaking  of  the  stream  as  it  issued  from  tlie  stockade,  Jones 

says : 

As  these  waters,  loaded  with  filth  and  hnniaii  excrement,  flow  sliigirishly  tlirough  the  swamp  below,  filled  with 
trees  and  reeds  coated  with  a  filthy  deposit,  they  emit  an  intolerable  and  most  sickening  stench.  Standing  as  I  did 
over  these  waters  in  the  middle  of  a  hot  day  in  September,  as  they  rolled  sluggishly  forth  from  the  stockade,  after 
having  received  the  filth  and  excrement  of  twenty  thousand  men,  the  stench  was  disgusting  and  overpowering;  and 
if  it  was  surpassed  in  unpleasantness  by  anything,  it  was  only  in  the  disgusting  appearance  of  the  filthy,  almost 
stagnant,  waters  moving  slowly  between  the  stumps  and  roots  and  fallen  truoks  of  trees  and  thick  branches  of  reeds, 
with  innumeral)le  long-tailed,  large  white  maggots,  swollen  peas,  and  fermenting  excrement,  and  fragments  of 
bread  u.  d  meat. 

But  the  pollution  of  the  soil  was  not  confined  to  the  bottomdands.  Many  of  the  men 
were  so  prostrated- by  diarrhoea  and  scurvy  that  they  were  unable  to  reach  the  low-grounds 
on  every  call  of  nature,  and  the  general  surface  of  the  enclosure  became  covered  with  their 
morbid  dejections.  The  ground  was  honey-combed  with  small  pits  a  foot  or  two  in  depth, 
which  were  used  as  latrines  and  emitted  an  intolerable  stench,  l^ater,  the  tattered  clothes 
of  these  men  became  the  receptacle  for  their  involuntary  discharges;  and  ultimately  the 
foul  and  wasted  forms  were  carried  out  for  burial.  In  the  vicious  atmosphere  of  this 
prison-pen  myriads  of  flies  and  mosquitoes  were  developed,  which  would  have  made  life  a 
misery  even  to  healthy  men. 

There  is  one  form  of  disease  which  is  almost  too  horrible  to  be  witnessed,  yet  we  cannot  understand  the  wretch- 
edness of  the  prison  without  looking  upon  it.  This  is  not  a  solitary  case,  but  we  shall  find  numerous  ones  before  we 
leave  this  living  charnel-house.  We  instinctively  pause  as  we  reach  the  awful  sight  before  us,  holding  our  breath 
lest  we  inhale  the  terrible  stench  that  arises  from  it.  Here  is  a  living  being  who  lias  become  so  exhausted  from 
exposure  that  he  is  unable  to  rise  from  the  ground,  suffering  from  diarrluva  in  its  last  form.  He  is  covered  with  his 
own  fa'ces;  the  vermin  crawl  and  riot  upon  his  flesh,  tumbling  undisturbed  into  his  eyes  and  ears  and  open  mouth; 
the  worms  are  feeding  beneath  his  skin,  burying  themselves  where  his  liml)S,  swollen  with  scurvy,  have  Imrst  open 
in  running  sores;  they  have  even  found  their  way  into  his  intestines  and  form  a  living,  writhing  mass  within  him. 
His  case  has  been  represented  to  the  surgeons,  but  they  have  pronounced  Lim  incurable,  and  he  is  left  here  in  his 
misery,  in  which  he  will  linger  for  three  or  four  days  more.* 

But  all  the  sick  in  the  stockade  were  not  left  thus  to  die  when  their  strength  had 
failed  them.  The  ]  ,292  fatal  cases  in  which  no  diagnosis  was  made  may  be  supposed  to 
represent  those  exceptional  cases  in  which  the  medical  officers  on  duty  became  first  aware 
of  the  sickness  by  a  knowledge  of  the  death.  It  will  be  observed  that  such  exceptions 
constituted  one-tenth  of  the  total  mortality. f 

In  fact,  an  effort  was  made  to  aggregate  the  sick  of  the  stocktide,  nearly  2,000  in 
number  at  the  period  of  Jones'  visit,  in  four  long  sheds  open  on  all  sides  and  situated  at 
the  north  end  of  the  enclosure.  Here  the  haggard,  helpless,  h'^peless  miserables  lay  side 
by  side  on  the  boards  or  upon  such  ragged  and  vermin-covered  blankets  as  they  possessed, 
without  bedding — without  even  straw — while  foul  emanations  and  swarms  of  flies  consti- 
tuted their  atmosphere. 

The  Confederate  Congress  in  May,  1861,  passed  a  bill  providing  that  the  rations 
furnished  to  prisoners  of  war  should  be  the  same  in  quantity  and  quality  as  those  issued 
to  the  enlisted  men  in  the  Army  of  the  Confederacy.  The  daily  ration  per  man  officially 
consisted  of  one  pound  of  beef  or  three-quarters  of  a  pound  of  bacon,  and  one  and  one- 

*  Op.  cit.,  last  note,  page  40. 

tit  appears  that  Andersonville,  Ga.,  was  not  the  only  prison  in  whic-h  the  sick  were  left  to  (lie  in  quarters  without  tlie  care  or  knowledge  of  the 
surgeon.  A  letter  to  this  office  from  the  Adjutant  (lenerars  Office,  dated  June  2"-},  1878,  states  that  for  the  month  of  December,  1864,  alone,  the  Confed- 
erate "burial  report"  at  Salisbury,  N.  C,  shows  tliat  out  of  1,115  deaths,  223  or  20  per  cent,  died  in  prison  quarters  and  were  not  accounted  for  in  the 
report  of  the  surgeou. 


40  SICKNESS    AND    MORTALITY 

quarter  pounds  of  corn-meal,  with  an  occjasional  issue  of  beans,  rice,  molasses  and  vinegar. 
Although  this  may  have  been  the  issue  at  first,  there  is  no  doulit  that  it  was  dirninishod  at  a 
later  period.  Isaiah  IF.  Whitk,  chii'f  surgeon  of  the  pi'isdii,  in  a  report  dated  August  ('), 
1864,  speaks  thus  of  the  diet  wf  the  prisoners  : 

The  ration  consists  of  onc-tliird  iiound  of  baton  and  oiit^  and  a  (iiiaiter  )>(>iinds  of  meal.  The  meal  is  nubolted, 
and  when  l)aked  the  liiead  is  coarse  and  irritatinj;,  jiriKliicinj];  diseases  of  tlie  or<j;ans  of  tlie  digestive  system  [diar- 
rhoea and  dy.sentery].  Tlie  absence  of  ve};etable  diet  has  produced  scurvy  to  an  alarminf{  extent,  especially  among 
the  old  prisoners. 

It  is  also  well  established  that  this  nuserable  diet  was  generally  not  onlv  of  an  inferior 
but  of  a  dangerous  quality.  The  beef  was  often  tainted,  the  bacon  decomposing,  and  the 
meal  musty,  innutritions  and  irritant,  th<>  cob  having  been  ground  up  with  the  grains. 
Moreover,  the  ration  was  frequently  issued  to  the  prisoners  imperfectly  cooked.  Nearly 
three  months  after  the  establishmcMit  of  the  prison  the  surgeon  in  charge  reported  to  the 
commanding  officer  that — 

The  bakery  and  other  culinary  arrangements  have  just  been  completed,  up  to  which  time  there  had  been  an 
inadf(|uatc  sup])ly  of  cooking  utensils,  and  in  conse(iuencc  thereof  the  articles  of  diet  have  been  insufficiently  cooked. 

FrrqiK'ntly  the  food  was  issued  in  the  raw  state.  Those  of  the  prisoners  who  had 
thr  strength  and  energy  to  cook  their  allowance,  lacked  the  necessary  fuel  and  kitchen 
utensils,  while  many  were  incapable  of  the  effort  had  all  the  facilities  been  aflforded.  The 
issue  had,  therefore,  to  be  devoured  in  this  condition,  if  the  pangs  of  hunger  were  acute 
and  the  individual  had  not  as  yet  rcache(l  the  stage  of  apathy  that  preceded  death.  Many 
also  were  incapable  of  eating  the  ration  even  if  properly  cooked,  on  account  of  the  condi- 
tion of  their  teeth  and  gums.  Lieutenant-Colonel  D.  T.  Chandler,  Assistant  Adjutant 
and  Inspector  General,  in  his  report  of  an  inspection  of  the  prison  on  August  5,  1864,  says 
of  the  rations  and  their  preparation: 

The  sanitary  condition  of  the  prisoners  is  as  wretched  as  can  be,  the  princii>al  cause  of  mortality  being  scurvy 
and  chronic  diariho'a,  tlu^  perctmtage  of  the  former  being  dis])r(iportionately  large  among  those  brought  from  Belle 
Isle.  Xotliing  seems  to  have  been  done,  and  but  little  if  any  eti'ort  made,  to  arrest  it  by  procuring  proper  food.  The 
ration  is  J-  pound  of  l>acon  and  li  jiounds  of  unbolted  corn-meal,  with  beef  at  rare  intervals,  and  occasionally  rice. 
When  to  lie  obtained — very  .seldom — a  small  quantity  of  molasses  is  substituted  for  the  meat  ration.  A  little  weak 
vinegar,  unfit  for  u.se,  has  sometimes  been  issued.  The  arrangements  for  cooking  and  baking  liave  been  wholly 
iiiadei|uafc,  and  though  additions  are  now  l)eing  completed,  it  will  still  be  impossible  to  cook  for  tlie  whole  number 
of  prisoners.  Raw  rations  have  to  be  issued  to  a  very  large  proportion,  who  are  entirely  unprovided  with  proper 
ufensils,  and  furnished  so  limited  a  supply  of  fuel  they  are  compelled  to  dig  w  ith  their  hands  in  the  filthy  marsh 
before  mentioned  for  roots,  &c. 

But  as  this  motiotonous  diet,  inferior  in  quality,  insufficient  in  quantity,  and  having 
its  intrinsic  harmful  properties  aggravated  by  the  absence  of  facilities  for  its  proper  prepa- 
ration was  undoubtedly  the  cause  of  the  diarrhu'a,  scurvy  and  starvation,  which  killed 
three-fourths  of  the  prisoners  who  were  buried  at  Andersonville,  and  contributed  largely 
to  the  fatal  event  in  the  remainder  of  the  cases,  all  details  concerning  it  have  a  high 
etiological  value.  The  following  is  therefore  submitted  from  the  lleport  of  the  Committee 
of  the  House  of  Representatives,  already  cited: 

The  rations  consisted  of  corn-meal,  bacon,  fresh  beef,  peas,  rice,  salt  and  sorghum  molasses.  The  coru-meal 
Avaa  unbolted,  some  of  it  ground  with  the  cob,  and  often  filled  with  sand  and  gravel.  Much  of  it  had  apparently 
been  put  up  while  warm,  and  had  become  sour  and  musty  either  during  transportation  or  while  in  store.  The  bacon 
was  lean,  yellow,  very  salt  and  maggoty;  it  bad  been  brought  to  us  unpacked,  and  was  covered  with  dirt  and 
cinders;  it  was  so  soft  with  rust  that  it  could  easily  be  pulled  in  pieces  with  the  fingers.  The  beef  was  slaughtered 
near  the  i>rison,  to  which  it  was  brought  and  throw  n  dow  u  in  a  pile  in  the  north  cook-house,  where  it  lay  until  it 
was  issued  to  the  prisoners.  Here,  in  the  hot  climate,  it  was  soon  infested  with  tlies  and  maggots,  and  rapidly 
changed  into  a  greenish  color,  emitting  an  ofl'ensive  odor  peculiar  to  decaying  flesh;  it  was  very  lean,  but  the  heat 


AMO.Nil    rxiOX    TlKioPs    IX    I'ONKKliKRATK    PRISONS.  41 

Veiideied  it  nuitf  teiidi'V  Im-Ioic  it  was  st-ivcd  np,  TIr'  :iiti<li'  (li-iiiiiiiiiiutfil  lilark  (icas,  or  f(>\v-j)fas,  was  brought  in 
sacks,  appaiviitly  just  as  it  liail  left  tlie  threshing;  j^iouud  ot'  tlu'  jnodiiiii .  liaviiiy;  luxri-  lit-iii  winnowed  or  tleansed 
(if  tlif  tint"  jiods  4)r  dirt  wliicli  iiaiiirally  mingles  with  all  leguniiiinus  plants  while  growing  in  1  he  field ;  liesides,  they 
were  tilled  with  Imgs.  and  many  of  them  were  so  I'aten  as  to  h'live  iiiitliing  lint  the  thick,  tough  skin  of  the  jiea  in 
its  natural  shape.  The  rice  was  snnr  or  musty .  and  hail  apparently  lieeii  put  up  in  a  lialf-dried  slate,  when  it  became 
hi'ated  and  wholly  untitte<l  for  use. 

There  were  two  cook-houses  used  in  eonneetion  with  the  jirison.  The  (irst  of  these  was  in  ]>ideess  of  erection 
when  the  detachment  to  vhieli  I  belonged  entered  thi'  pen.  and  wiMit  into  operation  aliont  the  middle  of  May.  It 
was  located  on  the  ncjrth  side  of  and  near  the  swamp  west  of  the  luison.  and  Wiis  subse(|uently  ench)se<l  by  the 
defensive  stockades.  At  the  lime  it  was  l>nilt  it  was  supposed  to  lie  of  snlticienl  capacity  to  iierform  all  the  cooking 
necessary  for  the  )irisoners,  au<l  contained  three  large  brick  ovens,  and  several  kctth'S  set  in  biick-work.  for  boiling 
the  meat  and  jieas  or  rice:  bul  ii  lieing  found  inadeipiate  to  sujiply  the  wants  of  the  men,  another  building  was 
constructed  some  time  in  the  latter  jiart  of  .August.  It  was  located  aliout  a  hundred  yards  north  of  thi^  defences,  on 
a  line  with  the  west  wall  <if  the  prison.  This  was  designed  and  used  exclusively  for  boiling  the  peas  and  the  meat, 
and  contained  jierhaps  a  dozen  large  jiotash  kettles  set  in  brick- work.  The  old  cook-house  was  thereafter  used  for 
baking  the  corn-meal.  A  strong  force  of  paroled  juisoneis  was  ajipointed  to  peif'orm  the  work  in  tliese  eook-lmn.ses, 
lint  with  constant  labor  was  unable  to  supply  onr  wants,  and  about  one-half  of  the  rations  were  issued  raw. 

The  meal  was  prepared  for  baking  by  first  |ionring  it  in  i|nantity  into  a.  large  trough  nnide  for  the  jmrpose.  A 
little,  salt  was  then  added,  when  water  enough  was  poured  in  to  make  it  of  the  iiroper  consistency,  and  the  whole 
stirred  with  sticks  to  nnx  it  thoroughly.  The  dongh  was  baked  in  sheet-iron  pans  twenty-lour  by  sixteen  inches 
in  surface  and  two  and  one-half  inches  dee]i.  The  wlude  was  divided  into  poiu'S  containing  about  a  iiound,  and  each 
of  these  poiu's  constituted  a  day's  ration  of  bread  for  one  num.  The  utmost  cleanliiu'ss  could  not  be  observed  in 
mixing  this  ''stutt';'"  the  meal, as  above  stated,  was  jiartly  corn  and  jiartly  cob, and  often  contained  materials  that 
were  neither  of  these;  the  water  was  dipped  in  qiuintity  from  the  creek,  and  lu)  means  of  cleansing  it  were  fnrnished; 
and  these,  with  the  haste  necessary  to  he  made  in  juejiaring  the  dough,  conspired  to  make  the  mixture  nn](alatahle 
and  sickening,  ])articularly  when  cold.  The  jirisoiKus  who  had  charge  <if  the  cook-hou.se  undoubtedly  tried  to  l>re- 
]>are  the  food  as  well  as  they  could,  but  all  of  their  efforts  were  in  vain  with  such  limited  facilities  as  they  hail. 

The  J>eas  and  rice  were  boiled  in  the  north  co<ik-honse;  they  were  turned  from  the  bags  as  they  weie  brought 
to  the  prison,  without  cleansing  or  se])arating  from  the  chatf  and  dirt,  into  the  large  potash  kettles  containing  the 
water  in  which  the  meat  had  been  boiled;  the  cooks  here,  as  in  the  south  cook-house,  had  no  means  of  cleansing  the 
raw  material,  and  had  they  j)ossesse(l  the  facilities  they  had  no  time  to  devote  to  the  purpose.  To  winnow,  semi- 
weekly,  a  suHicient  anmnnt  of  peas  for  10,000  rations,  allowing  a  third  of  a  pint  to  (^ach,  requires  a  long  time  even 
with  the  aid  of  the  best  nuichines;  lint  for  twenty  men  to  ]iick  over  liy  liaml  this  vast  amount  is  simjily  impossible. 
Of  tlie.se  cooked  rations  there  were  daily  issued  to  each  prisinuM'  about  a  pound  <if  liread,  a  fourth  of  a  pounil  of 
hacon,  or  four  or  six  ounces  of  beef  (including  the  bone)  in  jilace  of  the  liacon,  and  a  teaspoonfiil  <if  salt;  twice  a 
week  a  pint  of  peas  or  rice  wer<^  i.ssued  in  addition,  and  occasionally  a  couple  of  tahles])oonfuls  of  sorghum  molasses. 
Sometimes  a  sort  of  mush  was  nnide  to  take  the  place  of  the  i)one,  hut,  althougli  it  was  a  change  from  the  nionoto- 
nons  corn-hread,  it  was  so  unpalatahle  that  tlie  hread  w.as  j)referred.  About  half  of  the  rations  were  issued  raw; 
*  *  *  one-half  of  the  prisoners  receiving  raw  food  one  day  ami  cooked  the  next.  I  have  here  given  the  quantity 
issued  during  the  early  jiart  of  the  season  ;  but  as  the  liot  weather  advanced  and  the  number  confined  here  increased, 
the  daily  allowance  diminished  until  it  became  but  a  mere  morsel  to  each  num.  »  »  »  »  » 

Some  time  in  the  afternoon  the  ration-wagon  drove  into  the  stockade  laden  with  corn-meal,  hacou  and  salt, 
which  were  thrown  down  into  a  heap  in  an  open  space  about  midway  tlie  enclosure.  It  was  a  horrible  sight  to  wit- 
ness the  haggard  crowd  gathered  about  this  precious  pile,  while  the  commissary  superintended  its  division  among 
the  squad  sergeants;  gazing,  meanwhile,  with  wolfish  eyes  upon  the  little  heap  as  it  diminished,  or  following  their 
sergeant-commissary  back  to  his  (juarters,  as  famished  swine  follow  clamorously  the  footsteps  of  tlieii-  master  as  he 
carries  their  food  to  the  accustomed  trough.  The  rations  were  distributed  by  the  division-sergeant  to  the  mess- 
sergeant,  who  then  divided  them  among  the  men.  To  avoid  (luarrelling  during  the  last  distribution,  it  was  the 
custom  among  all  the  messes  for  the  mess-sergeant  to  separate  the  rations  into  as  many  small  parcels  as  there  were 
men  in  the  mess:  one  man  of  the  mess  was  placed  a  short  distance  off,  with  his  back  towards  the  parcels,  in  such  a, 
position  that  he  could  not  see  them;  the  mess-sergeant  then  pointed  to  one,  with  the  words,  "Who  has  this?"  to 
which  the  man  replied  announcing  the  name  of  the  recipient,  when  it  was  given  to  him.  In  this  manner  the  whole 
number  was  gone  through  with,  with  satisfaction  to  all. 

Iron  hake-pans,  like  tho.se  used  by  the  Confederate  soldiers,  had  been  i.ssued  to  the  prisoners  who  tirst  arrived 
at  this  place,  in  which  to  bake  their  own  meal  and  fry  their  bacon;  but  nothing  of  the  kind  was  ever  given  out 
afterwards,  to  my  knowledge.  The  United  States  soldiers,  as  is  well  known,  were  never  provided  with  other  cook- 
ing utensils  than  mess-kettles  and  mess-pans,  both  too  large  to  be  transported  in  any  other  way  than  upon  army 
wagons.  At  the  time  of  our  capture,  in  numerous  instances,  the  tin  cups  and  plates  which  we  had  were  taken  from 
us;  our  knives,  it  will  be  remembered,  were  confiscated  at  Danville;  nothing,  therefore,  was  left  in  our  po.s.session 
with  which  to  cook  our  raw  food  after  it  was  given  us.  How  to  accomplish  this  necessary  feat  was  a  grave  question. 
We  made  shift,  however,  with  chijis,  half  canteens,  tin  cups  that  had  escaped  confiscation,  and  pieces  of  sheet-iron, 
to  bake  one  side  of  the  stuff,  while  the  other  was  scarcely  warmed  through.  The  solder  of  the  tin,  melting  and 
mingling  with  the  bread,  added  another  to  our  almost  inunmerable  hardships.  I5ut  with  all  our  care  and  labor,  the 
rations  were  at  last  devoured  in  a  half-cooked  state — a  fact  which  aided  in  the  increase  of  the  frightful  misery  that 
subsequently  occurred,  quite  as  much  as  the  small  quantity  that  was  issued. 
Mei.   Hi.sr.,  I'T.  Ill— 0 


42  SICKNESS    AND    MORTALITY 

The  prison  hospital  covered  about  five  acres  of  ground.  It  was  established  in  a  grove 
of  forest  trees  which  aflforded  a  grateful  shade  to  the  unhappy  and  suffering  men.  Its 
atniosphere  was  polluted  l)y  tlie  foul  effluvia  from  the  stockade;  but  irrespective  of  tliis, 
its  (Avn  (Mnanations  rendered  it  as  unfit  for  occupation  as  was  the  general  pen.  Tlie  men 
were  crowded  together  in  old  and  I'agged  tents;  neither  beds  nor  straw  were  furnished,  and 
the  patients  lay  in  bunks  or  on  the  ground,  often  without  even  a  blanket  over  them.  Sick 
men,  unable  to  visit  the  latrines,  made  use  of  small  wooden  boxes  in  the  lanes  behind  the 
tents. 

Millions  of  flio.s  swaniifd  over  everytliiiij^  and  covered  the  faces  of  the  sleei)iiig  jiatients,  and  crawled  down 
their  open  months,  and  deposited  their  niagfjots  in  the  gangrenous  wounds  of  the  living  and  in  the  months  of  the 
dead.  Myriads  of  mos(iuitoes  also  infested  the  tents,  and  many  of  the  patients  were  so  stung  hy  these  pestiferous 
insects  that  they  a])]i(':ired  as  if  they  were  sufi'ering  from  a  slight  attack  of  measles.      *■«**» 

The  cooking  arrangements  were  of  the  most  miserable  and  defective  character.  Two  large  iron  pots  similar 
to  those  used  for  boiling  sugar-cane  were  the  only  cooking  utensils  furnished  by  the  hospital  for  the  cooking  of  near 
two  thousand  nu'ii;  and  the  patients  were  dependent  in  great  measure  upon  their  own  miserable  utensils.  They 
were  allowed  to  cook  in  tlie  tent-doors  and  iu  the  laues,  and  this  was  another  source  of  tilth  and  another  favorable 
condition  for  the  generation  of  Hies  and  other  vermin.* 

Tlie  rations  of  the  hospital  appear  to  have  differed  from  those  of  the  stockade  only  in 
having  an  occasional  addition  of  potatoes.  Indeed,  it  would  seem  that  but  for  the  shelter 
of  the  ragged  tents,  the  shade  of  the  trees  and  the  increased  area,  the  hospital  patient  had 
little  advantage  over  the  prisoner  in  the  stockade.  The  supply  of  medicines  was  generally 
deficient,  often  exhausted,  and  medical  comforts  were  unknown. 

At  the  time  of  Dr.  Jones'  visit  one  medical  officer  attended  to  the  sick  in  the  stockade 
while  three  were  on  hospital  duty.  Generally,  however,  the  medical  staff  consisted  of  six 
or  eight  for  the  prison  and  four  or  five  for  the  hospital.  These  officers  labored  faithfully 
to  alleviate  the  misery  and  suffering  by  whieli  they  were  surrounded,  but  unfortunately 
they  were  powerless  to  effect  a  change  in  the  methods  of  the  establishment. 

Day  after  day,  for  weeks  and  months,  those  surgeons  labored,  breathing  the  unwholesome  air,  and  in  constant 
contact  with  those  horrible  diseases ;  but  they  were  patient,  faithful  men,  and  their  sympathy  with  the  victims  often 
benefited  them  as  much  as  the  medicines  they  prescribed.  »  #  »  j  gladly  record  the  little  acts  of  kindness 
performed  by  them,  for  they  were  verdant  spots  in  that  vast  .Sahara  of  misery.  Dis.  Watkins,  Eow'zie,  Tiiohxbuux, 
Reeves,  Williams,  James,  Thomp.sox,  Pilott  and  Saxdeus  deserve,  and  will  receive,  the  lasting  gratitude  of  the 
prisoners  who  received  medical  treatment  at  their  hands  during  that  memorable  summer  at  Andersonville.t 

The  medical  profession  owes  a  debt  of  gratitude  to  the  gentlemen  mentioned  in  the 
above  extract,  and  to  their  colleagues  on  duty  in  the  prison  hospital,  in  that  their  labors, 
however  fruitless  on  behalf  of  the  unfortunate  men  confined  at  Anderson ville,  have  permitted 
one  unsullied  paragraph  to  appear  on  that  foulest  page  of  American  or  any  other  history. 
The  papers  published  by  Dr.  Jones,  and  by  the  Committee  of  the  House  of  Representatives, 
show  tliat  Dr.  I.  H.  White,  the  surgeon  in  charge  of  the  prison  camp,  repeatedly  called  the 
attention  of  his  superiors  to  the  deplorable  condition  of  the  prisoners,  appealing  for  medical  and 
hospital  supplies,  additional  medical  officers,  an  adequate  supply  of  cooking  utensils,  hospital 
tents  and  even  for  straw  for  bedding.  It  is  true  his  requisitions  and  recommendations 
should  have  been  put  in  stronger  language;  but  he  probably  recognized  how  utterly  fruitless 
and  unprofitable  would  be  appeals  to  the  humanity  of  an  authority  whose  inhumanity 
rendered  such  appeals  necessary.  The  following  extract  from  his  report,  dated  August  6, 
1864,  to  General  Jno.  H.  Windee,  the  Commandant  of  the  prison,  shows  him  neither 
insensible  to  the  suffering  around  him  nor  ignorant  of  the  causes  that  made  the  prison-pen 
a  charnel-house. 


*  Jones,  page  520.  t  H.  M.  Uaviosox,  1st  Ohio  Light  Artillery,  page  49  of  the  report  of  the  Committee  already  i-ited. 


AMONG    UNION    T?K^OPS    IN    rONFRDI-;RATE    PRISONS,  43 

The  evils  within  tlie  power  o(  ihe  iiio]»i-  ainhoiitie.s  lo  cDnecl : 

I.  I'hi  criiinled  coiiilitiiiii  of  thi  iiri>:(>ii<  r^. — The  iiuiiiber  within  the  ^stookade  should  not  exceed  fifteen  thousand. 
Tliis  would  allow  iinii)le  room  for  Ihi'  icinaiiider  to  lie  eauiped  in  order,  with  streets  of  suflieient  width  to  allow  free 
cironlatiou  of  air  and  enforeeiiient  ol'iioliee  ie>;ulations.  All  that  port  ioii  of  the  eamii  on  the  north  side  of  the  streiini 
eould  then  lie  used  for  exercise,  where  roll-eall  iMiuld  also  lie  held,  tln'reliy  materially  aidin>;  tin'  eommamlant  of  the 
interior. 

II.  Conxiniclidii  of  IxirravIiS  and  lioxpilal  Kciviiiiiiiiiliilinii. — There  should  be  no  delay  in  the  eonstruetion  of 
barracks;  with  the  greatest  amount  of  eucrj;y  it  will  be  diliieult  to  eom|ilete  them  befori'  the  eold  weather  eonu'S  on, 
when  they-  will  bo  required  more  than  at  present.  Too  great  stress  eanuot  be  )ilaced  on  the  necessity  for  the  con- 
struction of  proper  aecomniodat  ions  for  the  sick.  There  a  re  at  |ireseut  two  thousand  two  hundred  and  eight  in  hos]utal, 
all  poorly  provided  for,  and  some  three  hundred  w it  luiut  any  slielter  whatever.  There  are  also  at  least  one  thousand 
men  now  in  stockade  who  arc  helpless,  and  should  be  at  once  rcuu)vcd  to  hospital.  Their  removal  is  prevented  by  the 
absence  of  accomuuidatious.  The  construction  of  hospitals  should  be  at  once  begun,  and  in  the  uu'antinu)  the  sick 
should  be  at  once  transferred  to  s(une  ]ioint  where  they  can  lie  jiroperly  jirovided  for.  An  ollicer  should  be  employed 
to  arrange  the  stream  jiassing  through  tlic  stockadi'.  The  li<itt(un-lan(l  sliould  be  covered  over  with  sand,  the  stream 
be  made  deejier  and  wider,  the  walls  and  bottom  covered  with  plank:  the  sanu-  arraugeuu-nts  to  coutinm^  outside, 
conducting  the  drainage  freely  to  the  creek  beyond,  and  if  necessary,  build  a  dam  to  prevent  the  overflow  of  the 
banks.  The  stream  from  stockade  to  the  railroad  should  also  be  improved,  and  Ihe  use  of  it  by  the  troops  outside 
should  Ije  prohibited.  Sinks  shonld  be  at  once  arranged  over  the  stream  of  such  a  nature  as  to  render  them  inviting: 
at  present,  those  who  have  an  inclination  to  use  them  have  to  wade  through  mud  and  fa-ces  to  us<'  them.  At  the  upper 
part  of  the  stream  projicr  bathing  arrangements  should  lie  constructed. 

III.  EiiforcliKj  xlrhiiji'nt  2>olic('  nijiiUilionK. — Some  stringent  rules  of  police  should  be  estalilished,  and  scavenger 
wagons  should  be  sent  in  every  day  to  remove  the  collections  of  tilth.  A  large  (luantity  of  nmuldy  bread  and  other 
decomposing  matter  scattered  through  the  camp  aiul  beyond  the  dead-line  sliould  be  rcuuived  at  once.  If  necessary, 
sentinels  should  be  instructed  to  tire  on  any  one  committing  a  nuisance  in  other  places  than  the  sinks. 

IV.  Extahlhhment  i>f  ref/iilaliotis  in  rvj/ard  in  vhaiiUnexx. — It  should  be  the  duty  of  Confederate  sergeants,  attending 
roll-calls,  or  others,  to  see  that  all  the  men  of  their  conuuaud  bathe  at  stated  intervals,  and  that  their  clothes  are 
washed  at  least  once  a  week.     For  this  purpose  soaji  shonld  be  issued  to  the  prisoners. 

V.  Tiiijirorrmcnt  in  ridiotix. — The  uu'al  should  be  bolted  and  sifted  before  being  used.  Arrangenu'uts  should  be 
speedily  mad(!  by  which  rice,  beans.and  other  anti-scorbutics  should  be  issued  during  the  present  season;  green  corn 
might  lie  issued  in  lieu  of  bread  ration,  if  not  regularly,  at  least  three  times  a  week.  If  possible,  the  prisoners  should 
lie  supplied  with  vinegar,  and  with  an  occasional  issue  of  molasses  in  lieu  of  the  meat  ration,  which  wonld  tend 
greatly  to  correct  the  scurvy  which  prevails  to  a  great  extent. 

The  deaths  at  Camp  Sumter,  Andersonville,  Ga.,  tluring  the  fourteen  months  of  its 
occupation  numbered  about  13,000,  when  the  unrecorded  cases  are  taken  into  consideration. 
But  these  figures  greatly  underrate  the  mortality  consequent  on  the  treatment  to  which  the 
prisoners  were  subjected.  Thousands  of  men  died  after  their  liberation  from  this  and  other 
southern  prisons.  There  are  no  records  on  file  showing  the  subsequent  history  of  the 
Andersonville  captives;  but  the  following  communication  indicates  the  probabilities  with 
respect  to  them,  in  detailing  the  condition  of  those  exchanged  from  Richmond,  Va.: 

I  have  the  honor  to  make  the  following  general  report  of  the  condition  of  patients  (sick  and  wounded)  who 
arrived  at  and  were  admitted  to  this  hospital  from  "Belle  Island,"  Va.,  per  flag-of-truce  steamer  "New  York,"  via 
City  Point,  Va.,  on  the  29th  instant : 

This  vessel  left  City  Point  with  one  hundred  and  eighty-nine  sick  and  wounded.  Before  she  arrived  at  Fortress 
Monroe  four  men  died ;  on  the  trip  from  Fortress  Monroe  to  this  place  four  more  died — leaving  one  hundred  and 
eighty-one  to  be  admitted. 

Language  is  inadequate  to  express  fully  the  condition  of  this  number,  and  none  but  those  who  saw  them  can 
have  any  appreciable  idea  of  their  condition,  I  do  not  pretend  to  particularize,  for  every  case  presented  evidences 
of  ill-treatment :  every  one  wore  the  visage  of  hunger,  the  expression  of  despair,  and  exhibited  the  ravages  of  some 
preying  disease  or  the  wreck  of  a  once  athletic  frame, 

I  only  generalize,  therefore,  when  I  say  their  external  appearance  was  wretched  in  the  extreme.  Many  had 
neither  hats  nor  shoes,  few  had  a  whole  garment;  many  were  clothed  merely  with  a  tattered  blouse  or  the  remnant 
of  a  coat,  and  a  poor  apology  for  a  shirt.  Some  had  no  underclothing,  and,  I  believe,  none  had  a  blanket.  Their 
hair  was  dishevelled,  their  beards  long  and  caked  with  the  most  loathsome  filth,  and  their  liodies  and  clothing 
swarmed  with  vermin. 

Their  frames  were  in  most  instances  all  that  was  left  of  them.  A  majority  had  scarcely  vitality  to  enable 
them  to  stand.  Their  dangling,  bony,  attenuated  arms  and  legs,  sharp,  jiinched  features,  cadaveric  countenances, 
deep,  sepulchral  eyes,  and  voices  that  could  hardly  be  distinguished  (some,  indeed,  were  unable  to  articulate)  pre- 
sented a  picture  which  could  not  be  looked  upon  without  calling  forth  the  strongest  emotions  of  pity. 

Upon  those  who  had  no  wounds,  as  well  as  on  the  wounded,  were  large  foul  ulcers  and  sores,  principally  on  their 
shoulders  and  hips,  produced  by  lying  on  the  hard  ground;  and  those  that  were  wounded  had  received  no  attention, 
their  wounds  being  in  a  filthy,  oftensive  condition.     One  man,  who  died  on  the  trip  from  Fortress  Monroe,  told  the 


44 


SICKNESS   AND   MORTxVLITY 


Hurfjfeou  previous  to  deiitli  that  liiK  winmd  liiiil   not  l)eeii  (Ircs.stMl  since  the  Inittle  of  (ietty.sbiirg,  Pa.,  where  he  was 
wounded  in  tlie  liead,  havinji  liotli  tahh-n  of  the  jioHterior  ])art  of  tlie  skull  fractured. 

Most  of  the  casi's  wi're  sutlering  with  diarrho'U — some  <if  them  witli  involuntary  evacuations — their  clothes 
being  the  only  receptacle  foi  them,  and  they  too  weak  to  remedy  the  ditllculty.  'I'liis  ))eiiif;  the  case,  you  can,  of 
course,  imagine  the  stench  emitted  from  them.  .Many  had  luieumonia  ;  somt^  in  the  advanced  stages  were  gas]iing 
for  breath.  Delirious  with  fever,  many  knew  not  tlicir  destination  or  were  not  conscious  of  their  arrival  nearer 
home;  or  racked  with  |)ain,  many  caied  not  whitluM-  they  went  or  considered  whether  life  was  (h-ar  or  not ;  in  some 
life  was  slowly  ebbing,  from  niere  exhaustirni  and  the  gradual  wasting  of  thts  systeni.  How  great  must  be  the 
mr)rtality,  then,  of  these  men,  and  how  dreadful  among  those  still  suffering  the  horrors  of  imprisonment.  Kvery 
man  who  could,  rejoiced  over  his  esca|ie,  <leplored  thi>  scenes  thiough  which  he  had  i)assed,  an<l  mourned  the  lot  of 
tho.se  he  had  left  behind.  Weak  and  di-bilitafed,  they  wished  but  to  die  among  tlieir  friends,  a  wish  which,  unfortu- 
nately, will  be  realize<l  in  too  many  iMstan<-<^s. —  t.ilhr  of  AcHikj  Axuiatiuit  Siinjcoii  S.  .1.  K.\i>cr.ii  fk,  I'.  .S.  A.,  Mcilind 
Olfirir  of  thr  (hi;/,  ill  Ihr  U.S.  Oeiiiriil  Ifonjiitiil,  Dirixioii  .\o.  1,  .liiiiKpoliH,  .Mil.,  irjiorliiii/  to  the  Surgeon  in  vhiiryi'  the  coii- 
ilitioii  of  till'  aiik  mill  iniiiiiiliil  (iiliiiiltril  Oilohir  2i),  l><t)3, ./Vd/h  Jielle  I.ile,  via  ("ilij  I'oiiit,  J'a. 

Tilt'  records  of  lliv  prison  lio.spitul  ;it  Duuvillc,  Va.,  extoiidiiig  tVoiii  Novembi'f  2:), 
1863,  to  Alaivli  27,  1H()5,  lurnish  ii  total  ol'  4,;)32  cases  admitted.  As  157  of  these  were 
cases  of  wounds  and  injuries  and  7  cases  in  wliicli  no  diagnosis  was  recorded,  the  num})er 
romaiiiing  as  due  to  s[)ecifiod  diseases  is  1,1()(S.  Hut  since  there  is  no  record  of  what 
Ijocame  of  429  of  these  cases,  the  iiuinl)er  of  terminated  cases  of  specified  disease  is  reduced 
to  i),739,  (>['  which,  1,074  or  28.7  per  cent,  were  fatal.  An  (.'xaiiiiuation  oi'  the  following 
table  will  discover  the  absolute  and  relative  mortality  of  the  ]»rominrnt  diseases  for  com- 
parison with  the  Andersonvillc!  record,  already  presented,  and  with  the  records  of  our 
Northern  prisons,  to  be  submitted  hereafter. 

Tahle  XVTT. 
Summarizing  the  Records  of  the  Prison  Hospital  at  Danville^  Va.,  Noik  ^3, 186S,  to  March  27 ^  18G5. 


Total  cases  . 


Wotinds  and  iiijuri*'S. 
Nt)t  s|Hioified 


Specified  di^t 


Continned  Fevers 

Maliiriul  Kevers 

Eruptive  Fevers 

Diarrhuni  and  Dysentery  . 
Debility 


Dropsy 

Ccnisunij»tion 

Kheinnutisui    

Scurvy 

Urmu^hitis 

Pnentiionia  iitid  IMcurlsy- 
Other  diseases 


Cases  admitteil  into 
hospital. 

Cases   with    results 
unrecorded. 

Total  pases  with  re- 
corded results. 

Died. 

41 

OJ    5    OJ 

gll. 

X 

Ratio  of  deaths  per 
1,()00  deaths  from 
specified  diseases. 

Pereentajre  (tf  fatal 
cases. 

4  ;i32    1 

437 

3,  SM 

151 
5 

1, 084 

157 

^  1 

I  - 

2 

10 
0 



—  — 





— 

4,l(i8     1 

4ay 

:i,  7:t',i 

1,074 

1 ,  000 

1,000 

28.7 

_ 



(59 

12 

57 

IS 

16.7 

11. 1 

21.1 

•iX> 

111 

■Jl« 

17 

5t;.4 

15.8 

7... 

880 

aw 

(ia-j 

IHfi 

an.  1 

1.T3.  (i 

»;.  5 

1,418 

51 

i,:m;7 

4.-.l(,-) 

340.  2 

420.  0 

32.8 

178 

18 

11 10 

13 

42.7 

12.  1 

8.1 

i:-2 

(i 

X 

24 

14.0 

22.4 

42.9 

18 

1 

17 

7 

4.3 

(i.  5 

41:2 

:t48 

17 

331 

18 

83.5 

Hi.  8 

5.4 

'.11 

n 

89 

Ii 

21.8 

5.ti 

fi.  7 

2()it 

1^ 

s.w 

31 

(14.5 

28.9 

12.1 

314     ■ 

19 

2il5 

88 

75.3 

81.9 

29.8 

■J8t; 

14 

2--i 

242 

Ii8.6 

225.  3 

89.0 

(a)  Dr.  Wooi>\v.\Kl),  on  patj-e  Ilf).  Part  II  ol  tliis  wrk.  yivrs  llir  number  of  deaths  from  diarrliuea  and  dysentery  as  r)9J  instead  of  4.11.  The  record 
shows  that  wliiie  in  l,:jt>7  terminated  rasfs  then-  oreurretl  4.">1  deatlis,  l»y  foll(»win^  out  the  histories  of  the  rases  oilier  than  diarrhtea  and  dysentery  141  of 
these  are  found  to  have  proved  fatal  hy  the  supervention  of  the  prevailing  intestinal  Hux.  This  accounts,  for  instance,  for  the  Uijfh  death-rate  attaehln^ 
to  (he  eases  tabulate^l  under  the  caption  of  "  other  diseases." 


AMO\(i    UNIOX    TKUUi'.-^    IN    COXFKUKKATK    TKISONS.  45 

niiUTli(«.'i  iiiul  tlie  eruptive  fevers,  small-pox  chiefly,  occasioned  tlie  lursi;est  iinmlter  of 
admissions  us  well  as  of  deatlis.  Diarrhoeas  constituted  340.2  of  every  tliousund  cases  of 
disease,  and  caused  420  of  everv  thousand  deaths  from  disease.  But  scurvv,  which 
cxei'cised  so  I'atal  an  infhience  at  Andci'sonville,  was  less  manifest  here,  as  it  occasioned 
oid\-  21.8  of  every  thousand  cases  and  5.(5  of  everv  thousand  deaths.  The  general  per- 
centage of  fatal  cases  of  disease  in  this  prison  was  or,lv  28.7,  as  compared  with  73.7.  the 
Andersonville  percentage.  Evidently  the  prisoners  at  Danville  were  treated  with  com- 
parative humanity,  although  the  mortality  among  the  cases  was  nearly  three-fold  that 
reported  among  the  Confederate  soldiers  treated  in  the  Chimborazo  IIos])ital  at  Richmond, 
Va.*  The  ratios  of  sickness  and  deaths  to  the  strength  present  were  no  doubt  correspond- 
ingly augmented  among  the  jirisoners,  although  in  the  absence  of  data  it  is  impossible  to 
give  any  other  than  this  vague  expression  of  the  facts. 


IV.— PREVALENCE  OF  DISEASE,  AND  MORTALITY  THEREFROM,  AMONG  THE  CONFEDERATE 

TROOPS  IN  UNITED  STATES  PRISONS. 

The  rebel  soldiers  that  died  in  our  Northern  prisons  numbered,  according  to  the 
monthly  reports  on  file  in  the  Surgeon  General's  Office,  30,716.  Death  in  5,569  of  these 
cases  was  the  result  of  wounds;  in  404  the  cause  was  unknown,  and  in  1,152  unstated. 
There  remain,  therefore,  23,591  deaths  reported  as  from  specified  diseases. 

The  Confederate  prisoners  were  confined  in  a  number  of  prison  camps,  many  of  which 
have  already  been  mentioned. f  The  statistics  of  nine  of  these  camps  have  been  exam- 
ined, consolidated  and  tabulated  to  indicate  the  diseases  and  classes  of  disease  that  were 
the  principal  causes  of  the  sickness  and  mortality  among  the  prisoners.  Tlie  records  of 
these  nine  camps  includj3  18,808  deaths  from  specified  disease,  or  about  80  per  cent,  of  the 
whole  number  of  deaths  reported  as  caused  by  di.sease.  The  statistics  of  the  smaller 
camps  might  readily  have  been  added  to  these,  but  their  addition  would  have  materially 
increased  the  size  of  tlie  tabular  statements  without  adding  correspondingly  to  their  valu(>. 
Everything  of  interest  susceptible  of  illustration  by  mere  figures  relative  to  the  diseases  of 
the  prisoners  may  be  gathered  from  the  figures  given  below.  Table  XVIII  consolidates 
the  data  of  each  prison;  Table  XIX  consolidates  the  data  of  the  whole,  and  deduces  ratios 
by  which  comparisons  may  be  instituted. 

On  comparing  the  latter  consolidation  with  Table  XIII  it  will  be  found  that  the  items 
making  up  the  total  number  of  cases  of  disease  among  the  prisoners  did  not  differ  much 
from  those  constituting  the  total  among  the  Confederate  troops  iti  the  field.  Thus  the  two 
classes  of  disease,  diarrhoea  and  dysentery  and  the  malarial  fevers,  which  caused  the  largest 
number  of  cases  among  both  these  bodies  of  men,  have  their  prevalence  expressed  by  very 
similar  figures.  Among  the  Confederate  forces  cases  of  diarrhoea  and  dysentery  constituted 
277  of  every  thousand  cases  of  disease,  while  the  malarial  fevers  numbered  141  in  the 
thousand.  Among  the  prisoners  the  corresponding  figures  were  268  and  157.  The 
eruptive  fevers  formed  54  of  every  thousand  among  the  troops  on  service,  and  68  among 
the  prisoners;  pulmonary  affections  51  among  the  former,  58  among  the  latter;  and 
rheumatism  36  and  34  respectively. 

*  See  Table  XII.  '  t  Pages  3fi-40,  Part  II,  of  this  work. 


46 


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AMONG    ('U.NFP:DEKATE    TKOUI'S    IK    v.    S.    PRISONS. 


47 


Tablk  XIX. 

In  which  the  facts  of  Table  XVIII  are  consolidated  and  expressed  in  average  annual  7'ates  per  thousand 
of  strength,  with,  the  ratio  of  cases  of  sjiecified  diseases  to  cases  of  all  diseases,  of  deaths  from 
specified  diseases  to  deaths  from  all  diseases,  and  the  percentage  of  fatal  cases  of  specified  disease. 
Average  strength  present  40,Slo  men. 


DiSKASES, 


Coiitiiiiu'il  Fcvt'rs 

Malarial  Fevers 

Eruptive  Fevers 

Uiarrluea  and  I>ysentory- 
Ana^mia  ;ind  Debility  . . . . 

Consumption 

Rheumatism 

Scurvy 

Broncliitis 

I'neunionia  and  Pleurisj'  . 
*  >ther  diseases 


Total  specified  diseases 


Total 

nuinlier  of 

cases. 


a,  5r)9 
3H,  587 
Hi,  fill? 
(io,  .-,80 

3,  'JIl'J 
.53:1 

H,  34t) 
K;,  2.57 

4,488 
14,319 
74,151 

244,  fi93 


Total 

number  of 

deaths. 


1,  1119 

1 ,  naii 

3,  453 

5,  'Xr, 

15fi 

331 

95 

351 

133 

5,  042 

1,147 

18,808 


Annual  ratio  per  thousand 
of  avera^^e  strength. 


Cases. 


Cases  i)er 

thousand 

cases  of  all 

diseases. 


;            31.4 

13.  e 

10.  5 

472.  7 

12.6 

157.7 

204.  2 

42.3 

68.1 

803.4 

73.0 

268.1 

39.3 

1.9 

13.  1 

(i.  n 

4.1 

2.  2 

102.2 

1.2 

34.  1 

199.  1 

4.3 

66.  4 

.5.5.  0 

I.li 

18.3 

17.5.  4 

61.7 

.58.  5 

1            908. 3 

14.1 

303.1 

2,  997.  G 

230.4 

1,000 

Deaths  per 

tliousand 

tleatlis  fniln 

all  diseases. 


59.  0 

54.6 

183.6 

317.1 

8.3 

17.5 

18.7 

7.1 

268.  1 

61.0 

1,000 


Percentage 
of  fatal 


43.3 
2.7 

20.7 
9.1 
4.9 

lil.9 
1.1 
.,  o 

3.0 

35.2 

1.5 


But  although  this  similarity  existed  among  the  cases,  showing  that  the  diseases  prevail- 
ing in  the  prisons  were  precisely  those  that  were  at  the  same  time  affecting  the  Confederate 
soldiers  who  were  not  prisoners,  the  fatality  in  the  cases  of  the  confined  men  was  7.7  per 
cent,  as  against  3.8  per  cent,  in  the  Confederate  ranks.  No  doubt  the  relative  mortality 
was  considerably  greater  among  the  prisoners  than  among  the  men  on  service,  but  the 
increase  shown  by  the  statistics  is  in  the  main  due  to  a  failure  to  take  up  certain  cases  on 
the  sick  report,  the  deaths  consequently  forming  a  larger  percentage  of  those  that  were 
taken  up.  The  annual  number  of  cases  of  disease  entered  on  the  surgeons'  reports  per 
thousand  prisoners  was  2,997.6;  the  annual  number  among  the  troops  in  the  field  per 
thousand  of  strength  was  4,404.  The  apparently  greater  prevalence  of  disease  in  the  field 
was  obviously  due  to  the  entry  of  men  on  sick  report  for  slight  ailments  necessitating 
temporary  excuse  from  military  duty;  and  the  greater  fatality  of  disease,  as  figured  by  the 
statistics  of  the  prisons,  resulted  in  part  from  the  absence  of  such  cases  from  the  records. 
Prisoners  with  slight  ailments  did  not  require  the  surgeons  signature  to  excuse  them  from 
duty,  as  in  general  they  had  none  to  perform. 

On  the  assumption  tliat  as  many  trivial  cases  occurred  among  the  prisoners  as  among 
the  Confederate  ranks — and  it  can  hardly  be.  supposed  that  there  were  fewer — the  per- 
centage of  fatal  cases  Avould  be  5.2  instead  of  7.7.  On  the  assumption  that  the  trivial 
cases  outnumbered  those  occurring  in  the  ranks,  the  prison  rate  of  fatality  would  be  pro- 
portionately lessened. 

The  actual  increase  in  the  percentage  of  fatality  was  occasioned  by  tlie  greater 
prominence  of  diarrhcea  and  dysentery,  the  eruptive  fevers  and  pneumonia  as  death  causes. 
The  continued  fevers  constituted  a  larger  proportion  of  the  mortality  among  the  troops  on 
service  than  among  the  prisoners.  This  is  explained  by  the  greater  prevalence  of  these 
fevers   in  the  regiments,  where  they  contributed  45  to  every  thousand  cases  of  disease. 


4S 


srcKNKSS    AND    IVroUTAMTY 


iiisteatl  III"  10.5  sis  amonu-  tlic  prisoners.      Nevertheless,  the  fatality  of  the  prison  cases  was 
greater,  43.3  per  <-i'!it.,  than  that  of  those  occurring  in  the  i-aiiks,  33.27  per  cent. 

Tlui  terrible  pi-oiiiiiiciici>  of  diarrhcjea,  dysentery  and  scur\-y  as  causes  ol  sickness  and 
ileath  at  Auders(_)nvilh''^'  is  m.t  nianifcsli.'d  on  the  records  (^f  our  northern  prisons.  Diar- 
rheea  ami  dvs(.Mitei-v,  which  occasioiwil  oDo.'i,  and  scurvy,  which  occasi(jiie'd  '-VISX)  ot  rveiy 
thousand  iloaths  at  .\ndci-sonvillc,  aiv  seen  bv  the  ahovo  tabulation  to  have  caused  in  our 
prisons  oidy;')17.1  and  lS.7  rrs[ioctivrl\-.  The  large  nuinlier  of  deaths  from  these  diseases 
among  the  unl'oilun;ite  I'\:deral  [)risoni.'rs  r('durc(l  iIk;  proporti(_)n  caused  by  other  diseases; 
thus,  according  to  their  reei.irds,  the  eontinuiMl  feviM's  are  held  J'espousible  lor  but  '2\.(  and 
the  malarial  fevers  for  oidy  14.7  of  evdy  thousand  deaths,  as  against  59.0  and  54.(3  among 
the  captui-ed  Confederates.  Not  that  these  and  many  (jther  diseases  were  more  |)revaleut 
or  more  fatal  in  the  northern  prisons;  tla;  deaths  were  merely  more  generally  distributed 
uinong  the  varnnis  causes. 

But  the  death  rates  per  thousand  of  strength  afl'ord  a  moi'e  ready  means  of  apprecia- 
ting the  relative  mortality  amijng  these  men.  The  iiimal(.'S  ol'  tho  nine  jtrisons  tabulated 
lost  annually  by  disease  230.4  out  of  every  thousand  present,  as  contrasted  with  53.48 
a,mong  our  white  troops;  143.4  among  oui'  coloi'ed  troo[is;  i67.'>f  m  tin;  I'eliel  armies, 
and  732. ()  among  the  Audcrsonville  prisoners.  44je  chief  causes  of  these  stated  mortalities 
are  shown  in — 

Tahlk  XX. 

(Jontrastiwj  fhe  Mortality  Ratcn,  per  thoui^and  of  utrength,  among  the  White  and  the  Colored  Troops  of 
the  U.  S.  Army  and  the  Union  and  the  Confederate  Prisoners  of  War. 


Mortality  rate  jxm-  1,00()  strength  froni- 


All  diseases 

Biarrhu'a  and  Dysentery. 

I'nennion  ia 

Eruptive  Fevers 

Continued  Fevers 

Malarial  Fevers 

Scurvv 


Northern 

Anderson-  ■ 

White       ■ 

prisons. 

ville. 

troops. 

230. 4 

7:i2. 6 

53. 48 

'            7.3.0 

4r..-).6 

1,-..  62 

HI.  7 

27.4 

ti.  34 

10.  F, 

8.2 

4.  r-iO 

y.i.ii 

20.  5 

U.tiO 

12.  ti 

12.2 

5.04 

4.8 

1 

102.  8 

0.  l(i 

Colored 
troops. 

143. 4 


3,5. 27 
28.87 
18.  3() 
12.45 
Its.  81 
2.02 


The  causes  of  the  large  mortalitv  from  diarrh<n>a  and  dvsentei'v,  pneumonia  and  the 
eruptive  fevers,  will  be  t)etter  understood  by  investigating  the  sanitary  suri'oundings  of  the 
captives  as  descril)ed  m  the  monthly  reports  of  the  Medic;d  Inspectors.  From  these 
documents  the  following  aecounts  have  been  compiled: 

Prisox-c.v.mp  and  Hospital  at  Camp  Doi-ulas,  near  Chicago,  Illinois. — This  camp  was  estahlished  in 
Jannary,  18H2,  and  elosed  in  fiepteniber,  1865.  Its  situation  was  within  one-fourtli  of  a  mile  of  the  shore  of  Lake 
Michigan,  and  about  one  and  a  half  miles  from  the  southeastern  suburbs  of  the  cit.v  of  Chicago.  The  site  was  a  flat 
and  treeless  prairie  about  fifteen  feet  higher  than  thi^  level  of  the  lake.  It  had  been  ])reviously  used  as  a  fair-ground. 
The  enclosed  area  measured  80  acres,  nearly  one-half  of  which  was  set  apart  for  prisoners,  the  remainder  for  the 
garrison  and  hosiiital.  The  soil  was  a  sandy  loam  on  a  substratum  of  l)lue  clav.  As  the  surface  of  the  camp  was 
not  favorable  to  drainage  it  was  often,  in  the  wet  weatlier  of  its  eiiiliev  history,  softened  and   muddy,  unpleasant 


*  See  Tabli;  .\V,  yagt'  34. 


f  See  stqira,  j>age  33. 


AMONG    rOXFF.DEEATE    TROOPS    IN    U.    S.    PRISONS.  49 

and  unhealthy.  The  hnihlings  were  at  first  poorly  constructed  wooden  shanties  arranged  in  parallel  lines,  east  and 
west,  with  avenues  between.  The  whole  camp  was  in  form  a  parallelograin,  one  long  and  one  short  side  being  used 
for  prisoners,  the  other  short  side  for  officers  and  the  other  long  side  for  offi<'es.  The  average  size  of  these  buildings 
was  48  X  25  X  10  feet,  with  kitchen  in  the  rear  H  feet  distant.  These  kitchens  were  small  and  were  used  also  as  mess- 
rcjonis.  The  whole  camii  was  surrounded  V)y  a  high  wooden  I'ence,  and  the  liarracks  l)eing  in  close  ])ro.Kiniity  to  it, 
very  little  flesh  air,  acconliug  to  Dr.  Kkknkv's  report  for  September,  18ti2,  found  its  way  into  tlie  ilark,  dingy  and 
poorly  ventilated  quarters.     In  tlie  mouth  UK'ntioned  7.79S  jirisoners  of  war  were  conline<l  in  this  camp. 

An  extensive  iire  which  occurred  shortly  after  this  destroyed  a  large  number  of  the  barracks;  the  buildings  by 
which  they  were  replaced  were  of  a  much  better  character  in  all  particulars.  The  inspection  report  for  December, 
1862,  says  of  t  liis:  "  Some  of  the  liarracks  have  lieeu  burnt  and  others  more  sulistaiitial  havi'  lieen  built  in  their  places. 
The  recent  contlagrat ions  have  been  attended  witli  one  salutary  ett'ect,  in  the  immense  destruction  of  aninml  life,  in 
tlic  form  of  lice,  and  had  less  of  the  tilthy  and  rickety  (luarters  lieen  spared  still  greater  salutary  elfects  would  have 
been  the  result." 

The  report  for  .June,  1S61,  says  that  these  <|uaiters  were  "one-story  high,  frame,  illy  constructed,  floors  raised 
four  feet  from  the  ground,  ridge  \cutilation  and  openings  at  side  and  ends  ample  in  numlier."  Their  condition  was 
further  improved  subsecjuently,  for  the  report  for  (October,  1864,  says  of  them:  ''Fifty-two  in  number,  each 
70  X  24  X  7.8  feet,  with   kitchens  20  X  24  x  7.8,  attached,  in  good  order;  eight  new  ones  in  course  of  construction." 

In  January,  18l»,  they  were  described  by  Dr.  Coolidge  as  follows:  "The  jirisouers  of  war  are  confined  within 
an  area  of  al)Out  forty  acres,  surrounded  by  a  strong  oaken  barricade  twelve  feet  in  lieight,  surmounted  by  a  railed 
platform  for  sentinels.  The  prison  barracks  are  one-storied,  ridge-ventilated  buildings  erected  on  ])OSts  four  to  six 
feet  from  the  ground,  to  yirevent  escape  liy  buirowing.  These  barracks  are  sixty-four  in  number,  four  of  which  are 
for  convalescents  exchisively :  thirty-one  have  been  built  since  January.  IStil.  They  are  arranged  in  streets  of  suit- 
able width,  and  are  all  of  the  same  dimensions,  viz:  90  feet  long,  24  feet  wide  and  about  12  feet  to  eaves.  »  »  • 
Each  barrack  is  subdivided  into  a  kitchen  and  dormitory,  the  former  20  x  24,  the  latter  70  X  24,  the  dormitories  fitted 
up  with  wooden  bunks  three  tiers  in  height.  In  several  of  the  barracks  at  tlie  time  of  my  inspection  there  were 
165  men,  each  having  a  cubic  space  of  142  and  a  superficial  area  of  10  siiiiare  feet.  The  prisoners  of  war  confined  in 
this  camp,  January,  1864,  uuiubered  5,(549,  and  7,652  were  received  during  the  year,  making  a  total  of  13,301.  The 
cases  of  sickness  treated  during  the  year  amounted  to  23,037,  and  the  deaths  to  1,156,  of  which  416  were  from  small- 
pox. The  number  of  prisoners  present  December  31,  1864,  was  11,780,  of  whom  577  were  sick  in  hospital  and  1,547 
in  quarters." 

The  prison  hospital  building,  in  common  with  that  of  the  post,  was  described,  in  September,  1862,  by  Dr. 
Kkkxky  iis  follows:  "The  lios)iitals  are  pretty  much  the  same  as  the  men's  barracks:  though  isolated  from  them 
they  occupy  grounds  in  the  square.  They  are  more  thoroughly  ventilated,  but  still  are  very  defective  in  this  partic- 
ular: on  an  average  23  patients  occupy  a  ward  where  7  should  be,  allowing  1,000  cubic  feet  of  air  to  each  patient." 

In  the  report  for  the  following  month  Dr.  KEENEYsays:  "The  hospital  accommodations  of  this  camp  have 
reached  their  utmost  limit,  *  *  sickness  is  on  the  increase."  He  recommended  that  the  serious  cases  be  transferred 
from  the  camp  hospitals  to  the  general  hospitals  at  Chicago,  and  this  appears  to  have  been  done. 

The  building  is  described  in  the  inspection  report  for  June,  1864,  as  follows:  "One  building,  two  stories  high, 
with  two  wings,  newly  built,  well-constructed  frame,  enclosed  by  a  high  board  fence,  well  ventilated  by  the  ridge 
and  base,  windows  and  high  stories ;  180  beds,  and  117  in  pest  hospital;  air-space,  800  cubic  feet  in  hospital  and  1,200 
in  pest  hospital;  total  lieds,  297." 

The  pest  hospital  was  composed  of  two  buildings,  isolated  and  comfortable  in  every  way. 

The  report  for  October,  1864,  says:  "Buildings,  two  two-story  pavilions,  two  one-story  pavilions,  and  one 
barrack  for  convalescents,  all  in  good  condition;  six  wards,  325  beds;  air-space,  650  cubic  feet;  superficial  feet,  54 
each;  overcrowded."    At  this  date  there  were  7,361  prisoners  of  war  in  camp,  397  in  hospital  and  860  in  quarters. 

In  .January,  1865,  Dr.  Cooi.lDGE  described  the  buildings  as  follows :  "The  prison  hospital  is  within  the  garrison 
grounds  but  outside  the  prison  square,  enclosed  with  a  strong  oak  fence.  It  consists  of  a  central  building  with  two 
wings,  all  two  stories  in  height;  four  wards  in  each  wing;  the  lower  are  99  feet  long,  27  feet  wide  and  12  feet  high, 
well  lighted  and  ventilated  by  cold-air  shafts  opening  in  the  floor  and  vertical  shafts  in  the  walls,  opening  some  near 
the  floor,  others  near  the  ceilings.  The  upper  wards  are  99x27x11  feet,  well  lighted  and  ventilated  by  shafts 
opening  at  the  ridge.  At  time  of  inspection  each  of  these  wards  had  60  beds  occupied,  so  that  each  bed  had  500  feet 
of  air-space  and  45  feet  of  area.  *  *  *  In  addition  to  the  hospital  proper  there  was  a  single  barrack  ward  80  x  20 
feet,  with  30  beds  for  erysipelas." 

The  pest  hospital  was  about  one  mile  from  the  camp,  and  consisted  of  two  ridge-ventilated  frame  buildings, 
204  x  28  and  10  feet  to  eaves;  divided  into  three  wards,  1.50  beds.  During  the  year  1864  1,519  of  the  prisoners  were 
admitted  with  small-pox  or  varioloid,  and  416  of  these  died.  During  the  same  period  144  cases  were  admitted  from 
the  Union  troops  at  the  post,  and  of  these  24  were  fatal. 

Few  alterations  were  made  in  these  hospitals  after  this  date  except  in  minor  points,  all  of  which  tended  to 
improvement. 

The  diet  of  the  prison-camp  was  the  ordinary  army  ration  with  vegetables  added.  Some  complaint  was  made 
of  a  scarcity  of  these  by  Dr.  Keeney,  who  said  in  Septenil)er,  1862, — "I  am  inclined  to  believe  the  prisoners  have 
been  stinted  in  vegetable  matter.  The  best  indication  of  this  is  the  apj)earauce  of  the  scurvy  lurking  about  the 
command.  There  are  many  cases  of  incipient  scurvy  in  camp."  But  the  inspection  reports  of  later  dates  speak  of 
the  rations  as  good  and  sufficient. 

The  diet  in  the  prison  hospital  was  rendered  superior  to  that  of  the  prison  by  the  addition  of  delicacies  pur- 
Med.  Hist.,  Pt.  Ill— 7 


50  SICKNESS    AND    MORTALITY 

chased  by  the  hospital  fund,  which  appears  to  have  been  expcndiMl  in  this  iimuucr  us  fast  as  it  accrmd.  Ur.  C^oolidge 
reports  for  January,  18(i5,  as  follows:  "Tlu'  piircliases  liy  tlie  hospital  fund  w^'rl^  as  follows:  (Some  items  only.) 
Milk,  1,237  "lallons;  jiotatoes,  KIT  bushels;  drii-il  api)l<s,  427  ])ounils;  butter,  i>il4  pouu<ls;  cliiekeus,  20  dozen  ;  oysters 
(cans),  5  dozen — a  ^reat  contrast  to  flic  treatnient  of  onruicn  in  rebel  jirisons.''  Kxcclleut  soft  liread  was  issiu'd  from 
the  post  bakery  at  all  tinu's  to  tlw  prisoners  in  camp  and  liosi>ital. 

An  abundant  water-sn]iply  was  brou;j;ht  from  the  lake  to  tlic  camp  by  tlic  city  watcr-pipcs. 

The  drainaf;e  of  the  camji  was  at  first  imperfect.  Dr.  Keknky  speaks  of  it  tlius:  '■  Tlu' (Irainage  is  exceedingly 
bad.  The  commanding  otlicer  and  tlie  sur};<>on  liavt^  repeatedly  submitted  plans  of  diaiiiai;c  to  t  lie  dc])artment,  urging 
the  necessity  of  such  as  a  means  for  preserving  tlu*  licalth  of  tlie  I'amj).  As  yet,  notliing  lias  l>ecn  done  hut  to  permit 
long  open  sewers,  (extending  for  nearly  a  (piartcr  of  a  niih^,  botli  in  front  and  rear  of  tlie  (|uarters,  containing  the 
garbage  and  other  refuse  of  the  kitchens  of  months'  standing,  to  add  their  miasms  to  the  already  noxious  air  pervading 
the  cam])."  Again,  in  October,  1862:  "  'i'he  grounils  are  so  low  that  no  drainage,  without  much  expense,  can  be  had. 
Every  rain  converts  the  camp  into  a  nnid-holc,  and  in  conse(|Ucncc  of  the  thituess  of  the  ground  and  the  want  of 
drainage,  all  the  tilth  and  refuse  of  the  c(un])any  quarters,  of  the  men's  sinks,  and  of  the  hospital,  are  to  bl^  removed 
only  ))y  the  process  of  evajioration.  Already  there  exists  in  and  !U(>un(l  the  company  i|uaiters  iiiid  hosjiital  siitticient 
animal  and  vegetable  matter  to  contaminate  tlie  whole  camp  and  geueiate  fevers  of  the  most  malignant  ty|>e.'' 
This  condition  <d"  atlaijs  appears,  however,  to  have  been  remedied,  for  tlie  rcjiort  for  .lunc,  1801,  sjieaks  of  the  drain- 
age aa  "naturally  bad,  but  artificially  good.''  Tht^  camp  was  well  gradcil,  and  a  system  of  stnvcrs  built  which 
could  be  flushed  into  the  lake. 

The  sinks  at  early  dates  were  shallow  pits,  many  of  them  merely  surrounded  by  a  few  poles  aii<l  brush  insnth- 
cient  to  afford  privacy.  Dr.  Kkeney,  in  his  report  for  Sei)tcmber,  1862,  says:  '-The  sinks  are  numerous,  near  the 
men's  (juarters  and  badly  constructed  ;  they  are  iu)t  sutliciently  deep,  nor  are  they  filled  up  often  enough  and  renewed. 
The  wood-work  is  not  close  enough,  conse(|ueutly  the  mephitic  gases  are  wafted  to  the  quarters,  hospitals  and  over 
the  parade  grounds.  This  stench  is  intolerable."  At  a  later  ])eriod  these  privies  were  built  over  a  large  sewer  and 
the  excreta  effectually  removed  by  flushing. 

Prisox  AM)  HnspiT.vi.  AT  Alton,  Illixoiss. — The  iirison  at  Alton,  111.,  was  opened  in  .January,  1862,  and 
c]o.sed  in  .June,  18(15.  Its  site  was  that  of  the  Illinois  State  Penitentiiuy,  on  the  hillside  at  the  northern  end  of  the 
city  of  Alton,  overlooking  the  Mississipjii  river,  high,  dry,  well-drained  and  considered  healthy,  though  subject  to 
malaria  from  the  river  bottom  at  certain  seasons  of  the  year. 

The  buildings,  nearly  all  of  limestone,  formed  a  siiuare  which  was  surrounded  by  a  high  wall.  Many  of  the 
smaller  buildings,  used  as  executive  offices,  etc.,  were  isolated.  The  north  side  of  the  prison  was  formed  by  a  building 
containing  2.">6  cells,  arranged  iu  four  tiers  in  the  interior,  each  tier  consisting  of  two  rows  facing  the  north  and 
south  walls  respectively.  The  cells  were  each  7  X  7  x  3|  feet  :=  171. 5  cubic  feet;  they  were  ventilated  and  lighted  by 
the  gratings  which  formed  their  doors.  They  were  used  only  for  refractory  prisoners  or  when  the  i)rison  was  crowded, 
which  the  inspection  reports  show  to  have  often  been  the  case,  jiarticnlarly  in  the  earlier  months  of  its  occupation. 
Bunks  were  erected  along  the  corridors,  between  the  central  cell  structure  and  the  walls  of  the  building.  In  addition 
to  this  there  were  two  large  rooms,  each  45  X  1.5  X  10,  occupied  as  quarters,  one  of  them  at  one  time  exclusively  by 
Confederate  officers. 

Dr.  liE  CoNTE  in  his  report  for  May,  1863,  says:  "  In  the  main  building  many  of  the  cells  are  occupied  by  men 
who  are  not  confined  therein,  liut  sleep  there  for  want  of  better  place.''  He  reconunended  that  "  the  ca|)acity  of  the 
prison  should  J)e  considered  as  not  greater  than  1,000,  and  that  not  more  than  that  number  should  be  confined  within 
it  at  one  time."  The  prison  had  been  built  to  accommodate  300  convicts,  and  at  the  time  of  Dr.  Le  Coxte's  visit  it 
contained  1,500  prisoners.  Dr.  Keexey  in  his  report  for  .July,  1863.  says:  *  *  *  "Fifteen  hundred  prisoners, 
both  Federals  and  Rebels,  have  each  about  100  cubic  feet  of  impure,  air  for  respiiiitory  purposes.  This  deficiency  of 
pure  air  alone  is  a  sufficient  cause  to  explain  the  gnfat  mortality  within  its  enclosure."  In  August,  1863,  there  were 
1,200  prisoners;  in  October,  1863,  1,446;  and  in  November,  1863,  1,800. 

In  order  to  afford  increased  accommodations  for  the  prisoners,  tents  were  at  times  erected,  and  the  prison  hospital 
was  removed  from  the  permanent  stone  building  to  one  specially  erected  of  wood,  thus  giving  additional  space  for 
the  inmates  of  the  prison. 

The  reports  at  first  speak  of  tht^  hosj)ital  as  consisting  of  one  large  ward  in  thi^  basement  of  the  penitentiary. 
In  April,  1863,  the  hospital  department  was  removed  into  a  separate  brick  building  in  the  prison  yard,  having  room 
for  70  beds.     An  additional  building  was  used  as  a  iiest-house. 

In  August,  1863,  out  of  117  sick  in  the  hospital  (jO  were  small-pox  patients,  and  to  properly  isolate  these  a  new 
building  was  erected  at  "  Sickleyville,"  on  an  island  in  the  river  about  three-quarters  of  a  mile  from  the  town  of 
Alton.  This  building  was  of  wood,  well  built  and  comfortably  arranged;  capacity,  100  beds  with  670  cubic  feet  of 
air-space  per  betl. 

In  order  to  afford  increased  accommodations  for  the  relief  of  the  over-crowding  in  the  i)rison  quarters,  a  new 
two-story  wooden  pavilion  building  was  erected  inside  the  prison  enclosure  as  a  hospital,  and  all  the  permanent 
buildings  were  henceforth  used  as  quarti'rs.  This  new  ])rison  hos])ital  was  divided  into  two  wards,  183^^x40x13  = 
95,420  cubic  feet  each,  the  lower  story  being  used  for  executive  purposes,  the  upper  only  for  the  sick.  A  fine  and 
well-appointed  bath-room  was  attached  to  this  ward;  iu  fact  the  hospital  arrangements  were  complete  in  every  par- 
ticular. The  small-pox  ward  on  the  island  was  200  x  26  x  13  feet  clear  =  67,000  cubic  feet,  and  had  67  beds.  It  was 
well  constructed,  one  story,  with  roof  and  side  ventilation.  Thus  the  hospital  accommodations  at  this  place  were 
at  length  made  comfortable  and  complete. 

The  rations  pf  the  prisoners  in  quarters  and  hospital  are  reported  as  abundant  and  good.    The  hospital  fund, 


AMoX'i    I'ONKKDKliATK    TP.OOPS     I\     IT.    S.    PRISONS.  §.1 

as  it  afcrnod,  was  lil>pralh'  exiiciKb-d  in  tlif  imrr-liase  of  delicacies  fur  the  use  of  tlie  siek,  the  snrrouiHlinj;  farms 
fiirnishiiiK  vegetaliles  in  ahnmlance. 

Tlie  water-supply  was  at  first  hauled  from  the  river  to  the  prison  hy  teams;  later  a  steam  foree-pumii  was 
employed  and  an  abundant  supply  was  obtained. 

The  sinks  were  at  first  shallow  pits  situated  too  near  tlie  (luarters,  often  over  full  ami  foul-smellinf;.  At  this 
time  no  water-closet  was  attached  to  the  hospital,  and  the  excreta  had  to  lie  remiiMMl  hy  hand.  Hut  tliese  defects 
weie  remedied.  The  report  for  Ajiril,  1S(15,  says  of  those  attached  to  the  lios])ital — "  Water-closets  clean  and  huild- 
ini;s  t;ood."  The  remarks  on  those  of  the  jirison  are  less  satisfactorv:  "Water-closets  and  sinks  ami)le  lint  as  foul 
as  possible."  In  fact  the  condition  of  the  sinks  in  the  jirison  was  fienerally  severel.v  criticised  by  the  medical 
iusiieotors.     The  bathiui;  facilities  were  characterized  as  ''amide  and  fjood.  with  ■jood  furniture  and  fixtures.'" 

The  drainage  was  naturall.v  good  and  the  sewerage  satisfactory  ilurini;  I  he  early  occu)int  ion  of  the  prison  :  but 
in  April,  1865 — "most  of  the  sewers  having  been  clogged  with  trash,  have  lieen  (ip<Mied  their  entire  length,  and  are 
open  gutters  of  fa-ces,  slops  and  all  kinds  of  filtli.  The  sewc'rs  not  thus  opened  are  choked;  ci)nse(|Uently  the  whole 
establishment  stinks  intoleiablv  and  the  stench  extends  to  the  jirivate  residences  in  thi'  vicinit.v  of  the  prison  walls. 
It  is  pi'oposed  to  put  earthen  sewers  here,  and  the  woik  should  lie  done  at  (Uiee." 

The  following  extracts  show  the  condition  of  this  prison  when  at  its  worst: 

Dr.  Keexey,  November,  1862:  "The  quarters  .are  poorly  ventilated,  ami  some  have  no  ventihition  at  all. 

The  grounds  and  (juarters  are  in  a  shocking  condition.  Tlu^  jirisoners  are  permitted  to  lounge  about  in  their 
filth,  witli  no  other  duty  to  perform  seemingly  than  to  amuse  themselves  bv  slaughtering  the  vermin  crawling  about 
their  filthy  persons.     This  seems  to  be  their  genenil  avocation  and  amusement. 

The  kitchens  are  shining  with  greasi>,  the  tloors  seldom  washed,  the  tables  and  other  kitchen  furniture  also 
filthy. 

The  cooking  arrangements  are  good;  the  ranges  large  and  amph'  for  all  purjioses. 

The  rations  fumished  are  of  the  best  quality,  excepting  fiour,  which  is  bad.  Hut  there  is  a  great  dispropor- 
tion between  animal  and  vegetable  matter,  a  deflciency  of  the  latter.  I'nless  more  vegetable  matter  is  furnished 
scurvy  will  soon  make  its  appearance. 

The  grounds  around  the  company  quarters  and  kitchens  are  the  connuou  receptacles  for  bones,  damaged  meat, 
mouldy  bread,  etc. 

The  prisoners  do  tlieir  washing  on  a  slope  where  all  the  soapy  water  runs  iij>on  the  ground  and  dries  up 
under  their  feet. 

The  sinks  are  located  in  their  midst  and  are  exceedingly  foul;  the  pits  hut  three  or  four  feet  deep.  There 
is  no  drainage  to  them,  consequently  they  soon  become  filled  np,  and  if  not  often  removed  they  become  an  intol- 
erable nuisance;  such  is  the  case  now.  I  have  called  the  attention  of  the  connnanding  officer  to  this,  and  have 
recommended  them  to  be  filled  up  and  new  pits  dug  twenty  feet  deep  and  walled  up. 

I  also  find  ])risoners  occup.ying  the  cells  where  the  air  is  cold  and  dam])  and  without  ventilation,  and  where 
pneumonia  and  rheumatism  were  fast  increasing.  As  these  occujiants  were  not  condemned  to  the  cells,  I  recom- 
mended the  connnanding  officer  to  remove  them  innnediately  to  a  large  open  room  where  the  sun's  rays  might 
occasionally  brighten  their  dingy  walls. 

As  above  stated,  there  are  1,040  prisoners  inside  these  -Oralis.  Sick  in  hospital  60;  in  quarters  70;  total  130. 
The  prevailing  diseases  are  erysipelas,  pneumonia,  dyseuter.y,  typhoid  fever  and  diarrlnea.  The  prevalence  of  the 
last  disease  arises  from  the  sour  liread  furnished  b.v  dishonest  contractors,  under  the  administration  of  an  inefficient 
connnanding  officer. 

The  hospital  accommodations  consist  of  one  open  ward  with  low  ceiling  and  badly  ventiliited.  The  walls  are 
dingy,  the  floors  dirty,  the  bedding  filthy,  and  the  patients  unwashed  and  alive  with  vermin. 

The  medical  attendants,  four  in  number,  are  Confederate  prisoners  of  no  account  as  medical  practitioners. 
Dr.  Hakdkn  has  not  time  to  give  his  attention  to  individual  cases.  The  ward  is  now  crowded,  one  bed  riding 
another.  In  this  loathsome  ward  each  patient  has  about  200  culiic  feet  of  foul  air  for  respiratory  purposes. 
Among  the  sick  I  found  some  eight  or  ten  cases  of  erysipelas  fast  running  into  a  contagious  form.  It  is  on  the 
increase." 

Dr.  Kken'ky,  July,  186.S:  "The  percentage  of  deaths  has  been  as  high  as  HO.  Through  the  able  administration 
of  its  jiresent  counuauder,  Ma.jor  IIexhuicksox,  If.  S.  Army,  and  its  present  medical  officer,  Assistant  Surgeon  Wall, 
77th  Ohio  Volunteers,  the  mortality  has  been  reduced  to  12  or  15  per  cent. 

The  general  state  of  police  of  the  entire  prison  is  now  almost  faultless,  including  tlie  two  wards  used  for 
hospital  purposes.  The  rations  are  issued  in  abundance  and  of  the  best  (|uality,  and  the  cooking  is  both  well 
done  iind  served.  The  patients  in  hospital,  some  85,  are  well  provided  with  underclothing  from  the  (Jovernment, 
and  are  amidv  supplied  with  everything  to  make  them  comfortable  as  far  as  the  present  capacity  of  room  will 
|)ermit.  In  this  there  is  a  sad  deficiency,  and  Rumanit.v  deuumds  an  immediate  change  for  the  better.  In  one  ward, 
in  the  very  midst  of  these  1,5(X)  prisoners,  there  are  20  or  more  cases  of  small-pox  under  treatment;  in  tlie  other  and 
only  ward  are  typhoid  and  malarious  fevers,  erysipelas,  scabies,  pneumonia,  etc.,  etc. 

Erysipelas  often  makes  its  appearance,  assuming  a  contagious  form  from  the  vitiated  air  and  animal  poisons 
constantly  being  eliminated  from  the  body.  In  fact,  all  forms  of  disease  that  would  be  mild  with  plenty  of  pure  air, 
have  in  these  dingy  and  loathsome  rooms  assumed  the  most  virulent  forms  and  batfied  medical  treatment. 

In  order  to  check  in  a  measure  this  great  and  unnecessary  mortality  from  disease,  I  have  recommended  the 
conuuauding  officer  to  procure  immediately  a  suitable  building  a  mile  or  so  from  the  prison  and  city,  and  have  it 
fitted  up  for  the  accommodation  of  the  sniall-pox  cases. 


52  RICKNKSS    AN  I)    MOKTAI.ITY 

Ah  this  lri;ithK(iiiii'  ilisc:isc  kcciiin  a  coiistiinl  iimiutc  (if  tlic  prison  in  sjiitc  of  \  iicciii.-ition.  it  will  hp  necessary  to 
keep  i\]>  till'  sMiall-|»)\  liospital  continuMJly.  ;in<l  to  ciiiploy  an  :ilil<-  plivsirian  to  attend  lo  this  hospital  alone.  The 
persisti'Mce  of  sniall-po\  in  the  piisoii  is  due  lo  con^iaiit   iiopoital  ions  ot   tin-  iliscasc. 

I  havi^  also  rec'iininirnd.-d  that  the  liest  vcntihitrd  and  nuist  isolated  fooms  now  occnjiied  liy  the  well  prisoners 

lie  appi(>i)riate(l  to  the  eiysipelatons  aiul  ot liei  contafiioiis  diseases,  ami  t^e  root )w  oceii]iied  liy  the  sinall-jxix 

lases  lie  tinned  n\iy  to  the  well  jii  isoneis  as  soon  as  it  i.s  in  proper  condition  to  receive  them. 

I  wonid  also  .'all  yonr  atti'ntion  to  the  irreat  necessity  of  immediately  authorizing  Major  II|-.ni>hicks(i.\  to 
eiiiiiloy  two  aide  ph\sieiaiis,  one  to  attend  to  tin-  small-pox  hospital  as  soon  as  openeil.  anil  the  otiiei'  to  assist  Dr. 
W.M.I,  to  attend  Ihe  prison  hosiiital.  The  duties  in  this  hospital  .ire  too  much  for  one  m;in  to  do  Justice  to  tlie 
nuineroiis  had  cases  of  disease. 

If  Ihesi'  snf;;;estioiis  are  carried  out  the  condition  of  the  sick  will  he  ameliorated  and  the  percenta>,'o  of  death 
lessened." 

I'i!i.si)N-i!.\i!i{A(K.s  .\Ni>  HdSi'iTAi,,  KocK  Isi..\Ni),  I  i.i.iNOis.— I'liis  prison  was  established  Novoinber  13.  1863, 
and  discontinued  alioiit  Aiifiiist,  l«t;r>;  the  prison  hospital  was  ojiened  in  Ueceinher,  1863,  and  clcsed  in  June,  1865. 

K<ick  Island.  emhraeiiiH  about  l/KX)  acres,  is  situated  in  the  Missi.ssippi  river  between  the  cities  of  Kock  Lsland, 
Illinois,  and  Davenport,  Iowa.  The  soil  is  a  stiff  loam  on  a  limestone  foundation.  Its  well-wooded  and  nndiilatiiio; 
surface  was  considered  to  offer  a  healthy  site  for  a  ])ri8on-camp. 

The  I)arraekH  <'onsiste(l  of  eighty-four  one-story  wooden  pavilions,  each  of  which  was  considered  suitable  for 
the  aecoinmodafion  of  one  hundred  men.  They  were  well  built  and  comfortably  ariansed,  ventilated  l>y  the  ridge 
and  well  lighti'<l ;  their  floors  were  raised  fr(un  tlie  ground,  and  were  (comfortably  bunked.  They  were  Imilt  in  streets 
KHI  feet  wide,  crossing  each  other  at  right  angles,  and  there  was  a  central  avenue  200  feet  wide.  Each  barrack  was 
ll»0  feet  long,  22  feet  wide  and  10  feet  high,  l>nt  2(1  feet  of  each  was  partitioned  off  to  form  a  kitchen  and  mess-room. 
'I'lie  whole  area,  l,20()X  8r)0  feet,  was  enclosed  by  a  strong  wooden  fence  12  fei^t  high,  with  a  tailed  platform  near  the 
lo|i  on  w  liieh  the  guard  patrolled. 

Dr.  Tow  NMiKNi)  reports  the  result  of  his  iusjiectioii  in  .January,  1864,  tliiis:  "Tlie  ])risouers  on  tlu^  island  num- 
ber ti,."i(H).  They  are  comfortably  (|iiartercd  in  barracks  well  built  and  well  arranged  for  comfort  and  security.  The 
a))l)earanee  of  Ihe  men  is  highly  creditable  to  themselves  and  to  the  otticers  having  them  in  charge.  In  good  weather 
the  i)risoners  are  employed  in  various  duties,  which  secure  to  them  the  benefits  of  ont-(h)or  exercise;  these  duties 
are  therefore  regarded  by  fhem  as  a  privilege.  The  discipline  of  the  prison  is  admirable,  being  efticient  without 
being  harsh." 

The  prison-hospital  buildings,  from  .lannary  to  Ajiril,  181)1,  consisted  of  a  number  of  the  barrack  pavilions 
inside  the  prison  enclosure.  At  the  last-mentioned  date  ten  of  tliese  barracks  were  used  as  hospital  wards;  but  in 
May  a  new  ]>rison  hospital  was  opened  for  the  reception  of  patients.  The  buildings  consisted  of  seven  one-story 
frame  jiavilions  arranged  iii  icheloti,  tolerably  well  constructed,  with  ridge  ventilal  ion  along  tlu^  entire  length  of  the 
roof.     Kach  ward  contained  50  beds  and  had  a  lavatory,  bath  and  water-closet  atta(ditcd. 

Ihe  increasing  necessity  for  additional  liosiiital  accommodations  caused  seven  additional  pavilions  of  the  same 
pattern  to  be  erected,  and  the  insjiection  report  of  January,  186.5,  describes  them  as  follows:  "The  prison  hospital 
is  situated  on  elevated  ground  near  the  centre  <d"  the  island.  It  consists  of  an  administrative  building  two  stories 
iu  height,  60  X  10  feet,  and  fourteen  ]iavilion  wards,  each  110x21,  II)  feet  higli  at  the  »NlV(^s  and  11  feet  to  the 
ridge,  a  small  si)ace  lieing  partifioned  off  for  nurses  and  attendants;  ,50  beds  to  each  ward,  giving  a  cubic  sjiace  of 
tUS  feet  to  each  bed."  A  kitchen  and  mess-hall  was  also  erected,  112  X  40  feet,  situated  between  Ihe  two  rows  of 
wards;  to  this  liiiilding  was  also  attached  a  well-sup])lied  laundry. 

In  addition  lo  the  above  there  was  a  small-pox  hoH])ital  consisting  of  six  pavilion  wards,  each  150  x  21  and  12 
feet  high  to  the  eaves.  Eaidi  ward  contained  50  beds,  and  gave  861  cubic  feet  and  72  square  feet  per  lied.  These 
buildings  were  isolated  from  the  hospital  proper,  being  situated  on  flie  Illinois  side  of  tht^  island.  They  W(ae  well 
drained  and  su|)iilied  with  every  convenience. 

Notwithstanding  the  natural  advantages  of  thtc  site  and  the  substantial  and  complete  character  of  the 
buildings  at  this  ])lace  the  rates  of  sickness  and  mortality  ai)pear  to  have  been  high,  chiefly  due  to  an  outbreak 
of  sniall-pox.  Dr.  Tuw.vjsiikxd's  report,  already  quoted,  says:  "The  present  condition  of  the  hospital  may  be  con- 
sidered good;  but  much  suffering  has  occurred,  and  many  deaths  during  the  present  month  from  causes  beyond  the 
control  of  the  ollicers  in  charge.  Many  of  the  prisoners  arrived  during  the  extreme  cold  weather,  a  large  proportion 
of  whom  were  subse(|uently  attacked  with  pneuinonia.  The  same  cold  weather  interfered  with  railway  communica- 
tions and  lu-evented  the  receiiit  of  hosiiital  stores  and  medicines.  In  addition  to  the  above,  many  of  the  prisoners 
■were  found  to  have  small-pox,  and,  of  course,  had  subjected  many  others  to  exposure.  These  unforeseen  difficulties 
appear  to  have  been  met  with  the  utmost  proiui)tif iide  by  the  medical  officers  and  the  post  commander." 

The  diet  of  both  the  prison  and  the  hosjiital  was  always  of.good  (quality,  ample  means  being  atforded  for 
cooking  the  rations.  No  complaints  appear  under  these  headings  in  any  of  the  inspection  reports.  In  the  hospital 
file  fund  was  liberally  exiiended  in  the  luirehase  of  delicacies  for  the  use  of  the  sick.  Good  light  bread  and  corn 
bread,  with  potatoes  three  times  a  week,  were  issued  to  the  jirisoners. 

The  \vater-siip]ily  was  abundant  and  of  fair  (quality.  It  was  pumped  from  tlie  Mississippi  river  into  a  reservoir 
and  distributed  to  the  camp  and  hospital  by  pipes.  An  artesian  and  three  ordinary  wells  inside  the  prison  enclosure 
furnished  a  good  supply  in  addition  to  that  from  the  river. 

Ihe  sinks  were  at  first  simply  pits,  from  which  the  accumulations  were  removed  by  carts  and  thrown  into  the 
river.  At  later  dales  these  were  abandoned  and  a  large  latrine  was  constructed  in  the  prison,  coninmnicating  with 
the  river  by  means  of  a  trench.  Daily  flushing  swept  the  deposits  into  the  river.  The  sinks  in  the  hospital  were 
provided  with  zinc  buckets,  which  were  emptied  twice  daily. 


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AMONG    COXFEDKRATE    TROOPS    TN    t^.    S.    PRISONS.  53 

The  drainage  of  the  camp  and  hospital  was  naturally  good  on  account  of  the  rolling  Hnrface  of  the  ground; 
and  this  was  improved  from  time  to  time  until  the  drainage  system  was  considered  excellent.  Between  the  pri.^on 
and  the  hos|)ital  there  was  a  slough  or  liayou  of  some  extent  which  was  partly  tilled  up  and  drained.  Complaint 
w:is  sometimes  made  in  the  inspection  reports  of  the  unsatisfactory  character  of  I  he  drainage  in  cold  weather 
when  the  drains  were  frozen  up. 

The  following,  by  Assistant  Surgeon  M.  King  Moxley,  V.  S.  Vols.,  is  dateil  February,  IHM: 

"  The  ])revalence  of  small-i)ox  and  its  pro|)ortionally  great  mortality  is  a  sub.jecr  of  serious  consideration.  The 
disease  made  its  appearance  about  the  last  of  December.  The  number  of  those  aft'ected  iuc'reased  so  rapidly  that 
men  had  to  be  allowed  to  remain  in  barracks  after  the  eruption  appeared,  thus  infecting  the  whole  ])rison.  Three 
STruill  houses  were  used  as  a  jiest  hospital.  Eai'h  was  capable  of  containing  ten  patients,  but  three  times  as  many 
wore  crowded  into  them.  T'wo  large  buildings  were  erected  soon  after  I  assumed  charge,  .lanuary  Ki,  IXM.  These 
held  .50  jtatients  each,  allowing  over  NIO  cubic  feet  of  air  ])er  man.  Hut  as  the  nnmlier  of  cases  augmented  to  an 
alarming  extent,  I  asked  the  e<nnnninding  officer  for  the  erection  of  another  similar  l)uilding.  F'ive  days  elapsed 
before  the  order  was  given  to  build.  Meanwhile  the  cases  increased  on  my  hands ;  there  was  no  place  to  put  them 
but  in  one  of  the  barracks  used  for  hospital  purposes  in  the  prison  enclosure;  this  was  filled  in  two  days.  Surgeon 
A.  M.  Ci.ARKK,  U.  S.  N'ols.,  Acting  Medical  Inspector,  found  me  with  88  cases  In  I  lie  liarracks,  the  accumulation  of 
two  days,  although  I  was  removing  them  at  the  rate  of  twenty  a  day  and  crowiliiig  llie  pest-liosj>ital  in  hopes  of 
soon  getting  into  thi^  new  liuilding.  Had  this  liuilding  been  erected  w  hi'U  asked  for,  no  case  would  have  been  left 
in  the  barracks  an  hour  after  lieing  reported.  Another  of  the  prison-l)arrack  Imihlings  was  then  taken,  and  then 
another,  and  one  more  barrack  used  as  a  ward  in  the  hospital,  nuiking  four  used  as  small-pox  wards  within  the 
enclosure.  About  February  22,  for  several  days  as  many  as  thirty-five  new  eases  were  reporteil  daily,  and  during  the 
last  two  weeks  of  February  there  was  an  average  of  20  cases  each  day.  Three  new  barra<:ks  at  tlu^  pest-house  were 
erected,  making  six  in  all.  One  of  the  snuill  houses  previously  used  is  now  used  as  a  kitchen.  Tlit^  lour  barracks  in 
the  hosi)ital  and  prison  are  now  cleared  of  the  small-pox;  all  the  patients  are  in  the  six  barracks  and  two  small 
houses.  'I'here  are  at  this  time,  February  2St,  130  cases;  each  liuilding,  intended  for  50  nuni,  contains  70,  including 
the  nurses.  A  house  is  being  erected  as  a  dormitory  for  nurses;  this  will  U^avi'  nu)re  room  for  the  patients  daily 
reported.  There  has  been  a  scarcity  of  clothing  for  convalescents  returning  to  prison,  although  I  made  a  timely 
ai)plication  for  a  snjiply.  Hence,  many  had  to  be  retained  who  could  have  made  way  for  new  cases.  The  great 
mortality  results  from  several  causes:  1st.  Over-crowding,  which  could  not  be  avoided.  2d.  Want  of  proper  bed- 
ding, rough  cots  with  straw  being  the  only  beds  that  could  be  procured,  though  now  there  are  in  us<^  about  two 
hundred  bed-sacks  whi<li  were  obtained  from  the  <nnu'teiinaster.  ::!d.  Want  of  clothing  to  give  the  patients  a  change 
on  coming  into  lios])ital,  in  view  of  (hoir  previous  want  of  cleanliness.  4tli.  InsutlicicMt  vaccination.  Neaily  every 
jirisoner  had  a  huge  ugly  scar  on  his  arm,  the  result  of  impure  virus  imposed  on  him  while  in  the  Southern  army. 
This  did  not  jirotect  him  in  the  least.  Prisoners  have  been  received  on  whom  the  eruption  a])]icared  the  next  day 
following  their  arrival,  thus  showing  that  they  had  contracted  the  disease  l)efore  coming  here." 

Phison  and  Hosi'itai.  at  Oamp  Morton,  near  Indianapolis,  Indiana. — This  depot,  used  as  a  cam))  for 
I'nion  troojts  from  April,  ISOl,  was  opened  as  a  prison  for  rebels  Januaiy  21!,  1X62,  and  closed  in  August,  18(!.").  It 
was  established  on  the  State  fair-ground,  one  mile  and  a  half  northwest  of  Indianaixjlis,  Indiana.  I'he  site  was  ii 
level  plain,  nndnlating  but  slightly  in  some  parts,  and  hence  possessing  very  poor  natural  drainage.  The  soil  was 
an  alluvial  clay  on  a  subsoil  of  gravel.  The  area  enclosed  for  prison  purposes  was  at  first  about  twenty  acres, 
subsequently  increased  to  thirty,  and  was  abundantly  shaded  by  fine  forest  trees.  The  great  objection  to  the  site 
was  the  absence  of  running  water,  which  deticiency  was  repeatedly  noted  by  the  various  medical  officers  who 
iusjjected  the  j)Ost. 

The  prison  barracks  at  first  consisted  of  a  number  of  poorly  constructed  wooden  buildings  which  liad  been 
erected  and  used  liy  Union  troops.  They  are  described  in  July,  18t)-l,  as  "nine  dilapidated  barrai'ks,  each  l.'>0x2l 
and  10  feet  high."  The  ventilation  of  these  was  by  ridge  openings  running  along  the  entire  length  of  the  roofs' 
and  by  openings  in  the  walls  and  doors  at  the  ends  and  sides.  They  were  fitted  with  three  tiers  of  bnnks.  At 
this  date  there  were  also  210  condemned  tents  in  use  for  the  acconnnodation  of  the  prisoners.  Nevertheless  these 
t|uarter8  were  nnich  crowded,  there  being  only  (iO  to  80  cubic  feet  per  num  in  the  barracks,  while  five  men  were 
crowded  in  each  "A"  teiit  and  nine  men  in  each  bell  tent.  A  snuill  is<dated  building  within  the  enclosure  was  used 
for  a  few  cases  of  variola  that  occurred.  This  crowded  condition  continued  until  September,  1S()J,  w  hen  the  ))rison 
area  was  increased  by  adding  to  it  ab(mt  ten  addition.al  acres  of  ground.  In  November,  18t>4,  six  men  were  crowded 
into  each  "A"  tent  while  new  ])avilion  barracks  were  in  process  of  erection.  In  May,  IStio,  the  barracks  were  stated 
as  thirteen  in  number,  each  1.50x18  feet  and  9  feet  high,  giving  "sufficient  space."  Little  change  appears  to  have 
occurred  after  this  date. 

Ho8])ital  buildings  weri'  at  first  extemporized  by  the  occupancy  of  some  of  the  jirison-barrack  buildings  already 
described.  It  ajijiears  that  at  this  time  many  of  the  sick  and  wounded  were  sent  to  the  Indianajiolis  City  Hospital 
for  tieatment.  In  .June,  18(iM,  the  stated  capacity  of  these  buildings  was  8,3  Ijeds,  occupied  by  1(X)  men,  nuiiiy  of  w  hom 
were  on  double  beds.  The  re]iort  for  .luly,  18t)8,  says:  "  Enlarged  hospital  accommodations  are  much  needed  at  this 
idace.  The  present  facilities  are  too  limited  and  are  often  crowded  beyond  their  cajiacity."  In  these  buildings  the 
air-space  was  often  reduced  to  350  feet  per  man.  Few  facilities  were  attbrded  for  bathing:  bath-tubs  were  in  position, 
but  as  water  had  to  be  carried  a  distance  of  one  huiulred  yards  in  buckets,  they  were  seldom  used.  To  expand  the 
hospital  a  number  of  tents  were  pitched,  but  these  also  soon  became  crowded. 

In  December,  18()8,  the  hospital  department  was  much  improved  by  the  erection  of  two  new  pavilion  buildings, 
by  which  the  air-space  was  increased  to  550  cubic  feet.     In  July,  1804,  these  buildings  were  described  as  follows: 


54  SICKNESS    AND    MORTALITY 

"The  hospital  buildings  arc  four  in  nnnibcr,  itur  111x20  an<l  12  fei-t  lu,i,'li;  one  100x20  and  12  t'ect  hij;li;  one  40x20 
and  11  feet  3  inches  high;  and  one  !t!tx2l  and  11  leet  high.  Fnrnitiue  good  and  snfliricnt .  In  addition  a  niess-iooni 
30x24  feet,  12  feet  higli,  and  good  l^itelicn  acconiinodations." 

The  diet  in  both  ]>ri.son  and  lio.spital  was  good  and  snfticicnt  ;  vcgctalih's  wcii'  (Vccly  nscd  mid  llir  liosiiital 
fund  libeially  <-x])ciided  in  the  puicliase  of  dclicacifs  for  tlic  sirk.  Soft  l)rcail  of  cxi-cUcnt  (|ualit>'  was  issued  daily 
from  tlie  pont  liakery. 

Tlie  water-Hupi>!y,  derived  from  wells,  was  .suttieient  for  the  requirements  of  the  eainp.  Drainage  at  first  was 
iinperfeet.  A  diteh  of  irregular  (lei)th  ran  throngli  tlie  cjim])  and  earried  off  the  rainfall.  In  dry  weather  stagnant 
water  collected  here  and  there  in  the  deeper  ])arts  of  its  irregular  bottom.  These  wer<'  re)>cati'dly  denounced  by 
ins|(ecting  oflicers,  and  as  a  result  the  ditch  was  ultimately  straightened  deepened  and  converted  into  ,i  main  drain 
w  ith  which  laterals  from  the  area  of  the  camp  were  connected. 

The  sinks  were  simply  pits  in  the  ground  within  the  enclosure,  and  often  so  near  the  quarters  of  the  jirisoners 
as  to  be  ottensive.     Lime  was  used  daily  as  a  disinfectant. 

The  condition  of  the  camp  during  the  last  year  of  its  occupation  is  not  known,  as  no  detailed  accounts  of  a 
later  date  than  Jnly,  1864,  have  been  found  on  file. 

The  figures  for  Camp  Morton,  presented  in  Table  XVIII,  do  not  include  the  statistics  anterior  to  .lune,  181)3. 
An  estimate  of  the  mortality  previous  to  that  date  is  contained  in  the  report  of  Dr.  Humphreys  for  Sei>tember,  lM(i4, 
as  follows:  "There  have  been  treated  in  the  City  Hos))ital  of  Indiana])olis  84(1  rebel  sick  and  wouijded.  They  were 
all  of  the  Fort  Donelson  prisoners;  out  of  this  number  75  died.  The  men  were  broken  down  in  health  by  ])reviou8 
hardshijjs  and  exposure.  The  limbs  of  many  were  frosted  while  working  in  the  trenches  at  Fort  Donelson.  The 
prevalent  diseases  amongst  them  were  typhoid  fever  and  typhoid  pneumonia,  occurring  in  persons  in  whom  the  vital 
forces  had  been  reduced  to  the  lowest  possible  degree;  many  'dropjied  di'ad' while  walking  about  their  ((uarters, 
without  having  manifested  any  diseast^,  organic  or  functional,  except  gicat  general  del)ility.  In  persons  of  this 
class,  while  moving  about  looking  api)arently  in  medium  health,  the  action  of  the  heart  ami  arteries  would  be  so 
feeble  as  to  be  scarcely  perceptible  in  pulsations  at  the  wrist.  These  men  were  subsisted  and  treated  medicinally 
and  surgically  in  the  same  manner  as  the  sick  and  wounded  of  the  United  States  forces;  tlu^  same  air-space  in 
hospital,  and  every  facility  afforded  our  own  troops  were  given  to  the  rebels.  The  records  of  the  number  of  rebel 
prisoners  received  at  Camp  Morton  since  the  commencement  of  the  war  are  incomplete.  Colonel  Hiddi.k  of  the 
71st  Indiana  Infantry  has  been  in  commaml  of  the  camp  since  the  28th  of  January,  1863.  This  officer  reports  the 
number  of  j)risoners  of  war  in  this  camp  since  the  above  date  to  June  10,  1863,  to  be  4,(i04.  The  sick  in  hospital  out 
of  this  nvimber  were  591;  of  whom  43  died.  About  one-half  of  the  591  treated  were  wounded,  anu)ng  whom  were 
many  cases  of  hospital  gangrene.  The  total  numl)er  of  rebel  prisoners  brought  to  Camp  Morton  since  the  war  began 
exceeds  10,000.  From  the  undertaker  who- personally  superintended  all  the  internuuits  of  the  rebel  dead  at  this 
post,  I  learned  that  the  total  number  of  deaths  up  to  May  8,  1863,  amounted  to  353;  total  number  of  hospital  casjs 
treated  in  the  period  referred  to  1,685." 

Prison-camp  and  Hospital  at  Johnson's  Island,  neak  Sandusky,  Ohio. — The  inspection  reports  of  this 
prison-camp  present  a  most  gratifying  i)icture  of  its  sanitary  condition.  It  was  opened  some  time  in  18()2  and  closed 
in  October,  1865. 

The  island,  three  and  one-eighth  miles  from  Sandusky,  Ohio,  has  an  area  of  360  acres.  Its  natural  advantages 
as  a  depot  for  prisoners  of  war  were  very  great;  the  soil  was  alluvial  on  a  limestone  basis;  the  drainage  excellent; 
water  from  the  lake  abundant  and  of  good  (juality,  ami  the  salubrity  of  the  siti^  unsur])assed. 

The  buildings  in  the  camp,  frame  structures  two  stories  high,  with  bunks  along  the  sides,  were  well  lighted 
and  ventilated  by  doors  and  windows,  and  at  a  later  date  by  artificial  openings.  They  accommodated  2,000  men, 
giving  an  air-space  of  300  feet  per  num.  Their  capacity  was  largely  increased  in  1864.  The  j)rison-camp  was 
surrounded  by  a  high  board  fence,  enclosing  an  area  of  15  acres.     Officers  were  mainly  confined  in  this  ])rison. 

The  prison  hosjjital  was  a  two-story  frame  building,  giving  700  feet  of  air-space  to  each  of  80  beds.  It  was 
divided  into  four  wards  with  lavatories  in  each.  l?athing  facilities  were  art'orded  by  the  abundant  water-supply 
from  the  lake.  The  Bupi)ly  of  bedding  was  abundant.  The  diet  was  similar  to  that  furnished  to  the  LTnion  soldiers 
in  the  post  hospital.  Ice  was  furnished  in  abundance.  Vegetables  and  delicacies  were  freely  used.  The  medical 
officer  in  charge  was  assisted  by  Confederate  surgeons  confined  in  the  prison. 

The  sinks  at  first  were  excavations  in  the  ground,  but  later  box-sinks,  capable  of  being  drawn  out  and  emptied 
into  the  lake,  were  sul)St:tuted  for  the  old  vaults. 

The  natural  advantages  of  the  site  rendered  but  little  artificial  aid  necessary  to  perfect  the  drainage.  Garbage 
was  stored  in  barrels  and  carted  daily  from  the  camp. 

The  following  extract  from  the  report  of  Surgeon  T.  Woodbkidge,  128th  Ohio,  iu  charge  of  the  hospital,  sums 
up  the  conditions  attecting  the  prisoners  under  his  care  in  a  few  words.  The  report  is  that  for  June,  1863:  ''The 
rations  are  of  good  quality  and  the  cooking  excellent.  We  have  plenty  of  vegetables  and  an  abundance  of  fresh 
fish;  juire  air;  pure  water;  plenty  of  wood;  a  police  system  rigidly  enforced;  a  natural  salubrity  unsurpassed. 
We  are  as  perfect  in  what  pertains  to  hygiene  as  possible." 

Prison-camp  and  Hospital  at  Camp  Chase,  near  Columbus,  Ohio. — The  precise  date  of  the  establishment 
of  this  camp  and  hospital  is  not  shown  by  the  records  of  the  Surgeon  General's  Office.  It  was  used  as  a  prison-camp 
for  political  and  military  prisoners  early  in  1862,  but  the  reports  on  file  antedating  January,  1863,  are  valueless. 
The  hospital  was  not  closed  until  December,  1865,  although  few  i)risoners  renuiined  after  .luly  of  that  year. 

Camp  Chase  prison  was  situated  in  the  southeastern  part  of  the  enclosed  camp,  four  nules  from  Columbus,  Ohio, 
ou  the  National  road.     The  site  had  previously  been  a  race-course  and  fair-ground;  it  was  treeless  and  nearly  Hat  or 


AMONG    CONFEDERATE    TROOPS    IN    tJ.    S.    PRISONS. 


55 


Bomewliut  biiNin-like,  and  Kunounded  liy  forests,  which  made  it  close  aud  warm  in  snmnier.  The  soil  was  stiff, 
clayey  and  \vatcr-lioldiu<;,  poorly  drained  aud  destitute  of  runniujj  water. 

Tlie  liiiildings  in  the  prison-cami)  at  early  dates  were  poorly  constructed  wooden  liarrucks,  needing  constant 
repairs  to  render  them  habitable.  Dr.  HuMniUEVS  considered  them  little  better  than  the  huts  ordinarily  in  use  for 
the,  jirotection  of  domestic  animals.  They  were  divided  into  three  sets,  known  as  prison  No.  1,  for  othcers,  and  Nos. 
2  and  3  for  enlisted  men.  Each  prison  was  separated  from  the  other,  and  tlie  whole  was  surrounded  by  a  close  board 
fen<'e,  fifteen  feet  high,  with  an  elevated  platform  for  the  guard.  These  old  barracks  were  fitted  with  three  tiers  of 
bunks,  and  the  space  per  man  was  very  small.  To  accommodate  the  large  numbers  of  prisoners  received,  tents  were 
jiitched  in  the  avenues  between  the  barrack  buildings,  and  the  crowding  was  great.  The  dimensions  of  these 
buildings  and  the  particulars  of  their  construction  are  not  clearly  stated.  At  the  insjiectiou  in  September,  1863, 
the  i|iiarters  were  crowded:  at  this  time  there  were  ctuitined  1,7.")3  prisoners,  of  whom  only  27  were  sick — 25  in 
hos])ital  and  2  in  i|uarter.s. 

During  IWit  the  prison  underwent  a  radical  change:  its  area  was  increased,  its  buildings  remodelled,  aud  some 
of  a  better  character  erected.  Division  No.  1  of  the  prison  consisted  of  two  barracks.  No.  2  of  seventeen  barracks 
and  No.  3  of  twenty-seven,  making  a  total  of  forty-six  barracks.  Each  was  100  x  22  x  12  feet,  and  was  intended 
to  accommodate  192  men,  giving  137  cubic  feet  per  man.  They  were  all  of  tlu^  pavilion  pattern,  with  door  and 
windows  at  the  sides,  tloors  well  removed  from  the  ground,  ridges  ventilated,  and  the  tiers  of  bunks  reduced  to  two. 

Tlui  ])rison-hospital  building  in  1802  and  the  early  part  of  1863  consisted  of  a  small  one-story  wooden  barrack, 
79  X  20  X  12  feet,  divided  into  two  wards,  having  600  feet  of  air  for  each  of  3t)  lieds.  It  was  situated  within  the 
enclosure  and  too  near  the  high  close  fence  for  good  ventilation.  It  was  well  siipjilied  with  furniture  and  cooking 
apparatus,  lavatories  and  sponge-baths.  The  capacity  of  the  hospital  was  increased  about  December,  1863,  by  the 
erection  of  a  new  pavilion,  which,  however,  was  of  an  inferior  character.  It  was  built  of  old  lumber  preserved 
from  some  condemned  buildings.  Its  size  was  84  X  12  feet  and  only  8  feet  high,  allowing  a  little  over  400  cubic 
feet  of  air  per  be<l.  Hoth  of  these  buildings  wens  afterwards  condemned  an<l  abandoned.  New  aud  superior  hospital 
jiavilions  were  erected  outside  the  ])rison  en(^losure.  They  consisted  of  six  wards  each  100  X  25  X  12  feet,  affording 
850  feet  of  air-space  to  each  of  216  beds. 

lu  addition  to  these,  three  isolated  buildings  south  of  the  prison  enclosure  constituted  the  pest-hospital.  Two 
were  used  for  small-iiox  and  one  for  erysipelatous  patients.  The  sniall-pox  hospital  was  240  X  24  x  12  feet,  having 
a  capacity  of  120  beds,  to  each  of  which  it  afforded  a  cubic  space  of  576  feet.  These  buildings  were  of  the  pavilion 
pattern,  well  constructed  and  supplied  with  everything  needful  for  the  comfort  and  well-being  of  the  patients.  The 
attendance  was  good  aud  careful  and  the  supplies  ample  aud  of  good  (luality. 

In  a  spe<ial  report  dated  March  14,  1865,  Dr.  Coolidge  compared  the  barrack  occupancy  of  the  Union  troops 
and  Confederate  prisouers. 


Barracks  kor- 


No. 


United  States  paroled 18 

ITuited  States  garrison  20 

United  States  recruits 20 

Confederate  prisoners 46 


Length. 


Feet. 
100 

60 

60 

100 


Width. 


Feet. 
24 

24 

24 
22 


Height. 


Feet. 
12 


14 
14 
12 


Bunks. 


48 
48 
48 
48 


No.  of 

men  to 
each. 


192 
96 
96 

192 


Air- 
space. 


Feet. 

150 
210 
210 
137 


Area. 


Feet. 
12.5 

15.0 

15.0 

11.4 


The  diet  in  the  prison-camp  was  the  army  ration  with  the  addition  of  vegetables,  potatoes,  onions,  etc.,  the 
]>ost  bakery  at  all  times  furnishing  a  good  supply  of  light  bread.  There  appears  to  have  been  a  prisoners'  fund,  but 
no  account  of  its  expenditure  is  on  record.  The  kitchens  of  the  prison-barracks  wore  furnished  with  brick  furnaces 
having  ca.st-irou  U>\m  with  holes  for  kettles.  Tlicre  were  few  complaints  made  by  the  inspectors  under  this  head, 
the  whole  aj)pearing  to  be  (|uite  satisfactorj-. 

The  jnisoii-hospital  diet  was  of  the  same  quality  as  that  of  the  prison,  with  the  addition  of  such  delicacies  as 
were  purchased  by  the  hospital  fund,  which  was  expended  as  fast  as  it  accrued,  and,  according  to  the  inspection 
reports,  it  appears  to  have  been  ample  for  the  purpose. 

The  supplies  in  both  prison-camp  and  hospital  are  spoken  of  throughout  as  having  been  good  and  sufficient. 

The  water-supply  was  derived  from  wells,  which  in  the  early  months  of  the  occupation  were  not  commended, 
although  they  were  regarded  at  a  later  period  as  capable  of  yielding  an  abundant  supply  of  good  but  somewhat  hard 
water  for  drinking  and  cooking;  it  was,  however,  never  sufficient  for  l)athing  or  washing  purposes,  and  on  a  few 
occasions,  after  juolonged  dry  weather,  the  low  water  in  the  wells  rendered  some  precautionary  economy  advisable. 

In  consequence  of  the  nearly  level  surface  of  the  camp  great  difficulty  was  experienced  in  effecting  a  satisfac- 
tory drainage.  The  system  consisted  of  a  main  drain  or  ditch  running  through  the  prison-camp  from  west  to  east, 
with  lateral  branches  opening  into  it.  But,  as  in  the  absence  of  running  water  these  drains  could  not  be  satisfactorily 
flushed,  they  became  foul  and  emitted  disagreeable  odors.  On  the  remodelling  of  the  camp  and  hosfjital  buildings 
the  diaius  were  planked  or  boxed,  and  provision  was  made  for  flushing  the  system  by  means  of  water  from  a  cistern. 
The  defective  drainage  of  this  camp,  arising  from  its  physical  conformation,  was  noted  in  almost  every  inspection 
report,  and  the  advisability  of  removing  the  prisoners  to  another  and  healthier  site  was  frequently  suggested. 


56  STCKNKSR    ANT)    MOKTALTTY 

The  sinks  at  first  were  merely  pits  in  whicli  lime  anil  aslies  were  used  as  deodorizers.  Mneli  difficulty  was 
experienced  in  keeping  them  in  good  coiiditinn.  They  were  afterwards  tilled  np  li'st  they  should  eoutaminate  the 
water-supply,  and  new  sinks  were  construeted  over  the  drains,  whiidi  were  liushed  i)eriodl(ally.  (iarliage  was  col- 
lected 111  barrels  and  caited  ott'  regularly. 

Pkisox-cami'  ANii  Hospital  at  Ei.miha,  N.  Y. —  Ehnira  barracks  were  built  at  the  beginning  of  the  war  as 
a  general  recruiting  depot;  but  in  July,  1864,  Division  No.  3,  of  the  barracks,  called  afterwards  Camp  (Jlicmung, 
was  converted  into  a  prison-cam)).  This  division  was  situated  on  the  rivei-bank  a  mile  and  a  ([uarter  west  of  the 
town.  The  site  was  believed  to  be  healthy;  it  was  level,  and  having  a  sandy  soil  resting  on  a  stratum  of  coarse 
gravel  a  few  feet  below  the  surface,  afforded  good  underground  drainage.  At  the  date  mentioned  twenty  of  the 
old  barrack  buildings  were  considered  fit  for  the  occupation  of  the  prisoners  and  ten  new  ones  were  constructed. 
The  former,  88  X  18  X  8  feet,  were  intended  to  accommodate  each  one  hundred  men.  Tlie  latter,  80  X  2.5  x  12  feet, 
were  each  fitted  with  bunks  for  ont>  hundred  and  forty-eight  men.  Mess-halls  and  kitchens  were  snitalily  furnished. 
The  barracks  were  built  of  pine;  they  were  well  lighted,  warmed  by  stoves  and  provided  with  ridge-ventilation. 
The  bakery  <'onld  turn  out  six  or  seven  thousand  rations  per  day.  Good  water  was  obtained  from  two  wells,  and 
any  deficiency  was  supplied  from  the  river.  Lavatories  and  baths  were  not  at  first  specially  provided.  Drainage  wajs 
by  means  of  jiits  dug  to  the  porous  subsoil.     The  sinks  were  covered  pits,  which  were  filled  up  when  necessary. 

The  grounds  of  the  camp,  conii)ri8ing  thirty-five  acres,  were  snrrouiKled  by  a  feiici^  twelve  feet  high  with  a 
platform  four  feet  from  the  top.  In  August,  over  a  thousand  tents  were  pitched,  each  to  accommodate  five  persons. 
In  one  inspection  report  the  drainage  is  said  to  have  been  into  an  open  ])ond  within  the  camp,  thus  forming  what 
was  called  a  perfect  pest-hole;  but  on  the  reconnnendation  of  the  inspector  this  pond  was  afterwar<ls  drained  and  an 
nndergrouiid  sewer  constructed,  while  defects  in  the  surface  drainage  were  remedieil  from  time  lo  time.  Nevertlieless 
the  grounds  were  fre(|uently  reported  as  in  a  muddy  condition  during  wet  seasons. 

The  prisoners  were  insufficiently  clothed,  there  being  at  the  same  time  a  great  want  of  Idankets,  esjiecially 
among  the  lU'isoners  in  quarters.  A  supply  is  said  to  liave  been  received  on  one  occasion  from  the  Confederate 
authorities.  Sometimes  the  want  of  clothing  was  incomjiatible  with  the  maintenance  of  healtli,  and  hospital 
patients,  after  having  sufiicienfly  recovered  to  be  up,  were  obliged  to  keep  their  beds  for  want  of  pantaloons. 
Needs  of  this  kind,  and  others  less  urgent,  on  becoming  known,  were  relieved  by  the  i.ssue  of  hosiutal  clothing. 
Bedding  was  supplied  in  quarters  only  to  the  sick,  and  consisted  of  sacks  of  straw  and  a  blanket.  The  men  in  con- 
finement here  had  the  full  prison  ration  as  supplied  at  the  other  prison  depdts.  They  had  also  a  fair  supply  of  veg- 
etables purchased  by  the  prison  fund.  Desiccated  vegetables  were  at  first  furnished,  but  as  they  were  not  acceptable 
to  the  prisoners,  fresh  onions  and  potatoes  were  substituted.  Inspector  Lyma.n  reports  on  November  11,  1804,  tliat 
onions  and  potatoes  were  supplied  on  three  days  out  of  five,  and  in  each  of  his  snbse(|ueiit  reports  speaks  of  the  sujiply 
of  vegetables  as  suiticient.  On  one  occasion  he  reported  the  beef  as  of  inferior  quality,  but  generally  tlie  diet  is  rej)- 
resepted  as  good  and  well  cooked,  the  kitchen  being  under  the  supervision  of  a  s])ecial  otticer. 

On  the  arrival  of  the  prisoners,  and  while  the  hospital  was  in  course  of  erection,  the  sick  were  treated  in  a 
pavilion  set  apart  for  their  rece])tion.  Mi'dical  supplies  and  accommodations  were  deficient  at  tliis  time.  An  inspec- 
tion report  dated  .Tuly  15,  18(j4,  says:  ''They  are  alisolutely  without  the  necessary  medical  and  hos|)ital  sujiplies. 
Requisitions  were  made  three  weeks  ago.  [hitil  the  day  of  my  inspection  tlie  sick  were  laid  on  the  naked  bunks 
from  the  inability  to  obtain  straw.  This  was  finally  jirocured  by  the  commanding  otticer  after  considerable  ditticulty, 
and  arrived  during  my  inspection.  A\'hen  the  requisition  for  medicine  and  hospital  supplies  is  tilh'd  they  will  be  in 
every  respect  suitably  provided  in  a  sanitary  view."  In  August,  medicines  were  reported  aliundant ;  liut  the  sick- 
ness was  large  and  the  mortality  great.  "  This,"  said  the  inspector,  "is  due  to  the  broken-down  condition  of  the 
prisoners  on  their  arrival."  There  were  at  this  time  9,170  prisoners,  of  wliom  55.3  received  hospital  attendance  and 
.558  were  prescribed  for  at  sick-call. 

The  medical  staff  consisted  of  a  surgeon  in  charge  and  eleven  or  twelve  assistants.  Confederate  surgeons 
sometimes  assisted  in  attending  to  the  sick.  Yisits  by  the  medical  officer  were  made  twice  a  <lay,  and  in  special  cases 
oftener;  and  any  complaint  against  a  medical  attendant  of  inattention  or  harshness  was  promptly  investigated. 
Competent  persons  were  selected  from  among  the  prisoners  to  compound  prescriptions  and  to  act  as  nurses  and  cooks. 

In  August  the  hospital  consisted  of  three  wards  of  seventy  beds  each,  and  one  of  eighty-two  beds,  with  624 
cubic  feet  of  space  per  bed.  On  October  4th  there  were  9,063  prisoners,  of  whom  3,873  slept  in  the  barracks  and 
5,190  in  1,038  tents.  The  air-space  in  the  larger  barrack  buildings  was  111  cubic  feet  per  man,  in  the  smaller  build- 
ings 92.5  cubic  feet.  There  were  1,560  men  on  the  sick  report.  The  hospital  had  been  extended,  consisting  now  of 
six  new  wards  averaging  62  beds  each,  with  654  feet  of  air-space  per  bed,  and  four  barrack-buildings  averaging  70 
beds,  with  342  cubic  feet  per  bed. 

On  November  11,  an  additional  hospital  ward  of  62  beds,  with  654  feet  of  space  per  bed,  had  been  completed, 
and  one  of  the  old  70-bed  wards  was  vacated  for  use  as  quarters. 

In  January,  1865,  with  a  view  to  diminish  the  sickness  and  lessen  the  mortality,  the  Medical  Inspector  made 
the  following  recommendations:  '"  1st.  That  additional  wards  be  constructed  and  provision  be  made  for  hot-water 
bathing  of  the  sick.  It  is  impracticable  to  give  this  thoroughly  in  the  wards,  and  it  is  very  much  needed.  2d.  That 
hospital  clothing  be  allowed,  which  would  afford  an  opportunity  for  cleansing  the  woollen  and  underclothing  of  the 
patients.  3d.  That  all  the  old  barracks  be  provided  with  additional  windows.  In  the  winter  season  the  men  con- 
fine themselves  to  the  wards  as  much  as  possible  for  warmth,  and  the  closing  of  the  doors  and  windows  renders  these 
barracks  too  dark.  4tli.  That  more  cubic  and  sujierflcial  space  be  allowed  by  the  erection  of  additional  barracks. 
The  type  of  disease  among  the  prisoners  is  that  which  results  from  over-crowding:  there  is  no  acute  disease, 
everything  assumes  a  typhoid  type." 


AMONG    CON" FEDERATE    TROOPS    IX    U.    S.    PRTSONS.  57 

The  coiiflitioii  of  tlu>  canii)  at  tlic  date  inentionefl  is  thus  (lesciibeil :  "The  whole  ii])pearan<'e  of  this  camp  i» 
greatly  impioveil  since  tlie  last  iiisj)c(tii>n.  The  siek  in  hospital  and  quai'ters  are  now  vi<;ilantly  watched;  the  food 
is  fjood  and  w<'ll  ccMikcil :  coal  stoves  have  lieeii  substituted  for  wood,  and  the  police  of  the  tiarracks  is  (juite  as  good, 
and.  I  think,  better  than  in  most  rt-LCiraental  barracks."  Smallpox  liroke  out  among  the  iirisonersiibout  this  time. 
From  December  1,  1S(U,  to  January  21,  181)5,  there  had  been  :^!)7  cases.  To  isolate  these  proi)erly  a  small-])ox  hospital 
had  be<Mi  improvis<>d  witli  tent.s;  but  a  new  |)avilir)n  was  ))eing  constructed  to  rei>lace  it.  During  .January  ."i.tHlO 
vaccinal  ions  and  reva<'cinatioiis  were  performed.  'I'o  replace,  and  afford  l>etter  shelter  tliau  the  tents,  twenty-four 
new  barracks,  each  J0(IX-IXl2  and  3  feet  |>itch  of  roof,  liad  been  c<)m|)leted  by  the  middh'  of  March,  and  six 
more  were  in  cour,se  of  construction.  I'hese  are  said  to  have  given  ISO  cubic  feet  of  air-space  i)er  num.  At  this 
I>eviod  there  were  1,738  on  the  sick-list  in  a  total  of  5,((31  pris<mers.  an<l  many  of  those  in  ijuarters  were  very  siek 
and  stood  as  mucdi  in  need  of  suitable  ward-accommodation  as  those  in  hosjiital,  into  which,  for  want  of  room, 
they  could  not  he  received.  ''I'he  condition  of  the  ])atient8  is  jiitialdc,"  says  thi'  insiiector:  "the  diseases  are 
nearly  all  of  the  lyjdioid  type,  and  much  of  the  sickness  is  justly  attributable  to  crowd-pcusoning.  In  adiliticui  to 
this,  the  clothing  during  the  winter  was  insutiicient.  The  deep  mud  prevents  the  exercise  of  the  i)risoners  in  the 
o])en  air,  an<l  there  is  no  occupation  for  most  of  them  to  relieve,  in  a  measnre,  the  depressing  influence  of  prison-life. 
The  Fort  Fisher  ])ri.sonera,  especially,  arrived  in  cold  weather  very  mu(di  depressed,  poorly  (dad,  and  great  nmnbers 
were  soon  taken  sick  with  jnieunuinia  and  diarrhnea,  ra))idly  assuming  a  ty])hoid  character.  The  surgeon  was 
recomnu'ude<l  to  ])rcss  constantly  upon  the  comnumdant  tlu^  necessity  for  aiii>ropriating  sonu'  of  the  best  barracks 
for  additional  wards,  the  iiiim((li((te  completion  of  the  tloor-ventilation,  the  alteration  already  conuneiiced  in  the 
hospital  latrines,  and  the  free  use  of  pernuinganate  of  potash  throughout  the  barracks  and  <i(  bromine  in  the  wards. 
1  would  renew  the  recommendation,  made  in  my  .January  report,  that  additional  light  be  given  to  the  old  J)arracks, 
and  greater  facilities  foi'  warm  and  cold  bathing  as  prophylactic  nu-aaures.*'  .Sul>seciuently,  up  to  .June  22,  18(55, 
the  date  of  tlie  last  report,  the  sanitary  condition  of  the  camp  and  I)uildings  is  reported  as  having  been  good.  The 
nundier  of  prisoners  continued  to  diminish  and  the  ratio  of  mortality  grew  steadily  less. 

Pkisux  l)Kf6T  AT  FoHT  Dki.awark,  DELAWARE. — This  fort  assumed  importance  as  a  prison  depot  in  .June,  1863, 
when  8,400  men  captured  by  Geneial  (Jrant  in  his  operations  against  Vicksliurg  were  sent  to  it  for  confinement.  On 
June  3,  Medical  Inspector  E.  V.  Voi.i.um,  V.  S.  Army,  insp'ected  the  post  in  accordance  with  instructions  from  the 
Surgeon  (Jeneral,  to  determine  the  character  and  extent  of  the  hospital  accommodations  to  he  provided.  At  this 
time  Jiarracks  for  8,000  men  were  in  course  of  erection.  The  condition  of  the  post  and  prisoners  when  at  its  worst, 
that  is,  shortly  after  the  arrival  of  this  large  body  of  men,  is  fully  depicted  in  the  following  report  by  Assistant  Sur- 
geon ('.  H.  Ai.DKN,  V.  S.  Army,  dated  July  11,  1863,  on  the  causes  of  the  sickness  and  mortality  in  the  cam]) : 

"  Fort  Delaware  is  situated  on  an  island  in  the  Delaware  river,  below  Pliiladeljihia  and  nearly  o])posife  Dela- 
ware City.  The  i.sland  has  an  area  of  about  90  acres  ami  the  soil  is  of  a  low  marshy  nature.  Fort  Delaware  proper 
is  a  large  casenuited  work  of  granite  and  brick,  which  accommodates  but  a  small  part  of  the  inhabitants  of  the 
post.  It  has  within  it  the  different  offices  of  the  post,  ofBcers'  quarters,  rooms  where  the  officers,  prisoners  of  war, 
are  confined,  and  guard-house  for  the  prisoners  of  the  U.  S.  troops.  Outside  the  fort  are  numerous  wooden  build- 
ings of  more  or  less  recent  date,  accommodating  the  rank  and  file  of  the  prisoners  of  war,  workmen,  the  hospitals, 
sutler's  store,  etc.,  with  a  few  cottages  for  officers'  (luarters,  and  a  numl)er  of  tents  occupied  liy  the  troops  com])osing 
the  guard.  There  are  now  some  7,100  prisoners  confined  on  the  island,  including  aJjout  300  officers.  The  guard 
numbers  about  800  men. 

The  barracks  for  the  prisoners  of  war  are  two  in  number,  the  old  and  the  new,  each  composed  of  one-story 
wooden  buildings  enclosing  a  rectangular  piece  of  ground.  They  are  ordinary  shed-l>uihlings  with  shingle  roofs. 
The  ventilation  of  these  buildings  is  very  defective.  The  old  Itarrack  has  small  windows  along  the  side  at  consid- 
eral)le  intervals,  and  a  ridge  ventilator  along  the  whole  length  of  the  building.  The  new  barrack,  though  some- 
what higher,  is  still  worse  in  its  facilities  for  ventilation,  the  ventilators  at  the  ridge  being  only  occasitmal  and  placed 
at  consideral)le  intervals.  The  interior  is  arranged  with  a  central  aisle  and  on  either  side  three  tiers  of  iMinks  or 
rather  shelves,  inclining  towards  the  centre.  The  prisoners  lie  on  these  shelves  with  their  heads  directed  to  the 
exterior  of  the  building.  In  the  old  barrack  are  confined  3,500  men,  a  number,  it  seems  to  nie,  far  too  great  for  its 
capacity.  A  rough  estimate,  l)ut  I  believe  a  tolerably  correct  one,  shows  that  each  occupant  has  less  than  100  cubic 
feet  of  air,  in  connection  with  which  should  be  remembered  the  small  opportunity  offered  for  the  renewal  of  the  air. 
The  new  l)arrack  is  not  yet  entirely  occujjied,  owing  to  a  portion  of  the  J)uilding  having  given  away  and  requir- 
ing repair.  This  will  in  a  measure  account  for  the  crowding  of  the  old  l)arrack,  which  will,  I  was  assured,  l)e 
relieved  as  soon  as  the  new  is  m  condition  to  be  occupied.  There  are  also  attached  Jo  the  barracks  mess-halls 
and  kitchens.  The  mess-halls  have  long  narrow  tables  at  which  the  prisoners  stand  at  meals.  The  Ijarracks, 
mess-halls,  kitchens  and  the  prisoners  themselves  were  in  a  very  dirty  condition ;  some  portions  of  the  Imildings  much 
more  so  than  others. 

The  island  is  intersected  by  several  ditches  and  inlets,  l)ut  the  drainage  is  very  imperfect,  and  the  grounds 
inside  the  prisoners'  barracks  were  rendered  very  nuiddy  by  the  recent  rains.  The  water  is  now  excluded  from  the 
Tiioat  around  the  fort  to  enable  the  workmen  to  build  the  counterscarp.  The  filth  received  into  this  moat  from  the 
drains  and  privies  of  the  fort  is  therefore  not  removed  by  the  water  and  lies  exposed  and  decomposing,  causing  most 
disagreeable  effluvia  on  a  warm  day.  The  water-closets  for  the  prisoners,  as  well  as  for  all  those  living  outside  of  the 
fort,  are  on  the  edge  of  the  island  i)rojecting  over  the  water. 

The  water  on  the  island  is  chiefly  rain-water  of  good  quality.  At  intervals  along  the  outside  of  the  bar- 
racks are  tanks  for  the  collection  and  storage  of  the  rain-water.  Of  these  there  are  a  large  number,  and  many  of 
them  appeared  pretty  full  from  the  recent  rains.  There  are  also  tanks  connected  with  the  hospitals  and  other  bnild- 
Med.  Hist.,  Pt.  Ill— 8 


58  SICKNESS    ANT)    ^rOKTA^,TTY 

iiigs  arouuil  tlie  fi)rt.  Uiidcr  tlit-  caKeiiiiitcs  of  tlic  iiiniii  work  Mic  :i  scries  of  lai};*;  cisterns  whicli  aie  designed  to 
lie  filled  liy  tile  niin-fiill  on  the  paraiu'ls  ]iereolating  tliroiigli  tlic  I'artli.  sand  and  gravel  (forming  a  filtering 
iirrangenient ),  down  into  tlieni.  'I'liey  an^  of  large  cajiaeity,  Iml  at  |Mesent  l]a\ c  a  small  sui)]>ly  in  tlieni.  W'lien 
lain-water  is  scarce  it  lias  liei'ii  tlie  juactii'e  to  send  foi-  wafer  liy  vessel  to  the  I.randywinc;  some  of  the  water  now 
on  tlie  island  is  from  this  source.  'I'lie  water  of  the  Delaware  river,  wliich  snrrounds  the  island,  is,  I  learn  from 
eredilih^  persons  who  liave  lived  thi'ic  some  years,  considered  entirely  tit  for  drinking  in  the  winter  and  early  s])riiig. 
At  other  Heasons  it  is  somewliat  lirackish.  If  taken  at  low-water,  liowever,  it  is  not.  even  in  summer  considereil 
decidedly  injurious.  As  far  as  1  conid  learn,  and  I  took  the  stafements  of  s(^veral  ollicers  and  of  tlie  iirisoners  them- 
selves, the  svijiply  of  rain-water  has  as  yet  been  suliicieiit  for  the  gairison,  anil  has  liecn  enough  also  to  afford  drink- 
ing water  to  the  jirisoncrs.  The  latter  use  tlii^  iiv(!r  water  in  iiart,  if  not  entirely,  for  cooking  imrjioses.  With  the 
present  iinmlier  of  jiersoiis  on  the  island  the  supply  of  water  on  hand  would  certainly  fall  short  soon.  Measures  are, 
liowever,  lieing  taken,  hy  liriiigiiig  water  from  the  Hrandywiue  and  liy  pumping  up  (liy  steam  ajiparatus)  water  from 
the  river,  throwing  it  over  the  jiarajiets  and  alhiwing  it  to  filter  through  into  the  cisterns  lieiieath,  to  obtain  a 
good  supply.     A  condensing  ajijiaratus  has  also  been  ordered. 

The  ratio:i  issued  to  tli(>  juisoners  is  the  ration  issued  to  the  II.  S.  Army  before  the  late  increase  in  ijuantity. 
The  meat  is  brought,  already  butchered,  from  the  main  land,  and  appeals  to  be  of  g<iod  (juality.  The  biead  is  jiartly 
baked  on  the  spot  and  jiartly  ]irocuied  from  Delaware  City.  The  lafte-r  is  veiy  good,  but  tlie  former,  though  <if 
tolerable  <iuality  generally,  ap]ieared  in  one  or  two  instances  a  little  sour,  liesides  this,  hard  bread  is  also  supplie<l 
to  the  prisoners. 

There  are  five  hospitals  on  the  island,  one  for  the  garrison  and  tour  for  the  jirisoneis  of  war,  all  outsidt^  tlie 
fort.  They  are  frame,  buildings.  Two  are  old,  badly  ventilatt^d  and  po<irly  adajited  for  the  ](iirpose;  the  three 
others  are  mere  sheds,  which  have;,  however,  the  advantage  of  being  tolerably  vi'iitilated  through  the  chinks  of  the 
rough  boarding.  One  of  the  waids  of  the  jiost-hospital  was  particularly  small,  and  thongli  it  had  Imt  17  men  in  it, 
they  had  an  allowance  of  less  than  'MH)  cubic  feet  of  air  ]ier  man;  it  was  besides  badly  ventilated.  Two  hospital 
tents  are  also  occu])ied  by  sick  piisoners  of  war.  All  the  hospitals,  but  more  particularly  tho.se  of  the  prisoners, 
were  in  ])0or  police;  the  grounds  around  them  parti<MilarIy  so.  There  was  a  great  deficiency,  or  rather  an  almost  entire 
want  of  stores,  (dothing  and  medical  sujijilies  of  all  kinds;  bedding  was  also  very  insufficient.  There  were  no  bed- 
steads for  most  of  the  sick  prisoners  of  war.  A  sufiiciency  of  stimulants  for  immediate  use  is,  1  was  inlbrmed. 
obtained  through  the  t^uartermaster's  department. 

Assistant  Surgeon  H.  R.  Sii.r.iMAX,  IT.  S.  Army,  is  in  (diarge.  It  is  due  to  him  to  say  that  he  was  assigned  to 
this  po8t  hut  a  few  days  ago.  I  have  no  doubt  he  will  immediately  make  elforts  to  have  the  defects  above  mentioned 
corrected.  He  informs  me  that  four  days  since  he  made  requisition  for  all  necessary  supplies  on  the  Medical  Director 
at  Baltimore.  The  hooks  and  records  of  the  hosjiital  were  in  much  confusion,  or  rather  none  were,  I  lielieve,  kept 
except  a  register  of  the  sick  of  the  ||arri»on  and  a  morning  report. 

This  want  of  correct  records  makes  it  difficult  to  obtain  exactly  the  number  of  sick,  deaths,  etc.,  but  the  fid- 
lowing  data  are  believed  to  be  tolerably  ac'curate:  Then^  are  210  sick  prisoners  of  war,  among  whom  are  included  a 
few  wounded  just  received  from  the  battlefields  in  Pennsylvania.  The  morning  report  shows  that  there  are  tii)  of  tht^ 
garrison  sick,  24  being  in  hospital  and  •!.">  in  quarters.  The  chief,  and  I  may  say  almost  exclusive,  disease  is  chronic 
diarrhcea.  Hosjiital  reports  reveal  the  fact  that  the  disease  and  the  incident  mortality  is  almost  entirely  confined 
to  the  members  of  the  rebel  regiments  from  Alabanui,  Mississijipi,  and  other  southern  states,  taken  jirisoners  by  (ien- 
eral  Grant's  army  around  Yickslmrg.  A  large  ])art  of  these  men  came  hither  broken  down,  emaciated  and  already 
the  subjects,  for  some  weeks  or  months,  of  this  disease.  The  long  journey  from  \'icksburg  to  this  place  seems  to 
have  exhausted  all  their  vital  jiowers,  aiul  many  died  soon  after  their  arrival.  There  is  very  little  sickness  and 
hardly  any  mortality  among  the  prisoners  of  war  brought  from  General  Lee's  army,  or  any  other  source  than  the 
army  around  Vicksburg.  All  are  equally  exposed  of  course  to  any  imperfect  hygienic  influences  existing  on  the 
island;  but>the  fact  that  the  sickness  and  mortality  are  almost  entirely  confined  to  the  prisoners  from  Vicksburg, 
shows,  I  think,  that  the  conditions  under  which  they  are  now  placed  are  chargeable  neither  with  their  sickness  nor 
mortality. 

It  is  important  to  bear  in  mind  that  the  majority  of  the  prisoners  have  been  upon  the  island  but  a  few  days. 
The  want  of  ventilation,  the  over-crowding  and  bad  i>olice  of  the  prisoners'  barracks,  which  I  have  mentioned,  have 
not  as  yet  had  .time  to  produce  any  marked  effect  on  their  health.  I  cauuot  hut  conceive,  however,  that  serious 
results  will  ensue,  if  these  causes  are  allowed  to  operate  for  any  length  of  time,  especially  at  this  season. 

I  deem  it  my  duty,  ifj  view  of  the  pressing  necessity  of  the  subject,  to  call  the  attention  of  the  commanding  gen- 
eral to  the  want  of  ventilation  of  the  barracks,  the  over-crow  ding  and  the  want  of  police.  The  prospect  of  a  deficient 
supply  of  water  had  fully  engaged  his  attention,  and  he  was  using  his  best  efforts  to  provide  for  it.  He  requested 
me  to  point  out  the  fact  that  the  tanks  attached  to  the  barracks  should  have  been  double  the  size,  also  the  need  of 
a  water-tank  boat  for  bringing  water,  and  suggested  that  the  new  hospital  for  600  beds,  now  in  iirogress  of  contruc- 
tion,  should  have  tanks  twice  the  size  of  those  contracted  for. 

The  attention  of  the  medical  officer  in  charg<^  was  called  to  the  urgi'iit  necessity  of  taking  measures  to  provide 
hospital  stores  and  medical  supplies.  He  was  advised  to  make  an  immediate  spiicial  retjuisitiou  on  Surgeon  Muuray, 
the  Medical  Purveyor  at  Philadelphia,  for  such  articles  as  were  most  neede<l,  stating  the  emergency.  He  was  also 
advised  to  have  the  hospitals  and  the  grounds  around  them  thoroughly  policed,  applying  for  a  detail  of  men,  if 
necessary,  and  to  have  the  buildings  whitewashed  inside.  It  was  recomnufnded  to  obtain  additional  hospital  tents 
and  remove  into  them  the  sick  fi'om  the  crowded  wards  of  the  garri.son  hospital,  and  also  to  have  a  pig-sty  near  one 
of  the  hospitals  taken  away.     Several  benevolent  individuals  having  ottered  contributions,  he  was  advised  to  a(«ept 


AMOXG    CONFEDERATE    TROOPS    IN    V.    S.    PRISONS.  69 

and  invite  tlieiu,  esiifciiilly  of  underclothing  and  hospital  stores.     This  seems  to  be  the  more  necessary,  as  at  present 
there  is  no  hosiiital  fund  with  whicli  to  jmichase  extras. 

Thi'  .snhjeet  of  allowing  the  |irisoners  to  hathe  iiut'ortunately  escaped  my  attention.  I  was  Informed,  however, 
liy  one  of  the  ollicers  of  the  post,  that  it  had  not  heen  ])ermitted  for  the  ollieers,  and  the  condition  of  tlu'  men  cer- 
tainly indicated  that  they  have  not  enjoyed  any  greater  privileges  in  this  resiiect.  If  occasional  bathing  could  not 
only  be  allowed  but  compelled,  it  would  of  coiir.se  contribnte  materially  to  the  health  of  the  prisoners,  and  tlu'ie 
seems  to  be  n(»  good  reason  why,  under  ])roper  and  sufli<',ient  regulations,  this  could  not  safely  be  i)rovided  for."' 

I'msox-C'AMP  AND  Hospital  at  Point  Lookoi'T,  Makyi,axi>. — This  camp  was  established  in  August,  lH(i'.i,  on 
the  eastern  side  of  the  point  at  some  distance  north  of  the  site  of  the  Hammond  (ii'Ueral  Hospital.  In  his  report  for 
July  of  that  year  Medical  Inspector  (Jeueral  .1.  K.  Kahnks,  1'.  S.  Army,  mentioned  the  jiroposed  settlement  of  ten 
thousand  prisoners  in  the  vicinity  of  the  hosidtal,  au<l  called  the  attention  of  the  Surgeon  (ieneral  to  the  fact  that 
at  least  700  of  the  beds  of  this  establishment  would  be  reijuired  for  the  use  of  the  sick  among  this  number  of  i)ri8- 
ouei-s.  The  ))oint  was  sandy  and  s]iarsely  dotted  with  shrubby  vegetation.  The  site  was  considered  healthy.  The 
])rlson-area  was  surrounded  on  three  sides  by  a  stockade:  on  the  east  side  it  opened  on  Chesapeake  Hay.  ()ne  or  two 
gun-boats  guarded  the  water-front  of  the  camp.  The  prisoners  were  sheltered  in  Sibley  and  A  tents,  which  were 
pitched  in  regular  lines  separated  by  well-graded  streets.  One  division  of  the  i)risouers  occupie4l  cracker-liox  huts, 
built  by  themselves  out  of  such  timber  as  was  obtainable  on  the  point  and  shlngle-like  fragments  of  the  emi)ty  hard- 
bread  boxes.  At  first  the  sick  were  sent  to  the  Hammond  Hospital,  but  after  a  time  a  prison  hos])ital,  in  whi<'li  cases 
of  a  less  severe  character  were  treated,  was  established  within  the  stockade.  The  water-supply  was  from  a  nuud>er 
of  wells  which  yielded  each  from  ,^)00  to  1,000  gallons  daily,  but  diarrhn-a  was  sometimes  attributed  to  its  \ise.  The 
soil  of  the  camp-site  was  ke]>t  unusually  free  from  excremental  taint,  as  the  sinks  were  built  over  the  waters  of  the 
bay,  which  promptly  carried  off  the  deposited  filth. 

The  first,  and  perhaps  the  only,  report  of  special  interest  from  this  camp  contains  a  protest  against  over- 
crowding. It  was  written  by  Surgeon  Jas.  H.  Thompson,  IT.  S.  Vols.,  Surgeon  in  charge,  June  30,  IWU:  "  Several 
thousand  prisoners  caj)tnred  during  the  present  camjiaign  have  been  received  into  camp  during  the  month  of  June. 
Many  of  these  were  suffering  from  exhaustion  and  diseases  incident  to  an  active  cami)aign.  It  will  be  ])erceived  by 
a  reference  to  tlu^  mortuary  report  that  nu)st  of  the  deaths  during  the  month  occurred  among  these  new  arrivals. 
The  types  of  all  diseases  o<<urring  in  camp  have  l>een  more  aggravated  than  during  ])revious  months.  Wounds, 
though  generally  i)rogressing  favorably,  have  in  several  instances  proved  troublesome  from  gangrene  and  proneness 
to  secon<lary  Inemorrhages.  Only  one  case  of  variola  has  occurred  and  fifty-five  cases  of  measles;  the  latter  disease 
is  increasing,  the  former  nearly  extinct.     Requisition  has  been  made  for  vaccine  lymph  to  x>rotect  the  new  arrivals. 

Subjoiiu'd  is  an  extract  from  a  report  forwarded  to  the  commanding  officer  of  the  Post  June  2'A,  18(U: — 

'  I  have  t  he  honor  to  call  the  attention  of  the  commanding  ofHeer  to  the  already  crowded  condition  of  the  pris- 
oners' cani))  at  this  post,  and  as  sanitary  officer  of  the  camp  to  respectfully  jirotest  against  the  reception  of  additional 
numliers  of  prisoners,  there  being  now  fully  fourteen  thousand  persons  within  the  camp,  and  nearly  twenty  thousand 
on  the  j>oint,  including  the  U.  S.  Hammond  General  Hospital  with  one  thousand  three  hundred  wounded  men,  the 
contraband  camp  of  indefinite  numbers,  the  Quartermaster's  department  and  troops  of  the  garrison.  In  addition  to 
these  are  the  Quartermaster's  stables  with,  I  suppose,  two  hundred  and  fifty  horses  and  mules. 

The  reasons  why  I  am  urged  to  make  this  protest  are: 

1st.  The  limited  area  of  the  camp  and  of  the  occupied  surface  of  the  point. 

2d.  The  already  insufficient  and  injurious  <iuality  of  the  water.  According  to  the  results  of  analysis  the  water 
of  some  of  the  wells  Is  unfit  for  use,  and  to  this  I  attribute  largely  the  increased  jjrevalence  and  fatality  of  disease 
during  the  i)a8t  month. 

3d.  Though  the  police  of  the  camp  is,  and  has  been  for  several  nmnths  past,  most  excellent,  still  every  precau- 
tion against  epidemic  disease,  with  this  over-crowding  of  the  camp  not  only  continued  but  rumor  says  yet  to  be 
increased,  will,  I  fear,  prove  futile,  and  we  may  see  ere  the  summer  is  past  an  epidemic  that  will  decimate  not  only 
the  ranks  of  the  prisoners,  but  aft'ect  alike  all  the  inhabitants  of  the  point, — 

I  therefore  recommend  to  the  consideration  of  the  conunanding  officer: 

1st.  That  no  greater  number  of  prisoners  or  troops  than  at  present  occupy  the  ground  be  allowed  upon  the  point. 

2d.  That  condensers  be  at  once  put  up  to  furnish  a  sufficient  (niantity  of  pure  water. 

3d.  The  diminished  issue  of  salt  pork  and  the  largely  increased  issue  of  fresh  vegetables;  this  in  consideration 
of  the  scorbutic  tendency  and  character  exhibited  in  the  majority  of  diseases  occurring  in  the  camp. 

4th.  The  immediate  construction  of  barrack-hospitals  for  the  accommodation  of  two  hundred  sick."" 

The  condensers  were  not  furnished,  but  to  supply  the  Increased  necessity  for  water  a  number  of  new  wells 
were  dug.  Free  issues  of  vegetable  food  were  made  to  the  prisoners  and  a  post-hosi)ital  of  six  warils  was  commenced 
outside  the  stockade.  Large  numbers  of  the  i)rlsoners  were  employed  under  guard  on  this  and  other  work  in  the 
vicinity  of  the  camp.  The  details  for  such  duty  were  eagerly  coveted  as  furnishing  occupation  and  change  of  scene, 
and  entitling  the  laborer  to  extra  rations  or  special  issues  of  tobacco,  as  might  be  desired. 

Hy  orders  dated  August  31,  18ti4,  from  headquarters  of  the  military  district  in  which  the  camp  was  situated, 
the  ])rovost  marshal  was  charged  with  the  duty  of  inspecting  the  camp  and  hospital  of  the  prisoners  of  war.  Daily 
inspections  were  enjoined,  and  weekly  reports  required,  covering  such  points  as  personal  cleanliness,  clothing  and 
bedding,  quarters,  kitchen  and  messing,  police,  sinks  and  drainage,  hospital  wards  and  attendants,  etc. 

From  a  perusal  of  these  reports,  now  on  file  in  the  office  of  the  Adjutant  (ieneral  of  the  Army,  it  is  evident 
that  few  prison-camps  were  iii  better  condition  than  this  depot  at  Point  Lookout.  During  the  warm  months  the 
prisoners  were  required  to  bathe  and  change  their  underclothing  once  a  week.     In  fact,  nuiny  took  frequent  advantage 


60 


SICKNESS    AiN'T)    MORTALITY 


of  the  general  permission  to  bathe  in  the  wiiters  of  Clies.ipealso  Ray.  During  tlie  winter  the  faeilities  for  personal 
cleanliness  were  not  so  satisfactory.  The  water-snp|)ly  from  wells,  twelve  to  twenty  feet  deep,  was  at  first  snfticient 
for  all  the  needs  of  thi!  eamp;  hut  as  fresh  (•omniitments  were  made  new  wells  had  to  l)e  dug,  and  on  a  few  occasions 
of  ]arg(^  and  unexpected  increments  of  llu^  population,  as  for  instance,  on  April  Ki,  lJSfc),5,  when  over  5,000  were 
received,  precautions  had  lo  lie  taken  against  waste  of  water  until  new  sources  of  supply  became  avaihilde. 

Besides  the  ordinary  body-clothing,  every  Jirisoin'r  was  furnished  with  an  overcoat  and  blanket  and  a  change 
of  nnderclotliing.  On  each  of  the  weekly  reports  are  noted  the  number  of  jirisoners  received  and  the  articles  of 
clothing,  etc.,  issued.  Sometimes,  when  a  large  commitment  was  made,  the  clothing  on  hand  was  insutlieient  foi-  thi' 
supply  of  the  new  anivals.  Thus,  although  during  the  week  ending  October  16,  181)4,  1,000  overcoats,  1,800  blankets, 
402  blou.se8,  202  ])air8  of  drawers,  168  pants,  (ifiO  shirts,  650  pairs  of  shoes  and  380  pairs  of  socks  were  issued,  it  is  stated 
that  to  make  the  prisoners  comfortable  and  provide  each  with  a  blanket,  further  issues  of  4,0(X)  shirts,  3,000  pants, 
2,500  pairs  of  shoes  and  1,.500  blankets  were  imjieratively  re((uired.  Reriuisitions  for  needful  articles  were  as  a  rule 
promptly  honored.  The  (|uartermaster  had  on  hand  at  this  time  a  large  number  of  pants,  but  as  they  were  of  the 
regulation  blue  color  it  was  deemed  inadvisable  to  distribute  them.  The  similarity  in  the  dress  of  the  guard  and 
I)ri8oners  Avonld  have  facilitated  escape,  jiarticularly  as  over  itOO  of  the  prisoners  were  daily  emidoyed  on  the  public 
works  outside  the  stockade.  During  the  winter  some  of  the  prisoners  received  extra  articles  of  clothing  from  their 
friends  in  the  south,  and  on  February  19, 1864,  twelve  bales  of  blankets  and  one  case  of  socks  arrived  from  New  York 
through  the  Confederate  Agency  for  the  supply  of  prisoners.  These,  and  subsequent  supplies  from  the  same  source, 
were  distributed  by  a  committee  of  prisoners  to  whom  this  duty  was  assigned.  The  report  of  March  5  states  that 
two  other  lots  of  clothing  had  been  received  from  (ien«^ral  He.vlk,  the  rebel  agent  in  New  York,  and  that  of  March 
26  has  the  further  statement  that  "the  supplies  of  clothing  furnished  by  tlie  Rebel  authorities  are  (|nite  liberal 
and  timely.'' 

The  quarters  consisted  of  Sibley  tents,  twelve  men  to  a  tent,  and  A  tents  with  four  men  in  each.  No  descrip- 
tion is  given  of  the  character  of  the  make-shift  shelters  constructed  of  cracker-boxes  and  fragments  of  old  lumber, 
but  as  ])ermission  to  build  was  regarded  as  a  favor,  it  seems  as  if  these  compared  favorably  in  point  of  comfort  with 
the  tents,  one-third  of  whi<-Ii,  towards  the  end  of  the  occupation  of  the  camp,  were  re]>orted  as  unserviceable. 

Six  kitchens,  with  large  mess-halls  attached,  were  used  in  the  preparation  and  consumption  of  food.  The. 
rations  were  uniformly  of  good  (juality  and  well  cook<«l.  At  the  time  these  inspections  were  instituted  vegetables 
were  issued  freely  to  counteract  the  tendency  to  scorbutic  manifestations  among  the  prisoners,  and  the.se  issues 
appear  to  have  been  kept  iip  to  the  end. 

The  camp  was  ])reserved  in  an  excellent  state  of  police.  All  cleaning  was  completed  before  9  .\.  M.,  at  which 
time  tlie  prisoners  formed  line  in  their  respective  divisions  and  were  inspected  by  the  provost  marshal.  To  supple- 
ment the  sinks,  boxes  were  in  us<'  for  the  convenience  of  the  prisoners  during  the  night.  These  were  removed  in  the 
early  morning  by  the  police  parties. 

At  the  suggestion  of  Surgeon  Thompson  nine  hospital  wards  of  sixty  beds  each  were  built  outside  the  stock- 
ade ;  they  were  reported  finished  on  October  30.  Tliere  were  in  addition  one  hundred  and  twenty  hospital  tents 
floored  with  lumber  and  fitted  uj>  with  hospital  beds.  Wards  were  set  ajjart  for  the  treatment  of  measles,  small-i)ox 
and  erysipelas.  These,  with  a  full  sf  all'of  medical  ofticers  and  attendants  and  ample  supplies  of  medicines  and  medical 
comforts,  were  ])rovided  for  the  cure  of  the  prisoners  when  sick  and  as  a  relief  to  the  wards  of  the  Hanniiond  Hospitiil, 
which,  however,  continued  to  keep  its  doors  open  for  the  reception  of  prisoners  when,  as  was  usually  the  case,  the 
prison-hospital  failed  to  acconnnodate  their  number.  On  December  18  Surgeon  Thompson'  insisted  on  the  necessity 
for  increased  hospital  facilities,  but  no  action  was  taken  on  this  recommendation  as  the  Hammond  Hospital  at  all 
times  acted  the  j)art  of  a  prison-hospital. 

Occasional  remarks  on  the  rei)orts  of  the  provost  marshal  l>y  Brigadier  General  James  Buhnks,  eonnuanding 
the  prison-camp,  testify  to  tlie  existence  of  a  uniformly  satisfactory  condition  of  aftairs.  "I  have,"'  he  says  on  the 
report  of  November  6,  "nothing  particular  to  add  to  the  statement  of  the  inspecting  officer  except  my  general 
testimony  to  the  kindness  manifested  by  the  different  officers  connected  with  the  duties  of  the  government  and 
discipline  of  the  camp.  Fortunately  the  general  good  conduct  of  the  prisoners  renders  unnecessary  any  act  of 
severity  towards  them,  and  is  at  the  same  time  sufficient  testimony  as  to  the  mode  of  their  treatment.*' 

The  following  extract  from  a  report  of  Assistant  Surgeon  J.  C.  McKee,  U.  S.  Army,  dated  July  1,  1862,  shows 
the  insanitary  conditions  at  one  of  the  minor  or  tenijiorary  iirison-camps — that  established  near  Springfield,  Illinois: 

"  C.\.MP  BfTi.EK,  Il.l.ixois,  is  situated  on  the  (ireat  Western  Railroad,  six  miles  from  the  town  of  Springfield. 
The  camp  is  established  on  a  rather  high  and  rolling  piece  of  ground,  surrounded  by  a  high  board  fence,  enclosing 
some  fifteen  acres  of  land.  It  was  originally  intended  as  a  eamp  of  instruction  for  volunteers.  The  barracks  were 
built  for  two  regiments.  Tliey  are  mere  shells,  single  boards  foriiiing  the  sides  and  roofs;  the  sides  very  low,  about 
eight  feet  in  height;  the  roofs  covered  with  tarred  paper.  Erected  by  contract  they  afford  protection  neither 
from  storms  nor  heat.  During  this  month  the  thermometer  has  been  steady  at  102°  for  days  in  my  own  room.  The 
effect  of  such  intense  and  continued  heat  on  the  sick  and  well  in  these  miserably  constructed  barracks  has  been 
prostrating  in  the  extreme.  The  prisoners  of  war,  over  two  thousand  in  number,  occupy  the  rows  of  barracks  on 
the  right ;  in  front  of  these  there  are  two  rows  of  tents  on  a  main  street  also  occupied  by  them.  Four  of  the  bar- 
racks in  this  row  are  used  as  hospitals,  part  of  another  as  a  drug  store.  A  line  of  sentinels  surrounds  all,  leaving 
ample  room  for  the  prisoners  to  exercise;  but  they  are  generally  indifferent  to  this  and  to  their  personal  cleanliness. 
Two  other  hospitals  outside  of  these  lines  are  now  allotted  to  convalescents  on  account  of  the  shade.  On  my 
arrival  here  in  May  I  found  the  hospitals,  six  in  number,  in  a  miserable  sanitary  condition.  No  one  had  taken 
the  authority  or  trouble  to  better  this.     The  floors  were  filthy;  deodorizing  agents  were  not  thought  of;  slops  and 


AMONG    CONFKDERATE    TKOOPS    IN    U.    S.    TRIHONS. 


61 


filth  wore  thrown  iurtisoriniinately  around.  The  sick  were  crowded  in  wooden  hunks;  some  on  the  iloor,  many 
without  hhiukets,  and  nearly  all  without  straw,  either  new  or  old.  No  attention  was  jiaid  to  ventilation  or  drain- 
ajfe.  The  stench  of  the  wards  was  horrid  and  sickening.  Food  was  aliundant  hut  liadly  )>rei)ari'd;  medicines  were 
deficient.  The  stcH-ards  were  if^norant  and  iieglijicnt  of  their  liusiness;  the  nurses  and  cuoks  insuliordinate  and 
inattentive  to  the  wants  of  their  sick  (u)mpani()ns.  Tlie  condition  of  the  iirisoners,  many  of  wliom  had  been  broken 
down  in  service  ])rior  to  their  cai)ture,  opened  a  favoralile  and  unlimited  field  for  the  devclo])meut  <d'  low  types  of  dis- 
ease, and  accordingly  typhus  and  typhoid  fevers,  ])neumonia,  erysijx'las,  etc.,  raged  with  violence  and  great  fatality. 

To  carry  out  my  ])lans  of  improvement  reijuired  much  explanation  and  persuasion.  I  was  successful  in  what 
I  undertook  for  the  comfort  of  these  unfortunate  sick.  Floors  were  scrubbed;  liuu'  applied  freely  on  the  walls  and 
floors;  ventilation  and  drainage  attended  to.  A  fever  hospital  (making  seven)  was  established;  another  hospital 
was  u.sed  for  ])neumonia  ;  another  for  erysipelas.  The  surgeons  (piisoneis  of  war)  were  assigned  to  their  own 
hospitals;  stewards  and  nurses  were  encouraged  to  emulate  each  other  in  the  cleanliness  of  tlieir  wards — all 
with  the  happiest  effects.  Cooks  were  supplied  with  necessary  kitchen  furniture  ;  liarrels  were  i>rocure(l  for  slops; 
water  was  furnished  in  abundance  for  the  sick;  wards  were  liuuted  to  the  number  of  30  patients.  Tins  hospital 
fund  procured  many  necessary  articles  such  as  ice.  The  Medical  Purveyor  at  Chicago  sent  me  a  full  su))ply,  according 
to  the  Standard  Sujiply  Table,  for  six  months.  A  drug  store,  under  an  excellent  druggist,  was  estal)lislied.  A  quantity, 
sufficient  for  a  change,  of  shirts,  drawers  and  sheets  was  olitained  from  the  Quarternuister;  fresh  straw  and  licd-sacks 
were  also  secured.  I'nder  these  changes  the  difference  in  the  mortality  of  my  hospitals  was  remarkable  and  exceed- 
ingly gratifying.     During  the  month  of  May  one  hundred  and  twenty-three  died,  whilst  in  June  only  thirty  died. 

Of  twenty-four  cases  of  camp  fevers  (typhus)  four  died ;  of  fourteen  eases  of  ty]>hoid  two  died;  of  thirty- 
three  cases  of  common  continued  fever  two  died.  In  two  cases  I  was  unable  to  diagnose  whether  they  were  typhus 
or  typhoid  until  after  a  post-mortem  examination.  The  former  disease  was  sudden  in  its  attacks;  in  two  cases 
the  patients  died  on  the  third  day.  Ammonia,  tonics  and  stimulants  had  to  be  used  in  large  quantities.  One  case 
(I  thought  of  fatal  relapse)  was  saved  by  blistering  the  whole  length  of  the  spine  with  ammonia  and  nmstard. 
Typhoid  or  enteric  fevor  was  treated  much  in  the  same  way,  with  the  addition  of  oil  of  turpentine,  of  which  I  cannot 
speak  too  highly.  Quinia  had  to  be  employed  freely  among  these  men  in  nearly  all  diseases.  They  generally  conie 
from  miasmatic  districts.  I  can  speak  with  the  highest  satisfaction  of  the  use  of  muriated  tincture  of  iron  in  the 
treatment  of  erysipelas;  alternated  with  quinia  it  controlled  the  disease  in  all  its  forms.  I  found  local  applications, 
as  of  iodine  and  nitrate  of  silver,  unsatisfactory  in  their  results,  not  controlling  the  spread  of  the  disease.  I 
abandoned  their  use  and  applied  emulsion  of  flaxseed,  saving  pain  and  trouble  to  my  patients.  The  two  fatal  cases 
reported  were  complicated  with  other  diseases." 

Having  obtained  from  this  investigation  of  the  reports  of  the  medical  inspectors  some 
idea  of  the  unhygienic  surroundings  of  the  prisoners  at  these  depots,  the  following  table, 
contrasting  their  mortality-rates  from  all  diseases  and  from  certain  prominent  classes  of 
disease,  may  be  consulted  with  advantage : 

Table  XXI. 

Comparing  the  Annual  Sickness  and  Mortality  from  certain  Specified  Diseases  at  the  Principal  Depdts 

for  Rebel  prisoners. 


Name  of  Pkison. 

Camp 

Duufirlas, 

111. 

Alton, 
111. 

Rock 

Island, 
111. 

Camp 

Morton, 
Ind. 

Johnson's 
Island, 
Ohio. 

Camp 

Chase, 
Ohio. 

Etmira, 
New  York. 

Fort            Point 

Delaware,    Lookout, 

Del,              Md. 

All  these 

deiMts. 

Annual  gick-rate  per  1,000  strength  . . . 

3,757 

10,072 

1,575 

•1,485 

811 

4,735 

1,544 

3,549 

2,471 

2,997.6 

Annual  deaUi-rate  from — 

19.2 
12.7 
36.7 
38.1 
2.1 
70.7 

24.5 
62.0 
188.0 
80.2 
2.1 
96.6 

6.4 

6.1 

51.0 

42.5 

1.6 

46.4 

7.0 
19.9 
14.3 
52.8 

1.0 
82.5 

5.9 
2.3 
3.8 
10.5 
0.0 
5.7 

10,4 

6.7 

71.6 

44.6 

1.0 

188.6 

21.  a 

9.9 

58.9 

211.5 

3.0 
117.3 

12.7 
14.2 
38.5 
52.4 
7.7 
32.7 

12.3 
9,2 

18,9 

116.3 

9.5 

23.7 

13.6 
12.6 
42.3 
73.0 
4,3 
61.7 

Diarrh<iea  and  Dysentery 

Scurvy 

214.5 

509.4 

186.1 

196.  8 

35.4 

343.2 

444.1 

179.1 

206.6 

2.30.  4 

Percentage  of  &tal  cases 

5.7 

5.0 

11.8 

13.3 

4.4 

7.3 

28.8 

5.0 

8.4 

7.7 

65.7 

Annual   death-rate  from  disease  per 
1,000  men  admitted. 

44.1 

55.0 

9a  0 

46.7 

9.8 

75.2 

241.0 

45.4 

46,4 

62 


SICKNESS    AND    MOKTALITY 


The  average  death-rate  from  disease,  230.4  annually  per  thousand  prisoners  present, 
was  exceeded  at  the  three  depots,  Alton,  III,  Elraira,  N.  Y.,  an'd  Camp  Chase,  Ohio.  At  the 
first  named  of  these  prisons  the  high  rate  of  509.4  annually  per  thousand,  calif*  for  special 
inquiry  into  the  conditions  tliat  ])ro(luc(:'d  it.  Excepting  scurvy,  every  one  of  the  diseases 
mentioned  in  the  above  taljle  had  at  tliis  post  a  death-rate  higher  tlian  among  the  prisoners 
generally.  The  exce])tioii  suggests  that  hei'c  tlie  inmates  had  a  l)etter  and  more  varied 
diet  than  was  served  at  prisons  whei'e  tlie  death-rate  from  disease  was  below  the  average, 
as  at  Fort  Delaware  and  Point  Tjookont;  the  diet,  at  least,  was  a})i)arently  not  responsible 
for  the  great  mortality.  This  large  death-rate  seems  at  first  siglit  an  argument  against  the 
use  of  permanent  brick  or  stone  buildings,  like  this  convict  prison,  as  depots  for  the  safe- 
keeping of  prisoners  of  war.  The  annual  rate  from  the  eruptive  fevers,  188,  as  against  42.3, 
the  average  among  the  prisoners  in  all  the  depots,  might  be  held  as  illustrating  the  ravages 
of  small-pox  when  such  close  ill-ventilated  buildings  become  infected.  The  death-rate  for 
the  continued  fevers,  24.5,  nearly  double  that  of  the  same  fevers  among  the  prisoners  as  a 
whole,  might  be  regarded  as  further  testimony  to  the  influence  of  crowd -poisoning  within 
substantial  walls  as  compared  with  the  influences  developed  by  similar  crowding  in  tents  and 
cheaply  constructed  wooden  pavilions.  But  when  it  is  observed  that  malarial  fevers  also 
were  largely  more  fatal  than  at  any  of  the  other  depots,  although  the  penitentiary  was  on  a 
high,  dry  and  well-drained  site,  it  must  be  concluded  that  the  facts,  so  far  as  presented,  do  not 
include  everything  bearing  upon  the  mortality-rate  per  thousand  of  strength  at  this  post. 

The  vast  number  of  cases,  10,072,  taken  sick  annually  at  Alton  in  an  average  strength  of 
1,008  men,  equivalent  to  ten  entries  on  sick  report  per  man  during  the  year,  also  requires 
explanation.  This  is  found  in  the  fact  that  the  strength  present  was  not  a  settled  population ; 
it  consisted  of  constantly  varying  elements.  Detachments  of  prisoners  were  received,  bring- 
ing with  them  their  sick  to  augment  the  sick  report,  whde  generally  only  the  well  men, 
those  fit  to  travel,  were  exchanged,  released  on  oath  or  enlisted  into  the  service,  the  sick 
remaining  to  swell  the  mortality  lists  of  the  post.  The  number  of  persons  committed  to 
this  depot  was  9,330,  and  as  the  average  strength  was  only  1,008,  the  stay  of  each  prisoner 
must  have  been  of  comparatively  short  duration.  Practically  the  strength  present  was 
changed  9.2  times  during  the  period  of  its  occupation  as  a  military  prison,  or  3.2  times 
annually.  When  the  deaths  are  viewed  in  connection  with  these  facts,  Alton  will  be  found  to 
have  been  by  no  means  the  terrible  pest-hole  suggested  by  the  enormous  rate  of  its  cases  to  the 
average  of  its  strength,  or  by  the  annual  demise  of  more  than  one-half  of  its  population. 

All  the  other  depots  except  Fort  Delaware  and  Johnson's  Island  had  a  larger  percent- 
age of  fatal  cases  of  disease  than  the  Alton  penitentiary.  The  Fort  Delaware  rate  of  5.0 
per  cent,  equalled  that  of  Alton;  only  at  Johnson's  Island  was  the  rate  of  fatality  smaller, 
4.4  per  cent.  The  ratio  of  deaths  to  cases  among  prisoners  is,  however,  not  of  much  value, 
as  uncertain  numbers  of  slight  cases  were  not  taken  upon  the  report.  But  when  the  deaths 
are  considered  in  relation  to  the  number  of  persons  who  entered  the  penitentiary,  the  annual 
rate  of  55.0  per  thousand  will  be  found  less  than  the  average  rate  of  all  the  prisons,  65.7 
per  thousand. 

Alton  may  not,  therefore,  be  considered  as  having  been  the  worst  specimen  of  our 
northern  prisons.  On  the  contrary,  but  for  the  heavy  mortality  of  its  small-pox  epidemic, 
it  would  have  compared  favorably  with  any  of  the  others  except  the  depot  at  Johnson's 
Island,  Ohio, 


AMOKG    CONFEJJKKATE    TKuOPS    IN    U.    S.    I'KlSOIvS.  63 

Similar  changes,  to  some  extent,  took  place  at  all  the  otlier  prisons ;  and  their  influence 
must  be  considered  in  estimating  the  unhealthiness  of  these  depots  from  the  death-rates 
expressed  as  ratios  of  the  average  strength  present.  A  statistical  table  contained  in  a 
report  of  the  Adjutant  General  of  the  Ariny,  appended  to  the  Report  of  the  Committee 
on  the  Treatment  of  Prisoners  of  War,  gives  tlie  total  number  of  conunitments  to  each 
of  the  prison  depots:  Oamp  Douglas,  111.,  received  26,060  men;  Alton,  JIL,  as  already 
stated,  9,330;  Rock  Island,  111.,  11,458;  Gamp  Morton,  lad.,  12,08:^;  Johnson's  Island, 
Ohio,  7,627;  Camp  Chase,  Ohio,  16,335;  Elmira,  N.  Y.,  12,147;  Fort  Dehiware,  Del., 
25,275;  and  Point  Lookout,  Md.,  42,762.- 

When  the  deaths  are  calculated  as  annual  I'atios  per  thousand  of  these  conunitments, 
the  depot  at  Elmira,  JST.  Y.,  and  not  that  at  Alton,  111.,  stands  h^rth  as  the  most  insalubi-i- 
ous  of  these  prison-camps.  Not  only  had  it  a,  liigh  mortality-rate,  444.1  annuallv  jHjr 
thousand  of  strength,  but  the  percentage  of  fatal  cases,  28.8,  was  more  than  double  that  of 
any  other  depot.  The  latter  rate,  like  the  corresponding  figures  from  t!ie  Anderson  ville 
prison,  gives  no  true  expression  to  the  ratio  of  deaths  to  cases,  but  it  indicates  such  an 
extensive  prevalence  of  disease  that  only  the  serious  cases,  too  often  destined  to  be  fatal, 
were  taken  up  on  the  registers  of  sick.  The  death-rate  was  equally  high  when  viewed  in 
relation  to  the  commitments,  241.0  annually  per  thousand,  as  compared  with  55.0  at  Alton, 
or  65.7,  the  average  of  the  prison-camps.  Diarrhoea  and  dysentery,  which  caused  more 
deaths  at  this  depot,  in  proportion  to  the  strength  present,  than  were  occasioned  by  all  dis- 
eases at  some  of  the  other  camps,  and  pneumonia,  which  produced  a  rate  nearly  double 
that  of  the  average  of  the  prisons,  were  the  diseases  which  gave  Elmira  its  unenviable 
notoriety.  From  the  reports  of  the  medical  inspectors  it  is  evident  tliat  while  a  lai'ge 
mortality  was  undoubtedly  referable  to  over-crowding,  insufficient  hospital  accommodation 
and  insufficient  protection  from  the  cold  of  a  northern  climate  in  the  earlier  history  of  the 
depot,  the  main  influence  underlying  all  these  and  raising  them  into  strong  relief,  was  the 
broken-down  condition' of  the  men  at  the  time  of  their  commitment:  most  of  tliem  suffered 
from  diarrhoea  of  a  chronic  character.  Of  the  1,394  deaths  attributed  to  diarrhoea  and 
dysentery  on  the  records  of  this  camp,  1,376  were  reported  as  from  chronic  diarrhoea  and 
only  6  from  acute  diarrhoea,  7  for  acute  dysentery  and  5  for  chronic  dysentery. 

Turning  from  the  high  rates  prevalent  at  Elmira,  it  is  a  pleasure  to  point  out  the  35.4 
per  thousand  of  strength  which  constituted  the  annual  mortality-rate  at  Johnson's  Island, 
Ohio,  its  fatality  rate  of  4.4  per  cent,  of  the  cases  and  its  9.8  deaths  annually  for  every 
thousand  commitments. 

The  absence  of  Confederate  records  showing  the  general  condition  of  the  men  on  active 
service  deprives  us  of  the  ability  of  learning  from  that  source  their  probable  state  of  health 
at  the  time  of  their  capture.  The  few  statistics  presented  in  Table  XIV  indicate  that  the 
Confederate  sick-rate  was  considerably  greater  than  that  of  the  Union  forces,  and  that 
diarrhoea,  dysentery  and  pulmonary  affections,  exceedingly  prevalent  in  both  armies,  were 
more  prevalent  among  the  southern  troops.  In  Table  XIII  these  diseases  were  observed 
to  yield  at  the  same  time  a  much  larger  percentage  of  fatal  cases  in  the  rebel  ranks,  the 
deaths  from  pulmonary  disease  constituting  as  much  as  18.89  per  cent,  of  the  cases  as 
compared  with  the  federal  rate  of  2.34  per  cent.  The  unbolted  corn-meal,  which  formed 
the  farinaceous  staple  of  the  Confederate  ration,  was  certainly  a  prolific  cause  of  intestinal 

•  Op.  cit.,  page  760  e(  stq. 


64 


WICKNESS    x\ND    MORTALITY 


irritation,  especially  in  troops  subject  to  the  intlueiicc  of  strung  predisposing  conditions. 
The  high  rates  in  puhnonary  affections  may  readilv  l)e  referred  tn  tli(j  exposun.'S  uf  tht' 
poorly  clad  and  iinpcffrctly  pi'Otectrd  southern  soldiers  dui'ing  s(,'i'\iro  in  a  noi-ljiem  and  less 
genial  climate  than  that  to  which  they  were  aecusloined,  Xo  inlorinatioii  is  on  file  cou- 
cerning  the  pi'evalence  ol'  scurvy  in  their  raidvs;  hut  that  it  was  present  to  a  greater  extent 
than  among  the  federal  troops  may  be  taken  I'or  granted,  in  view  of  the  liberal  ration  of 
the  latter,  the  efficiency  of  their  supply  system  and  their  greater  facilities  for  purchasing 
by  private  funds.  It  seems,  indeed,  highly  probable  that  much  of  tlie  scurvy  reported  on 
the  sick  lists  of  the  ])rison-cam}>s  affected  the  prisoners  at  the  time  of  their  capture.  At 
Johnson's  Island,  Ohio,  where  no  death  from  scurvy  took  place,  and  wdiere  the  abundance 
and  variety  ol  the  diet  negatived  the  idea  of  its  development  in  the  prison,  there  were, 
nevertheless,  fifty-eight  cases  reported  among  the  inmates,  most  of  whom  were  officers  of 
the  rebel  army.  These  cases  nuist  have  reached  the  island  in  the  scorbutic  condition 
which  necessitated  their  ap])earance  on  tin.;  sick  list.  And  if  scurvy  affected  the  officers, 
its  presence  to  a  greater  extent  among  the  men  cannot  be  doubted.*  To  the  better  condi- 
tion of  the  officers  of  the  Houthern  army,  as  ('(.impari'd  with  that  of  their  men  wdien  the 
fortune  of  war  consignetl  them  to  Johnson's  Island,  ( )hio,  luust  be  in  great  |)art  attributed 
the  slight  amount  of  sickness  and  mortality  that  aifected  them  during  their  «letention. 
They  were  sulyect  to  the  same  rules  and  regulations,  and  had  the  same  ration  as  the  pris- 
oners in  other  camps.  They  had  300  feet  of  air-space  in  (piarters,  a  more  liberal  allow- 
ance than  was  commonly  furnished;  but,  as  will  be  seen  directly,  the  mortality  among  the 
prisoners  generally  cannot  be  ascribed  to  the  limitation  of  bed-space. 

The  presumption  is  that,  at  the  time  of  their  capture,  many  of  the  prisoners  were 
suffering  from  diseases  resulting  from  insufficient  diet  and  from  the  exposures  and  continued 
fatigues  incident  to  the  military  movements  preceding  the  disaster  that  brought  about  their 
captivity. 

But  no  doubt  exists  as  to  their  condition  on  their  arrival  at  the  prison.  This  is  recorded 
by  many  of  the  inspecting  officers.  In  fact,  "the  debilitated  condition  of  the  men  from  pre- 
vious hardships  and  exposures,"  or  words  of  similar  tenor  are  of  frequent  occui-riMici'  in  all 
reports  relating  to  the  sickness  and  mortality  of  the  prisoners,  as  in  those  from  Elmira  already 
noted.  To  this  is  sometimes  added  a  reference  to  the  depressed  mental  condition  consequent 
on  their  status  as  prisoners  of  war.  Dr.  Alden  states  very  decidedly  that  the  mortality  from 
diarrhcea  and  dysentery  among  the  prisoners  at  Fort  Delaware  in  July,  1SG3,  was  almost 
entirely  confined  to  the  men  from  Alabama,  Mississippi  and  other  southern  states  taken 
by  General  Grant's  army  around  Vicksburg.  Most  of  these  men  arrived  in  a  broken- 
down  condition,  emaciated,  and  already  the  subjects  of  the  disease  for  some  weeks  or 
months,  while  at  that  time  the  prisoners  from  General  Lee's  army,  also  confined  at  Fort 
Delaware,  were  in  good  condition.  Dr.  Alden's  inference  that  the  influences  to  which  the 
prisoners  were  subjected  at  Fort  Delaware  were  not  to  be  charged  with  the  sickness  and 
mortality  then  occurring  among  them  seems  thoroughly  sustained. 

The  following  extract  from  a  report  on  the  sanitary  condition  of  the  depot  at  Hart's 
Island,  Xew  York  Harbor,  dated  June  21,  1865,  by  George  H.  Lyman,  Medical  Inspector, 

*  Dr.  Jones  says :  "The  large  annies  of  the  Confederacy  suifered  more  than  once  from  scurvy :  and  as  the  war  progressed,  secondary  h8em()rr)iage 
and  hospital  giingrene  increasetl  to  a  fjreat  extent  from  the  deteriorated  condition  of  the  bhwd,  dei>endent  on  the  prolonged  use  of  salt  meat;  an<l  but  fi.r 
the  extra  supplies  received  from  home,  and  from  the  various  benevolent  State  institutions,  scurv^v,  diarrhoea  and  dysentery  would  have  committed  stiU 
greater  ravages." — U.  S.  San.  Cum.  Memoirs,  p.  481, 


AMON<>    COXFKDERATE    TllOOrS    IN    U.    S.    PRISONS.  65 

U.  B.  Arniv,  is  suluiiitlcd  as;i  spcrial  illustration  <A  tlic  jioiiit  in  question,  while  showing  at  the 
same  time  tliat  the  insanitary  inllueiircs  allrcting  thr  prisoners  at  the  smaller  depots  were 
similar  in  chai'acter  to  those  alremlv  Jesenlied  as  rharaet(n'i>tic  of  tlK^  larger  prison-camps: 

Tlie  chief  ciiuse  of  tlio  mortality  is  to  lie  fouiiil  in  the  faet  that  large  muiibers  of  the  prisoners  arrived  at  the 
<le])ot  broken  down,  in  advanced  stages  of  disease,  some  in  faet  moribund,  and  others  past  all  hope  for  treatment. 

The  New  lierne  detaeliment,  captured  chiefly  in  the  Carolinas.  were  nearly  all  broken  down  on  arrival.  It  is 
said  tliat  less  tlian  100  of  tliem  could  be  considered  as  widl  men  or  even  in  fair  health.  The  surgeon  then  in  attend- 
ance having  been  relieved,  more  jirecise  information  on  this  point  is  not  now  available :  but  it  is  certain  that  the 
largest  i)ercentage  of  sickness  and  mortality  occurred  in  that  detachment. 

'J'heJargest  projiortion  of  deaths  occurred  from  chronic  diarrho-a  brought  with  them,  and  pneumonia,  whieli 
began  to  a])])ear  a  few  days  after  their  arrival.  The  men  being  jioorly  clad,  the  weather  wet  and  cohl,  and  the  bar- 
racks |irovide<l  with  no  other  bedding  than  sncli  as  the  ])risoners  brought  with  them,  the  pneumonic  cases  developed 
rapidly,  and  the  reduced  vitality  of  the  patients  favored  a  typlioid  type  of  that  disease,  increased  probably  to  some 
extent  by  the  crowded  and  unventilated  condition  of  the  barracks.  These  appear  by  nieasurenient  to  have  attbrded 
102  cubic  feet  of  air-space  to  each  man,  and  with  no  other  ventilation  than  that  aftbrded  by  the  doors  and  windows 
on  one  side.  Quite  recently  openings  for  ventilation  liave  been  made  upon  tlie  other  side  of  the  barracks,  it  cousti- 
tiiting  the  outer  wall  of  the  prison  enclosure. 

The  rations  have  ))een  good  and  in  the  (juantity  ordered  by  the  Commissary  (ieneral  of  Prisoners,  which  is 
sufficiently  liberal.     The  hospital  ration  has  been  such  as  is  used  in  our  own  hospitals. 

The  drainage  from  the  barracks  is  superficial  but  good.  The  sinks  are  outside  the  camp  and  over  tide-water. 
The  water  for  cooking  and  drinking  is  abundant  and  of  excellent  <iuality;  it  is  derived  from  wells. 

Tlie  prisoners  liave  had  access,  under  guard,  to  tlie  beacli,  and  have  availed  tlieinselvcs  of  it  freely  for  salt- 
water bathing.     They  have  also  been  required  to  take  daily  exercise. 

Over-crowding  was  regarded  bv  the  inspectors  as  the  most  serious  of  the  insani- 
tary  conditions  bearing  on  the  prisoners  during  the  period  of  their  detention.  But  this 
comprehended  more  than  the  mere  limitation  to  so  much  dormitory  space.  Under  it 
were  gathered  all  the  evil  consequences  of  suddenly  assigning  a  large  number  of  men  to  a 
camp  which  had  not  been  systematically  arranged  for  their  reception.  The  prisoners  were 
generally  destitute  of  clothing  and  blankets,  and  one-tenth  of  them  on  arrival  required 
hospital  treatment.  The  exposures  consequent  on  their  destitute  condition  speedily 
increased  the  disparity  between  the  hospital  accommodations  and  the  requirements  of  the 
sick.  The  wards  became  crowded,  and  the  more  recently  developed  cases  had  to  remain 
in  the  still  more  crowded  general  quarters  of  the  prisoners,  lacking  the  comforts  which  the 
hospital  provided  for-  its  less  unfortunate  inmates,  and  adding  grievously  to  the  harmful 
influences  of  the  quarters  containing  them.  Grenei-ally,  also,  healthful  exercise  was  pre- 
vented by  the  mud  and  dust  begotten  of  the  surface-soil  by  the  tramping  of  many  feet  in 
the  ordinary  occupations  of  prison  life.  Defotjtive  police  and  inadequate  arrangements  for 
the  disposition  of  excreta  rendered  the  external  air  in  many  places  foul  and  sickening.  A 
hastily  dug  series  of  pits  often  emitted  their  polluted  exhalations  in  close  proximity  to  the 
quarters,  because  if  placed  at  a  greater  distance  the  sick  men,  especially  at  night,  would 
fail  to  reach  them.  The  prisoners  had  foul  air  without  and  fouler  air  within  their  quarters. 
Under  these  circumstances  the  extension  and  aggravation  of  diarrhoeal  cases,  and  the  typhoid 
type  assumed  by  febrile  diseases  such  as  pneumonia,  naturally  followed.  The  evils  directly 
referable  to  tlie  commitment  of  an  excess  of  depressed,  debilitated  and  destitute  men  to  a 
given  camp  were  the  causes  of  the  large  sick  and  mortality  rates  that  prevailed.  Over- 
crowding, as  restricted  to  a  limitation  of  bed-space,  was  a  concomitant  but  minor  evil,  as  it 
alone  would  have  recpiired  some  time  to  produce  its  typhous  effects. 

Without  exception,  the  officers  in  cliarge  of  these  camps  and  hospitals,  and  the  medical 
inspectors  in  their  monthly  rounds,  recognized  the  conditions  in  fault;  and  their  earnest 
eflforts  at  improvement  are  worthy  of  all  commendation,  since  they  saved  many  lives  to  our 
re-united  country  and  preserved  our  annals  stainless. 

Mki).  Hist.,  Pt.  Ill— 9 


66  SICKKKSS    ANl.)    MoirrAl.lTV 

The  liistoi'v  of  each  of  tliosn  camps  siiuws  at  first  a  jioriod  of  overwork,  anxiety  and 
grave  responsibility  (in  tlie  part  of  the  officers  in  eharo-e  wlieii  tlieir  failure  to  provide  for 
the  urgi.'iit  iicccssilK's  ol'  tlu!  occasion  would  have  been  attended  with  disastrous  results. 
In  no  instance  does  it  appear  that  the  food-su{)[)ly  was  at  any  time  deficKMit;  lait  clothing, 
bedding,  shelter  and  kitchen  utensils  for  those  who  were  well,  and  lnjspital  accommodation, 
supplies  and  comfoi'ts  foi'  those  who  were  sick,  had  often  to  be  provided  at  short  notice  and 
under  various  difficulties.  Hospital  clothing  was  issued  to  the  destitute  until  the  arrival  of 
authorized  sujiplies.  Tents  were  obtained  for  use  until  barracks  were  built.  Barracks 
were  used  as  hospitals  until  special  buildings  were  erected.  Sinks  werc^  dug  for  the  excreta 
until  some  less  objectionable  method  of  disposal  was  planned  and  carried  into  effect. 
Trenches  were  opened  for  drainage  until  a  covered  system  was  j)rovided.  Nor  did  the 
improvements  end  when  all  were  sheltered  and  fitted  out  with  comparative  comfort.  New 
barrack  buildings  were  constructed  after  improved  plans,  and  the  old  were  destroyed  or 
retained  to  increase  the  available  air-space.  New  hospitals  with  better  conveniences 
replaced  the  old,  which  became  converted  into  increased  barrack-room.  Lavatories  and 
baths  and  the  accessibility  and  abundance  of  the  water-supply  for  flushing  and  other  pur- 
poses received  attention.  In  fact,  from  the  establishment  of  the  prison-camp  until  its  disuse 
at  the  close  of  the  war,  the  improvement  of  its  sanitary  condition  was  progressive  and 
uninterrupted. 

The  sites  selected  were  usually  such  as  were  considered  healthy;  that  at  Elmira  had 
been  used  from  the  beginning  of  the  war  as  a  recruiting  depot,  and  the  twenty  barrack 
buildings  formerly  occupied  by  the  recruits  formed  the  nucleus  of  the  prison-camp, — nor  was 
this  a  solitary  instance  of  the  kind.  The  bed-space  allotted  to  each  man  in  quarters  was 
sometimes  less  than  one  hundred  cubic  feet,  as  at  Fort  Delaware  where  three  tiers  of  bunks 
ran  along  each  wall  of  the  pavilion  separated  by  a  central  or  median  aisle.  Over-crowding 
to  this  extent  was,  however,  not  confined  to  the  prison-barrack  buildings.  The  wooden 
•  shelters  built  for  the  Union  regiments  at  depots  which  were  considered  permanent  were 
fitted  uj)  with  similar  shelves.  The  experiences  of  the  war  educated  our  people  in  sanitary 
matters.  At  an  early  ])eriod  of  its  progress  medical  inspectoi's  urged,  with  some  hope  of 
success,  a  reduction  of  the  bunks  to  two  tiers  in  the  prisoners'  quarters  as  well  as  in  those  of 
our  own  troops.  Their  request  must  not  be  ^steamed  a  measure  of  what  these  officers  con- 
sidered needful.  They  did  not  ask  for  all  they  wanted,  but  only  for  what  they  might  be 
likely  to  get.* 

That  the  luortality  among  the  (confederate  prisoners  was  due,  as  suggested  above,  to 
other  causes  than  the  mere  limitation  of  barrack-space,  is  shown  conclusively  by  some  of 
the  reports.  In  the  summary  of  the  sanitary  history  of  Camp  Chase  a  tabular  state- 
ment is  given  of  the  occupancy  of  the  barrack  buildings  by  the  Confederate  prisoners 
and  their  Union  guard,  showing  that  the  latter  had  an  air-space  of  150  to  210  feet  and  an 
area  of  12  to  15  feet  per  rnan,  while  the  former  had  137  cubic  feet  and  11.4  of  superficies. 
There  occurred  in  January,  1865,  while  the  buildings  were  thus  occupied,  8  deaths  among 
1,683  Union  troops,  or  1  in  210,  and  283  deaths  among  7,583  prisoners,  or  1  in  26.79;  in 
the  following  month  the  deaths  among  6,414  Union  soldiers  numbered  o6,  or  1  in  178, 
while  of  8,259  prisoners  495  died,  or  1  in  16.68.  These  enormous  differences  in  the  death- 
rates  cannot  be  attributed  to  the  comparatively  trivial  differences  in  the  air-space. 

*  *  The  dollble-tiered  bunk  was  not  finaDy  f  xiwlled  from  its  hwt  retreat  ill  a  western  military  p*>st  iititil  ten  years  after  the  war. 


.\:\roxi;  coxi-kdkrate  troops  ix  u.  s.  trisoxs.  67 

Hiiiall-|K)x  followcil  ilian'lidNi,  ilvseiitLTV  ami  piiruiiKniia  m  order  u(  uujiortauce  as  a 
cause  ol  ileatli  aiiuniL:;  tlii'  jirisoiiers,  having  ueeasioiiLMl  :)i'.p-'ur  the  2:)n.  1,  ilcatlis  that 
occurreil  aiiuuallv  tiMiu  dismast;  in  everv  thousaml  of  the  avel■a^■e  sti-eiiLi-lh  iireseiit.  Nothiuc 
is  on  record  eonceriung  the  |a-evalenee  of  this  disease  in  tlie  southern  armies.  Table  XIII 
shows  tliat  among  the  unknown  luunber  of  tlie  Confederate  forces  there  were  up  to  Decem- 
ber, 1S62,  44.438  cases  and  2.274  deaths  from  tlie  eruptive  fevers,  as  comjKvred  witli  lower 
figures  among  the  certainlv  larger  numlier  of  tlie  Union  troops.  But  these  statistics  include 
measles,  etc..  as  well  as  small-[)OX.  Nevertheless  its  frequent  occurrence  among  them 
may  be  inierred  in  view  of  the  fact  demonstrated  l)v  its  ravages  in  the  prisons, — the 
insutliciency  of  their  |)rotection  l)y  vaccination.  Certaiidv  in  some  instances  it  was  appar- 
ently introduced  into  the  jirisons  from  the  Confederate  ranks.  The  eruption  is  reported 
as  lia\ing  broken  out  on  some  of  the  prisoners  within  a  day  or  two  after  their  arrival  at 
the  depot. 

Our  medical  officers  appear  to  have  faced  the  emergency  with  spirit,  isolating,  some- 
times with  difficulty,  as  at  Rock  Island,  and  protecting  by  vaccination,  also  with  difficulty 
sometimes,  as  at  Camp  Douglas  and  Alton,  until  the  scourge  was  controlled.  In  reporting 
the  condition  of  Camp  Douglas  in  June,  1864,  Dr.  Hl'MPHKKYS  says: 

Of  tlio.se  prisoners  who  liave  been  vaccinated  in  prison  with  virus  that  produced  no  bad  effects  in  United  States 
troops,  (itJ8  have  healed  tardily,  while  912  vaccinated  are  suffering  from  phagedenic  or  indolent  or  irritable  ulcers. 
This  difference  in  the  results  from  the  use  of  the  same  virus  in  federals  and  rebels  must  be  attributed  to  the  cachectic 
and  scorbutic  condition  of  the  latter. 

In  a  report  for  January,  1863,  Dr.  Wall,  the  surgeon  in  charge  at  Alton,  remarks  as 
follows : 

Epidemics  botth  of  small-pox  and  erysipelas  visited  us,  the  former  with  fearful  violence,  and  what  rendered  it 
very  unfortunate  for  us,  the  vaccine  virus  that  we  obtained  from  St.  Louis,  Mo.,  proved  worthless,— thus  rendering 
abortive  for  a  while  our  attempts  to  stay  its  progress  by  vaccination.  I  am  contidtnit  that  if  we  had  been  successful 
in  procuring  good  virus  we  would  have  modified  the  epidemic  to  a  very  great  extent. 

The  probability  of  a  marked  scorbutic  taint  in  the  southern  troops  has  already  been 
suggested  as  accounting  for  much  of  the  sickness  and  mortality  directly  charged  against 
scurvy,  by  the  prison  records.  The  ration  furnished  by  our  Government  to  its  prisoners  of 
war  was  more  liberal  in  its  quantity  and  variety  than  that  issued  by  the  Confederate  Cov- 
ernment  to  its  soldiers  on  active  service.  Other  things  being  equal,  scurvy  was  therefore 
more  likely  to  affect  them  before  than  after  their  capture. 

The  Confederate  ration,  in  accordance  with  Army  Regulations,  consisted  of: 

Three-fourths  of  a  pound  of  pork  or  bacon,  or  one  and  one-fourth  pounds  of  fresh  or  salt  beef;  eighteen  ounces 
of  liread  or  Hour,  or  twelve  ounces  of  hard  bread,  or  one  and  one-fourth  pounds  of  corn-meal ;  and  at  the  rate,  to  one 
hundred  rations,  of  eight  cjuarts  of  peas  or  beans,  or  in  lieu  thereof  ten  pounds  of  rice,  six  pounds  of  coffee,  twelve 
pounds  of  sugar,  four  (juarts  of  vinegar,  one  and  one-half  pounds  tallow,  or  one  and  one-fourth  pounds  adamantine, 
O-  one  pound  of  sperm  candles;  four  pounds  of  soap,  and  two  quarts  of  salt.  On  a  camjiaign  or  on  marches,  or  on 
board  transports,  the  ration  of  hard  bread  is  one  pound.  »  »  ♦  When  the  officers  of  the  medical  department  find 
anti-scorbutics  necessary  for  the  health  of  the  troops  the  commanding  officer  may  order  issues  of  fresh  vegetaldes, 
pickled  onions,  sour-krout,  or  molasses,  with  an  extra  quantity  of  rice  and  vinegar.  (Potatoes  are  usually  issued  at 
the  rate  of  one  pound  per  ration,  and  onions  at  the  rate  of  three  bushels  in  lieu  of  one  of  beans.)  Occasional  issues 
(extra)  of  molasses  are  made — two  quarts  to  one  hundred  rations — and  of  dried  apples  of  from  one  to  one  and  one- 
half  bushels  to  one  hundred  rations. 

During  the  early  period  of  the  war,  when  the  full  ration  was  issued,  scurvy  was  com- 
paratively rare.  At  later  dates  the  supply  department  became  unable  to  furnish  coffee; 
corn-meal  had  to  be  largely  substituted  for  wheaten  bread  or  flour;   fresh  beef  was  irre^ru- 

*  See  Table  1. 1 1 1,  ji.  i;2'.l,  iiifia.  « 


68  SIOKNKS.S    AKI)    M()1MA1.1TY 

larly  supplied,  ami  tlio  issues  of  rice,  beans,  luolasses,  vinegar,  potatoes,  dried  apples  and 
vegetables  generally  were  diniinislu'd  in  frequency  and  in  (piantity.  Scurv\'  appeared  m 
consequence,  manifested,  according  to  Dr.  JoxKs: 

In  tbe  frequency  of  night-blindness,  in  tlie  numerous  accidents  after  vaccination,  in  tlio  increase  of  secondary 
haimorrliage  and  hospital  gangrene  after  wounds,  as  well  as  in  the  actual  manifestations  of  the  disease,  indisposition 
to  exertion,  spongy  gums,  uncertain  and  ill-defmed  muscular  pains,  and  obstinate  diarrliu'a  and  dysentery.* 

The  Subsistence  Department  of  the  United  States  Army  allowed  the  same  money 
value  for  the  subsistence  of  the  Confederate  prisoner  of  war  as  for  the  Federal  soldier. 
In  other  w^ords,  the  ration  allowed  to  the  prisoner  was  the  same  in  all  its  parts  as  that 
allowed  to  the  United  States  volunteer.  But  tlie  experience  of  our  army  had  demonstrated 
that  the  troops  seldom  consumed  tlie  whole  of  their  ration.  Arrangements  were  therefore 
made  by  which  the  money  value  of  the  unconsumed  portion  accumulated  in  the  hands  of 
the  subsistence  officers,  forming  a  fund  by  which  the  diet  of  the  men  might  be  varied  by 
the  purchase  of  articles  not  kept  for  issue  by  the  subsistence  department  as  a  formal  part 
of  the  ration.  A  surplus  of  bacon  or  cofliee  could  by  this  means  become  converted  into 
fresh  vesietables  if  needful  for  the  health  of  the  command.  Cooking  utensils  and  articles 
of  mess-furniture  for  the  comfort  and  convenience  of  the  men  were  also  authorii^ed  to  be 
purchased  with  this  fund.  A  similar  system  was  adopted  at  the  hospitals,  and  milk,  eggs, 
chickens,  oysters,  fruit,  vegetables  or  other  articles  not  issued  by  the  subsistence  or  medical 
departments  of  the  army,  and  needful  for  the  use  of  the  sick,  were  obtained  by  means  of 
the  money  value  of  the  bacon,  flour,  coffee  or  other  articles  of  issue  which  they  did  not 
consume. 

This  system,  in  use  in  the  forts  and  garrisons  of  the  United  States,  was  extended  to 
the  prison-camps  and  their  hospitals.  The  Commissary  General  of  Prisoners  published 
from  time  to  time  the  articles  and  quantities  to  be  issued  for  consumption  by  the  prisoners, 
and  the  differeitce  between  the  money  value  of  the  ration  thus  issued  and  that  of  the  full 
ration  allowed  by  law  to  the  United  States  soldier  was  set  aside  as  a  prison  fund  for  the 
purchase  of  such  articles  as  were  necessary  for  the  health  and  comfort  of  the  pi'isoners,  and 
not  expressly  provided  for  by  the  Army  Regulations. 

The  saving  on  the  ration  was  the  chief  but  not  the  only  source  of  the  prison  fund. 
The  sutler  or  camp-trader  was  taxed  a  small  amount  for  his  jorivilege  of  trade,  and  this  tax 
made  a  part  of  the  general  fund,  as  did  also  all  current  money  left  by  deceased  prisonei-s 
of  war  or  accruing  from  the  sale  of  their  effects,  and  all  current  money  clandestinely  for- 
warded to  prisoners  or  found  concealed  by  them. 

The  following  table  shows  the  ration  in  kind  allowed  to  the  prisoners  by  circulars  of 
the  dates  mentioned  from  the  office  of  the  Commissary  General  of  Prisoners,  together  with 
the  full  ration  of  the  United  States  troops  at  the  same  dates,  and  the  difference  in  the 
value  of  the  two  rations  credited  to  the  prison  fund.  Prior  to  April  20,  1864,  no  specific 
instructions  were  published  limiting  the  quantities  of  the  constituents  of  the  ration  to  be 
issued,  but  commanding  officers  of  j^i'ison-camps  were  directed  to  withhold  from  the  ration 
all  that  could  be  spared  without  inconvenience  to  the  prisoners,  as  a  basis  of  a  fund  for 
their  benefit.  After  the  establishment  of  a  special  prison-issue,  commanding  officers  were 
authorized  to  report  to  the  Commissary  General  of  Prisoners,  if  at  any  time  it  seemed 
advisable  to  them  to  make  any  change  in  the  scale  : 

*Mem.  U.  S.  SuuiUu-tf  Commission^  p.  024. 


AMONG    CONFKDERATis    TEOOl'S    IN    U 


PRISUN.S. 


()9 


IMusoNERS  or  War. 


riSTSONEltS   OK   W.M!. 


April  20, 
1864. 


June  1,     F-nn;!"yc<i  .,„ 
is,u  piililic  works, 

"^"*-       June  Ki,  J*i4.t 


I 


l*nrk  nr  liiicdii,  nr 

I'ri-sli  or  .~iilt  beef 

Flulir  .ir  bre:ia  (.soft),  or 

Iliiril  liriiul.  and 

(Jorn-Hieal 

To  eaeh  JOO  rations:— 

lieatis  or  pejis.  ami 

Rice  or  lioiiiiny     

ConV'P.  irrven.  or 

CoJfee,  roasti'd  and  ^^roinul,  or 

Tea 

Sugar 

Vinegar  

Canilles,  adamantine ,  .'m 


l»oz. 
l-l  «■/.. 
iB  oz. 
I'l  oz. 


n  qts. 

f   11>S. 

7  Ills. 
,'.  Ills. 
IH  ()/.. 

14  lbs. 


10  oz. 
14  ..z. 
IC.  oz. 
H  oz. 
|o  oz. 

1-JJ  lbs. 
c  lbs. 
....(*)     . 
...   (')  .  . 

y  cjts. 


12  oz. 

k;  oz. 

\i^  oz. 

llioZ. 


M  lbs. 
10  lbs. 

7  lbs. 

.5  lbs. 
Hioz. 
12  lbs. 

I!  .Its. 


s.«.r 

Salt 

Molasses 

Potatoes  (fresh) .«. 


Pepper . 


Average  cost  priee cts. 

Credit  jier  ration  to  prison  fund cts. 


4  lbs. 
2  qts. 
Iqt. 

M  lbs. 


4  lbs. 
yj  lbs, 

15  lbs. 


4  lbs. 
32  lbs, 
I  qt, 

;«)  lbs. 


10.48 
!).  7fi 


13.  G3 

12.61 


20,31 
r^.  !13 


I',  S,  Troops,  18(14, 


12  oz, 
211  oz, 
22  oz, 

lO  oz, 

20  oz, 

8  cits.  (!.">lbs,) 
111  lbs, 
III  lbs. 
:*  lbs. 

lima- 

1,'i  lbs, 
4  .its, 
U  lbs. 
4  lbs, 
33  11)8, 

1  gall, 

100  lbs.  three  times 
a  week. 


,laniiar\ 


10  oz. 
Hot., 


2fi,24 


12J  lbs, 

H  lbs, 
-.  ()-., 
...(*)... 
-  .(*).-■ 
...(•)... 
2  qts. 


!  lbs.. 
!lbs. 


16,  Rl 
10,92 


Ki..pl..yi.l 

on  publi.- 

works. 


12  oz, 

ii;  .iz, 

IS  ..z. 
12..Z, 
l,-  ..z, 

l,-i  lbs, 
11'  lbs. 

7  lbs. 

'<  lbs. 

1  lb, 
12  lbs, 

3  qts. 


4  lbs, 
33  lbs. 


24.20 
3,  5:5 


Troops, 
It^liS, 


12  ..z, 
20  oz, 
IH  ..z, 
12  ..z, 
20  .iz, 

l."i  lbs. 
10  lbs. 
10  lbs. 

f  lbs. 

U  lbs. 
15  lbs. 

4  qts. 

U  lbs. 
4  lbs. 
3}  Ite. 


4  oz. 


27.73 


*  Sugar  and  coffee  or  tea  were  issued  t.>  the  sick  and  wounded  only,  every  other  day.  on  the  recommendation  of  the  surg.-on  in  charge,  at  the  rate 
uf  twelve  pounds  of  sugar,  five  pounds  of  ground  or  seven  p.)unds  of  green  coffee  or  one  ii.niiul  of  tea,  to  every  hundre.i  rati.ms. 

t  l*ri8oners  employed  on  public  w.irks  other  than  the  proper  police  duties  of  their  camps  were  allowed,  if  mechanics,  ten  cents  per  day,  anil  if 
laborers  five  cents  per  day,  from  the  prison  fund,  which  all.iwanee  was  authorize.1  to  be  paid  in  tobacco  to  those  who  preferred  its  cxjicmliture  in  that  way, 

DLsbursenients  charged  against  the  prison  fnud  were  made  by  the  Commissary  of  Sul)8istence  on  tlie  order  of 
tlie  commanding  officer,  and  all  such  expenditures  of  fund.s  were  accounted  for  by  the  coniiuis.sary  on  his  moutlily 
statement  of  the  prison  fund,  showing  the  issues  made  and  the  articles  iind  quantities  purchased,  the  jirices  paiil, 
the  services  rendered,  etc.  Among  the  articles  authorized  to  be  purchased  by  this  fund  were  all  table  furniture  and 
cooking  utensils,  articles  for  policing  purposes,  bed-ticks  and  straw,  and  the  means  of  improving  or  enlarging  the 
barrack  accommodations.  E.vtia  pay  was  allowed  from  it  to  clerks  who  had  charge  of  the  camp  ])ost  office,  who 
kept  the  accounts  of  moneys  dejjosited  by  the  prisoners  with  the  commanding  officer  or  who  were  otherwise  engaged 
in  labors  connected  with  the  prisoners. 

The  hospital  fund  accumulated  from  the  savings  of  the  ration  of  the  sick  men  was  disbursed  on  the  recom- 
mendation or  requisition  of  the  surgeon  in  charge,  approved  by  the  commanding  officer.  It  was  kept  separate  from 
the  fund  of  the  liosjiital  for  the  trooj)s.  Disbursements  from  it  were  chiefly  for  the  purchase  of  articles  of  diet,  but 
when  the  fund  was  sufficiently  large,  it  was  ])ermitted  to  be  expended  for  shirts  and  drawers  for  the  sick,  the  expense 
of  washing  clothes,  articles  for  policing  puri)Oses  and  all  aiticles  and  objects  indispensably  necessary  to  ])roinote  the 
sanitary  condition  of  the  hospital. 

Clothing  was  not  charged  against  the  prison  fund.  The  commanding  officer,  through  his  ([uartermaster,  made 
requisition  on  the  nearest  depot  for  such  clothing  as  was  absolutely  necessary  for  the  prisoners,  and  the  papers  were 
submitted  for  the  approval  of  the  Commissary  General  of  Prisoners.  The  articles  when  furnished  were  issued  by 
the  quartermaster  under  the  supervision  of  an  officer  detailed  for  the  purpose,  whose  certificate  that  the  issue  had 
been  made  in  his  presence  was  the  (lunrtermaster's  voucher  for  the  clothing  issued.  From  April  30  to  October  1 
neither  drawers  nor  socks  were  allowed  except  to  the  sick.  When  army  clothing  was  issued  the  buttons  and  trim- 
mings were  removed  and  the  skirts  cut  short  to  prevent  those  wearing  such  articles  from  being  mistaken  for  United 
States  soldiers. 

The  efficiency  of  the  ration'  allowed  the  prisoners  of  war  depended,  as  in  tlic  case  of 
United  States  troops,  on  the  method  of  its  management,  and  on  tlie  market  price  of  vege- 
tables in  the  neighborhood  of  the  camp.     The  portions  of  the  ration  issued  were  certainly 


70  SICKNESS    AXD    MORTAl.TTY 

insufficiL'iit  to  prevent  the  appearance  of  scurvv,  for  tliat  disease  was  manifested  among  our 
own  troops  on  the  full  ration  duriuij;  the  war,  and  has  been  ohserxed  since  the  wai'  at  west- 
ern posts  where  vegetables  were  scarce  and  cori'espouilmglv  Ingli-pricoil.  Assuming  tJie 
ration  as  issued  to  have  contained  a  sufficiency  of  the  nuti-itive  elements  to  I'epair  the 
waste  generated  l»y  the  internal  work  of  the  body  and  the  slight  anuiunt  of  outward  mani- 
festations of  force  exerted  by  the  prisoners  in  their  enforced  contiucment,  the  want  of  varietv 
in  the  diet  would  in  time  have  produced  a  distaste  for  the  food  and  develojied  the  scorbutit' 
condition.  Their  j)rotection  from  this  de[)ended  on  the  proj^n-  application  of  the  |)rison 
fund.  Every  guard  was  apparently  placed  on  the  expenditure  of  this  fund.  The  subsist- 
ence officers  purchased  only  on  the  approval  of  the  commanding  officer,  and  their  action 
was  reported  in  detail  at  monthly  intervals  to  superior  authority.  Inspecting  officers 
usually  devoted  particular  attention  to  the  condition  of  the  prison  and  hospital  funds  and 
the  details  of  their  expenditure.  In  many  of  the  reports  the  extra  articles  of  diet  })ur- 
chased  during  the  month  are  itemized;  in  others,  when  a  scorbutic  tendency  was  detected, 
larger  purchases  of  such  articles  were  recommended.  Generally,  however,  the  issued 
rations  supplemented  by  the  purchases  were  considered  by  those  able  and  impartial  officers 
as  an  ample  provision  against  the  scorbutic  taint.  It  may  therefore  be  concluded  that  had 
the  prisoners  been  healthy  on  their  arrival,  instead  of  broken  down  physicaily  by  previous 
hardships  and  depressed  mentally  by  present  conditions  and  anxieties,  their  sick  and  mor- 
tality lists  would  have  been  no  more  burdened  with  scorbutic  cases  than  were  those  of  our 
own  men  Avho  underwent  the  strain  of  active  service  upon  the  same  allowances. 

In  summing  up  the  results  of  this  study  of  the  inspection  reports  of  the  prison  depots, 
it  may  be  said  that  the  hardships  and  exposures  entailed  on  the  men  by  the  military  events 
that  ended  in  their  capture  were  the  main  causes  of  the  disease  and  mortality  with  wliich 
they  were  afflicted  during  their  subsequent  confinement.  The  hurried  marches,  want  of 
sleep,  deficient  rations  and  exposures  in  all  kinds  of  weather,  by  night  and  by  day,  that  pre- 
cede and  attend  the  hostile  meeting  of  armies  result  in  larger  losses  by  disease  than  those 
that  are  directly  attributed  to  the  engagement.  And  as  the  wounded  of  a  defeated  army 
are  more  exposed  to  capture  than  the  uninjured,  so  the  exhausted  and  debilitated  rather 
than  the  vigorous  become  included  in  the  lists  of  prisoners  of  war. 

Fatigues  and  exposures  en  route  to  the  prison  depots  supplemented  those  already 
endured  in  exhausting  their  strength  and  producing  sickness.  The  prisoners  seldom  carried 
from  the  field  a  sufficiency  of  clothing  and  blankets  to  protect  them  from  ordinary  weather- 
changes,  and  to  these  the  journey  frequently  added  changes  of  a  climatic  character. 

The  depression  of  spirits  consequent  on  defeat  and  caj)ture,  the  home-sickness  of  the 
prisoners,  the  despondency  caused  by  scenes  of  suffi-ring  around  them,  the  gloomy  and 
vacuoirs  present,  and  the  uncertainty  of  the  future,  conspired  to  render  every  cause  of 
disease  more  potent  in  its  action. 

The  sudden  aggregation  of  tliese  men  at  camps  unprepared  for  their  reception  devel- 
oped many  insanitary  conditions  which  combitied  with  pre-existing  causes  in  evolving  sick- 
ness and  stamping  it  with  a  greater  virulence.  The  most  prominent  of  these  were:  the 
temporarily  defective  police  of  the  camp,  which  contributed  to  the  spread  of  diarrhcea 
and  dysentery;  the  insufficient  protection  in  quarters,  whi-ch  induced  inflammations  of  the 
respiratory  organs  and  gave  them  a  typhoid  character  by  the  over-crowding;  and  the 
insufficient  hospital  accommodation,  which,  in  leaving  the  sick  in  quarters,  tended  to  the 


AMONG    COXFKDKKATK    TEOOrs    IN    V.    S.    FRItJONS.  71 

(k'veldjiiaeni  of  now  cases,  or,  in  taking  tliein  into  liosj)ital,  lotsseuetl  tlio  cliauces  of  ivcovery 
of  those  already  there. 

But  tlu'  evil  influences  exercised  by  the  camp  conditions  would  not  have  heen  followed 
by  the  same  sickness  and  mortality  had  the  ground  and  shelters  been  crowded  to  the  same 
extent  with  well-disciplined  troops  awaiting  the  opening  of  a  campaign.  The  broken 
health  and  broken  spirits  of  the  inmates  were  the  main  factors  in  the  production  of  disease 
and  death. 


CHAPTEli    II.  — INTKODUCTOKV  TO  TIIK  I'liESKNTATIOX  OF  THE  CAMP 

FEVE118. 


The  fevers  which  prevailed  in  our  armies  were  reported  at  the  beginning  of  the  war 
under  the  respective  headings  of  t)/phus,  tijplioid  and  common  continued  fevers,  remittent 
fever  and  quotidian,  tertian,  quartan  and  congestive  intermittent  fevers.  Each  of  these 
names  indicated,  with  more  or  less  precision,  a  particular  series  of  morbid  phenomena.  The 
aggregation  of  symptoms  which  gave  tlie  disease  in  each  instance  its  individuality  might 
be  stated  from  an  extensive  personal  knowledge  of  tlie  clinical  and  pathological  views  held 
by  the  medical  men  who  dealt  with  these  febrile  cases,  but  this  would  be  admissible  only 
in  the  absence  of  general  and  more  trustworthy  data.  The  lines  defining  each  of  these 
specially  reported  fevers  miglit  be  drawn  from  the  clinical  records  of  the  regimental  and 
general  hospitals  of  the  time;  but  the  presentation  and  study  of  these  must  be  made  later 
and  in  other  connections.  Nor  is  it  necessary  that  this  study  should  be  attempted  at  the 
present  time,  for  the  clinical  and  other  facts  implied  by  the  titular  diagnoses  of  our  medical 
men  in  1861,  in  febrile  cases,  may  be  gathered  from  a  brief  reference  to  the  important  dis- 
coveries concerning  the  non-identity  of  certain  fevers  which  had  been  made  some  years 
before,  to  the  cliaracter  of  the  fevers  prevalent  in  this  country  at  the  outbreak  of  the  war, 
and  to  the  volumes  on  practice  of  medicine  which  were  furnished  by  the  Medical  Depart- 
ment of  the  Army  to  its  officers  as  books  of  reference. 

Typhus  and  Ti/phoid  Fevers. — Many  observers  from  the  time  of  Willis  and  Syden- 
ham described  epidemics  of  fever  differing  notably  in  their  characteristics  from  those  of 
the  typhus,  which,  under  such  names  as  pestilent,  malignant,  putrid,  contagious,  camp, 
skip,  jail  and  hospital  fevers,  prevailed  from  generation  to  generation  as  a  well-known 
scourge.  These  anomalous  cases  were  afterwards  named  slotv,  mild,  nervous  fevers,  or  low 
continued  fevers;  and  their  occurrence  was  considered  due  to  some  peculiarity  of  the 
ejMdemic  constitution  from  meteorological  or  other  alterations  in  the  condition  of  the 
atmosphere.* 

At  the  beginning  of  the  present  century  it  was  stated  by  Prost,  on  the  authority  of 
autopsical  observations,  that  these  fevers  had  their  seat  in  the  mucous  membrane  of  the 

*  SVDEXHAM  suf]^ge8t«tl  this  peculiarity  of  the  epidemic  constitution  as  arising  "  from  some  certain  secret  and  hidden  alterations  taking;  place 
within  tlie  Ixiwels  of  the  earth  and  pervading  the  atmosphere;  or  that,  [>erhaps,  it  mi^ht  chiefly  depend  upon  some  influence  of  the  heavenly  IXMiies." 
Sydtnham  Society's  Sydenham,  London,  1850,  Vol.  II,  p.  191. 


72  KJvM  A  K KS    1  N T i;o  I ) IJ( 'TOK Y 

intestine;  and  tor  sonic  years  nfterward  it  waw  taught  iii  tlu'  P'roncli  sidiools  tliat  tlioy  were 
essentially  an  enteritis.  Tii  181^  Pktit  and  Si;i;]:ks  .^liowci]  lliat  llio  lower  pari  of  tlic 
ileum  was  specially  affected,  and  thai  tlw  dise'as(.',  thus  ditl'.'rinu;  in  its  sitr  t'njin  an  ordinary 
inflammation,  must  be  of  a  si^'cific  character.  Bkktonxkav's  oljscrvaiions  in  ]81S-27 
localized  the  inflammation  in  tlie  solitary  and  agminated  glands,  and  d(.'monstrated  a  want 
of  correspondence  between  the  severity  of  the  local  lesion  and  tla*  gravity  of  the  general 
symptoms.      He  regarded  the  disease  as  an  internal  exantheni, — (lofhicj^enicnte. 

Two  years  later,  in  1829,  the  obscr\-ations  of  Louis  I'ccogui/cd  the  lesi(ai  of  the 
intestinal  glands  as  the  essential  or  characteristic  of  the  speciiic  fever  whi(di  he  tlescribed 
as  the  tyj)hoid  affection.  The  profession  in  America  became  familiar  with  Louis'  work 
through  Dr.  BowuiTon's  translation  published  in  LS3(3. 

Meanwhile  pathologists  in  England  failed  to  discover  the  glandular  lesions  in  their 
fever  cases  except  occasionally  in  such  as  presented  some  variations  from  the  tyjie  of  true 
typhus.  -Bright  in  London,  and  Alison  in  Edinburgh,  in  LS27,  reported  cases  in  which 
were  found  the  intestinal  lesions  of  the  ^"'rench  observers.  Thus,  while  the  French 
pathologists  considered  the  glandular  lesions  essential  to  tvphus  as  it  occurred  under  their 
observation,  the  British  regarded  them  only  as  a  comparatively  rare  and  accidental  com- 
plication. These  opposing  views  were  reconciled  by  a  demonstration,  made  in  Philadelphia, 
of  the  non-identity  of  the  British  and  French  fevers.  At  this  time  the  continued  fevers  of 
the  United  States  were  neither  so  contagious  nor  so  deadly  as  those  of  Britain.  In  the  pre- 
face to  his  translation  of  Hildenbrand  on  Contagious  Typhus,  published  in  1828,  Prof. 
8.  D.  GrROSS  said  of  our  so-called  typhus:  "Nor  is  it  perhaps  precisely  of  the  same  nature 
and  characterized  by  the  same  symptoms  as  the  typhus  of  Europe."  But  Drs.  GtERHARd 
and  Pennock  of  Philadelphia,  who  had  studied  the  typhoid  affection  under  Louis,  and  seen 
British  typhus  in  London,  recognized  in  the  former  the  prevailing  continued  fever  of  their 
own  country,  and  were  able  to  identify  the  latter  when  it  appeared  in  an  epidemic  form  in 
Philadelphia  during  their  service  at  the  hosjiital  Blockley.  Their  experience  of  this  out- 
break* established  its  identity  with  the  contagious  ty2)hus  of  Britain,  and  showed  the  charac- 
teristics which  distinguished  it  from  the  familiar  typhoid  or  dothienenterltc.  These  were 
the  activity  of  its  contagion,  the  suffusion  of  the  eyes,  the  dusky-red  color  of  the  counte- 
nance, the  stupor,  the  petechial  eruption  and  the  absence  of  special  abdominal  symptoms, 
together  with  the  general  progress  of  the  individual  case  as  manifested  in  the  succession  of 
the  symptoms.  In  1839  Dr.  SiiATTUCK  of  Boston  insisted  on  the  existence  of  two  fevers 
in  London  similar  to  those  described  in  Philadelphia  by  Gerhard.  His  paper,  read  before 
the  Medical  Society  of  Observation  of  Paris,  was  made  the  basis  of  an  argument  by  M. 
A^ALLEix  on  the  error  of  the  English  in  confounding  their  fevers,  one  of  which  was  identical 
with  the  Parisian  typhoid. 

As  a  result  of  these  investigations  Louis,  in  the  second  edition  of  his  work  issued  in 
1841,  recognized  that  the  typhoid  affection  of  Paris  was  a  different  disease  from  the  con- 
tagious typhus  of  Britain;  an<l  in  our  country  Bartlett  in  1842  and  Wood  in  1847, 
described  typhus  and  typhoid  as  (Hstinct  affections.  Some  opposition  was  raised  to  these 
new  doctrines,  but  its  influence  was  slight.  Professor  Dickson  of  Charleston,  S.  C,  in  his 
Elements  of  Medicine  published  in  1855.  adhered  to  the  view  that  fever  had  but  a  single 
cause,  and  that  tlie  variations  in  its  manifestations,  which  had  given  rise  to  such  names  as 


*  American  Journal  Medical  Sciences,  February  ami  August,  1837. 


TO    THE    CAMI'    KHVERS. 


73 


Ijiplnix  ijn(v\or  ;uul  'niihor,  piiJrul  and  ,irrro)/.s  I'ovcrs.  cerehral  and  (ihilomitidl  tj/phua,  were 
due  to  variations  in  tho  intensity  oi'  com/ontratioii  of  tlie  poison  and  to  influences  exerted 
on  tlie  condition  oi'  jiredisposition  of  the  subject;  as,  for  instance,  wliere  oelilesis  o-avo  to  eacli 
of  the  forms  the  character  of  jiutridity  or  malignancy.  lie  quoted  approvingly  from 
Campbell:'-'  "It  is  undeniable  that  the  two  diseases  are  inseparably  bound  together  in  ties 
of  the  strongest  and  most  indissolublo,  though  mysterious  atHnity;  the  necessity  which  any 
theory  may  involve  of  separating  them  is  enough  of  itself  to  declare  its  absurdity.'' 
Nevertheless  he  was  constrained  to  treat  of  typhus  and  tvphoid  in  his  Hlcments  undn-  twi; 
separate  heads,  in  deference  to  the  almost  universal  usage  in  America  at  the  time. 

Dr.  Baetlett  had  already  shown,  in  discussing  the  locality  of  typhoid  fever,  that  it 
was  the  common  continued  fever  of  our  Eastern  States,  and  that  it  occurred,  although 
perhaps  with  less  i'ri'quencv,  in  the  West  and  Bouth,  where  intermittents  and  remittents 
preyailed;  but  most  of  the  instances  cited  liy  him  were  of  epidemics  occiu'ring  m  towns. 
Some  years  later  I)r.  .Ias.  Pj.  Reeves  brought  pnnninently  to  the  notice  of  the  profession 
the  fact  that  enteric  fe\'er  was  of  common  occurrence  in  sparsely  settled  rural  districts  as 
well  as  among  urban  populations. f 

The  works  on  Practice  of  ]\[edicine  supplied  to  the  j\Iedical  Department  of  the  Army 
in  1S61  were  those  by  Wood, J  Wat.so^'||  and  I)ENNETT.§  In  the  first  the  distinction 
between  typhus  and  typhoid  was  clearly  given,  and  the  name  enteric  fever  was  suggested 
in  place  of  typhoid  to  emphasi/.e  the  distinction.  Dr.  WxITson,  influenced  by  Dr.  Jenner's 
presentation  of  the  arguments, ^|  had  recently  subscribed  to  the  doctrine  of  non-identity;  and 
in  the  volume  under  consideration  lie  tauglit  the  notable  diflerences  which  existed  in  the 
symptoms  and  course  of  the  two  diseases,  as  well  as  in  their  comparative  fatality  and 
exciting  causes,  regretting  that  the  affinity  of  the  names  imputed  a  similarity  in  the  dis- 
eases, and  approving  Dr.  Budd's  suggestion  to  replace  the  name  typhoid  by  intestinal  fever . 
In  Dr.  Bennett's  lectures  the  views  of  Jenner  were  given,  but  the  author  did  not  support 
them.  He  recognized  typhoid  and  typhus  clinically,  but  considered  them  as  "evidently 
produced  by  variations  in  the  intensity  or  the  nature  of  the  exciting  cause." 

It  appears  evident  from  these  considerations  that  our  medical  officers,  in  identifying  a 
case  of  idiopathic  fever  as  typhoid,  had  well-defined  ideas  concerning  the  aggregation  and 
sequence  of  symptoms  to  which  this  term  should  be  applied.  Of  typhus  they  had  practi- 
cally no  knowledge;  but  they  had  such  conceptions  of  this  disease  and  of  the  characteristics 
Avhich  distinguished  it  from  typhoid  that,  when  a  diagnosis  of  typhus  was  given,  it  neces- 
sarily meant  that  the  disease  diflfered  so  materially  in  some  points  from  the  familiar  typhoid 
fever  as  to  suggest  that  the  unfamiliar  typhus  of  Britain  was  under  observation. 

Common  Continued  Fever. — Many  medical  officers  no  doubt  looked  upon  this  appella- 
tive on  the  sick  reports  as  an  obsolete  term.  The  studies  and  observations  which  developed 
a  knowledge  of  tyi)hoid  fever  as  a  separate  disease  showed  so  many  instances  of  obscurely 
marked  fever  in  connection  with  well-marked  epidemics,  that  these  lighter  cases  were  con- 
sidered due  to  the  prevailing  typhoid  cause,  peculiarities  in  its  manifestations  being 
referred   to  variations  in  the  individual   constitution.      Thus,  while  separating  a  specific 

*  p.  285  of  his  Elements. 

\  111  till'  liniTalo  Medical  Journal,  IB5K,  and  in  a  Practical  Treatise  'in  Enteric  Fei^pr,  Pliiladelphia,  Pa.,  18.39. 

;  .1  Trcatite  on  the  Practice  of  Medicine,  liy  Georoe  B.  Wooii,  M.  I).,  Philailelphia,  1847. 

II  Lectures  on  the  Privciples  ami  fractice  of  I'htjsic,  by  Thomas  Watson,  M.  D.,  edited  by  I),  V.  CONIilE,  M.  D..  Pliiladelpliia,  1858. 

§  Clinical  Lectures  on  the  Principles  and  Practice  of  Medicine,  liy  J.  HniliKft  BENNETT,  M.  D.,  F.  R.  .S.  E.    American  edition.     New  York,  1860. 

T!  In  the  Edinburgh  Monthly  Journal  of  Medical  Science,  Vwls.  IX  and  .\,  18-19-50. 

Med.  Hist.,  Pt.  Ill— 10 


74  EKMARKS    INTRODUCTORY 

tyi>lioi<l  tVuin  a  «pecitic  typlius  liecau.se  iinliviihiul  or  rpidriiiic  constitutiDiiiil  pceuliuritirs 
seemed  insufficient  to  account  for  tlu'  notable  difierences  iti  tlu;  average  cases  of  eacli,  they 
liesituted  to  juisli  tlie  argument  and  thereby  separate  i'evers  of  short  duration,  unaccom- 
panied by  typhoid  symptoms,  from  the  cases  of  fully  developed  typhoid  fever.  Others,  on 
the  contrary,  recognized  in  these  febriculse  or  ephemeral  fevers  a  distinct  clinical  entity,  and 
reported  them  as  common  continued  fever  irrespective  of  etiological  considerations.  The 
unknown  or  suspected  cause,  whether  conceived  to  be  the  poison  of  tyjihoid  or  of  ty[)hus 
modified  in  some  way,  a  specific  poison  diflei'ing  from  these,  or  a  non-sp(,'citic  irritant,  had 
no  weight  in  the  formation  of  the  diagnosis.  Dr.  Wood  recognized  an  idiopathic  fever 
resulting  from  causes  of  irritation  having  nothing  specific  or  peculiar  in  their  mode  of 
operation— an  inflammatory  fever,  the  synoclia  of  Gullen,  but  without  any  local  lesion 
other  than  an  occasional  slight  inflammation  of  the  fauces  wholly  insufficient  to  account 
for  the  intensity  of  the  general  symptoms.  Bknnett  and  Jp:nner  also  recognized  a  febri- 
cula,  though  diftering  in  opinion  as  to  its  nature,  the  former  considering  it  a  modified 
typhus  and  the  latter  an  essential  fever  due  to  a  sj)ecitic  cause.  The  clinical  features  of 
the  cases  reported  under  the  name  of  common  continued  fever  may  therefore  be  readily 
appreciated. 

Hemittent  Fever. — The  paroxysmal  fevers  of  the  West  and  South  were  well  known  at 
the  outbreak  of  the  war,  even  to  those  of  the  profession  whose  practice  anterior  to  their 
military  service  had  been  in  non-malarious  localities.  The  importance  of  these  fevers,  and 
the  national  character  of  the  great  medical  schools  of  the  North,  called  for  as  thorough  a 
discussion  of  the  malarial  fevers  as  of  those  which  constituted  the  common  fever  of  the 
North  and  Eas-t.  The  text-books  gave  prominence  to  the  endemic  fevers.  The  American 
edition  of  Watson  s  Practice  contained  an  article  by  Dr.  C/ONDie  on  remittent  fever  to  fit 
the  work  for  its  new  sphere  of  usefulness.  The  medical  journals  showed  that  the  energies 
of  the  profession  were  as  much  engaged  on  malarial  disease  as  on  typhus  and  typhoid. 
The  medical  officer  from  the  North  was  therefore  well  prepared  to  recognize  malarial  remit- 
tents when  presented  to  him,  and  perhaps  better  qualified  than  the  southern  practitioner  to 
recognize  the  to  him  familiar  typhoid  fever  when  occurring  in  the  habitat  of  malaria. 
Bartlett  had  shown  that  typhoid  fever  was  to  be  found  in  such  localities,  and  Wood,  in 
speaking  of  the  diagnosis  of  enteric  fever,  called  special  attention  to  the  miasmatic 
remittent  as  one  of  the  diseases  liable  to  be  confounded  with  it,  especially  when  the  remit- 
tent was  protracted  or  attended  with  'typhus'  symptoms.  The  figures,  reported  by  our 
medical  officers  during  the  war  under  the  heading  remittent  fever,  may  therefore  be 
accepted  as  giving  a  fair  expression  of  the  prevalence  of  this  form  of  fever.  Mistakes  in 
diagnosis  no  doubt  occurred, —  remittent  fever  may  have  been  recorded  as  typhoitl, 
especially  when  it  assumed  an  adynamic  form,  and,  on  the  other  hand,  typhoid  may  have 
been  set  down  as  remittent  in  localities  where  the  latter  was  endemic;  this  will  be  con- 
sidered hereafter.  It  is  sufficient  for  the  present  to  know  that  the  nanae  remittent  fever 
was  given  to  a  definite  and  generally  appreciated  clinical  picture. 

Intermitting  Fevers. — The  interraittents,  including  the  congestive  form,  were  usually 
characterized  by  such  marked  and  well-known  peculiarities  that  the  conditions  indicated 
by  the  diagnosis  are  easily  understood. 

On  June  30,  1862,  two  changes  affecting  the  method  of  reporting  idiopathic  febrile 
diseases  were  made  in  the  sick  reports.     The  first  involved  the  disuse  of  the  term  common 


TO    THE    CAMP    FEVERS.  75 

continued  fever.  No  instructions  were  issued  regarding  the  disposition  to  be  made  of  such 
cases  as  had  heretofore  been  reported  under  this  designation ;  but  from  what  has  been 
stated  above  concerning  the  tendency  developed  by  the  study  of  typlioid  fever,  it  may  be 
assumed  tliat  many  of  the  cases  were  tlieroafter  reported  under  that  heading  while  tlie 
remainder  mav  have  found  phice  under  OtlnT  Miasiindic  DiseascH.  During  tlie  year 
ending  June  30,  1862,  when  the  term  couimon  continued  fever  was  in  use,  there  were 
reported  under  it,  per  tliousand  of  strength,  42  cases,  1.25  per  cent,  of  which  were  fatal, 
wliile  under  the  term  other  miasmatic  diseases  there  were  reported  oidy  27  cases,  with  .41 
per  cent,  fatal.  Dui'ing  the  following  year,  when  no  special  provision  was  made  for  the 
classification  of  the  cases  formerly  reported  as  common  continued  fever,  the  cases  returned 
as  other  miasmatic  diseases  rose  to  50  per  thousand  and  their  fatality  to  2.84  per  cent.  A 
large  number  of  the  common  continued  cases  may,  therefore,  have  been  returned  under  this 
indefinite  heading. 

The  second  change  consisted  of  the  insertion  in  the  re[)orts  of  a  new  term,  Ti/plio- 
inalarial.  The  writer  has  not  been  able  to  find  the  report  of  the  Board  tliat  recommended 
these  changes,  and  is,  therefore,  ignorant  of  the  arguments  which  led  to  the  abolition  of 
the  one  term,  but  Dr.  Woodward  has  detailed  the  circumstances  attending  the  introduc- 
tion of  the  other.*  In  the  autumn  and  early  winter  of  1861  the  medical  officers  of  the 
army  called  attention  to  the  fact  that  the  camp  fevers  then  coming  under  observation  dif- 
fered in  many  particulars  from  the  enteric  fevers  which  they  had  treated  in  civil  practice 
before  the  war.f  A  Board  consisting  of  Surgeon  A.  N.  McLaren,  U.  S.  A.,  Surgeon  G.  H. 
Lyman,  U.  S.  Vols.,  and  Assistant  Surgeon  M.  J.  Asch,  U.  S.  A.,  was  convened,  December 
16,  to  investigate  and  determine  whether  the  fever  then  prevailing  in  the  army  was  to  be 
considered  an  intermittent  or  bilious  remittent  fever  in  its  inception,  assuming  in  its  course 
a  typhoid  type,  or  a  typhoid  fever  primarily.  The  board  examined  the  fever  in  several  of 
the  division  hospitals  of  the  Army  of  the  Potomac.  It  comnmnicated  by  circular  letter 
with  many  medical  officers  whose  commands  could  not  be  conveniently  reached.  The 
replies  received,  in  their  general  tenor,  confirmed  the  opinion  which  the  board  had  formed 
on  the  basis  of  its  personal  observation,  that  while  a  certain  number  of  cases  of  ordinary 
typhoid  existed  in  the  army,  the  large  majority  of  the  febrile  cases  were  bilious  remittent 
fevers  which,  not  having  been  controlled  in  their  primary  stage,  had  assumed  tiiat  adynamic 
type  which  is  present  in  enteric  fever.  This  officially  pronounced  adynamic  remittent  pre- 
vailed extensively  during  the  Peninsular  campaign  of  the  following  year  and  was  familiarly 
known  as  Chickahominy  fever.  Dr.  Woodward  had  served  with  the  army  in  this  cam- 
paign, and  had  formed  the  opinion  that  these  fevers  were  hybrid  forms  resulting  from  the 
combined  infiuence  of  malarial  poisoning  and  the  causes  of  typhoid  fever,  modified  in 
individual  instances  in  accordance  with  the  preponderance  of  one  or  the  other  of  these 
influences  and  occasionally  by  the  presence  of  a  scorbutic  taint.  At  this  time  he  was 
detailed  a  member  of  a  board  to  revise  the  form  of  sick  report  in  use  in  the  army,  and 
actuated  by  the  strength  of  his  opinions,  he  induced  the  board  to  recommend  the  insertion 
of  the  term  typho-malarial  in  tlie  blank  form  for  the  monthly  sick  report  as  a  suitable 
designation  for  the  complex  conditions  which  he  believed  to  be  present  in  these  cases.  He 
afterwards  regretted  that  he  had  not  also  urged  upon  the  board  the  preparation  of  a  circiilar 

*  Tijphomalarial  Fere.r :  Is  it  a  Special  Type  nf  Fever  I     Philadelphia,  1**7(>,  pp.  10-12. 

t  For  an  illiiNtrutlon  of  the  characters  of  the  fevers  occurring  at  th«  time  specified,  refer  infra,  p.  216e/  seq.,  to  the  admirable  clinical  records  of  the 
Seminary  Hospital,  Georgetown,  D.  C. 


76  i;kmai;ks   ini'iioiu'ctory 

letter  to  ucc;oin]i;uiy  the  new  sick  r('|ii)rt,  cxjilaiiiiiiL;;  wiiv  this  tiM'in  hail  hiM/ii  ailojiti'd,  ami 
calling  for  sjiecial  repoi-fs  with  rcu-ai'd  to  the  eases  which  it,  was  intciidiMl  to  (lesiLniat(\ 
This  omission  was  imlccd  uiiloi'i  iiiiatc,  as  it  left  the  inedical  otiiccrs  willmut  a  guide  I'or  the 
use  of  a  term  not  only  <>i'  indctinitc  meaning  hut  ahsolutcly  of  doiililc  meaning.  Tlieso 
fevers,  in  aceordance  with  the  views  then  curn-nt,  were  either  remittents  with  low  or 
typhous  symptoms,  or  they  were  eases  of  enteric  fever  witli  accidental  malarial  complica- 
tions. The  uncertainty  attaching,  in  the  ahsiMice  ol"  the  necessary  instruclioiis,  to  the  \'alue 
of  the  Hrst  part  of  the  compound  woi'd,  permitted  it  to  he  used  as  a  diagnostic  title  f  )r  both 
of  these  series  of  cases.  Indeed  it  was  perhaps  better  suited  to  meet  acceptance  as  a 
designation  for  low  remittents  than  for  cases  of  true  typhoid  marked  by  malarial  symptoms, 
for  the  compound  term  f//jj/n>/(/-p)tfMjnouia  was  tamiliai'  as  a  household  word  at  the  time, 
and  no  meaning  was  conveyed  by  it  involving  the  presi.-uce  of  the  sj)ecifi.c  poison  of  enteric 
fever.  Xevertludess  Di'.  W^oODWAKD  subsequently  claimed  that  the  {)rompt  accejitance  of 
the  term  tvpho-malaiial  showed  how  widelv  the  (opinions  he  had  formed  were  shared  by 
the  medical  officers  of  the  ai'my.  ]>ut  the  s(>iise  of  the  pi'ofession  cannot  be  thus  construed 
in  support  of  the  view  of  a  specilic  enteric  essential  in  the  tvpho-malarial  cases  rejKjrted  at 
that  time.  During  the  month  of  Julv,  lS(^2,  tln^  tii'st  month  of  the  us(>  of  the  new  term, 
2,283  cases  were  I'eported,  while  Dr.  WooDW.VliD's  opinions  wert>  unknown  except  to  a  few 
personal  friends.  Indeed  his  views  were  not  published  until  the  issttance,  on  Septembers, 
1863,  of  C'lTcvJar  No.  15,  Surgeon  (Jeneral's  Office,  Washington,  D.  0.  Tn  this  the  mean- 
ing designed  to  be  attached  to  the  term  typho-nialarial  was  for  the  first  time  made  known 
in  the  following  words: 

Moreover-,  while  ii  ci'itain  ainount  of  imci)iii])liciit<'(l  OHtcric  and  leiiiitteut  fovcrs  (•<>rtaiiil,v  did  occur,  ospccially 
at  the  coiniiioiKH-iiicnt  of  the  war,  the  vast  iiia.jorit,y  of  the  cainii  fevers  of  the  army  were  of  a  mixed  character, 
exhibitiiift  midonhted  enterics  )(henoiiiena  variouNly  coniliined  witli  the  periodieitv  and  other  peculiarities  of  malarial 
disease,  and  still  further  modified  h.y  the  tendency  to  incipient  scurv.v,  which  is  the  ordinary  concomitant  of  cam)> 
diet.  To  indicate  this  mixed  nature,  the  term  tyi)ho-malarial  fever,  which  I  had  the  honor  to  suggest  to  the  Depart- 
ment in  June,  18()2,  appears  ajjpropriate,  and,  at  the  present  time,  is  coming  into  very  g(MU'ral  use. 

Up  to  the  close  of  the  month  of  August,  I8(i3,  shortly  belbre  the  publication  o|'  this 
circular,  27,399  cases  of  typho-malarial  fever  had  been  reported  in  a  total  of  19.87]  such 
cases  during  tln^  war.  In  other  words,  more  than  one  half  of  the  cases  were  reported  during 
the  fourteen  months  which  intervened  l)etween  the  apjiearance  of  the  term  on  the  re[)orts 
and  the  publication  of  a  casual  reference  to  the  meaning  designed  to  be  attached  to  it. 

The  nomenclature  of  the  fevers  as  officially  given  in  the  army  sick  reports  at  the 
beginning  of  the  war  gave  expression  to  species  with  marked  clinical  distinctions.  Uncer- 
tainties attached  to  the  etiology  of  the  small  percentage  reported  as  common  continued 
fever,  but  the  nature  of  the  uncertainties  was  fully  aj)pretdatod  —  and  the  segregation  of 
the  cases  rendered  them  available  for  special  study.  The  removal  of  this  term  from  the 
sick  report  complicated  the  statistics  thereafter  furnished  by  doubts  as  to  the  disposition 
made  of  ephemeral  and  other  febrile,  cases  not  distinctly  typhoid.  What  proportion  of 
these  were  sent  to  swell  the  lists  of  typhoid,  how  many  complicated  with  the  effi:M,'ts  of 
malaria  were  added  to  the  typho-malarial  list,  and  how  many  w\u-e  dropped  out  of  consid- 
eration altogether  by  being  placed  among  other  miasmatic  diseases,  are  questions  which 
constantly  recur  in  studying  the  statistics  of  fever  furnished  after  June  30,  1862.  The 
insertion  of  the  term  typho-malarial  was  also  a  grievous  complication.  The  true  value  of 
the  statistics  given  under  this  heading  can  never  be  known  in  the  absence  of  a  complete 
record  of  all  the  cases.     Such  cases  as  were  reported  with  more  or  less  of  detail  will  be 


TO    THE    CAMP    FEVEER.  77 

presented  hereafter,  and  tlu'  tij^inx's  tlu'insclw.s,  and  tlio^^e  allied  to  them,  will  be  examined 
in  this  ciMinoi'tion.  hi  tlie  meantime  a  con.sii.leration  of  the  conditions  nnder  which  the 
diauMio.ses  were  made  will  show  that  clinically  typho-malai'ial  cases  may  have  presented 
u;reat  diversity,  froni  the  severe  and  protracted  remittent  ending  fatally  witli  great  prostra- 
ti<jn,  low  delirium,  stupor  and  coma,  and  the  equally  severe  cases  of  typhoid  fever  ending 
fatally  in  like  manner,  but  with  some  modification  in  their  progress  from  concurrent 
malarial  poisoning,  to  the  mild  enteric  and  abortive  cases  viewed  doubtfully  as  tvphoid, 
and  diagnosticated,  when  such  diagnosis  was  officially  admissible,  as  common  continued 
fever,  yet  recorded  with  propriety,  in  accordance  with  the  views  of  Dr. Woodward,  as  cases 
of  typho-malarial  fever,  in  the  presence  of  indications  calling  for  the  exhibition  of  quinine 
as  an  antiperiodic. 


o 


CHAPTER  III— ON  TJFE  PAllOXYSMAL  FEVERS. 
I.  — THE    STATISTirS    OF    THE    MALARIAL   FEVERS. 


I.— MALARIAL  FEVERS  AMONG  THE  U.  S.  FORCES. 


Prevalence  and  Mortality. — During  and  immediately  after  the  war,  one-fourth 
of  all  the  reported  cases  of  disease  among  the  white  troops  was  of  a  malarial  character. 
There  were  224  cases  of  malarial  fevei'  in  evei'y  thousand  cases  of  reported  disease.  Typho- 
malarial  (oxt'V  is  included  in  tliis  statement,  as,  irrespective  of  the  views  entertained  con- 
cerning its  typhoid  element,  its  malarial  factor  was  definitely  recognized  by  all  parties.  Tt 
seems  proper,  therefore,  to  considei-  it  in  a  discussion  of  the  prevalence  of  malarial  disease, 
although  it  may  be  needful  to  know  more  about  it  before  its  mortality  can  with  propriety  be 
admitted  to  weigh  in  the  scale  with  that  due  to  the  purely  malarial  fevers. 

The  sim})le  intermittent  constituted  by  far  the  greater  proportion  of  these  febrile  cases, 
2,003  cases  per  1,000  of  mean  strength  having  been  reported  in  a  total  of  2,814  of  malarial 
disease;  in  other  words,  a  distinct  period  of  intej-mission  was  recognized  in  five-sevenths  of 
the  paroxysmal  fevers.  These  figures  represent  only  the  number  of  cases  in  which  inter- 
mittent fever  was  the  most  obvious  abnormal  condition  present.  They  by  no  means  express 
the  extent  to  which  this  disease  prevailed,  even  in  that  part  of  the  army  represented  in  the 
statistical  tables.  As  the  system  of  reporting  provided  no  method  of  recording  complica- 
tions, it  very  generally  happened  that  cases  of  intermittent  fever  complicated  with  serious 
diarrhoea,  dysentery,  pneumonia  or  other  grave  afi'ections,  were  reported  under  the  liead  of 
these  disorders  without  any  mention  of  a  co-existing  malarial  affection.  But,  althougli  under- 
stating the  facts,  the  statistics  convey  a  clear  idea  of  the  extensive  prevalence  of  this  form 
of  malarial  disease.  Out  of  1,213,685  cases  of  malarial  fever  863,651  were  cases  of 
simple  intermittent.  How  many  of  these  were  first  attacks,  and  how  many  recurrences  in 
individuals  already  affected  by  the  malarial  influence,  cannot  be  determined.    It  is  probable 


78  MALARTAT.     FKVERS 

tliat  the  majority  of  tlio  primai-v  attacks  arc  ini'linlfd  in  tli>'  !iuiiib(>i-,  for  a  soldier 
wlio  experienecd  au  aijae-iit  fur  llie  lirst  time  was  usuall\'  dis|)osfd  to  lie  alarmed  at  tlio 
vi<jlfiu-e  of  tlic  symptoms,  and  to  seek  medical  assistance,  even  if  tln'  nature  of  the  duties 
recjuired  of  him  at  the  time  was  such  as  to  I'ender  it  needless  for  him  to  report  for  tlie  pur- 
])Ose  of  l)eing  relieved  from  their  performance.  ( )n  the  other  hand,  it  is  certain  that  maii\' 
of  the  recurrences  which  took  place  were  not  re})oi'ted.  ALmi  became  accustomed  to  attacks 
of  this  kind,  and  visited  the  dispensary  after  the  ])aroxysm,  not  to  report  as  sick,  Imt 
to  procure  a  supply  of  quinine  to  prevent  a  return;  even  when  on  important  dutv  which 
they  were  incapable  of  perfoi'minu'  durinji'  the  attack,  such  men  would  l>e  tempurarilv 
excused  by  their  company  ofiicers,  the  medical  officer  of  the  command  remainiuLi'  in  igno- 
rance of  the  recurrence. 

In  more  than  one-half  of  the  agues  the  cvcle  of  morbid  phenomena  was  completed  in 
twenty-four  hours.  Tertians  followed  closely  in  order  of  frequency.  Quartans  were  com- 
paratively rare,  forming  only  one-twentieth  of  the  whole  number.  Of  the  2,00o  cases  of 
simple  intermittents  occurring  per  1,000  of  mean  strength  among  the  white  troo})s  during 
the  five  and  one-sixth  years  covered  by  the  statistics,  1.037  were  quotidians,  870  tertians 
and  96  quartans. 

Congestive  fever  was  fortunately  of  infrequent  occurrence,  it  having  furnished  but  32 
cases  per  thousand  of  strength,  constituting  3  of  the  224  cases  of  malarial  disease  which 
were  recorded  in  every  thousand  cases  of  all  diseases.* 

Remittent  fever  gave  664:  of  the  total  of  2,814  cases  of  malarial  disease  which  occurred 
per  thousand  of  mean  strength,  or  53  of  the  224  malarial  cases  recorded  per  thousand  cases 
of  all  diseases.  Excluding  the  typho-malarial  cases,  the  664  remittents  formed  part  of 
2,699  cases  of  pure  malarial  fevers  which  occurred  in  every  thousand  men  of  the  command, 
or  53  of  the  215  pure  malarial  fevers  recorded  in  every  thousand  cases  of  disease.  In 
simpler  figures,  the  remittents  formed  one-fourth  or  24.6  per  cent,  of  the  purely  malarial 
fevers,  and  a  little  less  than  this,  or  23.7  per  cent,  of  all  malarial  fevers,  including  the  cases 
recorded  as  typho-malarial .f  These  typho-malarial  cases,  115  per  thousand  of  strength, 
formed  only  9  of  the  224  malarial  cases  which  occurred  in  every  thousand  cases  of  disease. 

The  deaths  reported  among  the  white  troops  as  occasioned  by  malarial  fevers  num- 
bered 12,199;  but  if  to  these  be  added  a  due  ])roportion  of  the  42,869  deaths  from 
unspecified  diseases,  the  number  becomes  augmented  to  16.225.  Of  the  12,199  deaths 
specially  referred  to  malarial  fevers,  4,059  were  considered  due  to  typho-malarial  mani- 
festations, 3,853  to  remittent,  3,370  to  congestive  and  917  to  simple  intermittent  fevers. 

Although  congestive  fevers  were  infrequent  and  remittents  formed  only  one-fourth  of  tJie 
purely  malarial  fevers,  the  deaths  from  these  forms  of  malarial  aft'ection  were  in  striking 
contrast  with  those  from  the  simple  intermittents.  The  latter  numbered  less  than  2  per 
thousand  of  strength,  and  the  former  somewhat  over  7  and  8  j^er  thousand  respectively. 
Of  1,000  deaths  from  all  diseases,  94  were  caused  by  malarial  fever,  31  of  these  being 
due  to  typho-malarial,  30  to  remittent,  26  to  congestive  and  7  to  simple  intermittent  fevers. 

In  the  last  colunm  of  the  table  which  follows  is  shown  the  light  rate  of  mortality  in 
the  intermittents,  one  death  in  every  thousand  cases  of  quotidian  or  tertian  ague,  and  one 

*  The  relative  fre(|uency  of  the  types  nf  intermittent  fever  expres-seU  as  i»ereeiita)?es  uf  tlie  total  number  of  intermittent  ('ai^es  whieh  <ieenrred  iu 
each  of  the  military  departments  will  be  tjund  iu  Table  XX.XUI  infra,  p.  !IH. 

t  The  table  mentioned  in  last  note  gives  al.so  the  relative  frequency  of  the  forms  of  malaria!  fever  expresseil  iis  iiereentages  i>r  the  total  mimlier  of 
malarial  cases  which  occurred  in  each  of  the  departments. 


AMOXG    THE    r.    P.    FORCES. 


79 


death  in  every  five  liundred  of  the  quartans.  The  greater  mortality  in  tlie  last-mentioned 
form  is  at  variance  with  the  opinion  which  regards  the  quotidian  as  an  expression  of  a 
liigher  degree  of  the  malarial  poisoning  than  is  present  in  the  tertian  or  quartan.  Many 
of  these  deaths  might  he  passed  to  the  credit  of  congestive  fever,  as  the  fatal  result  was 
due  to  the  occurrence  of  a  paroxysm  of  an  aggravated  type;  while  others  with  equal  pro- 
jiriety  might  be  ti'ansferred  to  remittent  fever,  as,  although  the  case  was  intermittent 
originally,  and  so  reported,  the  fatal  issue  did  not  take  place  until  after  the  fever  had 
assumed  the  remitting  type. 

Remittent  fever  gave  a  fatality-rate  of  1.31  per  cent.,  or  one  death  in  76  cases,  and 
congestive  fever  24.65  per  cent.,  or  one  death  in  4  cases.  But  notwithstanding  this  high 
rate  of  the  congestive  fevers,  sucli  was  their  infrequency  as  compared  with  the  less  dan- 
gerous forms  of  the  disease,  that  the  deaths  from  the  })urely  malarial  diseases  amounted 
only  to  seven-tenths  of  one  per  cent.,  or,  including  the  deaths  from  typho-malarial  fever, 
to  one  death  in  every  hundred  cases. 

Table  XXII. 

Statement  of  the  Frequency  and  Mortality  of  the  several  forms  of  Malarial  Fever,  giving  the  totals  reported 
from  May  1,  186 1,  to  June  30,  IS66,  n-itk  the  ratio  of  cases  to  strength  and  to  cases  of  all  diseases, 
and  the  ratio  of  deaths  to  strength,  to  deaths  from  all  disease^i  and  to  cases  of  Malarial  Fever. 

WHITE  TROOPS. 


Disease. 


Number  reported 

duriiiji;  tlie   period 

from  May  1,  1861,  to 

June  30,  1866. 


Quotidian  Intermittent 
Tertian  Inteiniittent  _. 
Quartan  Intermittent.- 


Cascs. 


447,258 

375, 170 

41,223 


Total  simple  Intermittent . 

Congestive  Fever 

Remittent  Fever 


Total  pure  Malarial  Fevers  . 
Typlio-malarial  Fever 


Total  Malarial  Fev< 


863, 651 

13, 673 

286, 490 


Deaths. 


452 
381 

84 


1,163,814 
49, 871 

1,213,685 


917 
3, 370 
3,853 


Ratios  per  1,000 
of  strenittli. 


Cases. 

1,037 

870 

96 


Deaths. 


2,003 

32 

664 


8, 140        2, 699 

I 

4,059  115 


12, 199 


2,814 


.96 

.81 
.18 


1.95 
7.20 
8.23 

17.38 
8.67 


26.05 


,-r  ^ 
«  *   . 
£  *  " 

S  "  I' 
o 


82 
69 


159 

3 

53 


215 
9 


224 


^   X   so 
2  O  tS 

a 


3.49 

2.95 

.64 


7.08 
26.05 
29.78 

62.91 
31.37 

94.28 


.10 
.10 
.20 

.16 

24.65 

1.31 

.70 
8.14 

1.00 


But  although  the  mortality  from  these  fevers  was  comparatively  light,  their  influence 
in  detracting  from  the  efficiency  of  the  army  must  have  been  very  great.  We  have  no 
means  of  ascertaining  liow  many  men  constantly  on  sick  report  would  represent  this  loss, 
nor  can  we  learn  how  many  were  permanently  removed  from  active  service  by  discharge 
on  account  of  the  pernicious  influence  of  the  fever-poison  on  the  constitution.  The  statis- 
tics sliow  that  373  men  were  discharged  for  remittent  fever  and  480  for  intermittent  fever; 


80 


MALARIAL     FPIVKRS 


but  wlioii  it  is  recognized  tluit  tluTe  wcvc  2,221  cases  in  wliicli  dropsy  figured  as  the  cause 
of  disaliility  necessitating  discharge,  Id.oOO  having  debility  as  the  nominal  cause,  and 
25,915  in  whicli  tlie  cause  was  not  stated,  \vc  are  left  to  speculate  upon  the  influence  which 
tliese  fevers  may  have  exercised  in  tlie  production  of  temporary  and  permanent  disable- 
ment to  our  armies. 

The  malarial  fevers  as  they  affected  the  colored  troops  are  shown  in  the  following  table: 

Table  XXIII. 

Statement  of  the  Frequeney  and  Mortality  of  the  several  forms  of  Malarial  Fever,  giving  the  totals  reported 
from  July  1,  1863,  to  June  30, 1866,  with  ike  ratios  of  cases  to  strength  and  to  eases  of  all  diseases, 
and  the  ratios  of  deaths  to  strength,  to  deaths  from  all  diseases  and  to  cases  of  Malarial  Fever. 

COLORED  TROOPS. 


Disease. 

Number 
during   tl 
from  .Inly 
,Iune  3( 

Cases. 

reported 
e   period 
1,1863,  to 
),  186(i. 

Deaths. 

Rates  ]) 
of  stn 

Cases. 

er  1 ,000 
ngth. 

Deaths. 

1 

.91 
.85 
.23 

S  5  ^ 
¥  cS  :S 
n  "  =^ 
Q 

106 
84 

7 

Ill 

« 

2.11 

1.96 

.55 

o 

Z^ 

Ph 

.09 
.10 
.30 

Quotidian  Intermittent 

63, 992 

51,045 

3,923 

58 
54 
15 

1,047 

835 

64 

Total  simple  Intermittent 

Congestive  Fe\er 

Remittent  Fever     -- 

118,960 

2,536 

30,645 

127 

794 

1,002 

1,946 

42 

.501 

2,  189 
123 

2, 612 

1 

1.99 
12.42 
15. 67 

30.  08 
20.  35 

50.43 

197 

4 

50 

251 
12 

4.62 
28.88 
.36.43 

69. 93 
47.31 

117. 24 

.10 

31.31 

3.27 

1.26 
17.27 

2.02 

Total  pure  Malarial  Feveis -- 

Typho-malarial  Fever 

Total  Malai'ia!  Fevers                                     

152,141 

7, 529 

1,923 
1,301 

159, 670 

3,224 

263 

In  comparing  this  table  with  that  given  for  the  white  troops,  it  must  be  remend)ered 
that  while  the  latter  includes  the  statistics  of  five  and  one-sixth  years  the  former  embodies 
the  records  of  only  three  years  of  service.  If  it  be  assumed  that  the  rates  of  prevalence 
and  mortality  which  were  found  in  these  three  years  among  the  colored  troops  would  liave 
prevailed  had  the  observations  been  continued  for  five  and  one-sixth  years,  the  ratio  of 
cases  per  thousand  of  strength  would  have  been  4,498  as  compared  with  2,814  among  the 
whites,  and  the  deaths  86.88  as  compared  with  26.05,  or,  in  other  words,  for  every  100 
cases  occurrincf  amono-  a  sriven  number  of  white  soldiers  in  a  certain  time,  160  cases  would 
have  occurred  among  the  same  number  of  colored  troops  in  the  same  period,  and  for  100 
deaths  from  malarial  fever  occurrini>-  amono-  the  white,  334  deaths  would  have  been  recorded 
in  the  same  time  among  the  same  number  of  colored  troops.  This  is  definitely  show^i  in 
Table  XXVI,  where  the  sickness  and  deaths  for  both  races  are  tabulated  as  annual  averages. 

But  the  element  of  time  does  not  affect  the  comparative  value  of  the  figures  in  the 
last  three  columns  of  the  table  at  present  under  consideration.      Thus  tlie  increased  mor- 


AMO^"G    THE    U.    S.    FORCES.  81 

tality  which  hu.s  just  been  indicated  is  in  the  hist  cdhuiin  distributed  aniung  the  various 
Ibnns  of  fever.  Of  100  cases  of  congestive  fever  among  the  colored  troop.s  31.31  died,  or 
1  in  3.2  cases,  as  aiiainst  1  in  4  anionu'  the  whiti's;   of  the  same  number  of  remittent  cases 

'CD  O  ' 

3.27  died,  or  1  in  30,  as  against  1  in  76  amung  the  whites;  uf  lOO  typho-malarial  cases 
17.27  died,  or  1  in  5.8,  as  against  1  in  12  among  tlie  whites.  The  influence  of  this 
increased  mortality  in  the  more  dangerous  forms  of  malarial  fever  among  the  colored  troops 
was  such  that  the  percentage  of  fjxtality  of  the  malarial  fevers  as  a  class  among  the  colored 
men  is  found  to  be  as  larse  airaiia  as  that  whidi  obtained  amon^  the  white  soldiers:  thus, 
the  ])urely  malarial  fevers  gave  a  inortality  of  0.7  per  cent.,  or  1  in  113  cases  among  the 
latter,  and  1.26  per  cent.,  or  1  in  70  among  the  ibrmer;  while,  if  typlio-malarial  fever  is 
taken  into  consideration,  its  greater  fatality  among  the  blacks  will  be  found  to  raise  their 
percentage  of  fatal  cases  to  2.02  as  com})ared  with  1.00  among  the  white  troops.  But 
it  ma\'  not  be  inferred  from  these  facts  that  negro  troops  are  more  liable  to  malarial 
seizures,  and  more  prone  to  succumb  to  the  malarial  influence  than  white  troops,  until  it  has 
been  shown  that  both  bodies  of  men  were  exp6sed  to  similar  influences. 

The  tabulated  statistics  of  malarial  disease  have  reference  solely  to  the  fevers.  It  is 
not  j)ossible  to  ascertain  the  actual  number  of  men  who  suffered  from  chronic  malarial 
poisoning  during  the  civil  war.  Most  of  them  were  undoubtedly  reported  under  the  head 
of  the  intercurrent  diseases  which  were  developed  during  the  progress  of  the  cachexia. 
Large  numbers  were  registered  as  cases  of  general  debility  or  other  diseases  of  the  mias- 
matic order.  Under  these  headings  101,892  cases  wuth  1,981  deaths  were  reported  among 
the  white  troops,  and  11,887  cases  with  535  deaths  among  the  colored  troops;  moreover, 
there  were  14,500  white,  and  540  colored,  soldiers  discharged  the  service  for  debility. 
Under  the  head  of  anaemia  21,892  cases,  438  deaths  and  347  discharges  on  certificates 
of  disability  were  reported  among  the  white  troops  ;  2,771  cases,  258  deaths  and  35 
discharges  among  the  colored.  Men  broken  down  by  the  most  diverse  morbid  condi- 
tions were  included  in  these  figures;  and  although  all  who  liad  opportunity  of  observing 
large  numbers  of  such  cases  during  the  war  will  testify  to  the  frequency  with  which  the 
malarial  cachexia  occurred  among  them  either  as  the  chief  morbid  condition  or  as  a  com- 
plication, there  is  no  possibility  of  giving  even  an  approximate  numerical  expression  of  the 
fact.  It  may  be  added  that,  according  to  the  tables  in  the  J^irst  Medical  Volume,  1,977 
cases,  17  deaths  and  171  discharges  on  account  of  diseases  of  the  spleen  were  reported 
among  the  white  troops,  and  55  cases,  3  deaths  and  3  dischai-ges  among  the  colored  men ; 
and  although  the  majority  of  these  cases  were  instances  of  malarial  enlargement  of  the 
organ,  it  cannot  be  supposed  that  the  numbers  represent  any  very  considerable  proportion 
of  the  actual  cases,  which  were  usually  recorded  under  other  heads,  such  as  intermittent 
fever,  debility  and  anaemia.  Xor  is  it  possible  to  determine  the  number  of  cases  of  malarial 
cachexia  that  terminated  in  dropsy,  though  it  must  be  believed  that  a  large  number  recorded 
as  (jeueral  dropsy,  ahdoininal  dropsy,  and  dropsy  from  hepatic  disease  had  this  origin. 
Under  these  headings  7,337  cases  and  398  deaths  were  reported  among  the  white  troops; 
and  2,224  men  are  said  to  have  been  discharged  for  drojisy.  Under  the  same  headings 
1,427  cases,  272  deaths  antl  109  discharges  were  reported  among  the  colored  troops. 

Of  neuralgia,  another  manifestation  of  malarial  poisoning,  58,774  cases  were  noted 
among  the  white,  and  6,018  among  the  colored  troops.     A  number  of  these  cases  may  have 

Med.  Hist.,  1't.  111—11 


82 


MALAIU.M.     K1-;V1';KS 


been  due  to  Jiuilaria,  bnt  it  is  ditlioult  t<i  bt'lievo  tli;it  tlu;  majority  wore  so,  for  neither  in 
their  geograj>]iical  distribution  nor  iu  the  season  at  whicli  they  were  most  prevalent  do  the 
figures  reported  agree  with  the  distribution  of  tlie  reported  cases  of  intermittent  fever.* 

Tlie  occurrence  of  malarial  fever  in  connection  with  diarrhcea  and  dysentery  has 
already  been  shown. f 

Annual  variatwns  in  prevalence  and  mortality/. — Turning  now  to  Table  XXIV,  illus- 
trating the  relative  frequency  and  inortality  of  these  febrile  aflFections  among  white  troops 
during  the  several  years  covered  by  the  statistics,  it  is  found  that  their  prevalence  increased 
gradually  to  the  fourth  yeai',  or  that  ending  June  oO,  LS64,  when  the  war  maximum  was 
attained,  diminished  somewhat  during  tlie  hfth  year,  and  experienced  a  marked  increase 
during  the  sixth,  or  year  succeeding  the  war.  This  marked  advance  to  the  fourth  year, 
and  slight  diminution  during  the  fifth  year,  was  due  to  the  influence  of  the  mass  of  the 
intermittents  on  the  figures  representing  the  prevalence  of  the  other  forms;  for  both  con- 
gestive and  remittent  fevers  were  slightly  more  prevalent  during  the  second  year  than 
during  any  other  of  the  )ears  of  the  war. 

Table  XXIV. 

Helative  Freque^icy  of  cases  of  Malarial  Fevers,  and  Deaths  caused  by  them,  during  the  several  years  of 
the  war  and  the  year  following  the  lour,  expressed  in  annual  rates  per  1,000  of  mean  strength. 

WHITE  TROOPS. 


DlSKASEg. 

186( 
Cases. 

)-l. 

1861-2. 

186 

J-3. 

186 
Cases. 

i-4. 

1864-5. 

186 

5-6. 
Deaths. 

Deaths. 

Cases. 

Deaths. 

Cases. 

163.01 

134.23 

16.07 

313. 31 
6.45 

319.  76 
140.38 

Deaths. 

Deaths. 

Cases. 

221.  93 

184.  38 

)  9.  39 

425.  70 
4.90 

430.  60 

127.  84 

5.-)8.  44 
22.  91 

Deaths. 

.21 
.12 
.03 

.36 
1.12 

1.48 
1.86 

3.34 
2. 27 

Cases. 

56.17 
09.63 
1U.25 

126.-05 
5.20 

131.  25 
43.  60 

174.  85 

.02 

.02 

144.  36 
95.81 
12.  62 

252.  79 
7.99 

260.  re 

143.  26 

.11 
.11 
.01 

.24 
1.25 

1.49 
1.28 

.21 
.18 
.0(i 

.45 

1.55 

2.  00 
1.76 

3.76 

1.78 

230.  51 

210.  44 

22.87 

463.  82 
6.16 

409.  98 
114.13 

.17 
.19 

.(13 

.39 
1.53 

364.  92 

295.  58 

24.  71) 

.32 

.26  ] 

Quartan  liitprmitteiit 

.01 

685. 20 
8.20 

693.  40 
159.  70 

853. 10 
16.  62 

869.  72 

.59 
2.  26 

2.85 
2.57 

5.  42 
2.54 

7.96 

Total          ...            

1.92 
1.27 

3.19 
1.71 

Total  jnire  Malaria!  Fevers 

.02 

404.04 

2.77 

460.14 
38.00 

584. 10 
18.93 

Total  Malarial  Fevers 



174. 85 

.02 

404.04 

2.77 

498. 14 

5.54 

603.  03 

4.90 

581.35 

5.61 

Tlie  increased  prevalence  of  malarial  fever  during  the  year  succeeding  the  war  was 
probably  due  to  the  occupation  of  Southern  and  malarious  territory  by  the  army,  and 
the  concurrent  discharge  from  service  of  troops  stationed  in  Xorthern  and  less  malarious 
sections.  Although  this  increase  is  observable  in  all  the  forms  of  malarial  fever,  each 
reaching  a  higher  figure  per  thousand  of  strength  than  in  any  of  the  previous  years,  the 
intermittents  constituted  absolutely  and  relatively  its  greater  portion.  As  will  be  seen 
hereafter  in  Table  XXXII,  the  troops  in  the  Department  of  Arkansas  bad  the  highest 
malarial  record,  and  among  them  intermittents  were  relatively  more  frequent  and  remittents 
less  frequent  than  among  troops  in  less  malarious  localities. 


^  See  article  on  Neuralgia,  infra,  page  874. 


tin  the  second  part  of  this  work,  pp.  287,  398,  495  and  637. 


AMo.NH    TIIK 


l'(>];rKS. 


83 


Ty|)li(i-inalanal  Iwcv.  Juiwrvii'.  iluriii^  i\\v>c  wars  did  mil  tuUuw  tlic  course  of  tlio 
uiiiuuJitietl  malarial  Ir^wrs.  h>  |ii-i'.-ciii-r  wa>  uul  rt'iiurtu'l  ilui'ini.'  llic  lirst  two  years, 
eiiilirarcd  ill  Table  XXIV.  iUirinii-  the  vear  fiidiim- June  '■){),  ISdl).  there  were  3.S  cases 
}ier  tlnHisaml  nt  strength.  In  the  i'dllMwiiiu-  vear,  wlim  malarial  l\'Vers  were  at  their  war 
maximum,  tviilio-uialarial  iever  fell  otV  (lue-half,  tn  IS. 9:],  iucreasino;  sliiihtlv  Juriie-  the  last 
year  of  tln'  wai',  and  subsiding  to  its  minimum  when  the  pure  malarial  levers  were  at  their 
maximum  during  the  year  succeeding  the  war. 

In  general  the  mortality -of  the  malarial  fi-vors  increased  with  their  iiii-reased  frec[uency: 
thus,  in  the  year  after  the  war,  with  85:5  cases  per  thousand  ol'  >trcngth  there  were  5.42 
deaths,  while  in  1861-2,  with  40-1  cases  the  deaths  were  2.77.  iSut.  in  the  typho-malarial 
fevers  an  increased  mortality  was  associated  with  a  dimiiiishe<l  prevalence;  in  the  year 
18(52-3,  with  oS  cases  per  thousand  of  strength,  the  corresponding  death-rate  was  1.78, 
while  in  1865-6,  with  16.62  cases,  the  ratio  of  deaths  rose  to  2.54. 

Similar  results  are  obtained  by  an  examination  of  the  statistics  from  the  colored 
commands,  as  given  in — 

Table  XXV. 

Relative  Frequency  of  Cases  of  Malarial  Fevers  and  of  Dcaili.s  caused  hi/  them  among  the  Colored  Troops 
during  two  years  of  the  tear  and  the  year  following  the  irar,  expressed  in  annual  rates  per  1,000 
of  mean  strength. 


DlSK.\SES. 


1863-4. 


I 


IStil-."). 


18t).5-6. 


Cases,     t  Deaths. I     Cases.      Deaths. 


Quotidian  Intenni t  tent I      362. 60 

!  Tertian  Intermittent 276. 50 

Quartan  Intermittent 23.96 


.16 


308. 67 
11  2.i.-).  19 
13      •    21.57 


.29 
.26 
.08 


Cases. 


398.94 

345. 34 

19.02 


Deaths. 


.19 
.21 
.04 


Total  Niin]>lc  Intermittent 

Congestive  Fever 

Total  - -- 

Remittent  Fever 

Total  pure  Malarial  Fevers... 
Typho-nialarial  Fever 

Total  Malarial  Fevers 


663.06  '  1.00 

23. 62  7. 76 

I 

686.68  1  8.76 

147. 04  6. 43 


565.43  .63  I      763.30  I        .44 

11.12         3.42  I  9.97         2.33 


576.  .55         4.05         773.27  I      2.77 

173. 48  I      4. 72         173. 73  I      5. 04 


833. 72       15. 19 
56. 15       10. 85 


'  1  I 

750.03         8.77         947.00         7.81 


37.47         5.51 


34.21         5.49 


889. 87       26. 04 


787.50       14.28  1      981.21       13.30 


These  figures  cover  only  the  last  two  years  of  the  war  and  the  year  succeeding  the 
war.  The  year  ending  June  30,  1864,  yielded  a  higher  ratio  of  cases  than  that  which 
followed  it,  but,  as  in  the  case  of  the  wliite  troops,  not  so  high  a  rate  as  was  attained  after 
the  cessation  of  hostilities.  Here  also  the  preponderance  of  the  interniittents  is  the  cause 
of  the  varying  tides  in  the  annual  progress  of  these  fevers;  for.  while  the  congestive 
cases  were  most  prominent  during  the  first  year,  corresponding  in  this  respect  with  the 
interniittents  generally,  the  remitt(,'nts  were  least  prominent  during  that  year. 


84 


MAI.AIMAI.      KK\-KI<S 


Tyiiliii  iiialai'ial  casc'S  wiTo  iiinsi  pi'cvalriii,  ■")()  piT  llmiiMuiil  i<\'  iiK'aii  .str(Mii;ili,  ilui-iiiL^ 
the  first  vi'ar  of  tlio  sui-vkh;  of  the  (.-oloivd  (n.iops,  (liuiiiiisliunj;  to  37  and  'M  per  thousaml 
during  till'  t\v<i  lollnwinu'  yeai's. 

Jiclillirc  jirci'dlciicr  <tii<l   niorlnhli/  (Unomj  the  irliih    dud   l/ir  colorid  /roop>i. TIil'  lol- 

lowino-  tablf  consolidutf.'S  the  data  of  tlir  last  two  tallies,  u'ivmu'  llie  annual  averai/i'  ratios 
per  tliousnnd  of  .streiig'tli  as  dcilureil  IVdhi  llic  cxpericinT  of  fivi'  and  oiic-sixtli  years  of 
service  Lv  the  white  troops  ;uid  of  three  y<'ars  ti(  srrviee  hy  the  eolored  troops: 


TAm.K  XXVI. 

Relative  Frequency  (nnont/  the  White  cutd  the  (hloreil  'J'ro'ijis  of  O/.S'-.s'  of  Mdlariol  Feeern  and  of  Deaths 
caused  by  them,  an  shoini  by  tlie  arerdfje  numlter  aniiiadly  recorded,  reduced  to  ratios  per  1,000  of 
strength. 


Disk  ASKS 


Qiuitidian  Iiitcrmittciif 

Tertian  Intel iiiit tent 

Quaitau  Intermittent _. 


Total  simple  Intermittent. 
Congestive  Fever 


Total  Intermittents. 
Kemittent  Fe.ver 


Total  ]>ure  Malarial  Fevers  . 
Ty i>lio-nialarial  Fever 


Total  Malarial  Fevers  . 


Willi  K 

I'lidoi'S. 

('(M.dUKl 

Tuoiii's. 

Cases. 

Deaths. 

Cases. 

Deaths. 

200. 73 

.19 

348. 93 

.30 

ItiS.li!! 

.16 

278.  33 

.28 

18.50 

.03 

21.40 

.08 

387.  (!2 

.38 

648.  66 

.66 

t).  U 

1.39 

13.82 

4.14 

3(13.  7(i 

1.77 

(i()2.  48 

4.80 

128.  r.8 

l..")9 

lti7. 10 

5. 23 

.")22.  31 

3.36 

829. 58 

10.03 

(0)26.  15 

((()1.95 

41.04 

6.79 

a)  544. 72 

((1)5.04 

870.62 

16.82 

(a)  As  tho  annual  rates  of  tyiilu'-inularial  t'cvor  ainon^  tlip  w  liitc  tn«(>ii.s  aiv  ileiivcd  fnnii  the  statistics  nt'  tofir  years  while  tlie  rates  uf  tlie  totality 
of  the  malanal  fevers  cover  five  and  eiie-sixth  years  of  observation,  the  hitter  ilill'er  somewhat  from  tlie  sum  of  the  rates  of  the  purely  malarial  and 
tyjihO'-nalarial  fevers. 

The  greater  prevulenee  of  all  tonus  of  malarial  fever  among  the  eolored  troops  is  as 
well  shown  in  the  various  items  of  this  table  as  in  the  totals  of  544.72  eases  per  thousand 
of  mean  strentrth  amom^  the  white,  and  870.62  amous;  the  eolored  men.  These  figures 
are  as  100  to  160.  The  greater  mortality  among  the  negroes  is  equally  well  shown,  and  is 
especially  marked  in  the  more  serious  forms,  giving  an  average  annual  total  of  16.82 
deaths  per  thousand  of  strength  as  compared  with  5.01  among  the  white  troops;  figures 
wliicli  are  in  tlie  ratio  of  331  to  100.  As  has  already  been  seen,*  the  deaths  formed  1.00 
per  cent,  of  the  cases  in  the  white  and  2.02  per  cent,  in  the  colored  regiments. 

These  statistics  indicate  that  the  colored  race  exhibited  a  greater  susceptibility  to 
the  malarial  poison  than  was  sliowm  by  tlie  white  commands,  or  tliat  the  colored  troops 


♦Tables  XXII  and  XXIII,  pp.  79  and  80,  supra. 


AMOXO    THK    r.    S.    FORCES.  85 

were  exposed  to  influences  of  a  more  deleterious  nature.'^'  It  would,  however,  be  injudi- 
cious to  attach  weight  to  a  comparison  of  the  annual  averages  given  in  Table  XXVI 
as  l)earing  on  the  relative  liability  of  the  whiti'  and  the  colored  troops  to  the  malarial 
influence.  Large  numbers  of  the  white  troops  served  in  departments  which  were  com- 
jKirativelv  salubrious,  and  the  influence  of  their  reconls  is  felt  in  diminishing  the  average 
annual  rate  for  the  wliite  comuiands  as  a  whole.  The  black  men,  on  tlie  contrary,  w^ere 
aggregated  in  malarious  districts.  Those  serving  in  the  Atlantic  region  were  mainly 
distributed  in  the  Departments  of  the  South,  of  North  Carolina  and  of  Virginia,  and  those 
on  duty  in  tlie  Central  region  held  fortresses  along  tlio  ^[ississippi  bottom  and  in  the 
Department  of  the  Gulf.  Manifestly,  in  making  a  comparison  to  determine  relative  preva- 
lence, locality  must  be  tidven  into  consideration.  The  records  do  not  enter  with  sufficient 
minuteness  into  the  conditions  of  service  of  the  white  and  the  colored  commands  to  enable 
their  relative  susceptibility  to  be  determined.  In  fact  the  question  was  seldom  touched 
upon  by  our  medical  officers.  The  writer  is  aware  that  the  officers  on  duty  at  the  Field 
Hospital  for  colored  troops  at  City  Point,  Va.,  were  of  the  opinion  that  although  the 
colored  people  under  similar  conditions  of  exposure  might  be  less  liable  to  seizure  than  the 
whites,  they  were  assuredly  much  less  able  to  resist  the  febrile  influence  when  the  attack 
was  developed.  Surgeon  John  Fisti,  17th  regin^ient  Corps  d'Afrique,  appears  to  have  enter- 
tained the  belief  that  the  negro  was  as  liable  to  malarial  attacks  as  the  wdiite  soldier. f 

The  17th  lej^iment  Corps  d'Afriiiiie  was  recniited  at  Baton  Konge,  and  lirst  mustered  August  10,  1863.  Its 
strength  at  that  time  was  510  men.  We  left  Baton  Rouge  on  steamer  for  Port  Hudson,  vSeptember  18, 1863,  and  have 
been  on  duty  liere  ever  since.  Tlie  most  fre(iuent  diseases  have  been  (Uarrho'a  and  dysentery,  intermittent  fever, 
typhoid  fever,  scurvy,  pneumonia  and  rlieumatism. 

I  liad  supposed  tlie  black  man  to  be  peculiarly  exempt  from  diseases  due  to  malarial  induenoes;  but  I  should 
not  expect  to  have  encountered  a  greater  number  of  cases  of  intermittent  fever  in  a  body  of  white  troops  equalling 
ours  in  number  than  we  have  actuallv  had. — Fort  Hudao)},  La.,  Feb,  25,  18tU. 


*  Some  writers  have  claimed  for  the  neg-ni  race  an  immunity  from  malarial  disease.    Thus  Fekguson  in  his  article  Chi  the  Nature  and  History 

of  the  Marsh  J*niiion,  Trans.  Royal  Sooiety,  Edinburgh,  Vol.  IX,  says:  —  "The  adaptation  of  the  neg-ro  to  live  in  the  unwholesome  localities  of  the 
torrid  ■/.(•ne,  that  prove  so  fatal  to  Europeans,  is  most  hajipy  and  singular.  From  peculiarity  of  idios^-ncrus}''  he  api>ears  to  be  proof  against  fevers;  for 
to  liini  mai-ih  miasmata  are  in  fact  no  poison,  and  hence  his  incalcuhible  value  as  a  soldier,  for  (iekl  service  in  the  West  Indies.  The  warm,  moist,  low, 
and  leeward  situations,  where  these  pernicious  exlialations  are  generated  and  concentrated,  prove  to  Inin  congenial  in  every  respect.  lie  delights  in 
them,  f  T  'le  tliere  enjoys  life  and  health,  as  much  as  his  feelings  are  abhorrent  to  the  currents  of  wind  that  sweep  the  mountain  tups;  where  alone  the 
whites  lim!  security  against  endemic  fevers.  One  of  the  most  obvious  peculiarities  of  the  negro  as  compared  with  the  European  is  his  thick  oily  skin, 
rank  to  a  degree ;  and  fnun  this  circumstance  the  theorist,  when  he  speculates  upon  the  mode  of  reception  of  the  marsh  poison  into  the  constitution, 
whether  by  lungs,  stonuurh.  or  skin,  may  draw  a  plausil)le  conjecture  in  favor  cif  the  last." 

\  Dr.  E.  AndkEWS,  in  a  letter  published  in  the  Chicago  Med.  Examiner,  Vol.  Ill,  1862,  p.  481, — speaks  of  the  prevalence  of  intermittent  and 
remittent  fevers  among  the  troops  near  Memphis,  Tennessee,  during  the  summer  of  1862,  and  remarks  that  he  constantly  observes  these  fevere  among-  the 
negroes,  whose  pt)wers  of  resistance  he  conceives  to  have  been  greatly  over-estimated.  See  also  an  interesting  paper  by  Dr.  SAXFOltn  ii.  IlrXT — The 
Negro  as  a  Soldier,  The  Quarterly  Jour,  of  I'sychological  Medicine,  Vol.  I,  1863.  p.  161  et  seq.  These  fevers  were,  moreover,  exceedingly  coinm(m 
among  the  colored  people  who  received  medical  assistance  from  the  Freedman's  bureau.  In  an  article  entitled  Remarks  concerning  some  of  the  diseases 
prevailing  among  the  freed  people  in  the  District  of  Columbia  (KnmaM  Refugees,  Freedmen  and  Abandoned  Lands).  American  JourmU  of  the  Medical 
Sciences,  1866,  p.  366,  Dr.  R.  Rf.vbukX,  Surgeon  U.  S.  Volunteers,  cites  the  occurrence  among  these  colored  people  of  2,776  cases  <>f  remittent  and  inter- 
mittent fevers  in  a  total  of  7,949  cases  of  sickness  and  wounds,  or  al>out  3.5  jier  cent,  of  the  whole,  as  a  suthcient  answer  to  and  refutation  of  the  statement 
so  often  reiterated  in  our  text-books,  that  the  negroes  are  not  sid>)ect  to.  and  da  not  suffer  from,  malarial  disease.  "  Now  it  may  be  that  in  Africa,  and 
in  the  West  Indies  they  do  not  sutler  to  the  same  extent  as  imacdimatcd  whites  do.  but  they  certainly  are  not  exempt  from  these  diseases  in  tliis  country  ; 
and  as  far  as  our  own  opinion  goes,  we  are  strongly  inclined  to  the  belief  that  this  so-calle<l  exemption  has  no  foundation  in  fact  and  is  unworthy  of  cre- 
dence." The  only  testimony  in  favor  i>f  any  supposed  imnuuiity  of  the  colored  troops  froui  these  diseases  during  any  part  of  the  war  is  contained  in  a 
report  by  Medical  Inspector  N.  S.  TOWNHHEXO,  IJ.  S.  A.,  cited  in  the  American  Med.  Times,  Vol.  VII,  1863,  p.  65.  Tliis  rep^irt  is  on  tile  in  the  office  of 
the  Surgeon  (Jeneral  and  is  dated  May  li*,  1863.  It  relates  to  an  inspection  of  Forts  St.  Philip  and  Jackson,  near  the  mouth  uf  the  Mississippi  river,  and 
contains  the  following  i>aragraph:  "Of  the  troops  at  the  forts  four-fifths  are  of  the  13th  Maine,  and  onefifth  Lnuisiana  negroes.  The  comjiarative 
exemption  of  the  latter  from  tliseases  of  malarial  origin  is  most  marked.  Uf  the  entire  white  fon^e  10.8  per  cent.  Imd  intermittent  or  remittent  fever,  wliile 
of  the  colored  troops  only  .  8  jw^r  cent,  suffered  from  those  diseases.  In  resi>ect  to  other  diseases  their  liability  appeared  nearly  ecpial."  This  statement 
is  no  doubt  true  so  far  as  the  time  and  place  referred  to  are  concerned,  though  it  cannot  be  verified  because  in  the  report  uf  sick  and  womnled  at  this  ptat 
for  the  month  of  Ma}',  1863.  b}-  Surgeon  Jas,  M.  liATKS  of  the  I3th  Maine,  the  figures  for  the  white  and  c(»h>red  tnwps  of  the  garrison,  viz:  eight  com- 
panies of  the  I3th  Maine  and  one  battery  of  Louisiana  heavy  artillpry.  are  unfortunately  consoli<la1ed.  But  whatever  may  have  been  the  cause  of  the 
temporary  condition  reported,  the  subsequent  separate  reports  of  the  colored  troops  at  this  post  show  no  such  imnumity  from  intermittent  or  remittent 
fevers.  In  this  coimection  reference  may  be  made  to  the  statement  of  A.  Ci.  TehaI'LT  with  regard  to  the  "  Negroes  of  Virginia,"  as  cited  by  T.  P, 
Atkinson — Report  on  tlie.  anatomical,  phi/siolngical  and  pathological  differences  between  the  white  and  the  black  races,  etc.,  Trans,  of  the  Third  Annual 
Session  of  the  Med.  Soc.  of  \'irginia,  held  at  Staunton,  Nov.,  1872,  Richmond,  1873.  Api>en<lix  F..  p.  112,  "Oases  of  intractable  intermittent  are  rarely 
seen  among  them,  and  never  of  chronic  enlargement  of  the  spleen,  or  the  quartan  ague." 


86 


MALARIAL     FEVERS 


Hut  thiri  is  an  opinion  luised  U[)ou  unc-sidi'J  exj)eriencc.  To  a.soertaiii  the  fact,  statis- 
tics arc  rcqiiinM]  IVoiii  wliito  and  colored  cwnHiiands  camped  oi'  operating  in  the  same  loeaH- 
ties  at  the  saiiH>  time.  In  tlielr  aljsence,  tlie  foUowing  table  may  be  of  interest  as  pre- 
senting the  rate  of  prevalence  among  the  colored  troops  during  the  fourth  and  fifth  years 
of  the  war  in  juxtaposition  with  the  rates  prevailing  among  the  whites  during  the  same 
period  in  the  same  departments  or  sections  of  the  country .'"' 


Table  XXVII. 

A  Comparison  of  the  Prevalence  of  Malarial  Fevers  among  the  White  and  the  Colored  Troops  serving  in 
the  same  localities  during  the  tivo  years  from  July  1,  1863,  to  June  30,  1865,  the  figures  given 
being  the  average  annual  ratios  per  1,000  of  strength. 


White  Tuoors. 


Colored  Tkoops. 


?  a     I    3.5 


^  * 
K  +- 


o  =3  — I  ca 

H'2  ^.=^ 


Depaifinciit  of  \'iif;iiuii 

Departiiieiit  of  North  ('aroliiui 
DepartiiK'iit  of  i\\c  Soutli 


K8  070  25  789 

214     '  1,304  33     !  1,041 

108  497  40  051 


(»)  _-.-(«)....(«) 


(")  -- 


The  al>ov«  Depts.  of  th<^  Atlantic  liegioii 12i 


29 


786 


Department  of  tho  Gulf. 


147  779 


Division  of  Mississippi  and   Depaitnicnt  of  : 

Tennes.sce 144 


Department  of  Aikansus. 


100 


The  above  Dcjiartments  of  the  Ci'iitial  R»'<fion|       147 


Total  in  these  Bectir)ns  of  the  Athmtic  and 
Central  Regions  _- - 


33 

948 

24 
10 

950 
702 

542 


1,107  18       1,291 


664 


143 


692 


18  829 


412 

44 

596 

140 

..(«)-- 

'..(«).. 

..^«).. 

. 

44 

935 

176 

715 

857 


164 


615 


44 


823 


(a)  The  statistics  of  the  Colored  Tri)()ps  liaviii^  been  cdiisnlidated  by  regiuns,  it  is  impossible  now  to  distribute  the  oases  among  tlie  sevenil  Departments. 

From  this  table  it  appears  that  in  those  departments  of  the  Atlantic  region  in  whicli 
white  and  colored  troops  served  during  the  period  stated,  malarial  fevers  prevailed  more 
extensively  among  the  white  men,  they  having  presented  948  cases  per  thousand  of  mean 
strength  annually  as  compared  with  596  among  the  colored  troops.  In  the  departments 
of  the  Central  region,  however,  the  colored  men  suffered  more  than  the  whites.  The 
aggregate  rates  in'  these  various  sections  show  tlie  fevers  as  somewhat  more  prevalent 
among  the  white  troops — 857  per  thousand  annually  as  against  823  among  the  colored 
men. 


*  The  Mortality  Tables  (tf  the  Tenth  X'.  S.  Census,  1880,  do  not  furnish  satisfactory  information  concerning  the  relative  prevalence  and  fatality  of 
malarial  fevers  among  the  white  and  colored  population.  The  returns  arc  known  to  be  very  incomplete.  A  cuniparison  witli  the  death  records  of  the  regis- 
tration offices  i*f  the  States  of  Massachusetts  and  New  Jersey  showed  a  deficiency  on  the  part  of  the  census  tables  of  ■Jti.42  per  cent,  of  the  whole  number 
returned  by  them  in  the  fortner,  and  of  :i4.45  i»er  cent,  in  the  latter.  State.  This  would  not  affect  a  calculation  intended  to  give  expression  to  the  relative 
frequency  of  deatti  from  any  specified  cause  in  tlie  two  races  were  the  deficiency  equally  distributed ;  but  it  is  recttgnized  by  Dr.  BiLLIXCS,  p.  170(J,  Com- 
penilutm  of  the  Tenth  Census  of  the  United  Staten,  1880,  that  in  the  sections  of  country  having  the  largest  colored  population  tlie  greatest  deficiencies  were 
found,  and  that  these  were  probably  greater  among  the  colored  tlian  among  the  white  pt)pulation.  With  the  knowledge  that  the  ratitJS  for  the  col<»red 
people  were  in  all  likelihood  greater  than  is  represented  by  the  figures,  the  ftillcwing  table  nuiy  be  exauiiued: 


AMOX(!    TTIK    r. 


FORCKS. 


87 


The  statistics  do  not  furiiisli  tin;  iiecossary  data  for  detenniniiig  tlic  relative  mortality 
ainoiiu'  white  and  colored  conunands  (iperatinij;  in  the  sarne  departments. 


s  . 

9  >^ 


POI'ITI.ATION. 


(  wiiite  ;t,  H57,  m:) 

(Irniip  '^  of  C*'iisus  Tables,  Middlf  Atlantic  Coast \  I 

<C.>lore.l  ....'  r>18,  KG 

fWliil.-     ...  4,!l;lO,  r,87 

(iniuii  H  nf  Census  Tallies,  Interior  I'iateaii <. 

I  Colored  ....  724,  (I'.lll 

C  White   l.tlXi,  IWIi 

Group  I]  of  Census  Tables.  Soutlieni  Interior  IMateau < 

<  Colored  .    ..  1, '.172,  449 


il 

1,284 

3;i 

2;» 

46 

791 

l(i 

374 

ni 

1,411) 

HS 

1,7M 

SO 

The  se<'ond  ifroup  eouiprises  Delaware,  the  Distriet  of  Cidunibia  and  parts  of  New  York,  New  Jersey,  Maryland  and  Virginia;  the  eighth  includes 
parts  of  New  York,  Pennsylvania.  \'irp;inia  and  North  Carolina;  and  tlie  eleventh,  parts  of  .S<nith  Cantlina.  ( UHn^ia.  Alabama,  Mississippi  and  Tennessee. 
Ae<'ording  to  this  tabulation  the  eoloied  raee  is  nnire  lial)le  to  death  from  malarial  fevers  in  tliese  sections  of  the  Cnitetl  States;  but  that  this  does  m>t 
depend  on  distinctions  4if  race  seems  indicated  by  the  fact  that  altliongb  in  tlie  more  inaiarious  re^itins  the  death-nite  of  tioth  races  is  increased,  the  relative 
increase  is  tnilch  g;reater  aitiong  the  whites.  I'ntil  proved  otherwise  it  nitly  lie  jtssunied  that  the  hij^her  death-rate  amotijf  the  negroes  is  due  ti>  (greater 
exj^osuri's. 

The  mortalit.v  tiji^ures  returned  by  the  health  otticers  of  certain  <-itics  have  t)een  tiibnlated  below  as  bearing  on  tlu,>  point  at  issiu'.  'I'hese  tigtires 
having  l)een  obtained  hy  a  regular  system  of  registration,  liaseii  in  most  instain'es  on  the  recinireinent  of  burial  permits,  are  probably  very  nearly  aceunite : 
and  as  they  represent  deaths  which  occurred  within  certain  restricted  limits  of  territory,  they  may  be  considered  a.s  |>ossessing  Iwtter  qualiHcatiuns  for  a 
comparative  iiutuiry  than  the  figures  of  the  census  reports: 

Cttmparhon  of  the  Dcalh-ralf  from  MnUirial  Viseasf  amintrj  tlit-  W hit>'  antf  Cotoird  jntj)u!alinn  of  certain  n'tics  ft/  th     P'mlftl  States,  from  ihila  taken 
from  the  t'tmnoliilated  Mortality  Rejinrtnf  the  National  Board  of  Health  for  the  year  IbHl.    Bulletin  of  the  Board,  Vol.  HI,  pp.  324-,'J27. 


CITIKS  AND  TOWNS. 


District  of  ('oluinbia 

Norfolk.  A'irgiuia 

Kichmond,  Virgini.i 

IjyiK'hburg.  \'irgiiiia 

Petersburg,  Virginia 

Wilmingt<in.  North  Carolina. 
Charleston,  South  Carolina  . . 

Augusta,  Georgia 

Atlanta,  Georgia 

iSavatinah,  Georgia 

Mobile,  .-Vlabaina 

.Selnia,  Alabama 

Columbus,  Mississippi 

Natchez,  Mississippi 

Vicksburg,  Mississippi 

New  Orleans,  Louisiana 

.Slireveport,  I^(misiana 

Baton  Rouge,  Louisiana 

flalvc'ston,  Te.\as 

San  .\ntonio,  Texas 

Nashville,  Tennessee 

Memphis,  Tennessee 

St.  Louis,  Missouri 


PdlMI.AlIUX. 


Deaths  from         '  Ratio  of  <leal)is  per 
malarial  disease.      ]     1(M),001I  of  living. 


White, 


120,000 
n,93.T 
35,  756 

7,484 
10,000 

ti,  8113 
22  712 
12,  364 
21,  086 

15,  007 

16,  837 
3,  345 
2,760 
3,  421 
5,  U75 

158,  37!1 
3,  739 
2,917 
16,900 

17,  525 
27,  004 

18,  622 
328,  232 

868,  891 


Colored.        White.       Colored.       White.       Colored 


60,000 
10,033 

28,  047 
8,  475 
12,  000 
10, 468 
27,  287 
10. 659 
16,335 

15,  674 
14,368 

4,184 

2,  470 
3,637 
5,  839 

57,  761 
7,278 
4,300 
5,353 

3,  036 

16,  457 
14,  971 
22,  290 

360,922 


78 
17 
11 
o 

3 

6 
9 
6 
5 
30 
19 
8 
1 
2 

19 

237 

16 

5 

10 

12 

11 

20 

345 

872 


84 

21 

10 

4 

7 

13 

9 

5 

3 

24 

11 


1 

20 

119 

27 

7 


15 
27 
42 

480 


65.0 

142.5 

30.8 

26.7 

30.0 

87.0 

39.6 

48.5 

23.7 

199.9 

112.  8 

239.1 

36.  2 

58.5 

318.0 

149.6 

428.0 

171.4 

.59.  2 

68.  5 

40.7 

107.4 

105.1 

100.4 


140.0 

209.3 

3.5.7 

47.2 

58.3 

124.3 

3.3.0 

46.9 

18.3 

153.1 

70.7 

525.  8 

81.0 

27.5 

342.5 

2')6.  0 

371.0 

162.8 

93.4 

65.9 

91.1 

180.3 

188.4 

133.0 


88 


MALAFJAL     FEVERS 


It  is  not  possible,  in  view  of  these  figures,  to  decide  wlietlier  tlie  negro  is  less  sus- 
ceptible to  the  inaLirial  influence  than  the  white  race:   l>ut    tlie  assertion  may  be  allowed, 

In  twenty-three  riiited  States  oities  \vhi<:h  cuntuin  ii  iiutable  (Milnred  ]«<>]. iiliitioti.  Ilie  ileatli-nite  from  malarial  fever  amcjlig  the  white  people  in  1881 
was  in  nine  cities  lurtrer  than  that  r>f  the  eolored  people:  hut  tiie  excess  in  the  otlier  direction  was  so  j^rcat  in  the  remaining  fourteen  cities  that  in  a  total 
poimlation  of  f-tl^.H'.il  wliitc  and  3110.92^  colored,  the  deaths  were  IIK]  in  every  100,0(10  of  the  former  and  l:i:i  in  every  100,000  of  the  latter.  It  is  probable 
tlnit  hwal  conditions  were  involved  in  the  jiroduction  of  the  various  death-rates  piven  in  this  tal)le ;  for  altlmugh  in  some  towns  that  are  inttably  malarious, 
as  fShreveport,  Louisiana,  and  in  others  that  are  not  so.  as  Atlanta,  tleorji^ia.  the  death-rate  amotij,:  the  eolored  people  was  less  than  among  the  whites:  in 
some  that  are  notably  malarious,  as  Selina,  Alabauui,  and  Vicksl>urg,  Mississii>pi,  and  in  otliers  that  are  not  so,  as  Uichmond  and  I.yuchljurg.  Virginia, 
the  deatli-rate  atnf>ng  the  colored  peftple  was  greater  than  among  the  whites.  The  only  inference  that  may  with  propriety  he  drawn  from  these  iiumicipal 
statistics  is  that  whieli  has  been  reached  in  tlie  text  from  a  comparison  of  the  figures  relating  to  malarial  fevers  in  the  white  and  colore<l  commamls  (luring 
the  war:  that  the  eolored  race  suffers  greatly  from  these  fevers,  hut  whether  to  greater  or  less  extent  than  the  white  race,  caninit  he  determined  in 
the  absence  of  a  thorough  knowledge  of  the  surroundings  and  cxitosure.  Manifestly,  since  in  any  of  these  cities  the  eolored  people  may  ttr  may  jiot  have 
been  aggregated  in  unhealthy  localities,  nothing  can  be  said  of  tlieir  relative  liability  to  malarial  fevers  until  a  comparis(ni  is  made  of  the  prevalence  of 
these  fevers  in  the  two  races  in  certain  wards  or  sections  of  the  city  having  the  same  medicjil  topography. 

Our  army  experience  since  the  war  jiresents  statistics  which  ought  to  be  of  more  value  in  tins  C4)nnection  than  those  heretofore  adduced.  Certain 
posts  have  been  occu]>ied  In'  a  mixed  garrison  of  white  and  colored  troops.  The  two  commands  have  been  similarly  quartered,  clotheil  and  rationed ; 
they  have  perforuied  the  same  guard,  fatigue,  escort  and  scouting  duties,  and  have  necessarily  been  exposed  to  the  same  malarious  intiueiu-es.  More- 
over, the  .same  medical  authorit3-  lias  sui)ervised  the  reconl  of  the  sickness  of  both  races.  The  facts  tabulated  below  may  therefore  be  accepted  as 
obtaine<l  under  conditions  w  bich  permit  the  relative  liability  of  the  white  ami  colored  I'aces  to  he  as  satisfactorily  tested  as  if  they  had  been  specially 
arranged  for  the  experiuuMit.  I  'n  fortunately,  however,  owing  to  the  small  luuiiber  of  posts  garrisoned  by  mixed  eomtnands,  the  strength  represented  is  small. 
Table  exhibiting  the  Prevalence,  of  Periodic  Fevers  at  different  Posts  in  the  Department  of  Texas. 


•■t'S 


'        si 


Fort  McKavett,  Texas 
Fort  Ringgold,  Texas 
Fort  Ringgold,  Texas 
Fort  Ringgold,  Texas 
Fort  Ringgold,  Texas 


II 
3 


3 
I 

.10 

3 

21 

\'l 

10 

19 

1 

5 


16 
11 

14 
4 

01 

M 

14 
» 

31 

3; 

7 
22 

14 
2 
21 


<3 


113 

24 

18 

4 

p 

10 

11 
12 


Total  White 
Total  Colored 


lOf; 
4; 


358 
134 


4 
1 

10 
1 
1 


10 

1 


48 
G 


H         1 

Annual  rate  o 
of   .Malarial 
per  l.miO  stre 

in 

266.6 

11 

211.5 

14 

2.59.  3 

4 

153.9 

113    ' 

332.  4 

C 

107.1 

3.'; 

136.7 

8 

66.6 

3r) 

3.57.  I 

87 

373.7 

12 

184. 6 

26 

1S9.S 

29 

1 10.  3 

3 

50.8 

29 

1-a  8 

1 

33.3 

l.'il 

758.8 

27 

364.9 

41 

264.5 

17 

217.9 

22 

174.  6 

30 

252. 1 

15 

140.2 

18 

108.4 

512 

271.3 

188 

185.0 

At  Forts  Biiss,  Brown,  Clark  and  McKavett.  Texas,  there  was  a  greater  prevalence  among  the  white  tnwps:  at  Fort  Mcfntosh  the  white  and 

eolored  troops  suffered  at  about  tlin  same  rate;  whilt!  at  Fort  llinggdld.  in  tlie  year  1878-9,  there  were  more  malaria!  cases  among  the  colored  than  among- 
the  white  soldiers.  But  in  dealing  with  such  small  numbers  as  are  represented  at  each  nf  these  po.sts  the  records  (>f  a  single  garrison  do  nut  have  much 
value,  as  they  may  l>e  affected  by  unknown  local  conditions.  The  totals  tabulated  shtiw  a  less  degree  of  [irevalence  among  the  colored  troops,  the  annual 
rate  per  thousand  among  them  being  1^5. 0,  while  among  the  white  troops  it  was  271.  3. 


A^[0X<1    THE    V.    ?;.    KOP.CKS. 


89 


that  the  colored  troops  did  not  suffer  in  ;i  marked  degree  as  compared  with  the  wliite  men, 
althougli  it  is  n(jt  unlikely,  fi-om  the  then  generally  accepted  belief  in  their  partial  iiimumity. 
that  tliey  were  often  stationed  in  localities  that  would  have  proved  specially  dangerous  to 
white  men.  It  is  prol)abl(>.  therefore,  that  if  strictly  com|)arablc  figures  were  obtained  they 
would  show  the  l)lack  man  to  be  less  susceptiblr  to  malarial  attacks  than  the  white  soldier. 

Seasnnal  varied iom  in  PrevaJenrc. — The  t'ollowing  table  shows  the  monthlv  rates  of 
malarial  cases  among  the  white  troops,  and  permits  a  comparison  to  be  made  between  the 
rates  among  the  troops  operating  in  the  several  regions. 

Looking  first  at  the  totals  in  the  army,  the  purely  malarial  fevers  (the  intermitteuts 
and  remittents)  are  seen  to  have  a.  distinct  maximum  and  minimum  of  prevalence  in 
each  year.  These  seasonal  variations  will  be  more  readilv  folhnved  bv  a  reference  to 
tlie  diagram  facing  ptage  90.  The  maximum  in  the  year  ending  June  30,  1862,  was 
attained  in  the  months  of  September  and  October,  1861,  when  the  monthly  ratios  were 
61.3  and  60.7  respectively,  and  the  minimum  in  January,  Februai-y  and  ^larch,  1862, 
when  the  ratios  were  respectively  18.8,  18.2  and  17.0.  In  October  of  1862  the  maxi- 
mum, 62.6,  was  again  reached,  after  which  the  fevers  subsided  raj^idly,  and  comparatively 
few  cases  occurred  during  the  months  of  January,  February,  March  and  April,  1863,  the 
ratios  for  these  being  29. J,  26.8.  28.6  and  29.3.  A  steady  increase  in  the  number  of 
cases  reached  its  maximum  in  August  and  Be})tember,  witli  ratios  of  88.5  and  80.7  per 
thousand  of  strength.     The  fall  to  the  minimum  in  January  and  February,  1864,  was  as 

Table  XXVIII. 

Showing  the  Seasonal  Variations  in  the  Prevalence  of  3Ialarial  Fevers  among  the  White  Troops  in  the 
several  regions  during  the  years  of  the  War  and  the  year  following  the  War,  expressed  in  monthly 
ratios  per  1,000  of  mean  strength. 

YEAR  ENDING  JUNE  30,  1862. 


18fil. 

1862. 

a 
•< 

.      1 

Disease. 

REr.io.N-. 

10.2 

1 
< 

a. 

35 

a 
o 

34.6 

ss 
S 
i 

Ed 

O 
S5 

22.  2 

Ei: 

a 

n 

a 

14.2 

< 

<-> 

-9 

a 
< 

E 

< 

Z 
< 

12.3 

< 

s 

15.2 

u 

1-5 

Ed 
E 

OS 

o 

Intermittent  (iiieliulinBT  Cungpstive)  Fever  . . 

.\tlantio  . . . 

27.6 

39.4 

8.5 

6.9 

15.8 

195.9 

Central 

:)8. 9 

67.0 

56.9 

6.5.  5 

41.7 

30.  7 

21.9 

17.2 

19.1 

26.7 

27.6 

27.1 

379.9 

Pacific 

8.  2 
22.  2 

20.6 
35.9 

18.2 
43.2 

21.7 
44.2 

20.1 
28.4 

13.9 
19.6 

7.2 

10.1 

10.8 

8.8 
10.5 

10.0 

8.9 

13.0 

161.8 

Intermittent  in  all  the  re^inns 

11.7 

18.9 

21.2 

21.2 

260.8 

Atlantic  . . . 

Central. .  - . 

2.8 

las 

9.9 
31.6 

15.9 
26.3 

16.0 

18.4 

13.7 

18.6 

9.3 
13.3 

5.7 
11.3 

6.7 
10.0 

5.3 
9.5 

8.5 

12.6 

15.8 

1.5.7 

14.2 
17.9 

124.4 
.182.1 

Pacific 

.9 

.4 

1.3 

7.4 

3.1 

4.5 

1.2 

1.8 

4.3 

8.5 

1-7 

8.9 

55.0 

7.9 

14.3 

18.1 
5!5.2 

lfi.5 
.50.6 

14.9 

3.\y 
60.3 

10.5  ■ 

1 

23.5 

44.0 

7.1 

13.5 
3.3.2 

7.4 

15.1 
27.2 

6.5 

12.2 
28.7 

10.4 

20.8 
39.  3 

1.5.8 

31.0 
43.4 

15.9 

143,2 

Atlantic . . . 
Central 

13.1 
52.4 

37.5 

98.5 

30.1 
4,5.0 

320.3 
562.0 

8.3.  2  1  83.  9 

Pacific 

9.1 

21.0 

19.  5 

29.1 

23.2 

18.5 

8.4 

11.9 

13.1 

18.5 

10.6 

21.9 

216.9 

29.4 

50.2 

61.3 

60.7 

43.  3  1  30. 1 

18.8 

18.2 

17.0 

29.3 

37.0 

37.1 

404.0 

1 

Med.  Hist.,  Pt.  Ill— 12 


90 


MALARIAL     FEVERS 
YEAR  ENDING  JUNE  30,  1863. 


DlSE.iSE. 

RECilOS. 

18( 

-'■ 

1863. 

a. 
o 
&i 

191.2 
440.8 
124.  5 

319.8 ; 

123.3 

158.  3 

53.6 

•-3 

211.4 
32.3 
12.  5 

2,').  4 

21.4 
19.0 
2.4 

19.9 

41.8 
01.3 
14.9 

45.3 

i 

21.4 

■M.  8 
17.4 

OS 
M 

EC 

1 

to 

g 

1 

H 
% 

19.4 
46.0 
U.l 

33.2 

10.5 

12.  6 

5.7 

11.5 

a 

>• 

< 

3 
-< 

< 

< 

9.2 

29.2 

7.3 

< 

10.4 

28.6 

8.2 

15.3 

29.1 

7.7 

18.8 

44.0 

9.8 

Intermittent  (including  ('tingestiv«)  Fever.. 

Atlantic  . . . 

Central 

Pacific 

24.4 

56.3 
17.6 

30.8 
61.2 
11.4 

12.  9  i 

33.  9 

8.0 

11.3 

28.5 
■  8.2 

8.6 

26.9 

6.0 

Intermittent  in  all  the  regions 

28.8 

16.1 
18.1 
6.6 

16.9 

37.5 
54.9 
24.  0 

39.3 

46.3 

16.7 

16.3 

7.0 

16.3 

23.1 

8.0 
10.3 
2.7 

9.1 

19.9 

8.0 

11.2 

1.5 

17.9 

19.5 

20.3 

23.0 

34.3 

9.0 

14.9 

3.2 

Remittent  Fever 

Atlantic  . . . 
Central  -  - . . 
Pacific 

13.4 

18.4 

1.1.  () 

6.6 
11.2 

.7 

6.7 

11.6 

1.8 

6.8 

10.9 

4.0 

9.0 

8.5 

12.2 

3.6 

Remittent  in  all  the  regions 

15.8 

37.8 
74.7 
32.6 

9.5 

8.9 

9.1 

15.9 

40.8 

9.1 

28.6 

10.5 

12.5 

140.4 

314.5 
599.1 
178.1 

Intprniittent  and  Remittent 

Atlantic    . . 
Central. . .. 
Pacific 

47.5 
77.5 
18.4 

62.  6 

3.4 

3.2 
2.2 

3.3 

50.9 
80.7 
20.6 

65.9 

29.9 
58.6 
16.8 

44.7 

3.8 

2.3 

.9 

20.9 
44.2 
10.7 

19.3 

39.7 

9.7 

15.2 

38.1 

6.7 

26.8 

2.9 

3,9 

.8 

3.4 

17.2 
39.5 
12.2 

29.3 

2.5 
2.6 
1.3 

23.8 
41.3 
11.3 

33.5 

2.7 

2.1 

.7 

27.8 
58.9 
13.0 

45.7 

55.1 

3.3 
3.2 
1.6 

3.2 

32.  a  '  1  29.  4 

46.8 

3.5 
2.0 
2.2 

4B0.a 

42.3 

34.8 
18.0 

38.0 

356.8 
633.  9 

196. 1 

498.2 

Typhi  i-malarial  Fever 

Atlantic . . . 

Central 

Pacific 

6.1 
4.8 
2.0 

4.1 
4.5 
2.3 

4.3 

3.8 
1.9 
3.4 

4.2 

2.8 

.2 

3.4 

2.7 
3.3 

.7 

3.0 

18.6 

44.  1 

9.8 

31.6 

5.4 

3.0 

2.9 

2.6 

2.3 

2.6 

Intermittent,  Remittent  and  Typbo-malariul 

Atlantic  . .. 

Central 

Pacific  . . . . 

47.9 
56.1 
16.9 

41.6 
59.4 
26.3 

50.0 

41.1 
77.9 
34.2 

58.3 

33.7 
60.9 
17.7 

24.7 
46.1 
14.1 

23.5 

42.5 

9.9 

18.1 

42.0 

7.5 

19.7 
42.1 
13.5 

26.  5 
43.4 
12.0 

31  3 

60.9 
15.2 

All  the  regions 

50.7 

47.7 

35.1 

32.8 

30.2 

31.9 

35.8 

49.4 

YEAR  ENDING  JUNE  30,  1864. 


Disease. 

Region. 

1863. 

1864. 

< 
!« 

H 

OS 

o 

B 

P 
o 
s 
< 

44.7 
84.6 
15.7 

a 

O 

o 

>5 

i 

P 

23.5 
30.4 
10.7 

27.7 

< 

1-5 

< 

< 

>-• 

24.5 

37.6 
11.6 

Intermittent  (including"  Congestive)  Fever.. 

Atlantic  . .. 

Central 

Pacific 

27.6 
66.3 
13.8 

52.0 
74.7 
25.3 

47.8 
58.2 
25.1 

54.0 

38.8 
42.6 
15.7 

19.4 

28.6 
8.0 

17.1 

27.4 
7.4 

21.0 

32.1 
10.4 

24.2 
3.3.8 
10.6 

22.  2 

34.8 
11.8 

a59.7 

541.0 
161.8 

51.6 

11.2 
19.3 

5.0 

69.0 

65.3 

40.8 

25.1 

23.4 

27.7 

4.6 
6.3 
2.2 

29.7 

5.5 

7.7 
3.0 

6.8 

30.1 

32.7 

10.7 

13.5 

5.6 

12.4 

470.0 

Atlantic  . . . 
Central . . . 
Pacific 

17.6 

21.0 

5.1 

15.3 

15.7 

6.8 

12.3 

10.0 
11.3 

10.4 

7.7 
7.1 
11.6 

4.8 
4.9 
3.6 

3.8 
5.0 

2.7 

3.7 

5.5 
.9 

5.1 
9.8 
5.4 

8.2 

27.3 
44.6 

17.2 

38.3 

1.2 

1.0 

.2 

1.0 

99.8 

123.6 

61.4 

114.1 

4.59.  5 
664.  6 
223.  2 

58-1.1 

24.6 
16.  1 
3.0 

18.9 

484.1 
680.  7 
226.  2 

603.0 

16.2 

19.5 

62.3 
105.6 
20.8 

88.5 

4.2 

3.2 

.2 

15.4 

7.4 

4.9 

4.6 

4.8 

5.6 

Atlantic  . .. 

Central 

Pacific 

38.8 
8.5. 6 
18.8 

67.3 
90.4 
32.1 

80.7 

3.0 

1.9 

.3 

60.1 

68.2 
36.4 

64.4 

46.5 
49.7 
27.3 

48.2 

28.3 
35.3 
14.3 

32.6 

23.2 
33.6 
10.7 

20.8 

32.9 

8.3 

28.2 

2.5.6 
38.4 
12.6 

29.7 
41.5 
13.6 

36. 5 

.9 
.7 
.1 

.7 

35.2 
51.1 
17.2 

45.1 

3.1 

1.5 

.1 

2.0 

67.8 

4.4 

2.9 
.8 

29.7 

33.3 

.7 
.7 
.1 

Atlantic  . .. 

Central 

Pacific  .... 

2.8 
1.4 
.1 

1.8 

1.2 

.4 

1.4 

i.a 

.8 
.2 

1.0 

1.3 
.6 
.2 

.7 
.5 

.4 

3.4 

3.5 

3.3 

1.9 

.8 

.6 

.7 

Intennittent,  Remittent  and  Typho-malarial 

Atlantic  - . . 

Central 

Pacific 

43.2 

88.5 
19.6 

66.5 

108.8 
21.0 

70.3 
92.3 
32.4 

62.9 
69.6 
36.5 

48.3 

.50.9 
27.7 

29.5 

3t!.  1 
14.5 

33.6 

24.5 
34.2 
10.9 

21.5 
33.4 

8.7 

26.3 
39.1 
12.7 

30.6 
42.2 
13.7 

37.2 

28.5 
4.5.  6 
17.4 

39.3 

38.3 

52.6 
17.3 

71.2 

92.0 

83.0 

66.3 

49.6 

30.5 

28.8 

34.0 

47.1 

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AMOXii    THK    U.    S.     FORCES. 
VE.\i;  KNDINHi  JINE  Ho.  1865. 


91 


Interrnittent  (inchuliiip^  Cimefostivo)  l-Vvfr. .     .Allamii- 

Ceiilnil  - 
I'ucilU-  . 


32.  6 

41  3 

5-J.  II 

,11.0 

39.  1 

24.  li 

.tJ.  8 

62.4 

62.8 

!)3. ;! 

:)ii.  ,■•■ 

:<2.  ."> 

H.O 

14.9 

12.9 

1(1.4 

11.4 

?^. .') 

Intermittent  in  all  tlie  regions 


KeniiltiMit    l-\'ver .\tliitilic  17. -I  17.1 

CiMitral      ..  IH.  r,  ',>■,'.  8 

rai'ilii' .-,.4  8.  i; 

Remittent  in  all  the  regions   I  17.8  ,  20.6 


III.  (I 
3.8 


l:l.  7  9.4  11.7 
HI.  8  8.  4  7.  9 
8.3        l.t<        1.2 


Interniitlent  ami  Rpinittent '  Atlantic 

Centrtil . 
PaciHe  . 


Tn.tal  in  all  tlie  regions. 
Typbo-malKfial  Fever. - 


.  :A0  .'18.7 

.1  71.3  :  8.1.2 

.'  13.4  23.  .-> 

.1  61.7  74.4 


1,^  ;> 

ti8.  9 

78.3 

111.7 

1865. 


43.9  I  r.3.  8  :  .17.9     .11.  6     37.2     28.8  l!  24. 


12.0  !     8.7  I     7.3 


64.7  48.  .1  :  31.3 
(i4.  I  41.2  '  4(1.4 
21.7      V.V:        9.7 


6.8 
7.6 
2.  6 


25.  4 

37.  3 

11.8 


16.(1 
26.3 

9.6  1 

21.6 

-1.8 
7.  I 
1.9 

6.4 

22.  4 
33.4 

11.1 


19.6     20.0 

31.  3     33.  6 

9.2  I  13.4 


26.9     28.0 
34.  1      -.if.  1 


3.19.  3 

49.1.  I< 


21.  Ct 

6.8 
8.2 
2.6 

7.5 


2(i.  8 


H.O 
2.4 

7.3 


Atlantic 
Central . 
Pacific  . 


7.6 
2.  1 


Typho-inalarial  in  all  the  regions  . 


Intermittent,  Keniittfiit  ami  Typlio-Tnalarial     -Xtlantit^ 

<!entl'al- 
Pacilio  - 


All  the  regions 


6.6 

2.3 

.1 


57.6  I  6.1.3 
73.  4  87.  ;1 
13.  4     23.  6 


73  4 

4.8  j 
1.7  1 
.4 

2.9 

73.7 
80.  0 
17.1 

76.3 


26.4  i  26.7 

39.5  i  41.6 
11.8  '   1.1.8 


1.4 

1.2 

.1 


63.  6 

45.  9 

36.  1 

31.9 

28.  0 

33.1 

4.0 

2.9 

1.6 

1.4 

1.3 

1.5 

1.2 

.7 

I.  1 

.8 

.4 

1.0 

1.  1 

.5 

o 

.4 

2.4 

1.6 

1.3 

1.1 

.8 

1.2 

68.7 

51.4 

32.9 

26.8 

23.7 

27.9 

(15.  3 

44.9 

41.5 

38.1 

33.8 

40.5 

25.8 

13.7 

47.  5 

9.9 

37.4 

12.2 
33.0 

11.5 

28.8 

11.8 

66.0 

34.3 

1.2 

28.1 
42.  8 
15.  9 

35.3 


12.(1 

17.3 

142.  8 

29.4 

32.9 

429.  5 

7.  (i 

9.9 

119.3 

9.8 

11.7  1 

137.  3 

3.8 

4.1  • 

46.9 

8.7 

10.7 

127.8 

34.  5 

37.  9  ■ 

478.6 

43.  9 

49.8 

633.1 

1.5.8 

21.4 

189. 7 

:i8. 1 

43.6 

557.3 

1.7 

1.6 

34.4 

.8 

1.4 

14.9 
2.6 





1.2 

1.5 

22.9 
51.3.  0 

36.2 

39.5 

44.7 

.51.2 

648.0 

15.8 

21.4 

193.  3 

39.3 

45.1 

580.2 

YEAR  ENDING  JUNE  30,  1806. 


DISEASE. 

Region. 

1865. 

1866. 

B 

H 

« 
0 

c 
< 

66.5 
91.3 
23.9 

7S  9 

g 

8 

X 

i 

c 

.39.  0 
40.9 
22.8 

37.0 

s 

•-5 

18.5 
31.7 
12.9 

a 

a 

z: 
a 
1^ 

16.8 

25.4 

7.4 

a 
< 

20.4 
29.5 
12.0 

•< 
S 

i 

a 

34.7 
42.2 
21.7 

34.7 

8.7 

11.5 

2.3 

8.3 

Intermittent  (includin^f  Congestive)  Fever  . . 

Atlantic . .. 
Central .... 
Pacific  .... 

45.9 
63.4 

18.8 

54  7 

88.0 
96.1 
42.7 

92.7 
90.3 
41.4 

63.3 
73.  0 
37.5 

28.4 
25.2 

18.7 

33.3 

29.2 
18.1 

658.7 
808.9 
285.0 

Intermittent  in  all  the  regions 

86. 1  j  85.  6     63. 9 

21.8     16.0       6.5 

21.7     19.3       8.2 

5.0       4.7  i    3.2 

20.2  '  16.4  1    6.8 

23.6 

2.4 
3.5 
2.2 

2.9 

20.9 
3.1.  2 
1.5.1 

26.5 
.1 

18.9 

2.1 
4.1 
2.5 

3.1 

22.3 

3.1 
a  9 
as 

24.  9     27. 9 

4.5       5.1 

4.4  6.2 

2. 5  1    2.  6 

69a  4 

Remittent  Fever 

Atlantic  ... 

Central 

Pacific 

13.4 

19.3 

3.4 

16.3 

59.3 
82.7 
22.2 

71.0 

1.4 

4.5 

.6 

16.7 

26.1 

3.5 

21.3 

4.6 
5.1 

3.1 

1 

4.6 

4a  6 

46.0 
25. 9  ! 

41.6 

144.8 
197.2 
39.0 

as     4.0     5.0 

159.7 

Intermittent  and  Remittent 

Atlantic  ... 

Central 

Pacific  .... 

83.2  109.8    108.7 
117.4    117.8    109.6 
27.  4      47.  7     4(1.  1 

69.8 
81.2 
40.7 

18.9 

29.5 

22.0 

23.5 

3a  4 

15.2 

a>.9 

29.6 
21.  2 

38.4 
35  4 
20.7 

4a  4 

5a  7 

24.0 

803.  5 

1,006.1 

324.0 

Total  in  all  the  regiuns 

99.5 

1.7 
1.7 
.1 

108.3 

1.6 
1.0 

102.  0 

1.7 
1.1 

70.7 

.5 

.9 
_  o 

25.8 

28.9 

32.9 

4a  0 

853.1 

Typhn-malarial  Feyer 

Atlantic . . . 

Central 

Pacific 

.2} 

.3 

.1 

.3 

.1 

.1 
.1 

.2 

1.2 
.5 

lao 

22.5 
1.5 

.05 

.1 

3.1 

1.6 

1.1 

1.2 

.6         .2 

.1 

.1 

.02 

.05 

.1 

.7 

16.6 

Jntfirmittent,  Remittent  and  Typho-malariel 

Atlantic  ... 
Central .... 
Pacific 

60.7 
87.2 
22.8 

84.9    111.4 
119.1    118.8 
27.  5     47.  7 

110.  4 
110.7 
46.1 

70.3 
82.1 
40.9 

43.8 
46.3 
26.0 

20.9 
35.3 
15.1 

19.2 

29.5 

9.9 

23.5 
33.4 
15.2 

32.9 
29.6 
21.3 

38.5 
35.5 
20.8 

4a  6 
.54.9 
24.5 

816.5 

1,028.6 

325.5 

74.1 

101.1    109.4 

103.2 

71.3  1  41. S 

26.6 

22.1 

25.82  28.95 

3ao 

417 

869.7 

' 

92  MALARIAL     FEVERS 

rapid  und  equable  as  the  antecedent  increase,  the  ratios  for  these  months,  29.7  and  28.2, 
being  very  siniiUir  to  those  of  the  preceding  year.  The  luaxiinuni  was  again  reached,  74.4 
and  73.4,  in  August  and  September,  and  the  subsequent  nnnimum,  28.0,  in  February,  186;"). 
During  the  year  succeeding  tlie  war  the  liighest  figures,  99.5,  108.'^  and  102.0  were  reached 
in  August,  September  and  October;  the  fall  to  the  niininuuTi,  22.0,  in  the  following  Feb- 
ruary being  as  sudden  as  w'as  the  rise  wliich  preceded  it. 

The  intermittents  liad  siniihu-  waves  of  prevahnice;  in  fact,  the  contour  of  the  general 
malarial  waves  was  mainly  due  to  the  preponderance  of  fevers  of  this  type.  But  remit- 
tents also  followed  the  same  general  course,  having  their  maximum  in  July,  August  or 
September, — 18.1  per  thousand  strength  in  September,  1861 ;  19.9  in  July,  1862,  and  19.5, 
20.6  and  21.3  in  August  of  the  three  follo\ving  years.  Tiie  minima  corresponded  with 
January,  February  and  March,  and  often  included  December  on  the  one  hand  and  April  on 
the  other;  thus  the  average  monthly  ratio  for  these  five  months  was  8.4  in  the  year  1861-2; 
9.1  in  1862-3;  5.3  in  1863-4;  7.1  in  1864-5;  and  3.6  in  1865-6. 

It  is  noticeable  that  only  in  the  year  ending  June  30,  1862,  was  there  a  distinctly 
marked  occurrence  of  vernal  fevers,  as  notable  among  the  remittents  as  among  the  inter- 
mittents, but  in  both  cases  this  vernal  rise  culminating  in  May,  was  sepai'ated  from  the 
autumnal  increase  not  by  a  diminution  in  the  number  of  febrile  cases  in  June,  but  oidy  by 
the  failure  of  that  month  to  show  an  increase  corresponding  with  that  of  May  on  the  one 
hand  or  July  on  the  other.  A  tendency  to  a  stasis  in  the  advance  of  the  febrile  wave 
occurred  also  in  April  or  May  of  the  other  years,  and  was  most  defined  among  the  inter- 
mittents in  1864. 

The  great  prevalence  in  the  autumn  of  1863,  and  again  in  1865,  must  be  considered 
due  to  tlie  meteorological  conditions  of  those  years  favoring  the  evolution  of  the  disease- 
poison  or  to  the  operations  of  the  troops  carrying  them  into  more  dangerous  localities. 
But  these  high  waves  were  composed  largely  of  recurrences;  for  the  corresponding  winter 
seasons  were  not  characterized  by  that  increased  prevalence  which  would  have  resulted  from 
the  relapses  occurring  in  a  lai'ger  body  of  men  subject  to  attack  under  the  influence  of 
chill,  fatigue  and  other  so-called  predisposing  causes.  The  ratios  of  the  winter  months 
may  be  regarded  as  giving  expression  to  the  relative  numbers  of  men  under  the  influence 
of  the  malarial  poison  in  each  year,  for  there  are  not  wanting  reports  sucli  as  that  of  Surgeon 
J.  M.  Bates,  13th  Maine  Volunteers,  to  establish  the  principle  that  winter  attacks  were 
generally  recurrences. 

Every  case  of  intermittent  fever  lias  occurred  in  those  who  were  affected  with  the  disease  during  last  summer 
and  fall.  The  attacks  have  shown  a  very  general  tendency  to  recur  every  seventh,  fourteenth,  or  twenty-first  day. 
Two  companies  that  came  from  Ship  Island,  Mississippi,  about  the  middle  of  Fel)ruary,  have  as  yet  given  no  indica- 
tion of  the  disease,  showing  that  the  malarial  influence  is  not  sufficiently  strong  at  this  season  of  the  year  to  induce 
the  disease  in  tho,se  not  previously  affected. — Fort-t  Jackson  if  SI.  Philip,  La.,  March,  1864. 

In  view  of  this  principle,  it  may  be  recognized  as  a  fact  that  in  October,  1862,  our 
armies  became  as  fully  saturated  with  the  malarial  poison  as  in  any  of  the  after  years; 
for  while  the  minimum  in  March  of  that  year  was  as  low  as  17.0  per  thousand  of  strength, 
the  succeeding  minimum,  which  was  considerably  higher,  did  not  differ  much  from  those 
whicli  followed  it. 

Ty])ho-malarial  fevers,  which  are  included  in  the  table  and  on  the  diagram,  were  most 
prevalent  in  tlie  year  ending  June  30,  1863,  diminishing  gradually  in  the  after  vears.  The 
waves  of  prevalence  were  abrupt,  culminating  in  July  and  falling  gradually  during  the 
autumn  months. 


AMONG    THE    U.    S.    FORCES. 


93 


I'lUt  the  f^tudv  (if  those  seiis(_)iial  variatiouH  tor  tlie  several  years  may  be  niiirh  facilitated 
by  tlu'ir  cdiisolidation  into  the  average  figures  of  Table  XXIX  and  the  eorresponding  lines 
of  the  diagram  facing  page  94. 

Tablk  XXIX. 

Averof/c  moiUhlij  mnnhcr  of  Qtses  of  the  several  varieties  of  Malarial  Fever  among  the  White  Troops  from 
Juhj  1,  186 1,  to  June  30,  1866,  expressed  as  ratios  per  1,000  of  mean  strength. 


Dl.SEASES. 

22.  IHI 
18.00 
1.92 

41.92 
.82 

42.  74 

17.18 

.'">9. 92 
4.07 

63.  99 

i 

2<l.00 

24.  00 

2. 22 

,5.j.22 
.94 

.W.  16 
19.23 

u       1 

X 

S        ! 

b: 

zr. 

3(1.  (H) 

23.  (HI 

2.72 

55.72 
.89 

56.  61 

16.11 

-     ■ 
72. 72 

2.64 
75.36 

1 
O 

27.  IHI 

21.00 

2.  39 

50.  39 

.70  ! 

X 
V. 
u: 

'?. 

19.  (HI 

16.0(1 

1.  79 

36.  79 
.47 

37.  26 
9.96 

a; 

13.  IHI 

11.  (Kl 

1.18 

25.  18 
.42 

25.  60 
7.56 

X 

< 

Y. 

-> 

10.00 
9.  (HI 
1.31 

20.31 
.39 

20.70 

7.10 

X 

< 

X 

1(1.  (HI 
8.  00 
1.  1(1 

111.  10 
.32 

19.42 

6.  79 

26.21 
1.66 

27.87 

7, 

11.00 

10.  (HI 

1.07 

22.  07 
.32 

22.  39 

7.26 

29.  65 
1.65 

J 

12.  IHI 

U.IHI 

1.  14 

24.  14 
.37 

24.  51 
8.07 

32.  .58 
1.50 

13.  (HI 

12.00 

1.01 

26.01 
.  39 

26.40 
10.17 

36.  ,57 

1.51 

... 

38.08 

y. 

16.  IHI 
13.  (HI 

1 .  ."i3 

3(1.  .■>3 
.45 

30.  98 
IS.  61 

43.  .59 

2.  04 

45. 6:) 

'1  < 

■  <; 

204. (H) 
171. IHI 

Quartan  liitcnnittciit 

18.82 

Ti'tiil  .■^iiiiplf  Imcitiiiiirnt.-; ... 

;i9;!.  82 

li.  24 

1 

i 

1  400.06 

130.89 

.5:10.  95 
26.  15 

557. 10 

51.09 
13.55 

64.64 
2.45 

67.09 

Remittent  Fever 

Ttital  pure  Malarial  Fevers  . . 
Typho-inalarial  Fever  («) 

75.  39 

3.  ra 

78.91 

47.22 

1.98 

49.20 

33.16 

1.71 

34.87 

27.80 
1.  85 

Total  Malarial  Fevers 

29.65 

31.30 

34.08 

(a)  From  July  1,  1862,  to  June  30,  1866. 

From  these  the  purely  malarial  fevers,  and  the  intermittents  which  constituted  so 
large  a  jndiiortion  of  them,  are  seen  to  have  attained  their  maximum  in  August  and  Sep- 
tember. They  decreased  rapidly  during  October  and  November,  and  slowly  thereafter  to 
their  minimum  in  February.  Their  increase  was  slow  and  equable  from  March  to  June, 
and  without  any  vernal  wave  other  than  that  involved  in  the  gradual  formation  of  the 
autumnal  increase.  During  July  the  cases  occurred  with  greater  frequency,  leading  to  the 
maximum  in  August. 

The  remittents  prevailed  as  a  single  annual  wave,  rising  in  March,  culminating  in 
August,  and  falling,  more  abruptly  at  first  but  more  equably  than  the  intermittents,  to  a 
minimum  during  the  winter  months. 

It  is  noticeable  also  that  the  autumnal  increase  affected  the  intermittents  and  the 
remittents  alike,  i.  e.,  both  of  these  types  of  fever  contributed  to  the  annual  maximum  of 
malarial  fevers  the  same  percentage  of  increase  on  their  respective  minima.  Thus  in  the 
intermittents  the  difference  between  the  minimum,  19.42,  and  the  maximum,  56.61,  is  37  19, 
an  increase  of  nearly  two  hundred  per  cent,  on  the  minimum;  while  the  difference  between 
the  minimum,  6.79,  and  the  maximum,  19.23,  of  the  remittents  is  12.44,  also  an  increase  of 
nearly  two  hundred  per  cent,  on  the  minimum. 

The  seasonal  cui-ve  of  typho-malarial  prevalence  rose  abru}itly  in  June  to  its  maxi- 
mum in  July,  fell  gradually  during  August,  September  and  October,  and  thereafter  remained 
at  about  the  same  level  until  the  next  June  rise. 

A  similar  table  constructed  from  the  statistics  of  the  colored  troops  shows  the  maxi- 
mum of  the  purely  malarial  fevers  as  having  been  reached  in  August,  September  and 


94 


M.A.I,Ai;r.\I,     FKVKRS 


Octobci',  ui'tcr  wliicli  the  ImII  was  v:\\<\d  to  tli<'  miuiiiuiiii  in  P'(;liriiiiry.  A  notable  incroa.«c 
in  Ma\',  wltli  u  less  niai'ked  I'isc  in  Jniii'.  tiivcs  a  snu'a'estion  ol'  a  vernal  wave  as  well  anioiijj.' 
tlu'  remittents  as  amoiiL;;  tlic  interinilteiits.  'Flic  rennUeiits,  as  in  the  case  of  tlic  white 
ti-dnjis,  decreased  in  tln'  autumn  before  a  eorresponding  decrease  occurred  in  the  nundjer  of 
the  accompanving  agues. 

The  tvpho-malai'ial  cu)'ve  diifei'ed   Irom  that  of  the  remittents  in  falling  less  rapidly 
during  tSeptember  and  October. 

TAin.K  XXX. 

Avcntf/e  laonllihi  iiumhcr  of  Qt.scs  of  the  seviral  varieties  of  Malarial  Fever  among  the  Colored  Troops 
from  Juli/  J,  ISG3,  to  June  SO,  ISGd,  exjiressctl  in  ratios  per  J, 000  of  strenrjth. 


t^iit)t"ntiiiu  Iiitrrniittfiit 

'i'ertiatl  InttTliiitttMit 

Quartan  IiitiTinittent 


Total  hinipk'  Iiitermittt'iits. 
Congosti  ve  Ft'vcr 


:14.  no 

•S>.  00 

i.'.ia 

W). '.Ill 

i.rx; 


41.0(1 

3a.  00 
i.  S(l 


M.  110 
lifi.Od 

2.97 


o 


I 


7.').  a;     8t'.!i7 

1.57  I      1.93  1 


Total  ,    62.49 

Kcinilli-nt  Fi'vcr 2.120 


76.83 
23. 08 


90.  90 
21.lil 


Total  jmn-  Malai*i:il  I'rvfi> 
rypliu-iiuilariiil  \'r\  i-y 


f5.  69 

fi.:!4 


Total  Malarial  T.-vrrs 


99.91       112..M 
«.  H7  0. 1 1 


4!l.00 

39.  00 

2.  95 

90.  95 
1 .  99 

92. 94 
17..'il 

110.45 
4.44 


33.  00  a.').  0(1 

30.00  20.00 

1.98  1.04 

64. 98  46.  (14 


.94 

65.92 
12. 10 

78.02 
1.90 


1.17 

47.21 

8.  .57 

55.78 
1.66 


20.00  17.(10 
18.00  16.00 
1.14  I       1.24 


39.14 
.85 

39.99 

7.77 

__  j 

47. 76 
1.97 


34.24 

.72 

1 

34.96 
7.46  [ 

42.42 

l.."i6 


106.7^      118.62      114.89 


79.92  :     57.44  I     49.73       43.98 


19.00 

17.00 

21.00 

14.00 

16.  00 

15.00 

.91 

1.53 

2.01 

33.91 

34.53 

38.01 

.93 

.45 

.88 

34.84 

34. 98 

38.89 

8.51 

9.05 

13.61 

43.35 

44.03 

52.50 

2.13 

1.96 

2.95 

4.->.48 

45. 99 

55.45 

•-5 

20.  00 

18.00 

1.50 

39.  50 

.83 

40.  33 

15.08 

55.41 

3.29 

58.  70 

34!).  00 

278.  (HI 

21.  311 




■:i 

648.  39 

13.83 

6(i2 

22 

167 

10 

829 

32 

41 

06 

870.38 


Scdsoital  I'ariafioii'i  in  Morkditi/. — This  has  been  illustrated  by  the  plate  facing  page 
20,  on  which  are  delineatetl  the  monthly  variations  in  the  level  of  the  malarial  death-rale 
in  juxtaposition  with  the  cori't'sjionding  variations  in  the  mortality  from  certain  of  the 
more  fatal  classes  ot  disease  and  li'nm  diseases  in  general.  The  autumnal  prominences 
are  clearly  defined,  particularly  in  the  last  three  years,  the  culminating  points  being  in 
August  in  1863  and  ISfvf.  when  1.14  and  .94  per  thousand  are  reached,  and  in  September, 
1865,  when  a  rate  of  1.18  is  shown.  The  autumn  waves  in  1861  and  1862  do  not  have 
so  distinct  a  culmination.  Tdiese  death-rates  will  be  found  to  correspond  precisely  with 
the  variations  m  the  line  of  juvvalence  in  the  diagi'am  facing  page  9U:  whence  it  may  be 
inferred  that  in  general  tln'Si^  fevers  caused  death  within  the  month  of  the  attack, 

Itifinciicr  of  llcijii)!)  nil  Prcralfiii-c.  —  Table  XXVIIl,  alreadv  presented,  shows  the 
seasonal  variations  m  prevalence  as  atlected  by  the  climatic  and  other  influences  of  the 
ivgion  in  which  the  white  tro(.>ps  operated  during  the  several  years  of  the  war.  The  mala- 
rial fevers  were  more  frequent  in  the  Central  than  in  the  Atlantic  region,  while  in  the 
Pacific  region  the  ratio  of  cases  was  much  smaller  than  in  eitlier  of  the  others.  Durino' 
the  year  succeeding  the  war  the  increased  jirevalence  of  these  fevers  affected  the  troops  in 
all  the  regions.  In  the  ('entral  and  .Atlantic  regions  this  was  due  to  the  occupation  of 
southern  and  malarious  territory;   in  the  Pacific  region  it  was  owing  in  part  to  the  estab- 


I)ia(/r<inis  S'Jiowing  the  ^^verage  Annual  Curves  ofJWvedenee 

fjf  the  J\ht i art al  Fevers  among  tlir  Wliite  and  fJir  Colored  Troops  diiiiiig 

the  War,  in  Monthly  Rates  per  Thousand  oT  Strength  . 


Total  pure  maJaricd  facers. 
Intermittents . 


Mliite  Ti'oojj. 

V. 

IHtltl'^I^M"^^ 

114 

114 

112 

112 

110 

110 

108 

108 

106 

lOG 

104 

104 

108 

102 

100 

100 

98 

98 

96 

96 

94 

94 

98 

92 

90 

90 

88 

88 

86 

66 

84 

84 

82 

82 

80 

80 

78 

78 

76 

76 

74 

V 

74 

72 

72 

70 

70 

6d 

68 

66 

i 

66 

64 

64 

68 

62 

60 

60 

98 

58 

56 

36 

64 

\ 

34 

92 

\ 

52 

80 

50 

48 
46 

48 

46 

4-» 

' ' 

44 

4Z 

, 

42 

40 

/ 

-•jo 

38 

/ 

/ 

38 

36 

r 

1 

\  \ 

36 

34 

J 

1 

' 

34 

32 

f 

32 

30 

/ 

\ 

36 

28 

/ 

/ 

*% 

26 
26 

20 

* 

24 

<^' 

I 

24 

22 

^^ 

\ 

22 

20 

J 

20 

18 

y 

\. 

18 

lei 

<* 

V 

16 

14^ 

/ 

N 

14 

IS 

f 

\ 

12 

10 

y 

\ 

10 

8 

/ 

S 

8 

6 

■ 

*^ 

^ 

6 

4 

4 

2 







_4_ 

y. 

-. 



2 

2J 

\ 

M 

\  ** 

n 

1"  •* 

■>  i 

^l^ 

y 

1^ 

N 

0 

1 

Remittents . 
lypho  -jiicdariai . 


/ 

(//07- 

ed  'Iroop 

s. 

^H^i^^H^iH   1 

114 

1 

114 

112 

L  _ 

112 

110 

i 

"S 

110 

108 

I 

1 

108 

106 

1  / 

loe 

104 

1 

104 

102 

/ 

102 

100 

lOO 

88 

9* 

96 

; 

96  1 

94 

/ 

94 

92 

/ 

92 

90 

/ 

r'' 

90 

88 

/ 

88 

86 

f 

86 

84 

f 

84 

82 

88 

SO 

80 

78 

78 

76 

76 

74 

\ 

74 

72 

I 

I 

72 

70 

/ 

I 

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M 

/ 

I 

e6 

66 

/ 

I 

66 

64 

/ 

I 

64 

68 

/ 

\\ 

9i 

60 

\ 

60 

08 

\l 

S8 

06 

\\ 

06 

B4 

/ 

\ 

04 

02 

r 

02 

80 

00 

48 

48 

46 

V 

46 

4^ 

^ 

\ 

44 

42 

-* 

4S 

40 

\ 

'    40 

38 

X 

s, 

38 

36 

y 

\ 

30 

34 

*- . 

..^ 

^ 

34 

32 

sT 

3D 

"30 

28 

i& 

26 

26 

24 

24 

.   a2 

r~ 

>^ 

22 

20 

\. 

20 

IS 

s 

16 

1-i-l 

16 

14 

/ 

14 

18 

12 

10 

/ 

s, 

10 

8 

.^ 

r 

' 

s. 

s 

6 

X 

6 

4 

/ 

4 

2 

— 

S 

0 

■ 

0 

11  Mi 

\%^HkAh%A 

AMONT,    THE    r 


FORCES. 


95 


lisliiiiriit  ol  iicw  |M)f;ts  ill  uiiliL'iiltliy  liottiMii  IuikIs.  aiitl  ill  pai't  also  to  tlif  i,listril)utioii  over 
this  region  of  ivgular  Iroop.s  subject  to  intermittent  rela|)ses  I'roiii  previous  service  in  tlu^ 
iSoutlieru  States. 

Ill  Table  XXXI  the  statistics  of  the  malarial  fevers  among  the  wliite  troops  m  v:w]\ 
of  the  regions  have  been  eonsoliilated  into  average  monthly  ratios.  From  these,  or  from 
the  accom|ianyiiig  diagram,  it  will  be  seen  that  the  malarial  waves  m  the  three  regions 
presented  a  general  similarity  of  contour.  In  all  the  minimum  was  reached  in  Keljruarv 
and  tlie  maximum  iii  August,  Septemljer  and  October.  A  distinct  vt'rnal  wave,  allecting 
alike  the  remittents  and  the  intei-mitteiits,  is  presented  by  the  I'atios  of  the  I'acific  region. 

TAJ5LE    XXXI. 

Averwje  moiith/ii  number  of  Caxes  of  the  severed  form.'^  of  Mctlaridl  Fever  (imon</the  While  Troops  in  the 
seceraJ  Regions,  expressed  in  rcdios  per  ] ,000  of  strem/th,  calcnlated  from  the  cases  which  occurred 
from  July  J,  18G1,  to  June  30, 1866. 

ATLANTIC   REGION. 


J  ■ 

^    ,    ^ 

Quotidian  Iiilermittcnt ]  4.  4  ■  20.  6 

Tcrtiiin  lutcniiittfiit    l:i.  0      ia6 

yiuirtaii  Iiiteniiitl^'lit 1.1        1-2 

Coiig^t'.'ilive  IntfTinittniit  - 1  ,4 


'I'ofal  1  nterniitteut {  2S.  9 

HeinittiMit '  15. 8 


24.4 

17.8 

.5 


23.4 

17.4 

1.8 

.7 


'A 

16.3 

12.6 

1.2 

.4 


38.9     44.9     43.3     30.5 
1(1.3      15..<      14.  fi      10.1 


9.7 

7.8 
.7 
.5 

18.7 
7.3 


7.  a  j    6.  6 
5.  8       5.  2 


7.2  j  8.4  !  10.  (i  I  11.1 

6.  3  '  7.  ti  1     9.  1  ,  9.  y 

I 

.5  1  .»i  .5  ,  1.0 


Ttital  pure  IMalarial. 
T^-plio-nuilarial 


44.7  I  .'55.2     ii(l.4     .■w.li     4il.fi  \  25.9 
5.4       4.6  ,     3..i  '•     3.4  i     2.9  i     2.4 


Total  Malarial I  49.8     59.3     63.5 


60.6     42.9  !  27.9 


22.2     19.6     21.. 'i     24.1)     30.8 


'•< 

152.4 

123.  3 

11.3 

4.4 


13.9  12.5     14.2     16.8  20.4  '22.1  291.4 

6.3  !  5.7  {     5.9  ,     6.7       8.9      10.8  '  117.9 

20.2  18.2  '  20.  1   '  23.5  29.3     32.9    '  409.3 

2.6  1.8        1.7        1.6       1.9  ,     2.7  jl  33.5 


3.5.0   I    4.)6.e 


CENTRAL  REGION. 


Quotidian  lutt^rniittent  . 
Tertian  Intermittent- ... 
Quailan  Intermittent  ... 
Conjfestive  Intermittent. 


Total  Intermittent. 


Ed 

a: 

s 

S 

Eg 

>• 

3 

t. 

o 

^ 

H 

•^ 

< 

00 

o 

28.2 

:J5.9 

35.1 

30.8 

23.1 

29.4 

28.2 

25.3 

2.6 

3.0 

3.3 

2.9 

1.1 

1.3 

1.2 

.8 

55.0     69.6 


liemittent !  18.9  ,  22.0 


67.8 
17.1 


59.8 
13.0 


21.4 
18.6 
2.4 
.5  i 

42  9 
10.0 


!    % 


Ki.O 

14.4 

1.6 

.4 

32.4 

8.0 


13.3 

12.7 

2.0 

.4 

28.4 

8.1 


Total  pure  Malarial . 


-'  73.9  I  91.6  :  84.9     72.8  ,  52.9     40.4  ,  36.5 


Typho -malarial    3. 2 


2.9 


.1       1.9  ,    1.4 


1.2       1.4 


Total  Malarial  . 


.  1      94.4  ;  86.9  ,74.5  I  54.2  I  41.4      37.8 


12.5 

11.5 

1.7 

.4 

26.1 
8,0 


14.4 

13.6 

1.6 

.4 

30.0 

8.7 


15.5 
13.6 
1.6 
.5  ' 

31.2 


15.  5 

14.  5 

1.4 


31.9 
11.3 


19.5 

16.1 

1.9 

■< 
-  -  -\ 
38.1 

14.2 


35.7  !  40.2     41.7     44.3  i  53.6 


250.7  I 
21.5.  H 
25.4  i 
7.9 


499.6 
144.9 


34.  1   I  38. 7      40. 5      43. 2      52. 3         644. 5 
1.6       1.7  ,     1.5  ,    1.3  I     1.7    1      21.6 


664.2 


96 


MAI.APJAL     KKVKR? 
PACIFIC    K'K(iI().\. 


. 

J  a 

•<  - 

s  == 

^ 

<^ 

- 

< 

:_ 

< 

Y. 

<;; 

CJlliitiiliiiii  llilirriiillilit  . 
'IVrtiaii  Inli-riailtr'iit  ... 
i^uartan  IntHrniiltcnl  ... 
CoM^estivf  Itilt'rniitt<'ril . 


Total  Ititt^nnittetit 

Kcmitti-nt 


li.  H  il.n  17. -J  l.'i.  5     i:i.  H      K  !• 

4.(;  .">.(!  li.  li  7.8        '...5       ;i.8 

.'J  .'.I  .7  .(i 

.'J  .7  I     .;!  .-J 

i-j..".  18.5  ■i\.%  •i\.\     :.io.(i  '  i:i.:i 

I 

:i.  H  ."i.  T  ii.ii  7.  i;      .").  (I      ii.ii 


•J.  8 

.n 

.  I 

'.1. 1 

2.  1 


Ti.tal  pun-  Malarial  . 
Tyl'lio  malarial 


lti.;l     24.-'      31.1      :il.7      -'.5.0      IH.a 

.8  1       .el       .3  I       .8  I       ..')  I       .9 


-1.  !l  1  7 

2.(i  4.11 

.4  1.1) 

.1  .1 

8.11  I     B.8 

I .  n  -J.  8 

!l.  li  12. « 
.3 


li.  7 
4.li 


.1 


12.  a 
:i.7 


15.  !l 

.1) 


li.7 
4.li 

.:< 
.:i 

11. !» 
5.  I 

17.0 


9.4  I  111.:. 

4.2  55.  .■. 

1.2  8.11 

.2  l|  2.fi 

15.0  !  178.S 

4.6  I  5(1.  (i 

19.11  228.8 

.5  1,  5.8 


T.ita 


.0      24.7      iil.H      :12.4   I   2.'J.4       17.0       11.5        9.9  I    12.7      lfi.2   ,   17.1    I  20.1         KU.  7 


Dl.Mili.A.M  nh(iii-iii<i  lilt'  Sed.iDiiiil  rrci-dlincr  of  Ihi- 
Miihiridl  Fn-rrx  in  the  Jthailic,*  Cttilnili  inid 
I'adjict  Ucijiixis. 


*^     ii     *-      3^     ^   -^    "S^j    ^  ■^     !=»      ^      K?   wa 

100 

IflO 

9  t 

93 

96 

?6 

M 

9-t 

4  2 

^ 

9i 

■     So 

\ 

9  d" 

6  i 

\ 

*«■" 

ii 

/ 

\ 

86 

84 

/ 

81 

S3 

/ 

i1 

80 

/ 

fid 

78 

/ 

li  1 

^6 

/ 

76 

74 

/ 

7* 

72 

72 

70 

70 

68 

65 

66 

65 

G'i 

64 

6  2, 

6  1 

60 

1 

* 

iO 

S» 

/ 

Sfl 

56 

/ 

!i(. 

5* 

hSr 

5  J 

/ 

5J 

50 

J 

/ 

RO 

48 

/ 

/ 

48 

46 

/ 

/ 

4-6 

44 

/ 

/ 

44 

4-2 

/ 

4-2 

40 

/ 

+  0 

i      39 

y 

s 

38 

36 

/ 

\ 

36 

34 

/ 

\ 

U 

32 

al- 

30 

/ 

'a 

so 

28 

/ 

28 

1       26 

/ 

/ 

26 

24 

( 

U 

23 

/ 

/ 

22 

20 

/ 

/ 

20 

)8 

/ 

y 

s. 

/ 

\ 

|8 

1  e 

V 

16 

14 

/ 

14 

I  2 

r 

1  a 

1  0 

/ 

S, 

10 

< 

y 

6 

6 

4 

o, 

z 

1 

0 

1 

0 

;?^44"4tiJ-§4^4^ 

The  concurrence  uf  an  elevatdl  toniperature 
ami  liiu-li  ratio-s  from  malarial  t'over.-^,  so  well 
marked  in  the  seasonal  variations  in  prevalence,  is 
noted  also  in  the  geographical  distribution  of  tlie 
cases.  Table  XXXII,  which  follows,  exhibits  an 
increased  prevalence  in  the  departments  of  the 
southern  part  of  the  Atlantic  coast,  as  compared 
with  those  on  the  northern  part  of  that  coast.  The 
increase  from  an  annual  rate  of  144  cases  per  thou- 
sand of  strength  in  the  Department  of  the  Rast, 
through  the  Middle  and  other  coast  dejtartments,  to 


1,035  in  North  Carol 


ma  am 


1  930  in  the  Department 


ol  th(.!  Gulf,  shows  in  a  general  way  the  connection 
of  these  fevers  with  temperature  as  afiected  bv  lati- 
tude. In  the  interior  their  increased  prevalence  in 
the  river  towns,  as  compared  with  the  lii<i-her  u'round 
constituting  the  water-shed,  may  be  seen  in  the  5;>S 
cases  in  the  Department  of  the  Missouri,  the  8G5 
cases  in  the  Department  of  Tennessee  and  the  1,287 
cases  in  the  Department  of  Arkan.sas,  as  against 
227  in  Western  Virginia  and  265  in  the  Depart- 
ment of  thr()liio;  wliile  the  country  bordering  tlie 
gri.'at  lakes  gave  526,  as  against  238  in  the  north- 
west. 

In  compiling  this  table  it  was  found  that  the 
highest  malai'ial  sick-rate  for  any  one  year  was 
presented  by  the  Department  of  Xortli  Carolina,  in 
which  during  the  year  1863-1  there  were  recorded 
23,848  cases  in  a  strength  of  10,226  men,  or  2,353 
cases  per  thousand. 


AMONO    THK    TT, 


FORCES. 


97 


Tahi.k  XXXI 1. 

Shoirlvff  tlie  I'rcvdiencc  of  Mdlarial  Fevers  in.  the  JJeparlmoiLs  on  the  Eastern  and  Southern  Coasts  of  the 
United  States,  and  in  those  of  the  liigh  and  low  (jronnds  of  the  Central  Region,  expressed  in  annual 
ratios  per  ./  ,000  of  strength,  calculated  from  the  statistics  of  the  four  years  ending  June  30, 1SG5. 


l)eli;irtini'iit  nC  tlie  East 

Jliddli'  ])e]iiiitirieiit 

Doiiailim^nl  (if  \'ii-;;iiiia 

Dejiaitmciit  of  tlic  South 

I>f]>aitiiu'iil  dl'  Xortli  Carolina- 
Df']iartiiiciit  of  the  (iulf 


108 
172 
503 
39(5 
828 
788 


32 
81 
110 
131 
179 
148 


DciiartiiiLMit  of  Went  \'irginia  ... 
nepartiiRiit  of  t lie  Northwest.-. 

Deiiaitiueiil  of  the;  Ohio 

I'epaitmeiit  of  the  CiiiMlierhiixl  . 

Northeiu  l)e]iartlllflif 

I)e|>ai'lini'iil  of  Missouri 

Deiiarliueiit  of  'I'euiiessee 

I'epartTru'Ul  of  Arkansas 


146 
150 

187 
306 
386 
390 
()61 
1,103 


71 
82 
66 
135 
126 
136 
181 
166 


Total 

Typho- 

Malarial 

iiiaLirial. 

Fevers. 

4 

141 

11 

261 

37 

(SO 

31 

558 

28 

1,035 

41 

930 

10 

227 

6 

238 

12 

265 

15 

45(; 

14 

,526 

12 

538 

23 

865 

18 

1,287 

Iliit  wliilc  tlic  seasijiial  Wiive  was  iiuule  up  of  a  j)i'0[>ortioiiate  increase  of  the  iiiter- 
iiiittciit  ami  iciiiittciit  cases,  the  increase  in  the  nnmlier  of  malarial  cases,  which  coincided 
with  lower  lalitiidcs  tuid  lower  grounds  in  the  same  latitudes,  was  largely  composed  of  inter- 
niiid'iit  rases.  It  is  evident  that  the  32  remittents  in  the  Department  of  the  .East  do  not 
hear  the  s;iinc  relation  to  the  IDS  intermittents  of  that  command  that  the  166  remittents 
ot  the  Department  of  Arkansas  bear  to  its  1,103  intermittents.  Although  remittents 
increased  in  their  tdisolute  number  with  an  increase  in  the  total  of  malarial  cases,  their 
number  as  ti  )>ercentage  of  that  total  became  diminished  in  the  more  malarious  localities. 
This  is  readily  gathered,  from  Table  XXXIII,  in  which  the  various  types  of  fever  that 
occurred  in  each  department  are  tabulated  as  percentages  of  the  total  number  of  its  mala- 
rial cases. 

At  first  sight  it  appears  as  if  no  relationship  existed  between  the  prevalence  of  the 
remittents  and  iiilermittents;  for  of  the  two  dejiartmeiits,  the  East  and  New  Mexico,  which 
hail  less,  than  liOO  cases  of  malarial  fevers  annuallv  per  thousand  of  strength,  the  one  had 
(•)  per  cent,  of  iiilermittents  and  22  of  remittents,  while  the  other  had  61  per  cent,  of  the 
lornier  and  '.ro  ol  the  latter.  But  if  an  examination  is  made  of  the  figures  from  such 
•  iepartnients  as  the  Houtli.  the  iMissouri,  the  Northern  Department  and  Part  T  of  the  Mis- 
sissippi J)ivisioii,  which  had  an  annual  rate  of  from  500  to  600  malarial  cases  per 
thousand  of  sti-ength,  the  interinittents  will  be  found  to' have  constituted  from  71  to  73  per 
cent,  of  the  total  ami  the  remittents  from  23  to  25  per  cent.  It  is  noteworthy  also,  that 
Med.  Hist.,  Ft.  Ill— 13 


98 


MALARIAL     FKVKKS 


tlirsc  hmircs  a^Tcr  with  tile  u\m'n;>('s  iVnm  tlio  army  as  u  wliolu,  tnr  with  oHD  malarial  cases 
aniuuilly  [icr  thoiisaiMl  ui'  strciiuih  in  all  the  drpartmouts  the  iicreeiitage  of  lutcrmitleiils 
was  71.71  and  that  of  the  remittents  24.01. 

Tap.le  XXXTII. 
iSlwici)>(/ — J,  The  rt/utirr  2>rcv(i/<"tice  of  the  Mitlnrial  Feverx  (imong  the  White  Troopn  In  the  severed  Depart- 
menta  (Did  Reg'umi^  durinr/  the  four  years  ending  June  30,  lSl)~>,  expressed  as  ndios  per  1  flOO  of 
streiif/lh  ;  ;.',  The  /■(/(tlirefrcjuenei/  if  tlte  forms  of  these  Fevers,  expressed  in  percentages  if  the  fotat 
miinlter  of  cases;  aiid  3,  The  relative  freipteney  of  the  varieties  of  Jnteriniftent  Fever,  e-vprcssed.  eis 
percentages  of  the  total  number  of  Intermittent  eases. 


114 
2(14 
'-•S'4 
320 
3110 
315 

ass 

65() 

l.o:).'} 

5ri9 


I>t^Al^.ME^"^^  a.nh  REi;io,Nh. 


I).-|.itrlrn»'iil  >'(  (he  Kast 

Mid.ll.'  I)i').Mrtmeiil    

iJei'artiiu'nt  of  tin'  Slifnainiuali  .  .  . 

Miildlf  .Alililliiy  Divisimi 

I  )ppartiiit'nt  of  Wa.-^liinfrlon 

j  Army  of  tho  Potoiiiar. 

,  Department  of  the  liaintahaiuiock . 

Department  nf  Viro^inia 

Department  of  North  t'arolitia  . . .. 

Department  of  the  South 


42i    '  Atlantiij  Region. 


2.38 
5S6 
a>7 
S36 
afi.'i 
45<i 
8B.') 
.59.') 
457 
1,287 
H30 

648 

193 
212 


Department  ot  tlie  N'ortluvest    

Northern  Department 

Department  ipf  West  Virginia 

Department  of  the  Missouri 

Department  of  the  ( il>io 

Department  of  the  Cuniberlaml 

Department  of  the  Tennessee 

Military  Division  of  the  >[ississip|>i,  Part  1.  . 
Military  Division  of  tjie  Mississipj'i.  Part  II 

Department  of  Arkansas -....- 

Department  of  the  Gulf 


Central  Reg^ion 


Department  <if  New  Mexico  . 
Department  of  the  Paeifiu  .  - . 


207  II  Pacitio  Ke[ri,ni  . 


S-3 


B,  330  i 
12,  275 

4,560 
15,  297  ' 
40,  349 
138,  494 

4, 075 
67,249 
64,389 
36,  175 


75.07 
65. 04 
69. 99 
64.64 
62.51 
.52.  73 
53.50 
77.43 
80.011 
70. 82 


4,706 

20,085 

14,075 

.54, 1)93 

22,  645 

107,  603 

211,22!) 

65,  (104 

40,  8.55 

73,  477 

115,a<W 

729, 062 

2,987 

5,053 

8,039 

389,  193  :      65.64 


6:*.  07 
73.  X> 
64.19 
72.  .54 
70.44 
67.03 
76.43 
73.46 
70.43 
85. 74 
79.38 

74.97 


22.29 
30.  56 
30.06 
30. 13 
26. 15 
38.  43 
46.  .50 
16.90 
17.21 
23.50 

27.71 

34.  .59 
24. 03 
31.22 
25.  31 
25.07 
29.  75 
20.  88 
23.  44 
27. 30 
12.85 
15.87 

22.00 


60.73  I  35.15 
77.16   20.70 

26.08 


2.64 

4.47 

.  (a)  . . 

5.23 

11.34 

8.84 

.  (a)  .- 

5. 68 

2.79 

5.68 

6.65 

2.34 

2.62 
4.. 59 
2.  15 
4.49 
3.22  I 

2,  69 

3.  in 

2.37 
1.41 
4.74  I 

3.03 

4. 12 
2.14 

8.87 


1  = 

is 


4,752 

7,  984 

3,  189 

9, 889 

25, 224 

7.3, 031 

2,180 

52, 068 

51,512 

25,  619 

255, 448 

2,967 
14,  732 

!i,  035 
39,  239 

1.5,  g.v) 

72,  139 
161,145 
47,  7.'iti 
,  28,  775 
62,  999 
91,  517 

546,  .544 

1,814 
3,898 


5,712 


■Regions ,      1,126,294        71.71   |    24.011      4.28    !    807,704 


(  Percentage  of  Quotid- 
ians. 

1 
Percentage  of  Tertians. 

■i 

c 

C5 

c 

g 

"S 
s 

c 

i: 
& 

1 
= 

6  ± 

rl 
1.1 

0) 

45.27 

49.77 

4. 48 

.48 

'>».  20 

37.04 

3.31 

1.45 

64.  .36 

33.  68 

1.38 

.60 

.52. 89 

43.67 

2. 52 

.92 

47. 34 

47.29 

4.34 

1.04 

51.50 

41.27 

4.83 

2.40 

43.  53 

47. 16 

6.05 

3.26 

51.33 

43.48 

3.85 

1.34 

58.75 

:i8.07 

2.44 

.74 

47.73 
52.26 
61.61 

45. 56 

42.27 

-      - 
33.27 

4.77 
3.94 

1.94 

1.54 
1.08 

4.04 

,    5(.).  .55 

42.37 

.5.38 

1.70 

1     .50. 08 

46.00 

2. 7K 

1.14 

1 

48.79 

42.72 

«.  .34 

2.  15 

.52. 08 

42.23 

4.16 

1..54 

.52.  13 

4  1 .  02 

,5.19 

1.65 

51 .  71 

41.36 

5. 13 

1.77 

.52.  .53 

41.15 

4.  93 

1.39 

i     50.37 

44.92 

3.84 

.88 

49.21 

43.26 

6.14 

1.39 

44.23 

49.  IK) 

5.10 

1.66 

50.03 

43.18 

.5.19 

1.62 

—  — 

62.72 

27.62 

7.72 

1.93 

59.81 

33.  78 
31.83 

5.44 

6.16 

.98 
1.28 

60.73 

50.85 

42.77 

4.79 

1.59 

(o)  These  departments  became  merged  in  others  before  the  intntduction  of  the  term  typho-mahtrial. 

It",  however,  the  specially  malarious  localities  are  examined,  it  will  be  found,  as  indi- 
cated in  the  presentation  of  Table  XXXII,  that  the  renaitteiit  fevers  did  not  form  so  large 


AMONG    THK    V.    S.    FORCES.  99 

a  peri'ciitagc  '^t'  the  total  as  in  tlir  rlepartmeiits  wlieiv  the  laalarial  hifluence  was  manifestly 
not  so  extensively  prevalent.  Thns,  in  the  Departni(>nt  of  Arkansas  scarcely  13  per  cent, 
of  remittents  occurred  in  1,287  malarial  cases  annuallv  per  thousand  of  strength,  in  the 
(lulf  department  lli  per  cent,  in  930,  in  Xorth  Cart)lina  17  per  cent,  in  1,035  and  in  Ten- 
nessee 21  per  cent,  in  865;  in  the  wliole  of  the  Central  region  22  per  cent,  in  648,  and  in 
the  wliole  of  the  Atlantic  regicjii  28  per  cent,  in  422. 

Ill  other  dejiartments,  as  the  East,  New  j\texico,  etc.,  where,  with  similar  totals  giving 
expre5:sion  to  the  malarial  influence,  the  remittents  and  intermittents  were  not  similarly 
distrihuted,  it  is  j)robable  that  the  percentages  of  each  may  have  heen  largely  determined 
by  the  existence  of  those  conditions  wdiicli  are  recognized  as  predisposing  causes.  The 
higliest  proportion  of  remittents  occurred  in  the  Armies  of  the  Potomac  and  Rappahannock. 
Predisposing  causes  such  as  fatigue,  exposure  to  weather  changes,  loss  of  sleep,  improper 
food,  impure  water,  etc.,  were  undoubtedly  at  their  maximum  among  the  actively  engaged 
troops  of  those  commantis. 

The  typho-malarial  cases,  while  more  frequent  in  a  malarious  locality  than  in  one 
comparatively  free  from  malarial  disease,  do  not  appear  to  have  exhibited  any  fixed  rela- 
tionship to  the  malarial  fevers.  Thus,  the  Department  of  Arkansas 'had  the  lowest  per- 
centage of  typho-malarial  cases,  although  })resenting  the  highest  annual  total  of  malarial 
fevers,  and  the  Department  of  Washington  and  Army  of  the  Potomac  gave  by  far  the 
highest  percentag(!  of  typho-malarial  cases,  although  they  were  below  the  average  as 
regards  the  prevalence  of  malarial  disease. 

The  statements  of  medical  authors  as  to  the  relative  frequency  of  the  types  of  inter- 
mittents are  somewhat  at  variance.  Thus,  Brown"^'  represents  the  tertian  as  most  fre- 
quently met  with,  the  quartan  standing  next,  and  the  quotidian  as  in  some  degree  rarer 
than  the  latter.  CoPLANDf  also  gives  the  tertian  the  greatest,  and  the  regular  quotidian 
the  least,  [)r(>valence.  Climate  and  season  have  no  doubt  an  influence  on  the  production 
of  these  varieties.  HertzJ  says  that  in  temperate  climates  the  tertian  occurs  most  fre- 
quently, and  that  the  short  types  approaching  the  continued  form  prevail  in  the  tropics  and 
in  the  temperate  climates  during  the  hot  season.  Indian  experience  appears  to  sustain  this 
view.  SuLiJ  VAN  §  gives  the  order  of  frequency  as  quotidian,  tertian  and  quartan.  Maillot 
and  Fv  Collin  |1  have  published  statistics  of  prevalence  among  the  French  troops  in  Algeria 
which  show  a  similar  order  of /requency.  Our  own  statistics  give  the  following  percentages ; 
Quotidians  50.85,  tertians  42.77,  quartans  4.79  and  congestive  attacks  1.59. 

On  the  assumption  that  the  short  types  are  most  common  in  hot  weather  and  in  hot 
climates,  quartan  agues  ought  to  be  most  frequent  where  the  total  of  malarial  disease  is 
smallest.  But  the  table  just  presented  shows  similar  percentages  of  this  type  of  fever  in 
the  Department  of  the  East  and  in  that  of  the  South,  in  the  Northern  Department  and  in 
that  of  the  Gulf,  while  the  Department  of  Arkansas  had  many  quartans  and  the  Depart- 
ment of  the  Cuml)erland  comparatively  few.  The  tertians  were  more -frequent  than  the 
quotidians  in  tlje  Department  of  the  East;  but  the  same  statement  holds  good  with  regard 

*  .lOKFPH  BicOWN  in  thp  CydnpKdia  of  Practical  Medicine.  Phila.,  Pa..  11^45,  Viil.  II.  p.  206. 

t  A  Diclionarji  nf  Practical  Medicine,  by  J.VMKS  COFLANU,  London.  1»J8,  Vol.  I.  p.  9:i5. 

J  Hektz  in  Ziemssen's  Vyclapfedia,  Amer.  Transl.,  New  York.  1875,  Vol.  II.  p.  TMT^. 

J  Endemic  Diseases  nf  Tropical  Climates,  by  JOHN  Sri.I.lv.\x,  M.  D.,  I.imdon.  1877,  p.  Xi. 

II  F.  C.  Maillot — Trait'  des  Fi^.rres  Intermittcntcs.  Paris,  1831) — gives,  on  p.  414,  a  table  showing  tlie  oeenrrence  in  the  military  hospitals  at  Bone  of 
2,338  clearly  defined  intermittents,  of  which  I  ..")82  were  quotidians,  730  tertians  and  2')  quartans.  E.  (!oi.LIX— in  his  Recherches  stir  Us  affections  de  la  rate. 
published  in  Recueil  de  Mgmoiies  de  M^decine,  etc.,  2'  Htne.  T.  IV,  Paris,  1848— states,  p.  Ufi.  that  of  B,636  cases  observed  at  Philippeville  in  Algeria, 
3,523  were  quotidians,  916  tertians,  58  quartans,  303  erratic  of  variable  type  and  l,83fi  remittents. 


](')0  MALAIUAI,     FKVEKS 

totlir  1  •ciKirtiin'til  tit'  tlii'(!iilt.  A  cldSiT  ius|)Ocliiiii  ol'  till'  (|;it;i  fnnii  wlufli  t  In.-  ImIiIc  \v;is 
mmli!  ii|)  '^ivcs  L;i''';i.tcr  |irMiniiii'iii-i'  Id  tliu  irri'^-iihii-ity  in  this  i'es|)(_'ct.  WHiili'  the  iiatiinj  <it 
lilt;  irisi'iisf-j)i)isi)ii  is  iid  iloulit  the  iniiiu  t'lictur  iii  tli'tt'i'iiuiiiiiu;  the  tyjitj  ul  llio  tlisoasc,  it  is 
iii'tiliaMt!  IJiiit  hri'irispiisliiii;  cDinlil  imis  fXt.Tciso  ;i  sti'uiiii  iiifliiciici.i  on  tlic.  ivsiilliiiL;'  ievtT. 
(Joii^cstivtj  tt'V(,'r  t:(iiislitutr(l  .  Is  |ic'r  cenl.  of  the  iiilfniiitlfiils  in  tlif  [)c])arlini'iii  ot  the 
East;  .<■)<>  in  lln' SlicnaiitltKih  ;  .'Jli  in  tlif  MiiMh'  Military  hivisioii,  and  .OS  in  ihf  h.'pait 
ineiit  of  thu  i'acit"ic,  in  fa(,;li  of  \Ylii<-li  the  malarial  ttital  was  eoni))arativrly  small;  l.'H)  in 
the  Departinont  t)t'  the  Gulf,  ami  1.30  in  Arkansas,  in  which  the  totals  were  lar^r;  l)iit  it 
constituteil  only  .74  pel' cent,  in  the  Jiit^hly  malarious  l)e|uirtnifnt  of  North  CJartilina,  ami 
1.9:')  in  the  fiimparalively  healthy  territories  of  the  Department  of  New  Mfxico.  iSim-e, 
however,  the  lii^'hest  jn'opoi'titmate  niimher  of  congestive  cases  was  found  in  tin.',  Army  dI 
the  I'otomac,  1*.  10  per  cent.,  ami  in  the  l)e]iartment  of  the  Rappahamioclv,  3.26  jicr  cent., 
it  may  bo  assumeil,  as  in  the  case  oi'  the  reiiiitteiits,  that  these  pernicious  fe"ers  were  largely 
duo  to  the  fatigues,  e.\[iosures  and  ileprivatitMis  inciileiit  to  activt!  operations. 

ddie  ilistrihuiiiMi  i>f  the  malarial  fevers  tliiring  the  war,  presented  in  iiumljers  in  the 
last  two  (ahles,  has  also  Keen  illustrated  ]>y  the  tinted  map  which  faces  this  page.  It  is 
impossihle  tt)  show'on  a  single  ma[)  of  this,  or  perha[is  of  any  size,  the  many  changes 
which  the  exigencies  of  the  iiKiment  necessitated  in  the  boundaries  of  the  various  military 
dejiartmeiits.  Ftir  this  I'eason  no  attempt  has  been  made  to  secure  such  ofhcial  accuracy 
in  their  tiiitlines  as  wouM  Iju  requiretj  were  the  map  intended  as  an  illustration  of  a  mili- 
tary stutiy.  Nor  is  this  iieeill'ul,  lor  the  tle})th  of  tint  indicating  the  prevalence  of  malarial 
fevers  in  a  given  tle[iartmeiit  was  determined  not  by  the  malarial  character  of  the  depart- 
ment as  a  whole,  but  only  by  that  of  the  part,  oftentimes  a  small  one,  occupietl  by  the 
Union  forces.  The  lines  and  circles  of  solid  color  show  in  what  parts  of  the  various  depart- 
ments our  armit.\s  o[)eratfil  iliiring  the  years  of  the  war, — red,  yellow,  blue  and  green  res- 
pectively representing  the  portit>ns  hehl  iluriiig  the  years  cmliiig  June  30,  lS(o2,  '63,  '(ii 
and  "(io.  In  certain  of  tin;  ImnH^  il6[>artments,  as  the  Northern  Department  ami  those  of 
the  Ivist  and  Nurthwesl,  lit)  lines  tif  [)ositioii  are  given,  as  tlu;  trot)[)s  serving  in  tliese 
military  cummands  wen;  scattered  generally  over  the  country  at  recruiting  depots  ami 
camps  t)f  instruction,  etc. 

The  Departments  of  the  1  tapjiahatimick  and  Bheiiaiuloah  and  the  Middle  Military 
Division  are  m>t  represented  tm  the  map.  The  first  two  temporarily  formed  imlependent 
commamls  in  the  section  ol  cuuntry  which  was  for  most  of  the  time  kiitjwn  as  the  J.)epart- 
ment  of  the  Potomac,  and  the  last,  during  the  latter  jnirt  of  the  war,  included  AVest  Vir- 
ginia antl  the  Valley  of  the  Hhenandoah.  Nor  does  the  JMilitary  Division  of  the  Mississippi 
appear  on  the  maj).  Part  1  of  this  Division  included,  during  the  last  year  of  the  war,  the 
country  ct)mposing  the  De[»ai'tments  of  the  Ohio,  Cumberland,  and  Tennessee  and  such 
parts  ot  the  neighboring  States  as  were  i:)ccupied  by  the  army  under  General  Thomas;  while 
Part  II  coiiipriseil  the  territory  passed  over  by  General  Bherman's  army  in  its  march  through 
Georgia  to  the  Atlantic  Coast,  and  thence  northward  to  Washington,  D.  C. 

The  map  shows  in  a  general  way  the  greater  frequency  of  the  malarial  fevers  in  the 
southern  portions  of  the  Atlantic  and  Central  regions.  Apparent  exceptions  were  dm-  to 
easily  explained  circumstances.  Tiius,  in  the  Atlantic  region  the  troops  in  the  Department 
of  the  South  suffered  less  than  those  of  the  North  Carolina  command,  because  the  greater 
portion  of  the  former  occupied  tjuring  most  of  the  war  comparatively  healthy  sites  on  coast 


12)° 


122° 


iir" 


112° 


107" 


102°  Lanyladf  \yesi9?°"&om  fte«dwidt 


///r^  \ 


"*"  ^«-»v 


MAP      OF 

The  United  States 

showing  the  PREVALENCE  of  MALARIAL    FEVERS 

in  the  VTirious  Milil.iiT  DcpaJ-UiiPiits  during  J^p  Kcbollion , 

bvdopthor'rinl  proporlionod  to  Uio  Annual  Rnlios 

of  cases  per  Thousand  of  Strength  . 

Under200casesannually      CZH    GOO  -  SOOannuaily  CZm 
200-400    .,         ..  C    n   800-1000        ..       dn 

400  -  600    .,  ..  E      1    over  1000         -       K^ 


^oniitllde^ye»tjO^  fraii_}\aahin5ton_ 


KMorm  i  ^ii  r^i; 


AMONO    THE    V.    S.    FORCES.  101 

islands,  llail  tlie  forlniio  of  war  carried  thoin  into  the  more  malarious  districts,  tlioy  wnuld 
undoubtedly  have  had  an  exi)erience  similar  u>  that  of  the  n'hid  ti'oojis  that  held  those  dis- 
tricts.'^' Tims,  also,  in  the  CA'iitral  region  the  depth  ol  color  cxin'essive  of  ]irevalcnct^  is 
greater  in  the  Hepartment  of  Arkansas  than  in  that  of  the  (liilf,  on  account  of  the  occupa- 
tion h\-  tile  troops  of  the  unhealthy  bottom  lands  in  tlie  I'oi'nier  section  ol'  the  country. 

It  Would  be  interesting  in  this  connection  to  discuss  tlie  grogi-aphieal  distribution  of 
the  malarial  fevers  among  the  civil  populatiim  of  the  United  Stales  and  the  garrisons  of 
our  militai-y  posts  in  limes  of  peace.  Information  on  the  latter  hi\ad  will  be  fouiul  in 
FoHi;v's  bookf  and  in  tin'  imblications  of  the  Surgeon  ({eiieral's  (  MHce.J  As  lo  the  former, 
tlie  works  of  J)i;AKt';  and  llii:srii  ^  may  be  cc^nsulted.  I)oth  these  writers  havc^  i-elied  to 
a  considerable  extent  on  the  militaiy  statistics  compiled  by  F(>i;uv  and  (Jootjihik.    . 

Throughout  the  Atl.aiitic  region  malaruil  fevers  were,  during  the  war,  most  prevalent  in 
the  swamjjy  districts  and  lowlands  adjoining  the  sea  and  boidcriiig  the  water  courses:  they 
became  milder  in  the  drver  anil  more  elevated  districts  oi  the  interior,  tuid  disap])eari'(l  in 
the  hiii'hlands  of  the  Appalachian  chain  and  the  mountainous  districts  of  New  Kngland  and 
New  'S'ork ;  but  south  of  Pennsylvania,  they  were  Ibund  in  the  river  valleys  at  a,  consider- 
able elevation. 

In  the  Central  region  the  malarial  influence  was  most  intens(>  in  the  lowlands  border- 
ing the  (iiilf  of  jMc'xico  and  along  the  rivers  that  discharge  into  its  waters;  thence  it 
extended  northward  with  diminishing  intensitv  to  the  vicinitv  of  the  great  lakes,  wliere  it 
again  became  markeillv  ]>revaleiit.  On  the  Kast  it  penetrated  toward  (he  headwaters  of 
the  streams  arising  in  the  Appalachian  range,  and  on  the  Wi'st  it  became  gradually  milder 
towards  the  Rocky  Mountains,  finally  disappearing  on  the  lofty  slopes  of  that  system, 
thoiieii  si  111  existing  to  some  extent  in  its  elevated  valleys. 

Ill  till'  Pacific  region  the  relative  prevalence  of  the  malarial  inlliieiice  corresponded 
closely  with  that  which  obtained  in  the  Atlantic  regir)n  on  the  same  isothermal  line.s. 

•■  CunijiaO'  tliH  sliiteiiu'iits  nf  ttii'  rriMjiicucj'  of  tlif  intibil-ial  tVver.s  aiiKmjf  flic  Ciiiif'tMlrriitr  Iruups  in  tllcHc  very  districts,  {.'ivt'n  in  a  sill>«f'(il»Mit  part 
(if  this  chapter,  p.  lll'i,  ini  the  aullmrity  of  Dr.  .lOSF.l'll  .loNKS.  .See  al.so  llic  Icstinuiny  nf  Klll.l.urK,  cited  hy  .).  !■'.  V<isK\—lffiiiirl  on  tlir  liii«n/r,iiiliii  iiml 
fpiih-mic  ilisfirsfs  nf  the.  Stale  of  Oennjia,  Suutticrn  Med.  and  Stnx.  Jcur.,  Vul.  XIV,  1H5^,  p.  IIH — willi  rcijard  to  tlic  freedom  fnnn  uiiasinatic  fevers  of 
those  sea  island.s  on  the  C4)ast  of  tjeorgi.l,  which  have  "few  or  ih>  brackish  [ninds  ur  lajfinies  as  cnnipared  uith  the  op[n»site  main."  For  further  remarks 
<ni  the  meilical  topojrrapliy  of  this  part  of  the  Southern  .States,  see  a  reference  to  the  report  of  the  (/onfederate  Surjjeon  .S.vmi'KI.  Lor.AVj  i«*fVi?,  iK»ge  171. 

t  Sa.MIKI.  rdliliv — The.  Climale  of  the  I'mleil  Slalix,  'Jd  Kdit.,  New  York,  1S42.  See  also,  l)y  the  ,«aine  author.  S/Klhliciil  Rrsearches  eliichhiting 
the  nimnte  nf  the  United  States  mid  its  retatiim  v'l'th  diseases  nf  Matariat  oriyiii,  etc.  The  Anier.  .lour,  of  the  IMeil.  .Sci.,  \.  S.,  Vol.  II,  IP4I,  p,  Kl, 
and  the  Endemic  injluencps  nf  the  United  States,  in  thi*  same  volume,  p.  'Jl)3. 

;  See  the  Statistival  Kejtnrts  an  the  Sichiess  ami  Mnrtatiti/  in  the  Armif  nf  tlie  United  Slates:  the  first,  /Vom  Januari/,  IHllt,  lo  Janftaei/,  1831*, 
Washington,  If4l),  Edit,  liy  romiV;  the  second. ./"/-om.  .laniiari/,  I8:S!I,  tn  .lanuari/,  IKW,  Washington,  IK")i;,  edited  liy  U.  II.  Cool.ll>i:E«  the  third, /mm 
January,  l^'.^5,  to  January,  IHfiO,  Washintrton,  If^tifl,  edited  l>y  the  .siime :  also  the  two  reports  edifeil  l»y  .-Kssistant  Surp-oii  (now  .Surjjeon)  J.  .S.  Hii.- 
LINOS,  V.  S.  A.,  viz:  Circular  No.  4,  .Surfjeon  fieneral's  ( )f1i<'e,  Washington,  Dec.  .">,  If7l),— ^  Kejmrt  on  llarracks  and  Hospitals,  with  de.tcriptions  nf 
Military  I'nsts,  and  Circular  Nn.  8,  Surgeon  General's  Ofllce,  Washington,  May  I,  IfT.'i— .4  Re/tort  on  the  tfi/i/iene  of  the  United  States  Army,  with 
description  of  military  jiosis. 

§  I>-\N1KI,  Dkake — On  the  Principal  Diseases  of  the  Interior  Valley  of  Xnrth  America,  Cincinnati,  IH.50:  also,  the  same  work,  .Second  series, 
Pliil.adelphia,  If!ri4.  A.  HlliriCII — Uanilh.  der  hislnrisch-yeographischen  Patholot/ie.  Krlangen,  18*10,  lid.  I,  S.  1 1  et  setp  See  also,  iK'siiles  the  several 
essays  <-ited  l)y  lllKsni,  the  following:  Ol.IVEIt  WF.NIiia.I.  lUiLMKS — Facts  and  trailitinns  respecting  the  existence  of  indigennns  intermittent  fecer  in 
jSeic  Kngland :  being  the  lioylston  Prize  dissertation  fitr  the  year  IHMfi.  Boston,  IH:i8. — An  interesting  paper,  giving  a  giMid  deal  of  cviilence  to  show 
tliat  at  various  times  during  the  previous  century,  and  even  earlier,  intermittent  fever  prev;iiled  more  extensively  in  New  Kngland  than  it  did  at  the  time 
it  was  written,  or  indeed  for  a  nund)er  of  years  previously.  J.  W.  llKCSTIS — Medicat  fads  and  inipnries  respecting  the  cause,  nature,  prerentiou  and 
cure  'f  fecer  in  the  .\'outhern  Slates,  etc..  Cahawba.  .•\iiil>ama,  182.').  R.  S.  Hoi.MK.s,  late  of  the  .Meiru-al  Staff.  C.  S.  .\rmy— On  Mal<iria  in  connection 
with  .Medical  Topography.  The  Si,  Louis  .Med.  and  .Surg,  .lour.,  Vol.  V,  184.^,  p.  .OIW — coiniKires  the  topogr.tpliy  of  certain  military  i>i»sts  iu  Florida, 
Portland  and  Holton,  Maine,  Prairie  du  (!hien  on  the  rpi«'r  Mississippi,  and  certain  p<iints  in  Mcvico.  E.  D  I-'ennek — Soulhern  Medical  Rejiorls,  New 
Oileans  an<l  New  York,  Vol.  I,  184;»,  Vol.  II,  IS'jO.  .Ions  F.  P08EV— iJc/wr?  npnn  the  Topngraphy  and  Kpidemic  Di.ieases  of  the  State  /./'  (,'enrgia, 
Soutliern  Med.  and  Surg.  .lour,,  Vol.  XIV,  1858,  pp.  lOfl  an<l  191.  J.  C.  HAKltIs  of  .Vhiliama— .1h  Ks.iay  nn  the  climate  and  fevers  nf  the  Sonthwe.'itern, 
Smithern  Atlantic  and  Gulf  States.  The  New  Orleans  Jour,  of  Med.,  Vol.  X.\UI.  1870,  p.  401  et  seq.:  also  Charleston,  S.  C,  1872.  H.  DllONSoN— //istorj/ 
of  intermittent  fever  in  the  New  Haven  region,  with  an  attempt  to  distingui.th  the  known  from  the  unknown  cau.^es.  Proceedings  of  the  Connecticut 
Medical  Society.  2d  Series,  Vol.  IV,  l872-.'i.  p.  20.  A.  W.  liARROWS — On  Malarial  .fecer  in  New  England.  (Presidetit's  Adflress.)  Same  procee<l- 
ings,  1877,  p.  22.  .See  also  the  Rei>orts  nn  the  Epidemics  and  ClimatnltK/y  uf  various  States,  made  to  (he  .Section  of  Meteorology,  Medical  Topography 
and  Kpidemic  diseases,  scattered  through  the  volumes  of  Transactions  nf  the  American  Medical  Association  prior  to  and  including  the  year  1873:  subse- 
qitently,  many  of  the  reports  to  the  section  of  .State  Metlicine  and  Public  Hygiene  [organized  in  1873]  in  the  same  Transactions. 


102 


MALARIAL     KKA'KRS 


Til  oadi  of  those  regions  tlic  nmlai'iul  influetice  became  in  a  general  way  more  intense 
towards  the  south;  l)nt  local  criuihtions  everywhere  exercised  a  coiitn^llinL!;  or  niodilVin^J' 
power.  Malai'ial  Icyrs  were  less  jti-c\aleiiL  in  well-drained  rolling  districts,  clrvated 
plateaux  and  mountain  slo]ii-s,  whiji'  thc\-  increased  in  frequency  and  severity  on  low  jilains, 
in  moist  I'iver  valleys  and  in  swampv  lands.  In  fact,  their  distribution  during  the  wai' 
corresj)onded  intimately  with  that  already  outlined  by  P'orrv  and  OooLfLciK,  and  with  the 
indications  of  the  mortality  tables  of  the  Census  Reports'''  and  of  the  deaths  returned  by 
municipal  boards  to  tiie  National  Board  of  Health. f 


II.— MALARIAL  FEVERS  AMONG  THE  CONFEDERATE  TROOPS. 

Prevalence. — The  consolidated  monthly  I'eturns  of  the  Confederate  Army  of  the  Poto- 
mac, preserved  by  Dr.  T.  H.  Williams,  have  served  for  the  computation  of  ratios  indica- 
ting the  monthly  prevalence  of  malarial  fevers  in  that  army  from  July,  ISGI,  to  March, 
1862,  inclusive.  In  the  table  on  the  folhnving  page  these  ratios  are  given  in  juxtaposition 
with  those  for  the  Fedei'al  Armv  <if  tln'  I'dtoniac  during  the  same  months. 

These  ligures  show  that  malarial  fevers  were  even  more  prevalent  in  the  Confederate 
than  in  the  P'ederal  Army  of  the  Potomac.  The  average  monthly  strength  re]ii-esented 
liy  the  Confederate  si(d\  reports  ^vas  49,:>94  men,  among  wiiom  occurred  tlie  monthly  ratio 
of  3<S  malarial  cases  per  thousand,  while  the  average  strength  represented  by  the  Federal 
sick  I'eports  was  111,1  til)  men,  and  the  monthly  rati(j  of  malarial  cases  28. 

It  is  not  possible  to  contrast  statistically  the  mortality  of  the  two  armies  from  these 
fevers  during  the  period  in  CjUestion,  as  the  Confederate  returns  give  the  number  of  deaths 
only  under  the  heading  "total  from  all  causes." 


'  III  Ilii*t  rtiiiiiertion  tli*'  lollnuiiig  talili'  Iia.s  I i  i 

lit^-atlis  riuiii  malarial  fevers  per  11K),()01)  liviinf  persuiis: 


ii|.iliil  Iniiii  ihf  Sliilistii's  i.r  the  Census  years  IHTII  anil   InBO.     Tlie  fi|riires  lalmlateil  repip.spnt 


A[l. ANTIC   KkuION. 


Klioile  Island 

Veriiiiint 

Massaelnisetts 

Cunueetieiit 

Maine. 

Xew  llainpsliire 

Pennsylvania 

NVw  .Ic^rsey 

New  Vnrk   . . . .' 

Distriet  of  CiilillnlHa  . 


1B70. 

I      •' 

4 


1S80. 


1       I  Wi 


CF'.MKAI.    llKCIKIN. 


10 
If) 


!) 
4 

i; 

4 
5 

9 
29 

») 

47 


Delan.ire 18     I     24 


Maryland 

Virjfinia    

Niirili  ( 'anilina. 
•Siiiitli  Caruliriu  . 
(lenrg-ia 


Florida. 


3U 
21 
42 
52 
«0 
114 


28 
39 
fi9 
73 
69 
112 


\\'est  \ir^iui; 

Dakiilii 

Neliniska  . . . . 

Iowa 

Dili.. 

Michigan  — 
Kentueky  .  . . 

Indiana 

Minnesuta 

Illinois 

Tennessee    . . 

Missouri 

Kansas 

A  labnina 

Mississippi . . . 
Arkan.sas  . .  - . 

Texas 

Louisiana  .  .  - 


IH7II.     IfHO. 


Pacific  Kkmo.n. 


.S  ill         I'lah 

(i  y  Oregon 

...'     12  i    California 

i  ',   Nevada  .. 


IHTO.     IHHU. 


13 
14 
14 
21 
25 
31 
34 
3."i 

4"! 

(il 
66 
76 
77 
91 
114 
11,') 


17 
20 
45 
47 
4 
36 
59 
83 
72 

104 
91 

140 
93 
92 


New  Mexiei) 

Wash ingti 111  Territory. 

Arizona 

Colorado 

Idaho    

Montana 

W>'omincr 


13 

.1.1     15 


38 

47 


a 

IS 
18 
tl 
121 
11 
15 
15 
15 
20 
29 


f -See  note  on  p.  87,  supra. 


AM(.)X(;    THE    C'OXFEDERATK    TROOPS. 


103 


TliP  cases  pinhracfd  in  tlie  reports  ul'  i)r.  W'tlliams  consisted  of  9,954  interniittents 
and  (),S27  remittents.  Ul'  llie  former,  5,71^^  Wi-rr  <iuotidiiUis,  ;),76y  tertians,  3cS9  (luartans 
and  .So  conuestivf  t'ases. 

Table  XXXTV. 

A  Comjjarison  of  (he  Prevalence  of  Intermittent  and  h'nnittcnt  Fever-i  in  the  Confederate  an(t  Federal 

Armies  of  tlie  Potoniae  from  July  1,  186 1,  to  March  ,11,  ISO 2. 


.Julv,  IfHl 

SepteiiibiT    iHtll 

Oeti.her,   If^tll 

Ni.veniber.  iHCl       ... 

Dec«'inher,  If^tll     

Mur.li.  I^'fi-J 

CoNKKl'KKAIK    AHMY, 


Mniithly 


Null 

l.cr  ..1  (• 

.es. 

Ratio  per  ]. 000     1 
strength. 

1 

s 

a: 

1  Total  Malarial. 

i. 

a; 
c 

P5 

■c 

s     j 

1 

21,. '•.77 

!KI9 

330 

(lay 

14 

15 

29 

50.  .')-,'.'■> 

1,  (174 

l,71<i 

:t.  39(1 

33 

34 

■  67 

5C,  :i(iO 

1,739 

l,7:i9 

3,478 

30 

30 

60 

58,  918 

1.864 

i,a47 

;i,  ail 

31 

23 

ri4 

.15,  Oilft 

1,  40,5 

(104 

9,069 

'J6 

12 

38  ^j 

:&,  700 

1,  I4e 

477 

i,ti-r> 

'-'0 

9 

29 

,17,  ()89 

tiS7 

aca 

949 

\-i 

5 

17 

.54,  tiU) 

(irjo 

171 

8'Jl 

\-i 

3 

15  |l 

:tl,470 

488 

121 

609 

15 

4 

19 

49,  :)H4 

1,  lot) 

7,59 

1,  865 

23 

15 

38 

I    .    S.    .\UMY. 


.S'linihir  of  ('M>i' 


Hatio  per  1.000 
strength. 


17,709 
,50.  l',(lf 
,-.5,  ^ll^' 
I  I  3.  -.'04 
133,  669 
1 52,  7.59 
167,267 
1.53,308 
126,588 

111,169 


165 

1 .  607 
3,  .5:4 
3.  984 
3.011 

2.  151 
!.  170 
1,344 

793 

1,971 


z 
ta 

'E 

i 

63 

228 

."^'4 

2,  191 

1 ,  340 

4,  8.54 

1,7.56 

.5.740 

1.922 

4.  933 

1.474 

3.  625 

982 

2,  152 

1.  148 

2,  492 

664 

1,4.57 

1,  104 

3,  075 

13 
43 

51 

37 

24  ' 

13 

16 

12 


The  coiisolidatod  monthly  reports  for  certain  general  hospitals  in  Virginia  during  the 
last  foni-  months  of  1(S62  give,  in  a  total  of  34,890  admissions  for  disease,  8,095  admissions 
for  malarial  fevers,  distrihutcd  as  follows:  Kcmittents  931,  or  30  per  cent,  of  the  malarial 
total,  i|Uotidians  623,  tertians  1,309,  quartans  215  and  congestive  cases  17.  Unfortunately 
the  mortality  iVom  these  cannot  be  ascertained  from  the  I'eports. 

Accoi'ding  to  Dr.  Jones,  the  reports  of  sick  and  wounded  for  the  years  1861  and  1862, 
filed  in  the  office  of  the  Surgeon  General  of  tlie  Confederacy,  exdusive  of  those  from  the 
Trans-Mississippi  department,  gave  a  total  of  819,286  cases  of  disease  and  injury,  not 
including  gunshot  wounds,  while  the  cases  of  malarial  fever  numbered  1 15,415,  or  one  case 
of  malarial  fevei'  in  7.1  of  the  cases  constituting  the  total.  The  corresponding  figures* 
from  the  i-ecords  of  the  United  States  troops  give  1,709,416  cases  of  all  diseases  and  injuries 
exclusive  of  gunshot  wounds,  and  274,053  cases  of  malarial  fever,  or  one  case  in  eveiy  6.2 
of  the  total.  These  rates  indicate  that  the  jji'ojv.rtion  of  malarial  cases  to  tlu^  whole 
number  taken  on  sick  report  was  greater  among  our  men  than  among  the  Confed(>rates. 
Hut  it  would  be  unsafe  to  conclude  from  this  that  the  ratio  of  the  paroxysmal  levers  to 
strength  was  at  all  less  with  them  than  with  us.  Indeed,  in  the  few  instances  in  which  it 
has  been  possible  to  ascertain  the  ratios  of  cases  to  strength  in  certain  portions  of  the 
Confederate  army,  they  have  been  found  to  bo  actually  greater  than  in  the  corresponding 
parts  of  the  United  States  forces.  Among  the  statistics  preserved  by  Dr.  Jones  is  a  table 
relating  to  the  Confederate  Army  of  Tennessee,  the  figures  of  which  may  be  comi)ared  with 
those  of  the  Federal  Army  of  the  Tennessee  for  the  same  year.     The  table  covers  fourteen 


'  See  Table  XIII,  supra.  pa|fe  31. 


104 


MALAIUAL     FEVKRS 


months,  IVotn  April,  18^)2,  to  :\[ay,  18(13,  inclusive;  bui  tlit;  mean  sirentzili  Im-  tli.-  firpt  two 
iiiontlis  is  unrnrtuiiatcly  ik.I  ^;iv('ii.  Dr.  Jcjnks  remiirks,  also,  that  the  rciiii'iis  tor  .Iiilv, 
^Septciiibcr  aixl  Oclolirr,  \S&2.  aiv  '■  iiu-oiiiph.tc."  They  ropreseiit.  how^'Vi',  a  sutHcit'iitlv 
laTuv  part  of  the  tbrec  to  give  a.  i'aii'  iioiii.n  of  tho  i»rfvalonco  of  tin-  disease  inah-r  cniisid- 
cralion  in  the  whole  army,  lii  the  folli.wiug  tal.lc  the  malarial  statistics  ot  these  armies 
are  contrasted : 

Tahi.k  XXXV. 

A  Comparison  of  the  Prevalence  of  Intermiilenl  and  Remittent  Fevers  in  the  Confedernte  and  the  United 
States  Armies  of  the  Tennessee  from  June  J,  1862,  to  May  31,  1863. 


June,  iwa 

July,  iwa 

An|c<i»t,  IS'i- 

September,  IHti-J  . . . . 

OotolxT,  IHta 

November,  lHfi2    ... 

Dei'enitH^r,  IHd'J 

January,  IHt;;{ 

Kebruary,  iwa 

March,  IHIIH    

A|>rii,  lH(i:i 

May,  lecri 


Mtmthly  average  . 


CciMKhF.KA  IK    .MiSlY. 


40,  >~lU 
10,"  (i."-* 

;«>,  dj."; 
9,  :)i  I 

I. 1,08'.' 

;i:!,  7!M 

4H,  \m 
fio,  i;o4 

(ill,  nil 

(;4,'t4i 

.W,  121 
40,  282 


Niinitifr  nl'  <'asfs. 


1),  2ti9 

iwa 

2,  Hil 

.'')4:i 
i,:iio 

i,ti9,''> 

i,7!n 
2, 2i:i 
:i,  103 
;l,  7:i4 
4,  o:io 

2,144 


2,  4H7 
927 

l,r,9:! 

97 

2:10 

2t;.-' 
:;9H 

491 

i\n 

IIOH 
1,418 
1,49S 


:\  731; 
1, 909 
:i,  7.''i4 

1140 

1,  i;!2 

1,.".7H 
2,09;) 
2, 21'! ; 

2,  H2i; 

4,1111 

r,,  1,12 

.1.  .'■i2H 


911        3,0.15 


Ratio  per  1,000 
strt'iigtli. 


WO 
92 
72 
.If 
tio 

;)9 
:!.-. 
;i.i 

X, 
.10 
.18 
73 

.13 


~ 

[3 
_2 

t; 

— 

X 

H 

«1 

141 

Vl 

179 

.13 

12.1 

11 

(i9 

1.1 

71 

S 

47 

» 

43 

10 

4.1 

9 

44 

1.1 

01 

22 

80 

27 

lofl 

23 

7fi 

1 1.   S.    .M;mv. 


(ill,  042 
80,(147 
70,  997 
82,  972 
111,891 

\:v,,:m 

133,  Mil 
143,942 
141,  1,18 
14(i,  790 
143,  3(i7 
140,277 

11(1.47.1 


NdlllbtT  nC  ("ii^. 


c 

z 

2,  .141 

1,174 

3,04.1 

1,9-.'1 

3,  24.1 

1,72.1 

.1,  898 

1,702 

7,  338 

1,0(19 

(1,783 

1,043 

4,  (143 

1,40:". 

4,771 

1,891 

4,  .100 

1,711 

,1,070 

l,!119 

4,  (191 

1,73(1 

3,911 

l,.1(i.1 

4,709 

1,70(1 

HmI 


io  |.fr  1.000 
slreiitftli- 


4,  I  I.'. 
4,  972 
4,  970 

7,  000 
9,007 

8,  420 
0,048 
0,  002 
0,  2>'l 
0,  !I91 
0,431 
.1,  470 

0,415 


38 

:i8 
40 

71 
01 
10 
31 
33 

31 
33 

28 


24 
24 
24 
21 
1.1 
12 
10 

13 
12 
13 
12 
11 


In  tlie  case  of  these  confronting  ai'mies,  as  in  the  case  of  the  Confederate  and  Federal 
Armies  of  the  Potomac  previously  contrasted,'"  the  Confederates  had  actually  a  larger  jiro- 
portion  of  ceases  than  was  reported  by  the  Federal  Army.  Other  statistics  published  liy 
Dr.  JoNKS  point  in  the  same  direction.  The  rebel  command  serving  in  the  river  batteries 
below  the  city  of  Savannali,  Ga.,  reported  from  October,  1862,  to  December,  1863,  inclusive, 
a  mean  strength  of  878  officers  and  men,  with  3,313  malarial  cases,  of  which  2,824  were 
interinittents  and  489  remittents.  As  this  command  occupied  the  low  rice  lands  of  the 
Havannah  river  its  experience  may  serve  to  indicate  what  our  own  troops  in  the  Depail- 
ment  of  the  South  would  have  suffered  had  they  been  advanced  by  the  fortune  of  war 
from  the  comparatively  healthy  coast  islands  to  the  lowlands  of  the  main.  Tjooking  only 
to  the  statistics  of  the  year  1863,  Dr.  Jones's  figures  give  2,214  intermittents  and  461 
remittents,  a  total  of  2,675  cases  of  malarial  fever  in  a  mean  strength  of  873  men.  In 
ratios  per  1,000  of  strength  these  are  equivalent  to  2,536  for  the  intermittents,  528  for  the 
remittents  and  3,064  for  all  the  malarial  fevers.  Among  the  United  States  troojis  in  tlie 
Department  of  the  Soutli  the  latio  of  malarial  cases  for  the  year  ending  June  30,  1863, 

*  PitfTH  103,  siifini. 


AMONC,    THE    CONFEDKRATK    TROOPf!. 


105 


was  l)ut  528,  that  of  the  iuterniittents  Ix'iiig  :v59  and  <>i'  tht^  remittents  169;  whih.^  for 
tlie  following  year  the  malarial  ratio  was  594,  the  intermitt.'ut  ratio  being  492  ami  the 
remittent  102. 

Equally  instructive  is  the  contrast  between  our  reports  fi'om  the  Department  of  thi^ 
8outh  ami  those  published  l)y  JoxKs  as  iVdm  the  (.'ontVileratc  ti'ooiis  serving  in  the  Depart- 
ment ol  South  Carolina.  Georgia  ami  Floiida.  frum  .binuarv,  1m62.  to  Julv,  1S<):'>.  iuelusivc 
The  luean  strength  of  the  eoiimiaml  during  this  prrioil  was  2o.72:)  men,  and  the  eases  of 
malarial  fever  41,589,  of  which  35,925  were  intci-mittcnts  and  r),614  remittents.  Con- 
sidering only  the  figures  for  the  fiscal  vear  endinii;  June  ;')(•,  iStv'),  the  f  illowino:  results  are 
obtained,  which  may  lie  compared  with  the  ratios  just  stated  as  fi'om  the  Federal  [)e])art- 
ment  ol'  the  South:  Mean  strength  26,185;  numlier  of  intermittents  30,322,  or  1,158  per 
1,000  of  strength;  remittents  3,665,  or  140  jier  1,900;  total  of  malarial  levers  33,987, 
or  1,298  per  1,000. 

Another  table  presented  by  Jones  embodies  tlie  statistics  of  the  Coid'ederate  troops  in 
and  around  Mobile,  Ala.,  for  the  period  from  January,  1862,  to  July,  1863,  inclusive; 
Average  strength  6,752;  malarial  cases  13, (i)68,  of  which  10,500  were  intermittents  and 
3,168  remittents.  The  figures  for  the  vear  endintf  June  30,  1863,  o;ive  a  mean  streng-tli  of 
7,659,  and  a  total  of  malarial  fevers  amounting  to  10,878,  of  which  8,635  were  agues 
and  2,243  remittents.  The  ratios  obtained  from  these  numbers,  respectivelv  1.420,  1,127 
and  293  per  1,000  of  mean  strength,  exceed  those  for  the  same  year  from  our  Department 
of  the  South,  and  even  those  for  the  same  period  from  our  more  unhealthy  Department 
of  the  Culf,  whieh  rep(M'ted  per  1,000  of  strength  863  cases  of  malarial  fever,  696  being 
intermittents  and  167  remittents. 

The  Army  of  the  Valley  of  Virginia,  during  the  ten  months,  Januai'v,  1862,  to  Octo- 
ber, 1862,  inclusive,  had  3,885  malarial  cases  in  an  averat^je  strength  of  15,582  men. 
The  figures  for  the  first  six  months  of  this  period  may  be  contrasted  with  those  of  tiie 
Federal  ti'oops  in  the  Department  of  the  Shenandoah.  An  (>qually  trustworthy  comparison 
cainuit  be  made  for  the  remaining  foiu'  months,  liecause  during  that  period  the  Federal 
reports  for  the  district  in  question  have  not  been  separately  tabulated.''' 


*  We  may,  however,  etmtrawt  tlie  tigures  t'nriiislied  by  In.  .lONES  fur  the  ('onfederjtte  Army  <if  tlie  A'iilley  of  Virginiii  diirinir  the  mmith.'*  ol  .Iiil\-. 
Anffiist.  Septemher  anil  Octoher.  IWi-J,  wilh  those  of  the  Federal  troops  in  the  Middle  Department  for  the  same  i>eriod:  for  on  the  breaking  up  of  the 
DepartTiient  of  the  Shenandoah  the  sii^k  r^'ports  of  the  troops  whieh  remained  in  it  were  eonsolidated  with  tlnise  from  the  Middle  Department. 

A  Cimipiirison  rif  the  rrendenre  iif  Inlrrviittnit  anil  Hrmitlent  Fevers  in  the  Ctmfeilerate  Arm;/  of  the  ViiUey  of  Virginia  ami  thr  U.  S.  .Middle  Department 

of  the  .Atlantic  Ueyinn  for  the  period  from  July  1  /()  October  31,  I(*ti2. 


July,  18(i2 

August,  1862  .... 
Septemlwr,  18fi2  . 
October,  18fi2 


15,589 
15,  CA-i 
21,123 
34,200 


Monthly  average j  21,  r>39 


COXFEDERATK  ARMY. 


Number  of  Cases. 


473 
434 
348 
632 


239 
305 
127 
351 


712 
T39 
475 
983 


Ratio  per  1,C 
strength. 


727 


34 


U.  S.  Akmv. 


12,  3.i7 

9,135 

19, 101 

21,  531 


15,531 


Numlwr  of  Cases. 


2fi6 
214 
235 
473 

297 


150 

82 

139 

193 


141 


4u; 

29fi 
374 
6fi6 

438 


Ratio  (ler  1,000 
strength. 


.1      i 


28 


Med.  Hist.,  Pt.  Ill— 14 


106 


MALARIAL    FEVKRS 


Table  XXXVI. 

A  Comparison  of  the  Prevalence  of  Intei-mittent  and  Reiniitent  Fevers  in  the  Confederate  Army  of  Virginia 
and  the  U.  S.  Department  of  the  Shenandoah  from  January  1,  1862,  to  June  30, 1862. 


January,  181!-' 

February,  lyti^    , , . 

Murcli,  IBt'.a 

April,  1S(W 

May,  Ifti-J 

June,  \^ki-i 

.Miintlily  averajfe 


(■ 

>MKliFll.\lK 
t>er  ol'  Case.';. 

.\H.MV. 

- 

Nuiii 

IT.  .s.  .Au.^ 
>er  ol"  Case.s. 

V. 
Uat 

..  per  l.nOo 

Nuui 

Hal 

.1  |ier  1 

.000 

s 

sirenj^tl 

~ 

'^ 

tivinfil 

.-c 

* 

£d 

x 

!t. 

i 

:: 

i' 

^ 

a: 

^ 

Z 

s 

< 

i 

= 

i; 

4. 

^ 

f, 

^ 

E 

5 

^ 

^ 

o 

a. 

s 

- 

« 

E- 

■= 

» 

H 

<. 

" 

K 

H 

■5 

» 

H 

9,  ■J7ti 

23 

13 

3i; 

3 

1 

4 

17,  143 

121) 

85 

208 

7 

5 

12 

(<,  iy:i 

It; 

M 

ffi 

o 

1 

3 

21,498 

1.15 

9« 

251 

' 

,5 

12 

7,41S 

6 

' 

13 

1 

1 

tj 

27,437 

21  ;i 

127 

388 

9 

5 

14 

9,  .IM 

31 

3 

34 

3 

31 

4 

14,072 

181 

92 

273 

13 

li 

19 

lti,731 

291 

4f  1     339 

IT 

3 

ao 

9,  .'■.08 

82 

5U 

132 

9 

5 

14 

If,  U99 

:iio 

i>10  '     rr_>(l 

17 

1-. 

29 

14,391 

177 

7ti 

2.53 

13 

5 

18 

11,. 145 

113 

48  j     lUl 

lU 

4 

14 

17,341 

11)3 

88 

251 

9 

•-• 

14 

These  statistical  fragments  indicate  tliat  malarial  fevers  were  more  prevalent  amuno- 
til'"  Confedt^rate  than  among  the  Federal  soldiers. 

AfortuJity. — For  want  of  data  on  the  rebel  side  it  is  not  possible  to  determine  the  rela- 
tive mortality  from  these  fevers  in  the  opposed  armies;  but,  as  bearing  on  the  question,  we 
have  Dr.  Jonks's  statement  that  the  records  of  the  Hurgeon  General's  Office  for  the  years 
1861  and  1862  gave  l,!-)33  deatlis  in  connection  with  115,41")  cases  of  paroxysmal  lever 
and  31,2:'>8  deaths  from  all  causes  excepting  gunshot  injuries.  Table  XTII,  alieady  pre- 
sented, sliows  that  these  figures  are  ecjuivalent  to  43  deaths  from  malarial  fever  per 
thousand  deaths  from  all  the  included  causes,  and  to  a  fatality  rate  of  1.15  per  cent.,  or 
one  death  in  86.2  cases,  while  the  corresponding  figures  from  the  rcn-ords  of  the  U.  S. 
troops  are  eijual  to  160  deaths  from  malarial  fever  per  tliousand  deaths  from  all  causes, 
and  to  .95  per  cent,  of  fatal  cases,  or  one  death  in  evi^iy  105.3  recorded  attacks. 

According  to  these  figures  the  ratio  of  deaths  to  the  recorded  cases  was  greater  among 
the  rebel  than  among  the  northern  troops;  but  there  is  no  certainty  that  the  recorded  cases 
in  the  two  armies  bore  the  same  reLition  to  the  number  of  cases  that  actually  occurred.  It 
a])pears  not  unlikely  that  this  lai-ger  ratio  of  deaths  to  recorded  cases  may  have  originated 
in  a  failun;  to  report  the  lighter  agues.  The  familiarity  of  the  Southern  people  with 
7Tialarial  disease  suggests  that  many  attacks  which  would  have  appeared  on  tiie  sick  reports, 
had  they  occurred  among  Northern  men,  may  have  been  suffered  without  excuse  from  dutv 
in  the  Confederate  camps.  It  will  be  noticed,  also,  that  the  large  ratio  per  thousand  deaths 
from  all  causes  constituted  by  the  deaths  from  malarial  fevers  among  tlu^  U.  S.  troops,  as 
compared  with  the  small  corresponding  ratio  on  the  Confederate  records,  is  opposed  to  the 
view  that  the  fatality  of  these  diseases  was  greater  among  the  rebel  troops. 

The  summary  which  Dr.  Jones  has  given  of  the  field  reports  from  the  Department  i>\ 
South  Carolina,  Georgia  and  Florida,  is  available  for  estimating  the  gravitv  of  tlie  lualarial 
fevers,  as  he  has  fortunately  ])ublished  in  connection  with  it  a  tabular  consolidation  of  the 
liospital  reports  from  that  department  foi   the  same  jterind.     From  these  it  is  found  that 


AMONG    THE    COXFEDERATK    TROOPS. 


107 


41,539  cases  of  malarial  fever  corresjinniled  with  227  iL^atlis,  or  one  death  in  every  187 
cases,  constituting  a  smaller  ]-iercentao;e  of  fatal  cases,  .55,  in  this  mahirious  department 
tliaii  the  average  percentage,  .70,'-'  among  the  Union  troops  in  all  the  departments. 

The  opinion  that  the  rate  of  fatality  of  the  malarial  fevers  as  a  class  was  smaller 
among  the  Confedei'ates  than  among  the  Union  troo})s  gathers  support  fr(.im  a  study  of  the 
totals  in  the  following  tabl(\  which  shuw  that  the  percentages  of  the  ditlerent  types  of  fever 
were  not  the  same  in  the  two  armies: 


Tahlk  xxxvn. 

Shmvhtg — /,  The  lieJaiive  Frequency  of  the  Forms  of  Malaria/  Fever  among  the  Confederate  Troops  as 
compared  loith  lluir  Frequency  among  the  Troops  of  thv  United  States,  expressed  in  percentages  of 
the  total  number  of  Malarial  Cases;  and,  ii.  The  Frequency  of  the  Varieties  of  the  Intermittents, 
expressed  in  percentages  of  their  totals. 


Command. 


(iarrison  of  Savaniiah,  Ga. Cmifed. 

Deiiartnieiit  uf  the  South V.  S. 

I>K|>ui'liii('rit  or  South  Carolina, Ceorgia  anil  Florula Cc.iifed. 

Department  of  the  Soiitli i:.  S. 

lianiaon  of  Mobile,  Ala Confed. 

Department  of  the  (!ulf V.  S. 

Armv  of  Tennessee Confed. 

Department  of  the  TenDe8.see l'.  S. 

Army  of  Virginia Confed. 

Department  of  the  Shenandoah,  Middle  Department V.  S. 

Aiiiij  of  the  Potomac Confed. 

Arm.v  of  the  Potomac XL  S. 


I'KRIol> 
INDEK   OnsKR\ATliiN. 


Oct.,  '62,  to  Dec,  'C:!, 
15  months. 


Jan., '02,  to  Ju1.v,  "03, 
19  months.  j 


\jan.,'C2,to  Jul.v 
I      IK  nu)nths. 


-i 

)  April,'62,toMa,v,'63,  jf 
['     14  months.  j 


\jan.  to  Oct.,  1SC2,  11]/ 
L      months.  | 

)  July, '61,  to  Mar., '62,  j 
C     9  months,  ) 


Total  Conf.  derate |     119,501 

Total  United  States I     1 


"    ^  "    " 

. 

of 

?- 

SJ 

«5 

^1 

i  <*• 

g 

d 

V 

a 

E-i 

l-l 

IS 

3,313 

85 

15 

17,8S1 

7,9 

23 

41,539 

80 

14 

1I,,8I,S 

l» 

31 

13, 940 

77 

23 

SC,  783 

81 

19 

^      40, 133 

70 

30 

81,,  80S 

73 

27 

3,8s.'-. 

6G 

34 

3,2r,7 

«r 

SS 

10,781 

59 

41 

27,  U7S 

«4 

sc 

119,591 

76 

24 

17:1,21,3 

73 

S7 

P 

EKCEST.Ml 

Total 

E    OF 

Intermittents. 

Total   number 
mittent 

.s 
s 

O' 

1 

a 

i 

> 

I 

6 

2,  824 

47 

51 

1 

.07 

M,  .946- 

4S 

4.'^ 

0 

1.00 

35,925 

50 

47 

3 

.50 

Ul,  29/, 

S3 

.» 

fi 

2.00 

10,772 

36 

6U 

3 

.80 

2t,57C 

43 

5? 

3 

S.OO  ■ 

iv,vm 

47 

45 

0 

2.00 

€1,803 

ai 

iS 

« 

2.00 

2,573 

4(> 

45 

7 

2.00 

2,  107 

ti2 

33 

4 

l.VO 

9, 954 

57 

38 

4 

.90 

17,  739 

50 

40 

r^ 

.5.00 

90,147 

48 

47 

4 

.90 

117,  S25 

49 

43 

5 

S.OO 

The  remittents,  for  instance,  constituted  a  larger  proportion  of  the  malarial  cases 
among  the  Union  than  among  the  Confederate  troops.  It  must  be  rememberetl,  also,  that 
oidy  the  remittents  and  intermittents  occurring  in  the  Federal  forces  are  here  tabulated, 
the  tj'pho-malarial  cases  having  been  omitted  as  the  Confederate  reports  liad  no  corre- 
sponding heading.  No  doubt  some  of  our  typho-malarial  cases,  had  they  been  in  tlie  hands 
of  southern  officers,  would  have  been  reported  among  the  remittent  fevers,  as  some  of  the 
remittents  of  the  Confederate  surgeons  might,  on  account  of  a  dry  dark  tongue  or  other 
symptoms,  have  been  called  typho-malarial  had  they  occurred  in  the  practice  of  northern 
medical  men.  It  may  therefore  be  assumed  that  if  the  same  medical  views  had  determined 
the  diagnosis  of  all  the  cases  tabulated  above,  the  ditference  between  the  percentages  of 
remittents  in  the  two  armies  would  have  been  greater.  Had  the  diagnosis  been  made  by 
our  northern  medical  men  the  remittents  of  the  Confederate  armv  would  have  been  dimin- 


*  Table  XXII,  supra,  p.  79. 


108 


MALARIAL    FEVEKR 


islioii  l)y  tlie  abstraction  of  a  certain  num1)er  of  typlio-malarial  cases,  while,  liad  tlie 
south. Til  Mthcers  inaJf  the  reronl,  the  remittents  of  our  army  would  have  Ijeen  increased  in 
the  absence  of  the  typhd-malarial  gron]>.  On  either  supposition  the  prepomleranco  of  grave 
cases  of  malarial  fever,  shown  by  the  tabh^  as  having  existed  among  the  Union  troops, 
would  hav(^  been  augmented.  The  greater  pci'centage  of  congestive  casc'S  among  our 
troops  is  also  sug<j;estive  of  a  larger  mortality.  Indeed,  these  piM'centages  may  be  used  to 
deteiMihne  apj^roximately  the  average  gravity  of  the  nialarial  i'evers  among  the  (Jonlech'rate 
troops.  If  it  be  admitted  that  the  various  types  of  paroxysmal  fever,  as  they  occiu-red 
among  the  Confederates,  were  attended  by  the  mortality  which  characterized  them  in  their 
attacks  upon  our  soldiers,  as  shown  in  the  last  column  of  Talde  XXII, '"'  the  iuHuence  ^'\rv- 
cised  on  the  mortality  by  the  smaller  ]»roportion  of  remittent  and  congestive  cases  among 
them  may  lie  estimated.  The  deaths  thus  ealculat(>d  formed  .57  per  cent,  of  the  cases, -j- 
or  one  death  in  eveiy  175  cases  among  tlie  Confederate  troops,  and  .97  per  cent.,  or  oiu; 
death  in  every  lOo  cases  that  occui'red  among  the  Ibiited  Htates  soldiei-s  for  the  [lei'iods 
stated  in  the  table  above  presented,  it  seems  probable,  therefore,  tliat  altliough  attacks  ot 
malarial  fever  were  of  more  freijUeiit  t)ccurrence  among  the  Confederates,  the  gravity  ot 
these  attacks,  including  the  conserpient  mortidity.  was  less  than  among  tin'  Union  troops. 

Ill,— MALARIAL  FEVERS  AMONG  THE  PRISONERS  OF  WAR  HELD  BY  THE  REBEL  AUTHORITIES. 

It  might  reasonulily  be  supposed,  from  the  situation  of  the  ])rincipal  places  of  con- 
Knement,  that  malai'ial  levers  of  local  origin  would  not  have  prevailed  so  largely  among  our 
captured  men  as  among  our  troojis  on  active  service;  but  the  statistics  bearing  on  this 
question  are  not  of  a  satisfai-tory  ciiaracter. 

J)r.  .loNKs  has  endeavored  to  show  that,  the  Feilei-nl  prisoners  in  the  Ander.-ioiiville 
stockade  suft'ered  less  from  these  fever.s  than  the  rebel  troop.s  serving  in  Mouth  (Airolimi, 
Geore-ia  and  Florida,  or  even  in  such  an  tdevated  and  comparatively  healthy  region  as  tlie 
Valley  of  Virginia. ;|;  A  nd'erence  to  Table  X\n,§  compiled  fi'om  Hgures  published  by  him, 
will  show  that  during  the  six  months  of  iSdl,  March  to  August  inclusive,  there  were 
repoi'ted  aimaig  tla;  prisoners  2,9G6  cases  of  malarial  fever,  119  of  which  were  fatal.  Of 
the  cases  1,170  were  quotidians,  775  tertians,  195  quartans,  S  congestive  fevers  and  SlS 
remittents.  The  intermitteiits  caused  64  deaths  and  the  remitti'uts  55.  The  monthly 
ratio  of  cases  per  thousand  of  str(Migth  was  2o,  a  iiuml)er  considerably  smaller  than  the 
averatfe  monthly  ratio  among  our  white  troops  in  the  Atlantic  region  for  the  months  stated, 
us  may  be  seen  by  a  reference  to  Table  XXVIII. ||     Dr.  Jones,  however,  recognized  the 

*  .See  page  79,  supra. 

t  In  every  linndred  eases  of  pure  malarial  fever  there  were  — 


Among  the  Union  Thoops. 


3.1.8  (^ncitiilians  with  . 

31.4  Tertians  with  ... 

3.  f)  (Quartans  with. . . 


.Oms  .leaths. 
.0:il-l  deaths. 
.1X173  deaths. 


AMONf)   THE    CONFF.DF.KATK    TROOPS. 


2.2  Congestive  with 5398  deaths. 

27.0  Remittents  with 3537  deaths. 


100. 0  Malarial  with 9680  deaths. 


3t). 0  eases  with  . 

35.3  cases  with 

3.  0  oases  with  , 

f).  7  eases  with  . 

25.  0  <'ases  with  . 


.  I)3ti    deaths. 

.  0352  deaths. 
.IHJCO  deaths. 
.  l(i«4  deaths. 
.  3275  deal  lis. 


100.0  oases  with 


711  deaths. 


J  .See  his  Investigations  uf>OH  the.  di.iea.^es  o/  the  Federal  Prisoners,  etc..  cited  in  note,  page  2!',  supra. 
§  Page  35.  supra.  ||  Paeres  ?!^.  1^1)  and  91,  supra. 


AMON'.  Tin-:  i'RiMiM-:!;>  uk  war.  109 

tact  that  Ins  figure.-  dul  imt  iinliracr  llir  wImMt  uuhiIht  of  rases  tliat  occui'ivil  williiu  the 
stuckaili'  diii'iiig  the  six  iimnths.*  Their  ileiieieiiey  may  he  aiipreeiateil  hy  an  cxaiiiiiiatiiiii 
of  the  onginal  hosj)ital  I'egister  of  the  prisuii,  now  on  lile  in  the  oflice  ot  the  Adjutant  ( ienei'al 
<if  fhe  y\rniy.  This  document  shows  the  nundjer  of  (U'alhs  caused  l>y  these  levers  bet weeii 
February  21,  1864,  and  April  17,  1SG5,  to  have  been  10:);  of  which  11!)  occurred  during 
the  period  covered  by  JoNKs'  coiiiiiilatiou,  being  30  in  excess  of  th(jso  i-eported  by  him. 

lUit  the  re>'-ister  throws  no  direct  li^ht  wii  the  number  of  t;ases.  Onlv  a  small  minor- 
ity  of  the  malarial  fevers  occui'ring  among  the  prisoners  in  the  stockaile  were  admitted  to 
hospital.  While  l^r.  .Iti.xi'.s'  statemeid.  embraces  2,9(>()  cases  in  a  period  of  six  months, 
tlu'  hospital  register  atd^nowledges  the  admission  of  only  2;)4  cases  in  :\  perioil  ot  over 
fourteen  months,  which  included  the  six  months  aforesaid.  The  character  of  the  admitted 
cases  may  be  inferred  li'om  the  fact  that  l(i3  of  their  munlier  terminated  latally.  There 
wi'fe  Kit)  int(>rmittents  with  lOl  deafhs,  S.S  remitb'uts  with  T)!)  deaths,  and  (1  congestive 
cases  with  o  deaths:   in  13  of  tlu'  cases  no  disposition  is  recorded.f 

Dr.  .loNKS  has  ]x)int(Hl  out  that  after  a  considerable  increase  in  the  prevalence  of  the 
malarial  fevers  among  the  prisoners  during  the  month  of  May,  when  the  maxinumi  ratio 
of  77  per  thousand  was  attained,  the  cases  thereafter-  diminished  to  a  ratio  of  17  per  thou- 
sand in  July  and  15  in  August.  Although  the  figures  which  he  has  publisheil  have  no 
absolute  value,  it  is  probable  that  tlu'y  give  a  fair  expression  to  the  relative  [trevaicnce  at 
diflerent  times,  especially  as  confirmatory  evidence  is  obtained  from  the  mortality  as 
recorded  in  the  hospital  register,  which  sliows  149  deaths  from  malarial  fevers  diu'ing  tiie 
six  months  ending  August  3,  LSCU,  and  but  14  deaths  during  the  subsequent  eight  mouths. 
Tn  explanation  of  this,  he  has  suiiFested  that  the  morbitic  intlueuces  generated  by  the  over- 
crowded  and  Hlthy  condition  of  the  stockade  neutralized  or  destroyed- the  malarial  poison,;}; 
and  in  view  of  the  well-known  infrequency  of  malarial  fevt'rs  in  densely  peopled  cities  this 
suggestion  apf tears  probable  enougli. 

The  only  otlier  statistics  bearing  on  the  prevalence  of  malarial  levers  among  Federal 
jirisoners  in  the  Bouth  are  from  the  register  of  Division  No.  2  of  the  lios].ital  at  Danville, 
Va.  This  record  extends  from  November  23,  1863,  to  March  27,  bStif).  Thei-e  were 
4,332  admissions  and  1,084  deaths,  of  whicli  but  2;)3  cases  and  17  deatiis  are  attributed  to 
malarial  fevers.  Such  figures  suggest  similar  conditions,  so  far  as  concerns  the  occuri-ence 
of  these  fevers,  to  those  which  existed  at  Andersonville. 

IV. -MALARIAL  FEVERS  AMONG  THE  PRISONERS  OF  WAR  HELD  BY  THE  UNITED  STATES. 

The  alphabetical  registers  of  the  Surgeon  General's  Office  record  the  deaths  of  1,134 
Confederate  prisoners  from  'malarial  fevers  in  a  total  of  23,591  deaths  from  all  diseases; 
of  these  122  were  attributed  to  simple  intermittents,  l(i9  to  congestive,  489  to  remittent 
atul  351  to  typho-malarial  fever.     These  figtu'es  alTord  no  l>asis  for  calculating  the  ivhitive 

*  He  rerimrks,  in  speaking  (fpiierally  iif  the  slatistira  of  the  Aiiilersniiville  |.risoneis.— "  Nii  elassitieil  reciml  i.f  t!ie  fi.k  in  the  stm'kaiU'  n;i«  ke|it 
after  Ihe  estalilishment  of  the  hospital  without  the  prison.  This  (M-.t.  in  I'onjiinetion  with  faets  already  presented.  relalinK  to  tlie  iiisulHeieuey  'rf 
medieal  offleers,  and  tlie  extreme  illness,  and  even  deutli.  of  many  of  the  prisoners  in  the  tents  in  the  stockade  without  any  medieal  attention  or  ree.iril 
beyond  the  bare  number  of  the  dead,  demonstrati^  that  ttje  (ifrures,  larpe  as  they  appi'ar  to  be,  are  far  lielow  the  truth.''  P.  5:ill.  0^1.  cil.  When,  however, 
lio  comes  to  discn.ss  the  freiineney  of  malarial  fevers  anionf;  the.se  prisoners,  he  lakes  a  smnewhat  modified  view:  "While  it  is  evident  from  the 
results  of  the  e.xaminations  recorded  in  the  fourth  I'hapter  that  these  statislies  an;  below  rather  than  aliove  the  absolute  numbers,  still  it  does  not  appear 
that  the  errors  were  greater  in  this  class  of  diseases  than  in  the  others,  and  in  fait,  from  llie  nature  of  malarial  fever,  we  .should  Ih-  dis|Hised  to  consider 
them  less."  P.  Xfi,  up,  cit.  (.)n  the  eimtrary,  it  would  seem  that  in  an  establishment  where  the  n\edical  attemiance  was  insufficient,  as  at  .\ndi.rsonviUe, 
such  comparatively  nnid  forms  of  disease  as  ordinary  intermittent  fever  would  have  been  most  likely  to  escape  report. 

t  See  Table  XV,  p.  34,  supra.  \  Op.  cit.,  p.  ,-Jti8. 


no 


MAhARlAJ-     i'KVKRS 


frequency  or  tatrtlity  of  malarial  <liyoase  among  the  prisonerH;  but  the  following  ta1)Ie, 
compiled  from  the  montlily  rej)orts  of  «iek  aiul  wounded  from  the  principal  prison  depots, 
is  of  value  in  this  eonnection: 

Taklk  xxxviri. 

CaseM  of  Malarial  Fever  until  resti/linr/  morfaliii/,  reported  from  the  principnl  Prixon  Depots  as  hav'nxj 
occurred  aviong  the  Confederate  Prisoners  of  War;  with  the  annual  ratios  per  thousand  of  streiiytli 
)>resent. 


Average  number  of  prisoners  present 


=;  'JL 

>-.  — 

■/  i 

^■^ 

csi 

Cru 

C  " 

cs  A 

01 

5,;3fii 



i'i 


l.mit*       fi,030  I    y,8h5  I    '..',114 


Interinitlent  oases 

Remittent  oases 

Ty pho-malarial  i-ases 


o.&A      r>, •j:)4      i,:iii.')  '    1,03-J 


4, 1'Ji 

163 


i.aoo  ,   1,009 

7J-,'  ,  10 


Total  Malarial  Fevers 10,151        7,206  '     2,384 


Deaths  from  Intermittents  . . . 

Deaths  from  Remittents 

Deaths  from  Typho-inalarial . 


Total  deaths  from  Malarial  Fevers  . 


Annua!  ratios  per  thousand  of  strenfj^tli  for  eases  of — 

Intermittent  Fever - 

Hemittent  Fever 

Typho- malarial  Fever , 


30 


4U1 
50B 


228 
135 


3,570 

2,  527 
1,  72d 


J4  X 


y.i 


■^2 


U       1i 


All  Malarial  Fevers , 

Annual  ratios  pei-  tlnnisaiid  of  stren<rtli  h-r  deatlt>  froni- 

Intermittent  Fever 

Remittent  Fever 

Typho-maiarial  Fever 


320.5    l,?32. 9 

225.4        4:17.9 

K9  '■    252.9 


All  Malarial  Fevers. 


5.>1.8    2,523.^ 


2.  H  10.  5 

7.3  8.I-- 

2.8  ■       42.7 


159.8 

118.  I 

1.2 

279.1 


2.0 


12.7         fi2.0 


98 
119 


172.  9 
ti9.7 
84.8 

327.  I 


2.0 

1.5 

in.  4 

19.9 


54 

3 

417 

4,258 

_ 

3 

14 

3 

11 

4 

y 

10 

34 

51.8 

499.7 

30.7 

341.7 

12.2 

.ti 

;i4.7 

842.  0 

e,59i 

321 
305 


li.  40f> 


2,  498 


9,  HID 


5, 209 


Ii53  :     I,fi20 


(i28 


1,574 
4,725 


35 

H,  8H4 


65 


27 

57  103 

1 


91 

175 


48. 7       203. 5 
4(1.3 
.3 


161 


195. 4 
53.2  j  91.9 
128.2  I         2.0 


-0 


2.  / 

2.2 

1.8 


2.3 


95.  3 


.8 
8.9 


384.9 


38'.t.  3 


40,815 

24, 278 
11, 240 
3,  069 

:i8,  .587 

213 
424 

38;i 

1,  02(1 


2:17.  4 

137.  7 

37.  (i 

472.  7 


9.9  ,       14.2 


3.3 

5.9 

.0 

9,2 


The  ratio  of  cases  to  strength  at  Johnson's  Island  and  Elmira  was  very  small;  at 
Rock  Island  and  Camp  Morton  it  was  less,  and  at  Camps  Chase  and  Douglas  more,  than 
the  ratio  for  the  United  States  troops  in  the  Northern  Department — 526  per  thousand 
annually.  At  Fort  Delaware  and  Point  L(3okout  the  ratios  were  somewhat  less  than  that 
turmslicil  liv  (lur  own  ti'oops  in  the  Department  ot  \Vashmgt(^n — o')0  per  thousand.  ()iilv 
at  Alton,  Illinois,  was  the  ratio  such  as  to  suggest  the  existence  of  intense  hjcal  mahu-ial 
influences.  Here  the  pnjportion  of  cases  was  greater  than  in  any  part  of  our  army  except 
the  Department  of  North  Carolina  during  the  third  year  of  the  war.*  But  when  the  facts 
relating  to  the  frequent  changes  in  the  individuals  composing  the  average  number  present 
at  this  post  are  understood, f  the  large  rates  may  be  accouiiteil  for  without  assuming  the 

*  See  5Hj)ra,  p.  96.  t  .See  supra,  p.  62. 


AMONi'.    THE    r-KIxiNKKs    oK    WAR.  Ill 

•  'Xi^teiicf  iif  malarial   iiitluriiccs   (jT    Im-al    nnniu;    aihl    iihIi'ciI   tlir   prisuii,  ai-cnrdiiiu'  to  tlir 
rcjinrts  (it    tlif  iiis|HTl<,irs,  was  mi  a  ili'v,  clrvatccl  ami  LA'i'iicrally  hcaltliv  Mtc 

Tlif  ili'atlis  troiii  tlir  purclv  malarial  t'lA'crs  iii  our  armv.  as  slmwii  liv  Talilr  XX\'l, 
wnv  o.ofi  |MT  thnlisuiid  of  striaii:tli  aiiiiuallv.  or,  iiu-liiiliiiij;  the  dratlis  tVom  tvpho  laalai'ial 
I'i'Vcr,  5.(M  JUT  tliousaiid.  Tliesc  tiizurcs  arc  cxcrcili'd  liy  the  mortality  rates  i<(  all  the 
prisons  except  .Inlmsoii  s  l>laiid.  (Mi  the  dtliei'  liaiid  tlic  annual  mcnlalitv  rati'  amniiLj; 
oiir  eiiloi'ed  troops,  10. (>3  li>i'  tlie  pui'rU'  iiialanal  le\'i'rs,  oi'  1(>..S2  inclndiiiij:  the  txplni 
malarial  group,  was  ennsidcraliK'  greater  than  the  avoragc  of  the  prison  rates,  7.S  for  tli<' 
pui'e  malarial  levers  or  12. <1  inelusi\-c  of  tln'  t  \'plio-malai'ial  eases. 

The  extent  to  which  these  lev(>i's  prevailetl  among  the  Coiitedenite  armies  rentiers  it. 
prohalile  that  many  of  the  eases  that  oeeurri'd  among  the  prisoners  were  recurrences  of  it 
disease  ct)nlracied  m  the  Held  before  their  capture. 


II.— CLINICAL  RECORDS  OF  MALAlllAL  DISEASE. 

The  clinical  records  of  the  war  contain  hut  few  cases  of  malurial  disease,  and  these, 
as  a  rule,  are  exceedingly  meager  in  details,  seldom  giving  more  tlian  an  identitication 
of  the  jiatient  and  a  statement  of  the  diagnosis,  tivatinent  ami  result.  A  description 
of  the  svniptoms  as  thev  vai'ied  from  day  to  day  in  the  pi'ogress  of  the  fever,  or  as 
influenced  hv  remeilies,  was  rarely  attempted.  Hut  a  word  or  two  occasionally  introduceil, 
indicating  deterioration  of  the  constitution,  length  of  timt^  during  wliicli  tlie  disease  had 
heeii  in  progress,  or  the  existence  of  notable  comjtiications,  give  an  interest  to  the  records 
by  impressing  an  individuality  on  many  of  the  cases. 

The  absence  of  details  is  not  sur[irising,  in  view  of  the  great  prevalence  of  malai'iaJ 
levers.  Hisease  wdiich  is  of  daily  occurrence  is  not  usually  noted  by  the  profession  unless 
presenting  some  diH'erence  in  its  symptoms  from  those  generally  accepted  as  characteristic. 
Thus,  from  the  very  absence  of  records  it  may  be  concluded  that  tlie  intermittents,  remit- 
tt'iits  and  congestive  fevers  wdiich  were  so  prevalent  in  our  armies,  presented  little  to 
distinguish  them  from  the  same  diseases  as  observed  by  our  medical  men  in  their  practice 
before  the  war. 

]\Ioreover,  intermittent  cases  were  mainly  treated  in  the  Held  where  medical  officers 
had  few  facilities  for  note  taking.  Remittents  seldom  got  farther  away  from  active  service 
than  tlie  hospitals  at  the  base  of  supplies  except  by  furlough  during  convalescence,  for 
death  occurred  from  the  violence  of  the  morbific  agency,  or  a  cure  was  effected  Vjy  specific 
medication,  during  the  period  occupied  by  treatment  in  the  field  or  at  these  base  hospitals. 
The  tem])orary  character  of  the  latter  and  their  liability  to  be  at  any  time  crowded  with 
wounded  from  the  Held  of  battle  constitute  a  sufficient  explanation  of  the  paiicitv  of 
clinical  histories  among  their  records.  It  was  only  at  the  general  hospitals,  the  permanent 
establishments  situated  at  a  distance  from  the  coiiHictmg  armies,  that  clinical  records  of 
disease  were  kept;  and  malarial  cases  seldom  reached  the  wards  of  these  except  as  instances 
of  chronic  malarial  poisoning,  or  debility,  or  as  complicating  other  diseases  having  a  length- 
ened course,  such  as  diarrhoea  or  typhoid  fever. 

The  following  cases  may  not.  therefore,  be  considered  as  illustrating  malarial  dis- 
eases under  their  ordinary  aspects-,  but  as  presenting  certain  exceptional  features  wdiich  led 


112  CLlNIrAI.    RKCOKDr; 

to  tlunr  beiiiif  recorded,  the  oxceptioiiul  I'eaiure  in  siuin'  luytances  con.si8tiiig  of  iioiliiiitj; 
more  ronuirkaiilr  than  the  presence  of  the  case  in  the  wai'ds  of  a  genci'al  hospital  in  wliu'h 
clinical  records  were  kepi  with  more  or  less  I'cgularitv.  Nevei'tlieless,  most,  ot  the  cases 
mav  he  taken  as  typical  of  a  class  or  serii's,  lor  it  seems  unlikely  that  any  one  ot  tlioni 
Would  liave  Ijoou  unique  if  the  records  of  th(.'  whole  vast  nuiiilier  of  cases  had  lieen  presei'Ved. 

.1  qunlididii  intcrmittcni. — Cask  1. — I'rivali'  ratiick  Slu'liaii,  Co.  II.  MtitU  111.  Vols.,  was  aiiinittcd  Se]>t('nil)or 
2S.  IStll,  with  (piotidiaii  intrrniittent  tVvcr.  (^uiniud  was  fii\  rn  every  four  hours  for  three  or  four  days,  and  after- 
wards vegetable  tonics.  He  was  fuiloujjhed  November  1,  au<l  on  his  return  on  the  IXth  was  sent  to  his  eoiiiniand 
for  duty. — Gciural  Ilospiliil,  (Juiiici/,  III. 

A  fjiiotidian  irilh  r('l(q>srn. — Case  2. — Private  .1.  ^I.  Ilinehee,  Co.  K,  HSd  111.  A'ols.;  age  !!•;  was  admitted  October 
12,  1S()H,  haviiiff  l)een  atfeeted  with  intermittent  fever  siiiee  Sei)tember  lit.  On  the  ISth  he,  had  a  eliill,  for  which 
ei};ht  grains  of  (juinine  were  given  in  divided  doses.  TIk*  chill  returned  daily  until  the  21st.  It  recurred  on  Novem- 
ber 3,  and  afjjain  on  the  l.")th,  but  by  continuing  the  c|uiiiine  no  further  relapse  took  place  up  to  December  8,  when 
he  was  returned  to  duty. — General  Hospital,  Qiiiiici/,  III. 

A  tertian  with  rclapirn  allribniiil  to  nrvr-eatimj,  ,Vi. — Cask  H. — I'rivate  Aulliony  Monsieur,  Co.  C,  Kith  111.  Cav.;  age 
HO;  was  admitted  August  19,  lS(!:i,  with  tertian  ague.  His  skin  was  sallow,  conjunctiva'  yellowish,  tongue  coated, 
bowels  loose,  pulse  full  and  strong.  (Quinine,  blue-jiill  and  opium  were  given,  and  when  tlu^  paroxysms  were 
checked,  strychnia  was  administered,  lie  improved  rapidly  under  this  t  rcaluniit .  but  as  he  was  given  tc  excesses 
in  eating  and  drinking,  several  rela])s<'s  occurrcil.  lie  was  ultiuuitely  returned  to  duly  with  his  reginu'ut  October 
18,  IXIi;!. — Ocnrral  Hosjntal,  Qiiiiici/,  III. 

.1  iinarlan  uith  aliiw  rictirerij  after  "everal  relapxefi. — Cask  1.— I'rivate  .lanu's  W  right,  ( 'o.  F,  21st  111.  \'ols.:  age 
21;  was  admitted  Se]>tember  2"),  DSti:!,  h.iving  a  chill  c\cry  ihiid  d.iy.  His  skin  was  sallow,  tongue  coated  and 
bowels  loose.  Strychnia,  blue-i)ill  and  capsicum  were  prescribed.  He  improved  slowly,  sutt'ering  several  relapses; 
nltimately  Fowler's  solution  )>roved  ctfectual  anil  the  jiatieiit  was  returned  to  duly  February  11,  IStil. — General  Flas- 
pital,  t,hiinc;/,  III. 

Debility  from  recurrine/  attacl;s  of  atjne. — Cask  o. — I'rivate  William  Lambert,  Co.  (;,  litth  Mass.  A'ols.,  a  feeble- 
looking  boy,  was  admitted  Oitober  10,  istil,  much  prostrated  from  re]>eiite<l  attacks  of  ague.  He  had  one  paroxysm 
after  admission.  He  took  lifteen  grains  of  fiuiniiie  at  once  and  three  grains  three  times  a  day  afterwards.  He  was 
confined  to  bed  by  weakness  for  some  time:  but  after  this,  when  able  to  walk  out  a  little,  his  improvem(!nt  was 
more  rapid,     lie  was  returned  to  duty  on  November  20. — Heyimental  Hospital  Wtli  Mass.  Vohs. 

Cask  t!. — I'rivate  (ieorge  Fra/.er,  Co.  1*.  7lh  ^'a.  \'ols.:  age  20:  was  admitted  May  2H,  ls(>."i,  from  Lincoln 
Hos|)ital,  Washington,  D.  C.  He  had  contracteil  intermittent  fever  in  .March  in  the  pine  swanijis  at  Hum))hrey'8 
station  before  I'etersbiirg,  \a.  On  admission  he  was  very  weak  and  ananiic.  Fowler's  solution  in  five-drop  doses 
was  given  three  times  a  day  until  the  lilst.  On  .lune  7  he  was  placed  o'n  hosjiilalguard  duty,  and  on  .Inly  12  was 
returned  to  duty  with  his  command. — Satterlic  Hospital,  I'hihalelpliia,  I'a. 

Cask  7. — Corporal  .Ino.  W.  Moore.  Co.  K.  Ililh  Iowa  \'ols.:  agi^  24:  was  admitted  .Sept.  28,  IStllf,  with  dci>ilily 
from  intermittent  fever.  He  was  plaied  on  duty  in  the  ward  as  he  had  no  chills,  and  his  tongue  was  clean  and 
appetite  good.  (Quinine  and  iron  were  |irescrilied.  Aliont  (>ctober  211  lie  had  a  rigor  with  high  feverevery  few  days. 
Quinine  and  strychnia  were  given.  On  November  20  the  chills  continued,  and  there  was  some  diarrho'a,  for  uhiih 
nitrate  of  silver  and  oi)ium  weie  onlereil.  I!y  Decemlier  2.5  he  was  gaining  strength  slowly.  The  diarrluea  was 
checked  by  January  10,  1864,  but  the  chills  continued.  Fowler's  solution  was  given.  He  was  returned  to  duty 
March  22. — General  Flonpital,  (Jniney,  III. 

Cases  com^tlieuted  nitli  eliarrhtea  and  dijsenterji. — Ca.sk  8. — I'rivate  Dennis  ( I'Hrien,  Co.  C,  .")t>th  111.  Vols.;  age  37: 
was  admitted  October  11,  1862,  with  intermittent  fever  and  diarrluea,  with  which  he  ha:l  been  atfected  since  Septem- 
ber 2St.  He  was  treated  with  quinine,  blue-pill,  opium  and  turi>entine  emulsion.  He  improved  steadily  and  was 
returned  to  duty  on  the  27th. — General  Hospital,  Quincy,  III. 

C'ask  9. — Private  Frank  (Jad,  Co.  A,  81th  111.  A'ols.:  ag4'  17;  was  admitted  Sejit.  18,  IStil,  having  been  sick 
for  two  weeks  with  ([uotidian  intermittent  and  dysentery,  the  paroxysms  occurring  about  3  I'.  M.  The  bowels  were 
loose  and  the  tongue  <-oated  white.  Five  grains  of  i|uinine  with  three  of  Dover's  i>owder  were  given  every  three 
hours.     A  relapse  occurred  on  0<t<d)er  0.    The  Jiatient  was  returned  to  duty  October  27. — General  Hospital,  <)nineii,  HI. 

Cask  111.  —  I'ri\.-ile  Thomas  L.  Dixie,  recently  discliaigcd  ftoni  Co.  A,  38th  Iowa  \'ols.,  was  admitted  August 
20.  1863.  much  prostiateil  by  chills  and  fever  and  ,'t  diarrbo'a  of  ten  or  twelve  stools  daily,  from  which  he  had  suf- 
fered since  ,)uly  3.  The  diarrlicea  and  chills  were  checked  on  Sejitember  4,  and  his  appetite  imiiroved.  lie  went 
home  on  the  8tli.  —  I'nion  Hospital,  Mempiliis,  Tenn. 

Ague  n-itli  diarrliaa,  anamia  and  enlnrejed  spleen. — Cask  II.— Private  .James  .1.  Wolfe,  Co.  (i,  lOfh  111.  Cav.,  was 
admitted  August  30,  1863,  with   iiitermif tent  fever  anil  diaiihira.     He  had  been  subject  fo  diarrlio'a  for  more  than  a 

year,  but  the  ague  dated  only  fr< Inly  1.     On  admission  he  was  emaciated  and  ainemii:;  hi^  had  some  diarrluea,  a 

short  hacking  cough,  a  weak  [uilsc,  05,  an  anxious  countenance,  a  systidic  cardial^  murmur  and  a  sjilcen  which 
extended  three  inches  below  the  false  ribs:  he  had,  howevei,  a  good  appetite.  He  gained  strength  and  ultimately, 
on  October  23,  was  returned  to  duty.— L'niun  Hospital,  Memphis,  Tenn. 


OK    MAl.AIMAI.     DISl'-.ASH.  1  \'-^ 

.Uliif  trilh  iliiin-hiiu  mill  ihhilitii:  kIuh-  ricnn  iii  . — Cask  11'.  —  I'riv.itc  .Jiki.  .1.  ||:iii(l,  Cd.  K.  iL'Ttli  111.  N'ol.s.;  ii<;c  lil  ; 
u":is  [idiiiii  led  Si-iiIi-uiImt  '2'.'<.  isii:;.  with  iiitiTiiiiiicul  li-\i-i.  lli'  IkmI  :i  iliill  cvriv  <liiN  followed  liy  lii,i;li  trvt'r;  he  Iiiid 
also  (lys)iiioM  and  pain  in  1  lie  liy iKJcliondiiuiii  :  Icmniii-  iiacn-d  with  a  wliiti-  I'm  :  a|i|M-litc  moderate,  t^iiiiiiiu'  and 
tiiietili'e  (d'  iron  \veic  jiioei  ilied.  IManliiea  Mipeis  eiied  on  Oit<diei'  Id.  and  was  Heated  liy  idtrate  of  silver  and 
ojiiTiin  ;  tile  ajfiii'^li  l)aio.\ysins  eon  tinned  to  leeni-.  At  the  lieyinniiif;  of  X<i  vein  lief  he  was  fnrlonnhed  for  two  weeks. 
At  the  end  of  the  month  he  was  mindi  dtdiilitated.  having  tVom  thii'e  to  tivi'  dis(dniiges  from  the  howels  daily.  In 
Decemhei-  one-sixteenth  of  a  j;rain  of  stiychnia  was  j;iven  three  times  a  day.  lni|ii'ovement  «  as  very  slow.  Hi'  was 
not  returned  to  duty  niitil  March  !•. — GiiiirnJ  Iluxjiitiil.  (Jiiiiiri/,  I II. 

Ai/iii  fiilliiinil  III/  ili/siiili  ri/. — Casi:  l:;. — lloiaer  I  last  inys.  diiimnier,  Co.  II.  intli  Mass.  Wds..  was  admitted  on 
Noveiidier  2.  IMil,  with  (iiiolidian  intermitteiil.  L)ne  liftei'ii-n'rain  ilose  of  ijiiinine  was  jiiveii,  followed  by  live  f^rains 
three  times  a  day.  The  (diills  wen;  suiipiessed,  htit  the  iiatienf  had  some  bloody  and  painful  dis(diarges  fr<im  tlie 
howels.  While  takini;  Dover's  ])o\vder  and  acetiite  of  lead  the  passa,!j;es  lieeaim;  reduced  to  two  daily,  bnt  were 
aecompaiiied  with  iiineh  ;)ain,  ]irolriision  of  the  reetnm  and  fre(>  ha'tnorrhajie;  lie  had  illso  soim;  teiulerness  in  the; 
epigastric  rejjion,  w  hicdi  was  n-lie-,  ed  by  siinipisiiis.  The  toiij;iie  became  clean  iind  the  diai  rlnea  (dii'eked  on  Novem- 
ber 14,  and  the  patient  was  returned  to  (^narlcrs  on  the  Kith. — Uiifiiiiiiiinl  Uoxjiilnl  \',)lli  Miixs. 

Aijiie  protracUil  mill  aiiiijilitalcil  iiilh  Jiiiniilid  . — C.\.si-;  II. — I'rivate  .lames  .1.  K'ay,  Co.  1,  loth  Wis.  \'ols.;  age  26; 
was  admitted  Mandi  'S,  lSH;i,  emaciated,  tetdile  and  Jaundiced,  with  a  thickly  coated  tongue,  small  ajipetite  and  very 
rajiid  pulse,  lie  had  been  taken  with  inti'rmittent  fever  in  August.  1S(!2,  and  had  done  no  duty  since  that  time. 
After  his  admission  he  was  attacked  with  exerticiating  ])aiiis  in  the  bowtds.  Ife  was  treated  with  gelseiinnin,  taraxa- 
cum, iodide  of  |)ota.ssimn  and  extract  of  cinidiona.  He  imiiroved  rapidly,  gaining  in  tiesh  iind  strength,  and  was 
returned  to  duty  August  ;il,  18(11!. — (inimil  /luspilal.  (Jiiiiuii.  111. 

Af/iie  fiillowid  by  jmnidivf  mill  iliiirrliiiii. — Cask  \d. — Sergeant  Charles  Legrist,  Co.  E,  3.")tli  Mo.  Vols.,  had  an 
attack  of  intermittent  fever  early  in  August,  IXtl.'i:  jaiindii-i-  iind  diarrlnea  supervened.  Be  waN  admitted  October  1 
with  increasing  debility  and  a  <liarrh(ea  of  twelve  stools  daily.  He  failed  rapidly  and  died  on  the  10th. —  Union 
HoHpiial,  ilcmphis,  'J'niii. 

Protriictid  Ill/Ill- folloiriil  hi/  nirhiniih'. — Casic  l(i. — I'rivate  A.  Lydick,  Co.  I),  TXtli  Pa.  Vols.:  age  44;  was  admitted 
March  10,  IXtiH,  having  been  uiitit  for  duty  on  aeeonut  of  intermittent  fever  since  August,  lM(i2.  At  the  date  of 
admission  he  was  fevei  ish  anil  had  on  his  hack  a  large  and  painful  carbiini  le.  Tonics  were  given  and  creasote  dress- 
ing a])i)licd.  Tn  healing,  the  carbuncle  left  him  stoojied  very  iniich,  ami  the  cicatrix  was  very  tender.  He  was 
transferred  November  2.)  to  the  27tli  {'oin]iany,  2d  liattalion,  lnvali<l  Corjis. — Gnirriil  /lu.spitiil,  (,>iiiii('!/.  III. 

I'riilriiclid  iiiiiie  folliiiriil  hi/  iilfer.f  of  hij. — Cask  17. — I'rivate  .lohn  llogan,  t!o.  E,  llilth  HI.  Vols.;  age2'{;  was 
admitted  August  10,  ISOIi.  This  patient  had  intermittent  fever  from  ilay,  18()2,  to  March  it,  1803,  when  the  chills 
ceased  with  the  ajipeaiance  of  a  sore  upon  his  left  leg.  On  admission  his  leg  was  swollen,  red  and  iirni,  presenting 
between  the  ankle  and  the  upper  third  many  o](en  supjmrating  sores.  Cuder  the  use  of  iodide  of  potassinm,  rest 
and  bandages,  he  impro\  ed.  In  January,  18()li,  having  overstayed  a  pass  he  was  reported  as  a  deserter,  and  on  his 
return  was  transferred  to  the  care  of  the  jtrovost  marshal. — (leiurul  Uonjiital,  Quiiivy,  III. 

Aijiii'  with  coiifiiimptiiiii  .siipirnitiiiff. — Cask  18. — Private  M.  E.  Williams,  Co.  A,  87th  HI.  Vols.;  age  26;  admitted 
August  20,  186H.  This  tiian  was  taken  with  intermittent  fever  in  November,  18(i2,  and  did  no  duty  from  that  time. 
On  admission  he  complained  of  ])ain  in  left  subclavicular  region,  where  there  was  dulness  on  i)ercussion;  his  respi- 
ration was  hurried  and  diliicnlt,  pulse  frei|Uent;  he  had  hectic  fever,  night-sweats  and  colliciuative  diarrhcea.  Cod- 
liver  oil,  porter,  quinine  and  aromatic  sulphuric  acid  were  employed  in  the  treatment.  Afterwards  he  improved 
somewhat  while  taking  syrup  of  wild  cherry.  On  Xovemher  11  he  was  transferred  to  Cincinnati  for  discharge. — 
General  Hospital,  Qtiincy,  III. 

Tertimi  hccominy  qiiiitidimi  anil  nftiririirds  remittent. — Case  lit. — Lieutenant  H.  M.  Hideout,  10th  IT.  S.  Art'y,  was 
admitted  November  3,  1803.  He  had  been  attacked  ten  days  before  w  ith  a  severe  chill,  followed  by  fever  and  head- 
ache ;  two  days  after  this  he  had  a  second  chill  with  fever  and  some  delirium.  The  fever  was  acconiiianied  with 
much  pain  in  the  back,  anorexia,  gastric  irritation,  prostration  and  constipation.  The  chill  recurred  daily  during 
the  next  three  days.  After  the  tifth  chill  there  had  been  only  imperfect  remissions  of  the  fever.  The  patient  had 
been  on  duty  for  eight  months  in  the  low  swampy  lauds  of  Louisiana.  On  adnussion  his  pulse  was  120  and  skin  hot, 
dry  and  pallid.  Ten  grains  of  blue  pill  were  given,  and  (luinine  and  capsicum  ordered  every  three  hours.  Under 
this  treatment  the  fever  abated  and  there  was  no  recurrence  of  the  chills.  On  November  9  there  was  slight  fever, 
the  luilse  90  and  somewhat  corded,  but  this  condition  lasted  only  a  few  hours.  He  was  returned  to  duty  on  the  30th. 
— Hospital,  Xatehez,  Miss. 

Intermitteiits  becoming  remittent. — Case  20. — Sergeant  John  L.  Hopper,  Co.  I,  119tli  111.  Vols.;  age  28;  was 
admitted  October  31,  1802,  with  renuttent  fever,  having  been  sick  for  four  days  with  intermittent  fever.  On  adnus- 
sion the  tongue  was  (lean  but  red  at  the  ti]!,  ])nl,se  96,  skin  hot  bnt  moist,  bowels  loose:  the  patient  complained  of 
much  thirst  and  pain  in  the  back  and  stomach.  He  was  tieated  with  qxiinine  and  aromatic  powder,  morphia  and 
carbonate  of  soda.  Medication  was  stopped  on  November  4,  and  he  was  returned  to  duty  on  December  1. — General 
Hospital,  (Jnincy,  III. 

Cask  21. — Sergeant  Jas.  M.  Price,  Co.  («,  26th  Mi(  h.  \'ols.;  age  31;  while  en  route  with  his  regiment  for  New 

York  City  on  account   of  the  draft  riots,  was  taken,  while  in  Washington,  D.  C,  July  13,  1863,  with  intermittent 

fever,  which  recurred  daily.     On  admission  on  the  18th  he  was  much  prostrated,  having  just  passed  the  sweating 

stage  of  that  day's  jiaioxysm.     One  grain  of  qninine  was  prescribed  for  administration  every  hour  until  symptoms 

Mep,  Hist.,  Pt.  111—15  . 


114 


CLINIOAJ.    RKCOKIiS 


of  ciiicboiiisin  wi-ie  iiidihici-d.  Ili'  took  clcxcii  iri-.iiiis,  uiiil  next  day  tlic  skill  wiis  liot  iiud  dry,  tlio  tongue  coated, 
and  the  mint'  Iii^li  coloii'd  :iiid  s(niit.\  :  tow  a  ids  noon  i  lnic  u  as  a  rniiissioM.  ( )ii  llic  'J  1st  tlit*  iliscaso  was  distinctly 
remittent.  Quinine  w  as  <;ivcn  dm  in,u-  t  In-  icniissions  and  ac-i-tatc  of  ainnionia  dnrinj;  the  cxai-ciliations.  In  a  day  or 
two  the  fever  ceased  and  did  not  I'ecnr,  Imt  the  jialicnit.  was  (jnitc;  feelile,  anaonic  and  without  a]ii)etite.  On  the  2Sth 
be  stayed  U])  dressed  for  a  shoit  time.  Tinetiire  of  iron  was  i;iven.  He  was  returne<l  to  duty  on  Sej)tenilier  l.^.lcl. 
Alts' t  Sura.  a.  M.  Siiiitli,  r.  N.  Aninj.  I.iiiliis'  lliiiiit'  llnspitnl,  yiir  Viirk  ("lii/. 

Intnrmittciit  /re  ;■  h<'ciiiiiiii</  coiilhiiicd  mid  uiviiinjKiiiivd  irilh  iliiirriinii. — Casio  21'. —  Private  Orlando  Wood,  (General 
Steel's  escort,  taken  sick  with  intermittent  fever,  f(dlo\ved  hy  a  continued  level-  and  diairliu-a  alter  recurreiK'es  of 
the  intermittent,  was  admitted  ()id(d)er  11.  lSli2.  He  was  very  sallow.  (Jiiiniiie,  Idue  ]>ill  and  o])inin  were  liiven 
for  the  tever  and  turiieiitine  eiiinlsioii  for  the  diarrlnca.  The  ]iatient  im])roved  rajiidly  from  his  eiitiy  into  hospital, 
and  was  discharged  on  the  28th  on  acionnl  of  an  idd  frai'tnre  id'  the  femur. Iln/i/iiliil,  (Jiiimi/.  III. 

Intirmittinl  /ollnuid  In/  ti/phoid  J'lnr. — C.v.sE  2o. — I'rivate  O.  >S.  Kaymond,  (d.  I-',  2Mlli  Wis.  \'ols.;  age  10;  was 
admitted  June  21,  l«ti3,  with  typhoid  fever.  He  was  attacked  with  intermittent  fever  .dine  1,  while  in  caini)  at 
Helena,  and  the  fever  assuming  a  typhoid  type,  he  was  removed  to  this  lios]iital.  <  >n  admission  his  tongue  was  dry 
and  brown,  the  edges  and  ti))  red;  )iulso  X.'j;  skin  dry  and  harsh;  bowels  irritabh'  and  tymjianitic.  He  was  fur- 
loughed  .Vugnst  19  and  returned  to  duty  September  11. — Lnivson  Iliii<jiil<il,  SI.  Lihi'ik,  Mh. 

Cusin  of  ri'initUnI  I'l-nr. — Cask  21. — I'rivate  IJeorge  N'aden,  Vo.  1>,  21th  'lenn.;  age  2(»:  was  admitted  November 
6,  1864,  with  remittent  fever,  liaving  been  sick  for  six  days  before  admission.  Quinine,  capsicum  and  morphia  were 
given.  He  bad  no  fever  in  the  morning  after  the  Ttli,  but  every  evening  n\i  to  the  llith,  simie  felnile  action  was 
manifested,  and  the  tongue  remained  more  or  less  furred.  ISlue  ])ill  and  l-])som  sails  were  given  on  the  itth.  Clongli 
was  troublesome  on  the  IDtli,  and  muriate  (d'  ammonia.  ip<-eaeiiaiiha  and  opium  were  jiiescribed.  After  this,  iiuinine, 
Dover's  jiowder  and  ctiiisienm  were  gi\en,  and  a  blister  applie<l  on  the  l.")tli.  He  was  returned  to  duty  on  the  28th. 
—HoxintaJ.  UiK'k  L-'Unid.  III. 

C.\sK  2.">. — I'rivate  Iv  W.  Kirkland,  ( 'o.  H,  4tli  Ala.  Cav.;  age  30;  was  admitted  November  8,  IXM,  with  remit- 
tent fever.  He  had  been  si(d<  for  eight  days  prior  to  his  admission.  When  admitted  h<^  was  greatly  debilitated,  but 
had  no  fever,  which,  however,  returned  at  night  for  some  time.  Three  grains  each  of  (|uiniiu'  and  Dover's  powder, 
with  one  grain  of  cajisicum,  were  given  every  three  hours.  Hlue  pill  and  Epsom  salts  were  jirescribed  on  the  lOtli, 
as  the  bowels  were  constipated  and  the  tongue  much  furred.  Thcri^  was  great  irritability  of  stomach  on  the  13th. 
The  quinine  was  combined  w  ith  carbonate  of  ammonia  and  camphor,  and  whiskey  was  given.  A  blister  was  apidied 
on  the  Kith,  on  account  of  pain  in  the  left  side.  Treatment  w  as  continued  until  IJecember  (!.  The  patient  was 
returned  to  duty  on  the  10th. — Ho-tpital,  Kovk  Inland,  III. 

C.v.SE  2fi.— Private  Wm.  H.  Kimball,  2d  Batt.  V.  R.  C;  age  41;  was  admitted  May  12.  18154,  with  remittent 
fever.  He  had  heaclache,  -weakness,  jiain  in  the  back  and  limbs,  loss  of  appetite  and  much  thirst.  The  fever  was 
aggra\ated  in  the  morning,  and  did  not  remit  until  some  time  in  the  night.  His  tongue  was  yellow-coated  and  his 
skin  somewhat  jaundiced:  his  bowels  were  quiet.  (Quinine  and  bine  pills  were  administered,  and  on  the  20th  the 
patient  was  Improving  slowly.  On  June  11  he  was  jdaced  on  light  duty  in  the  ward,  and  on  the  18th  was  returned 
to  duty. — Art.  .Iuk'I  Siir;/.  I>.  ('.  Uu'iiin,  V.  S.  .irini/,  Ilunpitnl,  Qiiiiici/,  III. 

KciiiitUnt  with  rilitime. — ('.\SK  27. — I'rivate  Louis  I'.berhard,  Co.  I^,llltli  I'a.  \'ols.;  agi^  17:  was  ailinitltMl  A|>ril 
27,  18().5,  from  David's  Island,  New  York  Harbor,  as  a  convalescent  from  remittent  fever.  Ili^  was  in  goo<l  general 
health,  although  somewhat  debilitate<l.  Full  iliet  was  ordered,  but  no  medication.  Dn  Jlay  IX  he  w  as  placc<l  on 
fatigue  duty.  On  .June  14  he  re-entered  the  wiird,  having  been  sick  for  six  days  before  presenting  liinis(df  for  treat- 
ment. His  jiulse  was  full,  strong  and  bounding;  skin  hot  and  dry:  tongue  furred:  breath  fo'tid:  stools  light 
colored;  he  sutfered  also  from  headache.  Uliie-mass  was  ordered  on  the  loth,  to  i>e  followed  by  citrate  of  magnesia. 
Two  copious  stools  were  procured,  and  on  the  17th  he  was  in  lietter  condition,  although  flic  fever  cimtinucd  with 
anorexia  and  foul  tongue.  Blue  pill,  iiiecacuanha  and  ([uiniue  were  given  in  small  doses  every  four  hours,  and  on 
the  20th  the  jiatlent  was  able  to  sit  up.  The  medicine  was  omitted  on  the  21st,  and  on  the  28th  the  man  was  well 
and  walking  about. — Siitlcvhf  llospitdl,  l'hU(idilphin,,l'a. 

liemittoit  with  hi-putir  complication. — C.vsK  28. — Private  Charles  Laihn,  Co.  E,  IHth  111.  Cav.;  age  12;  intemperate; 
was  admitted  .July  31,  IMHS,  with  remittent  fever.  A  day  or  two  before  admission  he  was  taken  with  a  chill  followed 
by  the  usual  symptoms  of  common  renuttent  fever,  but  accompanied  with  pain,  tenderness,  slight  fulness  and 
hardness  in  the  region  of  the  liver.  He  was  trciited  with  quinine,  chalk  with  mercury  and  Dover's  powder,  sinapisms 
to  the  ankles  and  a  blister  to  the  heiiatic  region.  The  fever  ))egan  to  subside  on  .Vugust  2,  but  the  ])ain  and  fulness 
in  the  side  continued.  ( )n  the  7th  a  half  drachni  of  iodide  of  jiotassiuni  with  extract  of  h.voscianius  was  given  after 
each  meal  instead  of  the  i|ulnine  and  mercurial,  an<l  the  blister  was  reapplied  to  the  side.  He  improved  but  slow  ly, 
his  bowels  meanwhile  being  very  torpid  and  requiring  the  use  of  laxatives  and  enemata.  The  iodide  was  omitted 
on  September  10,  and  on  October  10  the  [laticut  was  returned  to  duty. — Act.  Ass't  Sur<i.  F.  K.  Bailcii,  V.  S.  Army, 
Hospital,  Quincij.  III. 

Case  2!t. — I'rivate  George  Hurst,  Co.  D,  25th  Ind.  Vols.,  was  admitted  October  12,  1803,  having  had  diarrhcea 
and  fever  for  three  days.  He  was  greatly  prostrated;  his  mind  dull;  countenance  sutfu.sed:  lljis  and  tongue  coated 
black ;  pulse  110  and  quick ;  skin  hot.  Next  day  he  was  delirious.  One  ounce  of  l)randy  was  given  every  hour.  On 
the  14th  the  fever  was  found  to  remit  in  the  morning,  becoming  Increased  in  the  afternoon.  Mercury  with  chalk  and 
rhubarb  was  given,  and  during  the  night  the  bowels  were  opened  twice.  Next  day  there  was  le.ss  fever;  (quinine 
was  prescribed  in  three-grain  doses  three  times  a  day.     On  the  16th  there  was  less  fever,  but  the  patient  vomited 


OF    MALARIAL    DISEASE.  115 

rif(|uciitl,\  .  T<-ii  grains  of  (jiiiniiio  wt-vi'  jiiviii  ;il  oiu'e.  iiuil  tin-  iin'icuiy.  i-li;ilk  and  rlinliaili  were  icix-atcd  with 
cailxiiKiti-  lit'  Mida.  ( )ii  till'  t'(dli)\viug  day  llif  licnvcls  wen-  ii|ii-ncd  ,sc\eral  times,  and  lln'  iriiiid  lifi'aiiic  cloairr.  'I'lif 
skill  and  (•on.jiincti\  a-  lifcanic  yellow-ciddii'd  nn  llic  IHtli.  and  on  tin'  L'Olli  he  liail  fjiistaxis.  Init  was  otlieiwisc 
iiii]iiovinj;.  He  \^■as  traiist'orii'd,  Deeenilier  l.">.  to  Adams  l!os]iital.  Meiiiiiliis  [and  al'teiwards  to  JetVeison  Hariaeks, 
St.  Louis,  ,Mo..  Felnnaiy  'JL'.  ISlilJ.     lie  was  nil  inialely  reimiied  lo  duly  May  -'>. —  I  iiiaii  Uospilnt.  Mmijiliin,  Tciiii. 

Itemittciit  with  .v<»cci/.— Cask  IHO. — I'livate  Samuel  W.  Kleniminn'.  Co.  1.  L'lilst  I'a.  \ols.:  aiie  L':i:  was  adinittccl 
NovcnilxT  4,  IStU.witli  remittent  fever  from  wliieli  hi'  had  been  snlierinu'  I'oi  some  lime,  lie  was  i|nite  prostrated, 
being  unable  to  speak  above  a  wliisper:  his  toni;ne  was  ]>ale.  giiins  spongy  ami  bowi'Is  moved  with  great  fie(|iieney: 
lie  was  aua'niie  and  bad  sinni'  ecnigli.  On  the  (ith  he  was  deliiions;  the  tongue  black:  the  teeth  covered  with 
Nordes  :  the  bowels  were  moved  less  freiiuently.  Inil  then'  was  great  teiiderni'ss  in  the  light  iliac  regiini.  Tnriient ilie 
was  ]>resc rilled.  (_)n  the  Idth  the  patient  was  miieli  iminiiv cd.  lie  was  retui  iied  to  duly  .la unary  II,  18t>."). — HoKpilal, 
Ah'jcunilrid,  Id. 

Ucmitlfiit  with  itiisiiitcrii  «iiji>ri-r}iiii(/. — Cask  :il. — Private  .\lbert  Franc.  Co.  C.L'lth  Ind.  N'ols.,  was  admitted 
September  21,  1S63,  with  dysentery.  [On  .\ngnst  X  this  man  liad  an  atta<k  of  ninittent  fever  jind  continued  sick 
for  four  weeks,  at  the  end  of  wliieli  iieriod  ho  wtis  much  (b'bilitatcd.  He  was  fnrlonghcd,  but  while  bound  liome- 
ward  liad  an  attack  of  dysentery  and  jiiles.  much  blood  passing  with  tin'  sto(ds.  |  On  adn'iissioii  lie  was  very  weak, 
emaciated,  and  had  abdominal  pain  and  tenderness,  with  twche  to  tiftecn  bloody  stools  daily;  his  appetite  was 
]ioor:  tongue  thickly  coated  brown:  ]>ulse  !•">  and  wetik  ;  skin  hot;  mind  <lnll.  On  the  28d  ]>aiii  in  the  umbilical 
region  was  somewhat  reliev<'d  by  sinapisms.  The  stools  were  fre(|uent  but  not  bloody  on  the  21th.  when  delirium 
iUid  dysjdiagia  supervened.  He  died  on  the  morning  of  tlu' 2."ith.  the  stoids  becoming  less  fri'(|nent  for  some  hours 
before  death. —  I'liiuii  Bw^jiiliil,  Mciiijitiin,  'I'liiii. 

Il(iiiitte)it  fircr  icith  vir<l>r<il  ^yijijiliiiiis. — Cask  H2.- — I'rivate  Henry  Taylor,  Co.  1>,  R'lth  I'a.  Vols.;  age  r>0;  was 
admitted  \ovember  3,  lS(i2.  convalescing  from  remittent  fever.  As  his  general  health  and  strength  improved  symp- 
toms of  cerebral  congestion  apjiearcd.  Of  medium  height,  thick  set,  with  a  short  and  full  neck  and  turgid  counte- 
nance, ho  was  more  or  less  <'onstantly  atfected  with  headache,  disturbed  vision  and  tinnitus  auriuiii.  Epistaxls, 
with  temporary  relief,  was  ot'  frei|nent  occnrrence:  the  bowels  were  constipated.  On  the  day  after  admission  the 
patient  was  bled  from  tin'  arm  to  the  extent  of  tifteen  ounces,  with  jirompt  and  decided  relief  of  the  prominent 
cerebral  syiniitoms.  Low  diet  was  enjoined,  and  under  the  repeated  use  of  active  hydragogue  cathartics  the  cerebral 
symptoms  gradually  yielded  :  but  the  jiatient  continued  to  have  at  times  slight  returns  of  ejiistaxis,  which  always 
gave  relief,  his  ])iilse  becoming  leduced  in  force  and  volume.  He  was  recommended  for  rettirii  to  his  regiment  Feb- 
ruary LI,  iiiid  left  the  hospital  to  join  it  on  JIarch  1.  Oii  this  ease  the  attending  jdiysiciiin  remarks:  "After  tlie 
.sujnmer"s  exiierience  of  hy])a'mia.  cachexiii  and  adynamia,  conditions  so  almost  universally  present  in  disease  as 
(diserved  at  the  military  hosidtals,  and  re(iuiring  as  they  did  a  supi)orting  iind  tonic  treatment,  it  was  with  curious 
iiurrcst  lliat  we  iccognizcd  this  exceptional  case  of  hyperiemia  demanding  depletion  from  the  general  circulation, 
conjoined  with  low  diet  and  active  catharsis." — Sutterhr  Iloipital,  I'hih((telphi'ct,  Pa. 

Case  33. — Ass't  Surg.  Samuel  S.  CJarrigeus,  29th  Mich.  Vols.;  age  30;  was  admitted  October  11,  1864.  He  was 
taken,  while  at  Detroit  on  the  7th,  with  a  severe  chill  which  lasted  an  hour,  and  was  followed  by  two  hours  of  fever. 
On  the  ^*tli  and  0th  he  luid  fever  but  no  chills.  On  the  morning  of  the  10th  he  took  eight  grains  of  bine  pill  and  a 
Seidlilz  powder,  which  procured  au  evacuation  but  caused  much  nausea  and  vomiting.  On  admission  he  had  fever, 
anorexia,  great  thirst,  oft'ensive  breath,  white  furred  tongue,  constipated  bowels  and  headache,  and  he  had  slept  but 
little  from  the  time  of  the  attack;  pulse  120,  respiration  30.  Sweet  spirits  of  nitre  and  extract  of  ipecacuanha, 
barley-water  and  cream  of  tartar  were  given,  with  a  Dover's  powder  at  bedtime;  next  da.v  (luinine  was  admin- 
istered. The  fever,  headache  and  constipation  continued,  and  on  the  14th  the  patient  was  delirious  during  the 
greater  part  of  the  day.  Eight  grains  each  of  calomel  and  rhnbiirl)  were  given,  followed  by  a  salini-  cathartic,  which 
moved  the  bowels.  Next  day  he  was  conscious,  his  pul.se  regular  and  slow.  Tea,  toast,  soujis  and  panada  were 
given.  After  this  he  improved  in  condition;  but  on  the  25th  he  had  symptoms  of  cerebral  congestion,  which  w^ore 
relieved  by  cold  to  the  head  and  mustard  to  the  feet.  Tliese  attacks  recurred  during  the  early  part  of  Xovemlier, 
but  hy  avoiding  excitement  and  errors  of  diet  they  cea.sed  to  trouble  him.  On  October  31  Fowler's  solution  was 
given  ill  Huid  extract  of  cinchona  and  continued  for  three  weeks. — Officem'  Hoxpital,  Louisville,  Ky. 

Cask  34. — Private  Jcdin  McCammant,  Co.  B,  84th  111.  Vols.,  was  admitted  August  24,  18(i2,  with  remittent 
fever.  During  the  night  following  admission  he  was  a  little  delirious,  but  next  morning  he  was  (|uiet.  A  blister 
was  ordered,  as  he  com|dained  of  soreness  in  the  bowels.  Aliout  2  I'.  M.  of  this  day,  as  he  was  resting  i|uietly  and 
I'ligaged  ill  ('oiiversatioii  with  a  friend  from  camp,  he  suddenly  s]>rang  from  his  bed  and  jumped  through  the  scuttle- 
way  from  the  iijiper  to  the  lower  floor  of  the  hospital,  a  distance  of  about  thirty  feet.  He  struck  on  his  head  and 
right  shoulder.  He  was  taken  up  unconscious  and  died  thirty-six  hours  after.  A  ciot  seemed  to  have  formed  behind 
the  right  orbit  as  the  eye-ball  soon  became  considerably  protruded.  Xo  puat-morttm  examiuatiou  was  made. — 
Hospital,  Qwincy,  III. 

lii'tnittent  with  diurrhaa  in  ti  paroled  prisoner. — Case  35. — Sergeant  Samuel  S.  Cook,  Co.  15,  27th  Conn.  Vols.; 
age  38;  was  admitted  May  17,  1803,  with  remittent  fever  and  diarrlnea.  He  was  taken  prisoner  at  Fredericksburg, 
Va.,  May  3,  and  inarched  to  h'ichmond.  He  had  a  chill  two  ilays  before  his  ca])ture,  follow  ed  by  diarrhrea  and  fever. 
On  admission  his  tongue  was  furred  and  dry;  he  ha<l  headache  and  pain  in  the  back:  his  jiulse  was  80  and  feeble, 
but  his  general  appearance  was  not  bad ;  one  stool  was  passed  in  the  twenty-four  hours.  (Quinine  was  given  in  five- 
grain  doses  every  four  hours.    Ou  the  I9th  liis  bowels  became  loose,  yielding  four  stools  on  that  day  and  on  the  20th, 


116  r.l.lNlOAJ.    RKCOKDS 

six  or  Keven  on  the  21st  and  only  two  <m  the  '_'2il.  On  the  2'Ad  tln^  dianlupa  ceased  and  there  was  no  fever.  The 
patient  (|uicl\ly  regained  Ills  sfrcngtli  and  was  rctiirm-d  to  duty  on  .June  lii. — Act.  .Isn't  Siiry.  E.  ./.  [liiddiffe,  U.S.A., 
Iloxpitdl,  AiniKpolis,  Md. 

Iliiiiiltciit  uilli  (I  pruljiil/U;  typhoid  cl(iiiiiil. — (ask.  iili. — .Seii;eant  .1.  N.  Kieliardson,  Co.  E,  '2d  West  Tenn.  Cav.; 
age  22;  was  admitted  September  24,  IXtil:),  with  remit  lint  fever.  He  liad  lieen  a  |)risoner  on  Belle  Isle  since  July  4, 
during  wliieli  period  he  suffered  from  diarrliiea  and  cliills.  ''  I'iiis,  lil<e  many  otlier  cases  of  fever  among  parcded 
prisoners  from  the  South,  has  lieen  very  nuiidi  utii  (/nicrix  and  dil'licult  to  classify,  having  symptoms  of  malarial 
remittent  and  of  typlioid.  It  lias  been  cliaracteri/ed  l>y  irregular  remissions,  the  pulse  sometimes  as  liigli  as  131), 
sometimes  as  low  as  SO,  irregular  diai'rh(ea,  dc^lirium,  swellings  under  the  chin  and  of  the  parotid  and  frecjuent 
micturition.  He  was  treated  with  quinine,  blue  pill  and  opium,  etfervescing  mixture,  chlorate  of  potash  and  sina- 
pisms. He  began  to  improve  in  strength  and  liesh  in  Xovendier  and  made  rajiid  piogress  to  health.  He  was  trans- 
ferred to  Ohio  January  (>,  181)4. "' — Act.  Asu't  Siiry.  A.  Claude,  V.  S.  A.,  Hospital,  A-)iiiiipoli.i,  Md. 

Ca.sk  hi. — Sergeant  William  J.  (ioode,  Co.  F,  Kith  111.  Cav.;  age  2.5;  was  admitted  .July  21,  18()3,  with  severe 
fever,  tongue  coated,  sl<in  iiot  and  dry,  i)ulse  frecjuent,  bowels  irritalde.  (^uinin<(,  Dover's  powder  aiid  turpentine 
emulsion  were  prescribed.  Hy  August  2  the  fever  had  lessened,  but  the  Iwwels  were  more  relaxed,  and  there  was 
abdominal  tenderness;  the  tongue  was  coated  (fxcept  at  the  tip,  which  was  red;  the  .stomach  was  irritaJ)le;  the  skin 
moist.  Medi(dne  was  withheld.  (In  the  14th  the  patient  was  impioved  but  feeble;  the  bowels  continued  loose  and 
the  abdomen  tender.  Klixir  of  calisaya  was  given.  Tlie  fever  returned  on  the  l!)tli,  and  recurred  nightly,  although 
the  a<lministration  of  (|ninin(^  was  resumed,  until  the  end  of  the  month,  when  profuse  sweatings  took  place  towards 
nmruing.  The  fever  al  lliis  timi^  was  recorded  as  having  l)ecome  "somewliat  typlndd."  (.)n  .Septeml)er  3  the  tongue 
was  red  at  the  tip  but  thickly  coatc<l  at  the  base;  bowels  loose;  pulse  (id,  feeble  and  compressil)le;  appetite  poor. 
Aromatic  sulphurie  aei<l  was  given  until  the  1  Ith,  when  it  was  replaced  by  the  elixir.  The  i)atient  was  pale  and 
feeble  on  the  Itith,  but  able  to  walk  about.  ( >n  the  22d  there  was  some  fever  at  night,  and  the  tongue  was  red  and 
coated  but  not  dry;  diarrhiea  continued.  < 'n  October  1  the  roof  of  the  mouth  was  sore  and  spongy.  Next  day  a 
blister  was  apidied  on  account  of  pain  and  soreness  in  the  left  hypoehondrium.  After  this  he  improved  rapidly,  and 
deserted  on  the  Kith. — Hospital,  (Jitiiici/,  III. 

accorded  as  ti/plioid  hut  treated  as  remittent. — Cask  3S. — I'rivate  Matthew  Baird,  Co.  C,  3d  Mich.  Vols.;  age  23; 
was  admitted  October  19,  18(>1,  as  a  case  of  tyi)hoid  fever.  About  October  5  he  had  been  seized  W'ith  pain  in  the 
head  and  liones,  fever  and  chills ;  he  had  some  nausea  and  vomiting  at  first,  and  a  diarrho'a  which  continued  for 
two  days;  the  hea<lache  lasted  four  days;  during  the  second  week  his  urine  had  to  be  removed  by  catheter.  On 
admission  his  pulse  was  t)2  and  of  fair  strength,  skin  solt  and  w  arm,  tongue  pale,  moist  and  slightly  coated,  brownish 
in  the  center,  teeth  and  gums  clean,  appetite  good;  he  had  tinnitus  aurium  and  giddiness,  but  no  pain,  eruption 
nor  sudamina;  one  thin  watery  stool  was  passed,  but  there  was  no  tenderness,  liorborigmus  nor  tymi)anites,  and 
the  abdomen  was  soft:  there  was  no  cough  and  the  urine  was  normal.  (Juinine  was  ])rescribed  in  full  doses 
three  times  daily.  Next  day  the  face  was  calm  and  natural;  the  pulse  lit,  steady  ami  of  fair  strength  ;  the  skin  soft 
and  warm  :  tin?  tongue  slightly  ])ale  and  tlabby.  but  moist  and  clean;  the  ajjpetiti^  good;  one  thin  fietid  stool  was 
])a.ssed.  On  the  22d  the  (luinine  was  rciluced  to  two  grains  three  tinu's  daily,  and  during  the  night  the  ])atient  liad 
a  chill,  but  next  day  its  effects  disappeared.  On  the  28tli  he  rested  badly  and  had  some  diarrhcea,  liut'there  was  no 
tenderness  nor  tym])anitis;  tlie  tongue  was  pale  and  nuust  and  the  appetite  fair.  The  skin  and  conjunctiva'  became 
jaundiced  on  the  31st.  Small  doses  of  calomel  and  oi)iuni  were  given.  On  November  4  he  slept  well;  his  mind  was 
clear,  counteiuince  calm,  bowels  regular  and  appetite  good.  He  was  transferred  to  Annapolis,  Md.,  on  the  18th. — 
Seminary  Hospital,  (leoryetoini,  I).  ('. 

Uemitteul  J'olloiviiiy  typlioid. — Cask  '.V.K- — Private  Sidney  Nafus,  Co.  K,  113d  Pa.  \'o!s.;  age  22.  [This  num  entered 
Stanton  Hospital,  Washington,  June  15,  1863;  Diagnosis — debility;  and  was  transferred  to  Satterlee  Hospital, 
Philadelphia,  on  the  17th;  Diagnosis — chronic  dysentery.  He  was  returned  to  duty  August  28,  but  contracted 
typhoid  fever  Octol)er  2,  and  was  confined  to  bed  for  four  weeks.  On  November  23  he  was  admitted  to  Douglas 
hos])ital,  Wasliington,  as  a  convalescent  from  ty]dio-nuilarial  fever,  and  on  tlu^  27th  was  transferred  to  Satterlei^ 
Hospital;  diagnosis — intennittent  fever.]  (Jn  December  13  he  was  reported  as  much  improved,  and  the  (juinine  and 
cart>onate  of  iron,  which  he  had  been  taking,  was  omitted.  On  the  18th  he  had  a  paroxysm  of  fever,  which  was 
repeated  next  day ;  pulse  12(1;  tongue  coated  and  somewhat  dry;  skin  moist;  headache;  tenderness  in  the  epigas- 
tric and  right  hypochondriac  regions.  Quinine  in  three-grain  doses  was  given  every  two  hours.  The  fever  con- 
tinued, but  with  diminishing  intensity  for  a  week,  the  skin  being  sallow  and  dry,  the  tongue  white  coated,  tlie 
bowels  regular  or  constipated.  The  medicine  was  omitted  on  the  28th;  but  on  .January  1,  18(54,  tlie  heart's  action 
became  much  increased,  pulse  138  and  skin  hot  and  dry.  Digitalis  was  given  and  a  blister  applied  to  the  chest. 
Next  day  the  skin  was  cool  and  the  ])ulse  reduced  to  !•(>.  ,\fter  tliis  he  was  treated  occasionally  with  digitalis,  but 
he  remained  weak  for  a  long  time.     He  was  put  on  guard  duty  April  25. — Satterlee  Hospital,  Philadelphia,  Pa. 

Continued  ferer  quickly  ckunyiny  to  remittent  and  intermittent. — Ca.sk  40. — Private  George  H.  (iardner,  Co.  G,19th 
Me.  Vols.;  age  19;  was  admitted  December  Ifi,  1862,  with  varicocele.  After  sonKs  time  he  became  affected  with  sore 
throat  and  i)ain  in  the  ears,  and  presented  symptoms  which  the  attending  physician  was  inclined  to  attribute  to  the 
presence  of  tlie  typhoid  fever  poison.  On  January  5,  1863,  the  first  day  on  which  these  were  noticed,  the  skin  was 
hot,  face  flushed,  tongue  furred,  pulse  tense  and  rapid  and  there  was  considerable  gastric  disturbance.  On  the  6th 
these  symptoms  were  much  increased.  On  the  7th  the  fever  was  accompanied  by  diarrhcea  with  tenderness  in  the 
abdomen,  jiul.se  about  05,  tongue  coated  but  moist,  red  on  the  edges.  Neutral  mixture  and  sweet  spirits  of  nitre 
were  given.     Next  day  there  were  two  rose  spots;  the  abdominal  tenderness  was  increased ;  the  mouth  not  so  moist, 


OF    >r AT.A  i;  1  A  1.     1  >rsKASE.  1  1  7 

lint  not  dry;  l)oth  ears  yvere  discharfjing  t'lt'ely,  and  tlieri'  was  j;icai  drowsiiu'ss.  On  tlic  iUli  thore  was  no  diaiTliu-a, 
but  the  abdomen  continued  painful,  esiiecially  on  j>iessnn>:  tlie  fcvtr  was  luucb  incicased,  tlie  pulse  haviuf;  liscu  to 
120;  but  towards  noon  there  was  a  decided  remission,  lastinff  abdut  three  lionvs.  during;  which  the  skin  was  cooler 
and  the  patient  in  a  ]>leasant  sleep.  At  noon  on  the  lOtli  a  distin<t  chill  was  toUowcd  by  a  fivcr  ot  aliout  three  or 
four  houis  duration.  Quinine  in  three-grain  doses  was  given  every  three  hours.  Tcndcriiess  and  pain  in  the  abilo- 
nicn  continued.  The  chill  recurred  at  noon  of  the  11th.  but  was  not  so  violent  as  on  the  previous  day;  tin'  ]iatient 
complained  of  great  pain  in  the  right  shoulder,  and  was  unable  to  nnive  the  arm,  which  was  very  sensitive  to  press- 
ure, but  witluuit  redness  or  swelling;  he  also  C(imi)laineil  of  ])ain  on  jiercnssion  over  the  liver:  thi'  eyes  were  not  at 
all  yellow  but  natural,  and  there  was  diarrlnea.  Tin'  (|iiinnu-  was  cimtinucil.  No  chills  nor  fcvci-  occurred  on  the 
12th;  the  pain  in  the  shoulder  <'ontinued,  but  there  was  no  more  pain  over  the  User  than  over  any  other  jiart  of  the 
abdomen,  in  which  there  were  acute  llying  pains  seemingly  neuralgic  in  character.  Next  day  the  patient  was  nuudi 
better:  tongue  cleaner,  api)etite  returning,  shoulder  less  painful  and  f<>ver  absent.  Qninine  was  continued  in  two- 
grain  doses  every  four  hours.  On  the  loth  he  sat  u|)  for  a  short  time,  Ivnt  the  pain  in  tlm  shoulder  was  troublesome 
and  was  felt  even  a.s  late  as  the  :iOth.  ''The  above  case  is  presented  as  a  curious  instance  of  what  was  api)arently 
typhoid  fever  in  its  coimnencement,  changing  to  remittent  and  then  to  int<'rmittcnt  fever  in  the  short  space  of  a 
week.''* — Siitterhe  Hoxpittil,  I'liiliidvlpliia,  J'li. 

Ilcmittcnt  followed  hy  intcnititlciil. — Oask  11. — Private  Thomas  (laitly,  Co.  K,  liMh  Mass.  \^)ls.,  had  a  jiaroxysui 
of  intermittent  fever  on  November  H,  1*<(>1.  He  had  lieen  recently  discharged  from  hos|)ital  (ui  recovery  from  remit- 
tent fever.  He  was  readmitted  on  the  10th  and  had  a  marked  jvaroxysm  on  admission.  Fifteen  grains  of  (jninine 
were  given  at  a  dose,  with  five  grain.s  in  a  half  ounc(!  of  wliisk<'y  to  ))e  taken  thcr<'alter  three  tinu'S  daily.  On 
November  12  there  was  no  return  of  the  chill;  tht<  patient's  appetite  was  good  and  he  felt  well  but  weak.  He  was 
returned  to  quarters. — lit'gimcntiil  Ilo«intal  \[)th  Manx.  7'<»/.f. 

Eemittent  ending  J'uldlhj. — Case  12. — l'rivat<-.  Christopher  ('(unmars,  (iilth  Co.  1st  liatt.  V.  R.  C;  age  22:  was 
admitted  Novemljer  11,  1S(!3,  with  remittent  fever.  He  said  he  had  been  sick  for  six  days,  but  had  continued  on 
duty  although  he  sullered  from  a  chill  on  the  lOth.  On  the  11th  he  had  a  severe  chill  an<l  was  seen  by  the  medical 
otticer  of  the  day,  who  ordered  him  into  the  ward.  Two  grains  of  nuinim^  were  given  thice  tinu'S  a  day.  On  the 
12tli  he  had  vomiting,  and  jiain  and  tenderness  in  the  left  side  of  the.  chest.  I'he  ([uiiiine  was  onutted  and  throe 
grains  of  calomel  ordered  every  four  hours  until  four  i)owdei's  had  been  taken,  with  a  Seidlitz  powder  after  the  last 
dose.  The  bowels  were  moved  on  the  13th,  but  the  vomiting  continued  until  death  on  the  15th.  During  his  sick- 
ness the  patient  expressed  no  anxiety  as  to  its  result;  he  was  confident  that  he  would  be  able  to  return  to  duty  in  a 
few  days. — Act.  Axu't  Siirij.  Ihiiiy  M.  Dean,  U.  S.  A.,  Lhieoln  Ilonjiital,  ly'itnlihii/toii,  I).  C. 

Cask  13. — Private  havid  Kensinger,  Co.  1,  8th  Tenn.  Vols.;  age  lit;  was  admitted  May  10,  IXtil,  sutfering  from 
remittent  fever  and  debility.  CJuinine  in  five-grain  doses  three  times  a  day  was  jirescribed  and  an  enenui  of  castor 
oil  administered.  On  the  13th  the  patient  had  a  hot  skin  and  frequent  pulse,  with  much  prostration,  wakefulness, 
restlessness,  loathing  of  food,  nausea  and  vomiting,  but  no  pain.  Carbonate  of  ammonia  and  brandy  were  prescribed. 
On  the  14th  there  was  a  slight  abatement  of  the  fever  in  the  morning  and  an  ex.'icerbation  in  the  evening,  which 
becaiue  more  marked  on  the  evening  of  the  15th.  On  the  litth  there  was  nuu'h  nervcuis  disturbance,  restlessness  and 
jactitation.  On  the  21st  the  stools  hecanu)  frequent  and  the  tongue  dryer  and  darker.  On  the  nu)rning  of  the  22d 
the  tongue  was  not  so  dry  as  during  the  preceding  paroxysm,  but  in  the  (evening  the  jiatient  became  delirious. 
After  this  each  successive  exacerbation  was  more  severe  and  protracted,  and  each  remission  less  decideil  until  death 
took  place  on  the  28th.  Clammy  sweats,  collapsed  features,  involuntary  passages  and  imperceptible  pulse  preceded 
death  for  several  hours. — Act.  Aks'I  Surg.  J.  If.  Coover,  U.  S.A.,  Jloapitul,  Annapolh,  Md. 

Muhirial  congest ioim. — Ca.se  44.^ — Private  11.  Straight,  Co.  C,  154th  N.  Y.  Vols.;  age  25;  was  admitted  December 
12,  1862,  with  Jaundice,  chronic  neiihritis,  enlargement  of  the  spleen  and  dulness  on  ])ercussion  over  the  summit  of 
the  left  lung,  with  sonu>  rude  respiration  and  a  dry  hacking  cough.  His  sickness  began  during  the  Peninsular  cam- 
paign with  a  severe  attack  of  remittent  fever.  Ho  was  much  emaciated  and  had  anorexia,  lassitude  and  mental  dul- 
ness; his  stools  were  deficient  in  bile;  his  urine  was  albuminous;  the  pulse  about  90;  rigors  and  exacerbations 
occurred  every  evening.  Iodide  of  potassium  and  bicarbonate  of  potash  were  prescribed,  each  in  five-'grain  doses 
three  times  daily,  with  fluid  extract  of  taraxacum  in  teaspoouful  doses  ami  the  a|>plication  of  tincture  of  iodine 
over  the  enlarged  spleen.  By  December  20  the  Jaundice  was  somewhat  lessened  and  the  stools  tinged  with  bile,  but 
the  cough  was  aggravated,  the  sputa  uunnuular  aud  blood-stained,  and  the  patient  complained  of  flying  pains 
through  the  body  and  of  constant  nausea.  On  enquiry  it  was  found  that  his  father  had  died  of  tuberculosis.  An 
anodyne  expectorant  mixture  was  prescribed.  Ten  days  later,  while  the  jaundice  was  disappearing  the  nephritic 
symptoms  became  prominent.  Tincture  of  iron  with  quinine  in  two-grain  doses  three  times  a  day  was  added  to  the 
]uevious  treatment.  By  January  8  the  nausea  had  ceased  and  the  appetite  was  better;  the  albumen  in  the  urine 
was  decreasing  in  quantity  although  the  iiatient  complained  of  great  pain  over  the  region  of  the  kidneys  and  along 
the  ureters.  The  iodine  mixture  was  omitted  and  the  following  ^substituted:  Ten  grains  of  bicarbonate  of  potash, 
three  drops  of  liquor  potass*,  five  drops  of  tincture  of  cannabis  indica  and  one  drachm  of  extract  of  uva  ursi  to  be 

*  It  is  possible  tiiat  an  explanation  of  tlie  anonialims  course  of  the  constitutional  disturi)ance  in  tliis  instance  might  have  been  discovered  by  a 
closer  examination  and  report  of  the  progress  of  the  aural  inflammation.  Diffuse  infiammatiim  of  tlie  ear  is  <iften  accompanied  with  much  febrile  action, 
headache  and  seeming  mental  dulness,  whidi  is  in  reality  a  disinclination  to  be  disturbed  by  enquiries.  The  fever  subsides  on  the  establishment  of  a 
disdiarge  from  the  e:ir,  but  slight  exposiu'es  not  uiifrequently  cause  a  sudden  suppression  of  the  discharge  with  a  recurren<:e  of  the  febrile  condition  of^en. 
times  preceded  by  rigors  and  gastric  disturbance.  The  local  intianunatiou  with  its  symptomatic  fever  superiuiposed  on  a  case  of  s[)ecific  fever  of  S4>  mild 
a  character  as  to  be  indicated  only  by  a  fugitive  diarrliu;a,  some  abdominal  tenderness  and  two  rose-six>tji,  might  be  regarded  as  accounting  for  the 
I'hanges  which  constitute  the  anomaly  in  this  case. 


118  CLINICAL    RECORDS 

tiikeu  in  a  tahlospoonfnl  of  mint-water  tliico  times  a  day.  On  .Taiiuaiy  11,  1863,  tlie  splenic  enlargement  and  lunj; 
syinptdins  continued  nncliiinncd,  but  otlicrwisti  the  ])iitiont'H  condition  was  nmcli  improved,  liy  .January  25  the 
albuminuria  had  ceased  and  tlic  patient  liad  ;;aiiied  tlesli  but  was  still  very  weak.  Cod-liver  oil  was  substituted  for 
the  potash  mixture;  tlu;  (|uiiiiue  and  iron  were  i-outiuued  and  iodine'  was  apjilied  over  the  sideeu.  On  February  « 
the  iiuluioiiary  symptoms  had  almost  disappeared  and  the  jiatient's  strenj^th  was  retuiuiuK-  He  was  sent  to  his 
regiment  for  duty  on  the  14th. — Sullerlre  Ilnspitiil,  I'hilmlilpliUi,  I'a. 

Case  45. — Private  ]iob<'rt  Wilson,  Co.  D,  1st  Ky.  Vids.;  age  24;  was  admitted  May  27,  1801.  He  had  been  sick 
for  two  weeks  with  inflammatory  rheumatism,  for  wliich  he  had  taken  colchicum,  (|uinine  and  opiates.  On  admis- 
sion he  had  fever  and  delirium,  pain  in  the  chest,  with  roughened  respiratory  murmur,  vomiting  and  relaxation  of 
the  bowels:  liis  tongue  was  hirgi^  moist  an<l  white;  skin  moist,  extremities  cool;  pulse  128  and  feeble.  (.)ue  grain 
of  (juinine  with  three  of  Dover's  powder  was  given  every  three  hours.  Me  was  very  restless  and  did  not  sleep  during 
the  following  night ;  his  bowels  weie  moved  fre(juently  and  sometimes  involuntarily,  the  stools  being  (hirk  green  and 
watery,  and  there  Avas  much  gurgling  on  pressure  in  the  right  iliac  region.  At  midnight  a  pint  and  a  half  of  dark- 
colored  urine  was  drawn  otf  by  catheter;  sudamina  appeared  on  the  abdomen  and  lower  part  of  the  ehest.  Next 
morning  the  ])upils  were  dilated,  the  right  to  a  greater  extent  than  the  loft,  and  there  was  dulness  of  hearing.  A 
l)int  of  urine  was  withdrawn.  There  was  a  good  deal  of  pain  in  the  chest,  but  the  bowels  were  ([uiet  until  2  i".  .M., 
after  which  the  stools  w(Me  freejuent,  dark  and  watery;  the  delirium  increased  and  the  tongue  became  so  swollen  as 
to  cause  much  suffering.  He  died  at  7  J'.  -M.  No  autoi)sy.  [After  death  a  medical  officer  stated  that  this  man  had 
been  seized  two  weeks  before  with  a  paroxysm  resembling  a  congestive  chill :  that  he  liad  been  bled  from  the  arm,  and 
that  reaction  had  been  established  with  mucdi  dilhculty.] — Murine  Iiu«piiiil,  (.'hiciiiiKdi,  Ohio. 

liimitliiit  fiiUnifiil  III/  ciiiifjcutivcj'ercr. — Case  40. — I'rivate  .James  S.  West,  Co.  I),  10th  111.  Vols.,  had  a  very  severe 
attack  of  remittent  fever  from  which  he  reeovere<l  and  was  detailed  on  hos])ital  duty.  On  July  3,  18ti2,  while  thus 
eini)loyed,  he  was  taken  with  a  eongestive  form  of  intermittent  fever.  Mere  u  rial  cathartics  and  enenuita  were  given, 
with  ciuiuiue,  iron  and  pepsin,  without  avail,  for  the  congestive  paroxysm  returned  daily,  and  tinally  the  patient 
sank  into  a  completely  tyjihoid  stat((  and  died  August  1st. —  Utiapital,  (^hiiiici/,  111. 

C'onyestive fn-i-r. — Case  47. — I'rivate  John  Bonuiu,  Co.  H,  5th  111.  Cav.,  was  adnutted  September  1,1863,  having 
had  diarrhipa  for  three  days.  Karly  on  the  following  morning  he  was  foniul  unconscious,  with  sluggish  respiration, 
(|uick  feeble  ])ulse  and  clannuy  yellow  skin.  He  had  voiuited  viscid  dark-green  nuitters  and  Dassed  involuntary 
stools  which  were  olfensive  and  bloody.  A  tablespoonful  was  given  every  hour  of  a  mixture  containing  thirty 
grains  of  quinine  in  two  ounces  of  cinnamon-water  acidulated  with  aromatic  sulphuric  acid.  At  4  p.  m.  the  i)ul80 
was  better.  Fifteen  grains  of  chlorate  of  potash  were  ordered  to  be  taken  every  four  hours  with  stimulants  and 
beef-tea.  He  rallied  much  during  the  night,  but  in  the  morning  relapsed  into  his  previous  condition.  The  adminis- 
tration of  quinine  was  resumed,  but  death  occurred  at  5  P.  M. —  Union  Hospital,  Memphis,  Tinn. 

Ca.se  48. — Private  Edwin  Graves,  Co.  D,  Xtith  N.  Y.  Vols.;  age  20;  was  admitted  March  17,  1802;  diagnosis — 
typhoid  fever.  He  was  taken  sick  about  March  12  with  pain  in  the  chest,  headache,  nausea,  feeling  of  general  swell- 
ing and  much  debility,  succeeded  by  a  chill,  fevei  and  jinduse  perspiration,  which  symptoms  recurred  daily  about  11 
A.  M.;  he  had  also  much  annoyance  from  a  numb  feeling  in  his  lingers.  On  admission  the  pulse  was  rapid  and  ([uick ; 
the  skin  hot  and  moist;  the  t(mgue  moist,  red  and  slightly  coated;  the  patient's  api)etite  was  j)oor  and  he  had  some 
diarrlui'a  and  pyrosis.  He  stated  that  the  (diill  and  fever  occurred  at  the  same  time  in  rapid  alternations  in  ditl'erent 
parts  of  the  liody,  the  paroxysm  lasting  two  or  three  hours.  Twenty-four  grains  of  quinines  were  directed  to  be 
taken  during  the  day.  He  was  doliricms  during  the  18th ;  his  pulse  rajiid  and  weak ;  skin  natural  ;  tongue  moist  and 
coated  white.  Punch  and  beef-essence  were  given  every  two  hours.  He  died  delirious  on  the  morning  of  the  litth. — 
Seminarij  Ho«pital,  Geort/etoirn,  I).  ('. 

Mulariul  rheumatism. — Case  4!>. — Sergeant  Michael  Lett'oy,  Co.  F,  UiUli  I'a.  Vols.;  age  24;  was  admitted  Mat;h 
20,  1863,  having  been  affected  with  intermittent  fever  since  early  in  January.  On  admission  he  had  pain  in  the  back 
and  left  side  and  tenderness  over  the  lumbar  vertebra' ;  he  had  tremors,  and  was  unable  to  stand  erect.  He  was 
treated  with  (|uinine,  powdered  iron,  morphine  and  camphor,  with  tincture  of  aconite  as  a  local  application.  He  was 
transferred  to  Christian  street  hospital  April  21  [where  his  case  was  diagnosed  chronic  rheumatism,  and  whence  he 
was  discharged  June  2,  because  of  general  del)ilityl. — Suttcrlee  llo«pil(il,  I'hiUtdeJphiii,  I'a. 

Malarial  iiniralijia,  dctiility  and  adeiiia. — C.vse  50. — I'rivate  Martin  L.  l^ol>ertsou,  Co.  K,  4th  Me.  Vols.;  age  23; 
was  admitted  December  12,  1802,  for  torpidity  of  the  liver,  which  was  treated  with  mercurials  and  salines.  During 
his  convalescence  be  had  a  severe  attack  of  tonsillitis  ending  in  supimration  of  both  glands.  Soon  after  this  he  was 
seized  with  violent  pains  in  the  head  and  face,  assuming  the  forms  of  supra-  and  infra-orbital  neuralgia,  the  parox- 
ysms of  which  were  distinctly  periodic,  sometinu-s  (|Uotidiau  au<l  again  on  alteriuit«'  days.  During  the  exacerbations 
he  complained  of  numbness  on  the  right  side,  with  prickling  of  the  skin  of  the  face  and  a  sense  of  fulness  in  the  head. 
Cups  on  the  back  of  the  neck  and  luugat  Ives  gav('  some  relief  to  the  symptoms,  liut  dimness  of  vision  followed,  with 
unpleasant  illusions.  Extract  of  belladonna  apidied  around  the  eyes  relieved  the  pain  slightly;  but  it  was  soon 
thought  advisable  to  have  recourse  to  cinchona,  the  (lisease  being  conceived  to  be  dependent  upon  the  action  of 
malarial  or  miasmatic  poisoning  contracted  on  the  Rappahannock,  but  remaining  until  now  latent  in  the  patient's 
system.  Quinine  was  perseveringly  tried  for  some  time,  but  it  failed  to  arrest  the  paroxysms  (as  had  been  previ- 
ously observed  in  some  analogous  cases  in  tlui  hospital).  Fowler's  solution  in  five-drop  doses  was  substituted,  and 
after  a  few  days, the  neuralgic  symjitoms  began  to  yield  sensibly  to  its  influence  (as  had  also  happened  in  similar 
cases  where  the  cinchona  had  failed).  After  exhibiting  the  medicine  for  a  week,  slight  sickness  of  the  stomach 
seemed  to  suggest  its  discontinuance,  and  it  was  accordingly  laid  aside  for  a  short  time,  when  it  was  again  resumed 


OF    MALARIAL    niSEASE.  119 

Trith  Tipneflt  at  intorvnls.  Tho  original  hp]i:itir  disorder  riap]Marrd.  ri'(iiiirin<;  a  repetition  of  the  merenrials.  The 
strength  of  the  ]iatieiit  had  faik'<l  consideralily,  but  liis  nutritinii  was  jiretty  well  maintained.  On  March  2X  he  had 
a  severe  bilious  attack,  requiring  mercurials  and  laxatives,  to  whiili  it  soon  yielded,  but  he  was  left  with  some  wan- 
dering neuralgic  pains  in  the  head,  arms  and  other  parts  of  the  body.  The  nervous  system  was  impaired  in  power, 
and  it  seemed  impossible  to  rally  his  strength  and  spirits.  Tincture  of  iron  was  given  after  tho  suspension  of  the 
Fowler's  solution.  On  April  2  the  neuralgic  pains  were  very  nearly  gone,  liut  his  system  remained  enfeebled  and  his 
spiri*:s  despondent.     At  this  time  he  was  transferre<l  by  order  to  a  hospital  in  Main<'. — Sullirlvr  Hiixiiital,  I'hihi..  I'u. 

Case  51.— Private  Jno.  V.  Martin,  Co.  t;,  18th  Wis.  Vols.,  was  admitted  Decenilier  S,  18('4,  as  a  marked  case  of 
ana'Uiia  following  intermittent  fever.  He  had  occasional  attacks  of  neuralgic  supraoi  bital  jiain  severe  in  character, 
with  serous  elfusi<m  around  the  eyes,  sometimes  almost  filling  the  orbit  ;  the  sclerotic  was  very  w  hite  and  the  eyes 
watery.  He  was  improving  rapidly  and  promising  a  speedy  return  to  health,  when  a  recMirrenco  of  the  intermittent 
fever  was  followed  by  a  return  of  the  sujiraorliital  jiain  and  the  aiia'uiic  con<litioii.  After  rallying  from  this  another 
recurience  was  productive  of  similar  lesults.  He  was  tieated  with  i|Miniue,  iron  and  wine.  A  jnescription  which 
ajipeared  of  value  in  this  case  consisted  of  forty  grains  of  chlorate  <  f  potash,  twelve  of  citrate  of  quinine  and  iron 
and  two  of  jmwdered  capsicum,  taken  in  four  doses  during  tlu'  day. —  lloxjiilitl,  (Jitiiicii.  III. 

CvSE  52.— Private  Daniel  W.  Hutf,  Co.  H,  104th  Pa.  Vols.;  age  2il;  was  admitted  Sei>tember  1,  1804,  sutfering 
from  enlarged  spleen  and  general  debility  induced  by  malarial  disease.  He  had  severe  neuralgic  pain  in  the  back 
and  limbs;  his  feet  and  legs  freijuently  became  very  much  swollen,  which  condition,  as  it  could  be  traced  to  no 
marked  lesion  of  the  viscera,  was  referred  to  weakness  of  the  circulation  and  aiiM'inia.  The  treatment  consisted  of  a 
general  alterative  and  supporting  course.  Iodide  of  ixitassium.  iron  in  various  forms,  vegetable  l)itters,  mineral 
acids,  stinnilants,  counter-irritation  and  anodynes  were  em]doyed  in  accordanct^  with  the  indications.  No  improve- 
ment, however,  was  apparent;  in  fact  he  seemed  to  decline.  After  remaining  in  hospital  three  and  a  half  months 
he  was  discharged  from  the  service  Deceml)er  16,  IXM. — HoapHal,  Alexandria   Va. 


III.— SYMPTOMATOLOGY  OF  MALARIAL  DISEASE. 

I. — Intermittents  aki)  Remittents. — The  cases  submitted  above  illustrate  the  recur- 
rence of  the  intermittent  paroxysm  daily,  every  second  day,  or  every  third  day,  with  the 
frequent  relapses  which  occurred  in  the  progress  of  the  disease  and  the  congestions  of  the 
abdominal  organs  as  manifested  by  enlarged  spleen,  diarrlioea,  dysentery  and  jaundice.  The 
debility  and  anaemia  consequent  on  the  prolonged  action  of  the  morbific  cause  are  incident- 
ally mentioned,  and  as  a  result  of  the  altered  condition  of  the  blood,  boils  and  ulcers  are  noted 
among  the  sequelas  of  the  disease.  Consumption  appears  to  have  found  favorable  conditions 
for  its  development  in  systems  broken  down  by  the  continued  influence  of  the  ague-poison. 
The  identity  of  the  cause  of  the  intermittent  and  remittent  fevers  is  indicated  by  the  inter- 
changeable character  of  these  fevers,  tertians  developing  into  quotidians,  and  these  into 
remittents  and  congestive  fevers,  and  the  remittents  becoming  intermittent  in  their  favorable 
progress.  The  remittents  also  appear  to  have  assumed  a  typhoid  character;  but  whether 
this  was  due  to  the  presence  of  a  specific  poison  or  to  some  depressing  agencies  developed  in 
the  system  by  the  malarial  influence  is  not  manifest  from  these  records.  On  the  other  hand 
remittent  is  seen  to  have  followed  typhoid  fever;  and  here  also  it  is  not  evident  that  there 
was  any  connection  in  this  other  than  the  accidental  sequence  of  the  disease  causes.*  The 
relapses  that  occurred  in  remittent  cases  are  illustrated  as  well  as  the  frequent  association  of 
diarrhoea,  dysentery  and  hepatic  congestion  with  the  febrile  phenomena.  The  concurrence 
of  scurvy  is  also  observed.  The  tendency  to  an  adynamic  condition  is  noticeable  in  so  many 
that  a  hypersemic  case  in  which  bloodletting  was  used  in  the  treatment  on  account  of  acute 
cerebral  congestion  was  considered  worthy  of  special  comment  by  the  repoiter.     More  or 

*  .S.  K.  TOWLE,  Surgeon  30th  Mass.  Vols.,  in  his  Notes  of  Practice,  in  the  V.  S.  Arjnt/  General  Hospital  at  Baton  Rouge,  La.,  during  the  year 
18*>'l.  i>ul>lislie<l  in  tlie  Hoaton  Medical  and  Surgical  Journal,  Vol.  I.XX  (18()4).  pp.  411-56,  alluding  to  the  ooinplicated  character  of  the  iliseases  olweired 
in  his  hospital,  says:  "Indeed,  the  symptoms  of  many  of  the  cases  would  indicate  ratlier  a  c<imbination  of  diseases  than  any  one  disease — fevers  being 
ine.xplicahly  combined  with  diarrhcea  i»r  dysentery,  and  vice  versa,  so  that  one  would  liardly  linow  imder  wbieh  class  to  make  the  reeofd.  And  again, 
with  the  different  variety  of  fevers,  the  record  will  often  depend  upon  the  period  of  observation;  an  intermittent,  with  well  inarKed  stages,  will,  if 
neglected,  often  in  a  few  days  become  an  equally  well-marked  remittent,  or  typlio-malarial,  or  a  little  further  on  will  prominently  exhibit  advanced 
typhoid  symptoms;  or  perhaps  u  few  weeks  or  months  later  die  from  chronic  diarrhcea  or  dj-sentery."  • 


120  SYMPTOMATOLOGY    OF 

less  of  congestion  of  the  brain,  lungs,  liver,  spleen  ami  kiJtiijys  was  occasionally  recognized, 
and  in  some  of  these  cases  the  internal  coni>-estion  was  so  sudden  and  violent  as  to  cause 
speedy  death.  Rheumatism  and  neuralgia  are  also  suggested  as  consequent  upon  tlie 
malarial  influence.* 

But  nothing  is  said  of  tlie  aggregation  of  symptoms  which  led  to  the  diagnosis  of 
intermittent  or  remittent,  as  the  case  might  be.  Tlie  presumption  is  that  in  general  there 
occurred  no  special  alteration  from  well  recognized  characteristics.  In  fact  in  some  of 
the  sanitary  reports  it  is  definitely  stated  that  notliing  unusual  was  ]»resented  by  tlie 
malarial  diseases  under  observation.  In  the  intermittents  the  onset  of  the  disease  may  be 
assumed  witli  or  without  prehminary  feelings  of  languor,  weariness,  indisposition  for  physi- 
cal exercise  or  mental  work,  depression  of  spirits,  yawning,  aching  in  the  bones  and  soreness 
in  the  muscles,  with  creeping  or  chilly  sensations  along  the  spine,  loss  of  appetite  and  per- 
haps nausea,  which  had  been  noted  as  having  recurred  for  days  prior  to  the  advent  of  the 
regular  paroxysm.  We  may  assume  the  cold  stage  as  having  presented  its  chills,  developing 
perhaps  into  rigors,  and  accompanied  with  goose-skin,  shrunken  features  and  lividity  of  the 
lips  and  nails,  and  witli  internal  congestions  manifested  by  nausea  and  irritability  of  stomach, 
epigastric  pain,  splenic  or  hepatic  uneasiness,  hurried  respiration,  rapid,  irregular  or  slow 
pulse,  irritability  of  temper,  headache,  confusion  of  mind,  drowsiness  or  even  stupor  and 
coma;  the  gradual  accession  of  i-eaction,  the  alternations  of  flushings  and  chills  until  in  the 
full  development  of  the  hot  stage  the  cheeks  became  flushed,  the  skin  hot,  the  mouth  dry, 
the  tongued  furred,  the  respiration  accelerated  and  the  pulse  full  and  strong,  or  frequent 
and  feeble,  if  the  patient  was  I'educed  by  previous  attacks  of  this  or  other  enervating 
disease;  and  lastly,  concurrent  with  the  outbreak  of  free  perspiration,  the  gradual  subsidence 
of  these  symptoms  and  tlie  re-establishment  of  a  comparatively  normal  condition  until  the 
commencement  of  a  succeeding  paroxysm.  We  may  assume  also  the  various  irregularities 
frequently  presented,  especially  by  the  cold  stage,  it  having  been  sometimes  almost  absent 
or  indicated  only  by  depression  of  spirits,  yawning  or  some  other  comparatively  trifling 
symptoms  quickly  followed  by  fever. 

In  the  remittents  we  may  assume  a  preliminary  stage  of  such  malaise  as  seemed  due 
to  hepatic  disorder,  followed  by  a  chill  and  the  development  of  a  febrile  condition,  with 
anorexia,  thirst,  nausea  and  bilious  vomiting,  epigastric  or  hepatic  tenderness,  pains  in  the 
back  and  limbs,  hot,  dry  and  perhaps  jaundiced  skin,  hurried  breathing  and  frequent  pulse 
with  throbbing  headache,  tinnitus  aurium  and  occasional  delirium.  We  may  infer  also 
constipation,  a  foetid  or  bilious  diarrhoea  or,  even,  dysenteric  symptoms,  as  presented  by  the 
bowels  and  a  large,  coated  and  furred  tongue,  cleaning  as  a  favorable  issue  was  promised,  or 
becoming  dark  colored  as  hiccough,  low  delirium,  involuntary  stools,  clammy  perspirations, 
collapse,  stupor  and  coma  indicated  impending  death;  while  the  exacerbations  and  remis- 
sions are  implied  in  the  name. 

On  examining  the  cases  that  have  been  presented  enough  may  be  found  to  warrant 
the  acceptance  of  the  above  remarks. 

The  skin  was  sallow  or  pallid  in  the  protracted  cases;  and  in  the  paroxysmal  recurrences  when  its  condition 
is  mentioned,  it  was  hot  and  dry  or  moist,  according  as  the  notes  were  taken  during  the  exacerbations  or  remissions: 
occasionally  it  is  said  to  have  been  jaundiced.    The  pulse  is  represented  as  rapid  in  the  majority  of  the  cases,  and 

*  Although  lu'iiralgiii  was  fro(tueiitly  regarded  as  a  clinieal  associate  of  malarial  fevers,  or  indeed  as  the  legitimate  (jfrspring  of  the  malarial  poison, 
the  cases  reported  on  the  nioiitiily  rcjiorts  had  no  autumnal  tides  of  prevalence  to  indicate  their  coimection  with  or  dei>enden(!e  upon  the  c.luse  of  the 
paroxysmal  fevers.  (See  diagram  facing  page  874  of  this  volume.)  To  account  for  this  we  must  assume  that  all  neuralgic  cases  in  any  way  connected 
with  imilaria  must  have  been  reported  under  the  In-ading  of  viiasmatic  ilismses,  or  which  seems  more  probable,  that  neuralgia  was  less  frequent  in  its 
association  with  malarial  dise;|se  than  was  currently  supjMjsed. 


MALARIAL    DISEASE.  121 

■when  its  volume,  impulse  ami  resistance  are  not  siicciticall.v  stated,  tVeltleness  may  be  inferred  as  its  characteristic, 
for  emaciation,  debility,  jirostration  oi-  an;emia  is  noted  in  twenty-three  of  tlie  cases.  The  pulse  is  reported  in 
case  40  as  tense;  but  in  this  the  malarial  <'liaiacter  of  tlie  attack  is  not  satisfactorily  established.  It  is  stated  to 
have  been  full  and  strong  in  three  eases,  one  of  which.  3,  was  a  case  of  tertian  ague,  the  second,  27,  a  relapse  in  a 
remittent  case,  and  the  third,  32,  a  remittent  reported  as  being  of  an  unusually  sthenic  type. 

The  tongue  in  twenty-tivc  cases  in  which  its  apiieurunce  is  recorded  was  clean  in  one:  white  or  furred  in  four- 
teen; pale  in  one;  large  and  white  in  one;  soft,  pale,  moist  and  coated  in  one;  browni.sh  in  the  centre  and  after- 
wards becoming  jtale  and  Ilaliby  in  one;  dark-brown  or  black  in  three:  red  at  the  tij)  in  two.  au<l  at  the  edges  in  one. 
The  clean  tongiu-  was  recorded  in  a  chronic  case,  7.  during  tlu'  absence  of  paroxysnnil  manifestations  ;  the  pale  tongue 
in  the  .scoibutic  case.  30.  in  which  it  afterwards  became  black  and  was  accompanied  with  delirium.  The  brown  or 
black  tongue  a]t])eared  also  in  three  cases,  21*,  31  and  43.  in  which  tlu-r*'  was  likewise  delirium  with  much  prostration, 
and  in  the  last  two  instances  a  fatal  issue.  The  tongue  was  red  at  the  edges  in  the  anonuilous  case  40,  and  at  the 
tip  in  two  eases,  in  one  of  which,  20,  there  was  nothing  to  suggest  thai  it  was  (ttlun-  tlian  a  remittent  attack,  while 
in  the  other,  23,  the  specific  poison  of  typhoid  fever  was  considered  to  be  present. 

Tlie  <'ondition  of  the  tongue  in  uuilarial  fevers  is  usually  stated  by  medical  writers  as  white  or  yellow -coated, 
becoming  dry  and  of  a  brown  or  black  color  when  the  case  assumes  a  serious  aspect :  as  for  instance  Horton,  Martin, 
Aitken,  Copland,  Watson,  Hartlett  and  others,*  many  of  wliom  speak  of  t!ie  edg4's  and  tip  as  being  of  a  brighter  red 
than  natural.  The  descriptive  clause,  red  at  the  tip  und  edtjes^  is  suggestive  of  the  couditi(tn  of  the  tongue  in  typhoid 
fever,  and,  indeed,  in  Ilorton's  statement  kA'  the  pathologi<ral  changes  in  his  febrile  ceases  tlu;  patches  of  Peyer  were 
sometimes  found  inllamed  and  ulcerated.  There  is  a  j)robability,  therefore,  that  specidc  typhoid  may  have  been 
present  in  many  of  the  tedious  and  low  forms  of  fever  that  occurred  in  the  practice  of  our  medical  men  before  the 
war;  and  that  the  condition  of  the  tongue  in  such  cases  nuiy  hav(^  been  embraced  in  the  account  of  the  symptoms 
of  remittent  as  given  by  Jones,  Doniphan,  I5oling  and  others.! 

Rut  in  Sir  .J.  K.  ilartiu's  description  the  red  edges  and  tiji  are  distinguished  from  a  similarly  stated  condition  in 
enteric  fever  by  the  words  ttxnted,  cJammfj  and  moint^  as  apjdied  to  the  tongue  generally.  His  account  of  the  disease 
corresponds  with  that  given  of  the  Rio  (Jrande  remittents  by  Dr  Feck  in  the  report  presented  b(^lo\j  ,t  in  whicli  the 
red  tip  and  edges  of  the  tongue  are  specially  mentioned.  In  the  Bengal  fever,  as  in  that  of  the  river  bottoms  of  New 
Mexico,  there  is  seldom  evidence  of  a  co-existing  enteric  lesion.  Hence  a  tongue  with  red  edges  and  tip  may  be  con- 
sidered present  in  fevers  of  a  purely  uuilarial  origin,  although  during  our  w^ar  this  condition  was  sehlom  noticed.  The 
tongue  was  generally  soft  and  ilabby,  somewhat  enlarged,  broadened,  thickened  and  indented  at  the  uuirgins,  of  a 
pale,  livid  or  bluish  tint,  and  more  or  less  coated  or  furre<l  white,  yellow  or  brownish,  according  to  the  severity  of 
the  pyrexial  attack. 

*  .T.  A.  n.  HoHTON,  y[.  !>.,  ill  his  treatise  on  Diseases  of  Tropical  CUmates.  London.  1879,  p.  6f>,  says  of  the  tongue  as  it  uppeiu's  in  the  marsh  remit- 
tent fevers,  tliiit  "it  is  mure  or  less  fiirreii,  redder  than  natural  at  the  tip  and  edges."  And  again,  on  p.  ()8 :  "  Tlie  toiii^iio  at  the  commencement  of  tlie 
disea.-^e  is  generally  eovered  with  a  tlilck  whitish  or  yeUowish-wliite  fur.  thicker  ttiwards  the  centre,  haviiif^  a  feeling-  tif  l)ein);f  large  and  tiabby.  and 
niarkrd  on  its  periphery  l)y  impressions  of  the  teeth :  the  edges  are  usually  red.  l)nt  in  a  more  advanced  staiie  the  coating  assunu's  a  darkish  br.»wn 
appeaiance.  Sometimes  the  tongue  is  dry,  presenting  several  furrows,  arcomi'anicd  with  severe  thiret."  Sir  .Fames  H.VN.vi.u  M.vftrix,  in  his  iNjiuriirf. 
of  Tropical  Cfimates,  London.  1861,  j).  314.  speaking  of  tlie  remittent  fevers  of  Bengal,  states  that  "  The  tongue  is  red  at  the  tip  and  edges,  loaded, 
clammy,  an4l  nmist :  at  other  times,  with  a  bitter  or  bud  taste,  the  organ  is  but  little  (Changed  ir(»m  the  healthy  appearance.''  ArrKEN,  in  his  Science  and 
Practice  if  Medicine,  describes  as  follows  :  *'  The  tongue,  in  the  mild  form  of  tlie  disease  (fever  and  ague),  is  clean  in  the  cnld  stage,  white  in  the  hot  stage, 
and  again  cleans  after  the  sweat  has  flowed.  In  severe  cases  the  tongue  is  white  during  all  the  stagi's,  and  also  during  the  apyrexla,  while  in  the  worst 
cases  the  tongue  is  brown  in  all  the  stages.'' — American  edition.  18H6.  Vol.  L  page  483.  (!orr.ANn's  Diciinnnrij  of  Pnu-tical  Me.iUcinf.  London.  IS.'iH, 
Vol.  I,  p.  948,  says  that  the  tongue  in  remittent  fever  is  "clammy,  moist  or  flabby  and  coated,  and  afterwards  dry,  rough  ()r  brown,''  and  »m  page  S*:J5,  that 
the  tongue  of  intermittent  fever  "is  white  and  loaded."  CONDJK.  in  the  American  edition  of  Wa'I.son's  Practice.  IMiiladelphia.  1H.">8,  p.  5(h*,  in  his  article 
on  Rilitius  Uemittent  Fever,  says :  '*  The  tongue  is  usually  moist,  red  at  the  sides  and  edges,  and  coated  on  its  upper  surface  with  a  whitish.  light  brown 
or  yellowish  fur.  which  often  ac(|uires  considerable  thickness."  BAKTLErT,  in  his  Feverg  nf  the  United  States,  lid  edition.  rhiladel[>hia,  Pa.,  18o,'.  p.  3tll, 
says  :  "  The  tongue  is  generallj-  more  or  less  thickly  covered  with  a  yellowish  or  dirty  white  fur — tlie  color  being  probably  occasioned  in  many  cases  by 
the  fluids  ejected  from  the  stonuu-h.  The  edges  of  the  tongue  are  often  somewhat  redder  than  natural.  During  the  early  periods  of  the  disease  the  tongue 
usually  retains  its  m(t!sture :  but  in  grave  cases,  especially,  and  after  the  third  or  fourth  paroxysm,  it  frequently  becomes  parched  and  dry,  dark  brown  or 
nearly  black  on  the  dorsum,  more  intensely  red  on  its  edges,  and  sharpened  at  its  point."  (JKOU'iE  B.  WOOD  thus  give»the  appearance  of  the  tongue  in 
a  fully-formed  case  of  remittent  fever:  "  The  tongue  is  n(tw  thickly  and  uniformly  covered  with  a  white  or  yellowish-white  coating,  wliich,  as  the  disease 
advances,  often  becomes  brown  or  blackish,  es{>ecially  in  the  centre.  In  modenite  cases  the  tongue  is  usually  rather  moist  throughout  the  diseiuse ;  but, 
in  those  of  a  higher  grade,  it  not  unfreiuently  becomes  dry  or  dryish,  and  sometimes  (^happed  or  fissured  ui»un  the  surface.  It  is  occasifuially  disposed  to 
be  dry  in  the  paroxysm,  and  to  become  moist  in  the  remission.  At  the  sides,  when  imt  covered  with  fur,  it  is  usually  red.  and  not  unfrequently  indented 
by  the  teeth,  in  consequence  of  being  somewhat  swollen." — ^eo  Practice,  of  Medicine,  Pliiladelphia,  Pa.,  1847,  Vol,  I,  p.  258. 

t.Io.sEl'U  JOXES.  in  Observations  on  some  of  the  Physical.  Chemical,  Physiolnffical  and  Pathological  Phenomena  of  Malarial  Fever,  Philadelphia, 
18.">9,  says.  p.  297;  "In  almost  every  case  the  papilla;  of  the  tongue  were  enlarged,  and  of  a  bright  red  color.  In  the  mildest  cases  the  tongue  was  only 
slightly  coated  with  white  anil  light  yellow  fur.  and  the  tip  and  edges  were  retlder  than  normal.  In  the  severest  cases  the  tij*  and  edges  of  the  tongue 
assumed  a  bright  red  coh)r,  and  the  tongue  was  much  drier  than  in  the  niildiT  cases."*  *  *  "  The  fur  on  the  timgue  in  many  cases  was  thick,  and  of  a 
brownish-yellow  color."  And  furtlier:  ■"  In  the  active  stages  of  remittent  fever  the  tongue,  in  many  cases,  especially  if  it  be  the  first  attack  of  fever, 
I'resents  upon  those  })ortions  which  are  clean  a  brilliant  scarlet  color,  and  dry.  glazed  surface:  the  papilhe  are  erdarged :  tlu?  fur  whii-li  frequently  cuats 
the  tongue  is  of  a  yelhiwisb  or  brownish-yellow,  and  sometimes  black  C()lor.  and  almost  always  dr}'  :  the  tongue,  in  many  cases,  feels,  when  the  finger  is 
passed  over  it,  as  dry  and  liarsh  as  the  surface  of  a  rough  boaril."'  D.  A,  DONUMIAX,  M.  D..  in  Remarks  on  the  Bilious  Remittent  Fever  of  certain  por- 
tions of  Louisiana.,  describes  the  tongue  in  the  early  stages  as  red  on  the  tip  and  edges,  ct)vered  on  the  dorsum  with  a  white  or  pale  yellow  cuat,  stating 
that  in  the  advanced  stage  it  "changes  to  a  brjjwn  or  dark  brown  dorsum,  wiiile  the  tip  and  edges  are  red.  an  t  present  a  glazed  appearance." — .See  West- 
ern Lancet,  Lexington,  Ky-  1840,  Vol.  IV,  p.  212.  Wm.  M.  BouN'G,  M.  U.,  of  Montgomery.  Alabama,  in  Obsm^ntions  on  Uemittent  Fever  (is  it  occurg 
in  the  Southern  part  of  Alabama,  says :  "  The  t(mgue  in  the  first  exacerbation  may  remain  mi»ist,  sometimes  almost  natural ;  but  in  most  cases  the  edges 
will  be  redder  than  in  i>erfect  health,  and  the  dorsum  covered  with  a  thin  yellowish  or  dirty  white  fur."  *  *  "In  the  third  or  fimrth  exacerbation  it  is 
apt  to  become  dry,  at  least  on  the  dorsum,  though  the  edges  remain  moist,  and  still  later  it  becomes  |xirched,  rough  and  cracked." — Am.  Jour,  of  Med.  Sci.^ 
Philadelphia,  N.  S.,  Vol.  XI,  184f),  p.  21)7. 

J  Page  124. 

Med.  Hist.,  Pt.  111—16 


122 


SYMPTOMATOLOGY    OF 


Thus,  Surgeon  S.  K.  Towlo,  liOtli  Mmss.  Vols.,*  rffcrriiifi  to  the  dinguosis  of  fevor  cases,  says:  "The  white,  thick, 
))ul|>y,  rounded  tongue  will  dunilily  spciik  of  niiiliiriii.''  Surgeon  K.  C  Bidwell,  .Slst  Mass.  Vols.,t  liiid  already  made 
note  of  tlie  thickening  and  rounding  of  tll(^  sides  of  tlii^  tongue,  and  considered  this  condition  an  unmistakable  evi- 
dence of  the  presence  of  the  malarial  (loisou  in  the  system. 

Ur.  T.  C.  Oshorn  of  AlaliMiiia.t  li;is  described  an<l  figured  a  condition  of  the  tongue  which  he  claims  to  be  a 
l)athognonionic  symptom  of  iiuilarial  disease  (existing  in  all  cases,  both  acute  and  chronic.  Its  essential  feature  is 
that  the  tongue  presc^nts  a  more  or  less  wide,  smootli  margin,  with  slightly  tlattened  and  crumpled  sides  and  edges. 
The  color  amounts  ordinarily  to  a  very  faint  bluish  tinge,  which  is  often  lost  or  merged  in  the  various  tints  or  furs 
])roduced  by  other  diseases.  According  to  Osborn  the  crenated  or  crumpled  condition  of  the  edges  is  not  due  to  tlie 
impression  of  the  teeth,  for  the  transverse  lines  are  closer  togetlier  than  would  happen  if  this  was  their  cause,  and  they 
are  observed  in  infancy  and  old  age,  when  no  teetli  are  jiresent. 

The  appetite  in  the  ('ases  which  have  been  |)i'esente(l  is  said  to  have  been  good  in  two  instances,  7  and  11,  but 
in  both  the  reports  were  nuide  during  the  progress  of  recovery.  Ordinarily,  in  acute  attacks  of  malarial  disease,  there 
was  anorexia  or  impaired  app(!tite  with  nausea  and  perhai)s  vomiting,  these  symptoms  being  noted  in  fifteen  of  the 
cases.  Thirst  appears  less  frecjuentiy,  having  been  recorded  only  in  two  (^ases.  Disordered  digestion  was  numifested 
in  two  cases,  27  and  33,  by  foetor  of  the  breath.  Constipation  is  mentioned  in  seven  an<l  diarrhoea  or  dysentery  in 
twenty-two  of  the  cases  in  winch  the  condition  of  the  bowels  is  recorded. 

Abdominal  pain  or  temlerncss  is  usually  rei)orted  as  having  been  in  the  epigastric,  hypochondriac  or  umbilical 
regions.  In  one  instance,  30,  the  scorliutic  case,  the  light  iliac  region  is  stated  to  have  been  tender.  The  abdomen 
was  tympanitic^  in  one  case,  23,  in  which  typhoid  fever  was  (HUisidered  to  have  been  present. 

Headacdie  is  reported  in  nine  cases,  in  two  td' which  delirium  also  is  said  to  have  existed:  but  as  there  are  six  cases 
in  which  delirium  occurred,  although  headaclKi,  if  present,  was  not  reported,  the  freiinent  ])resence  of  cerebral  symp- 
toms in  these  malarial  fevers  must  be  accepted.  Epistaxis  in  one  of  the  cases,  32,  in  which  the  delirium  was  accom- 
l)ani<'d  with  tinnitus  aurinm  and  disturbed  vision,  gave  temporary  relief  to  these  special  symptoms;  but  in  case 
2'J  the  spontaneous  bleeding  from  the  nose  did  not  take  place  until  after  the  delirium  had  I)egnn  to  subside,  Ringin«„ 
in  the  ears  was  present  also  in  cases  38  and  40;  in  the  former  a  diagnosis  of  typhoid  fever  was  entered,  but  the 
patient  was  treated  successfully  by  (juinine;  in  the  latter  an  aural  inflammation  gave  a  sufficient  explanation  of  the 
tinnitus. 

Tlie  delirium  in  a  few  of  the  cases,  as  in  32  and  33,  appeared  due  to  cerebral  hyperemia,  l)ut  in  the  iarger  num- 
ber it  was  manifestly  of  an  asthenic  character,  and  the  concurrent  symptoms  were  in  some  instances  such  as  to  suggest 
the  use  of  the  word  typhoid  for  tlieir  expression.  In  29  the  patient  was  greatly  prostrated  and  his  lips  and  tongue 
coated  black  ;  in  30  ho  was  unable  to  speak,  his  tongue  was  l)lack,  his  teeth  covered  with  sordes,  and  there  was  ten- 
derness in  the  right  ilia<^  region;  in  3(i  there  were  ''symptoms  of  tyjdioid''  and  swelling  of  the  salivary  glands;  in 
43,  clammy  sweats,  involuntary  passages,  collapsed  features  and  imperce])tible  pulse;  and  in  45,  involuntary  pass- 
ages, gurgling  on  pressure  on  the  right  iliac  fossa,  dilated  pupils  and  dulness  of  hearing.  Whether  these  symptoms 
wore  manifestations  of  the  malarial  agency  or  indicative  of  tlie  typhoid  fever-poison  cannot  be  decided  by  the  records, 
although  it  seems  likely  that  an  adynamic  condition  may  liave  existed  independent  of  tlie  specific  poison  of  enteric 
fever,  for  in  29  and  43  tliere  appears  nothing  to  warrant  the  sui)position  of  a  specific  typhoid  element. 

The  characteristics  of  the  interniittents  consisted  of  the  persisting  tendency  to  recur- 
rence induced  by  continued  exposure  to  the  influences  determining  the  primary  attacks,  tlie 
liabiHty  to  a  fatal  issue  by  a  change  to  the  remittent  type  or  by  the  sudden  onset  of  a  per- 
nicious attack,  and  the  gradual  production  of  thtit  depraved  condition  of  the  system  known 
as  chronic  malarial  poisoning. 

The  remittents  were  characterized  chiefly  by  the  accompanying  asthenia,  and  as  this 
was  present  in  cases  free  from  diarrhceal,  pneumonic  or  marked  cerebral  symptoms,  as  well 
as  in  those  in  which  one  or  more  of  these  symptoms  gave  increased  gravity  to  the  attack, 
it  must  be  referred  to  a  deterioration  in  the  constitution  of  the  subjects  caused  by  the 
malarial  or  some  antecedent  influence.     The  frequency  of  diarrhoea  as  a  concomitant  must 

*  In  his  paper  cited  supra,  p.  119, 

tTliis  offi(^er,  in  an  article  entitled  Diagnosis  of  Vie  Malarial  JHathf^is:  New  Test  Symptom,'' GixyB:  "It  is  a  very  peculiar  and  abnormal  ap- 
pearance of  tiic  ti>ngup.  in  wliidi  its  under  surface  appears  t(t  have  trespass(-'d  ll]>on  tlie  upper,  the  papilla'  of  the  latter  l)eing  supplanted  by  the  transverse 
rugse  of  the  former.  The  sides  are  thickened  and  rounded,  the  noi'inai  wc-ll-dejined  e<i<fe  being  ol>literated,  and  the  line  of  demarcation  moved  nearer 
to  tlie  mesial  line.  Tliis  ai>pearance  of  the  sides  may  i>e  as.sociated  with  anj'  and  every  possible  ajipearance  of  the  remaining  papillary  surface,  clean 
or  coated,  thiclv  or  thin,  light  or  dark,  just  as  the  malarious  disease  may  be  attended  by  any  and  every  variety  of  morbid  condition  of  the  system. 
Through  all  this  variety  it  is  perfectly  distinct,  and,  when  once  learned  by  actual  inspection,  is  unmistalvable." — Boston  Med.  and  Surg.  Jour.,  Vol. 
LXVIII,  18(i3,  p.  ati. 

JT.  C.  OsHoRX — Remarks  on  a  peculiar  appearance  of  the  tongue  in  malarial  disease. — The  We.ftern  Jour,  of  Med.  and  Surg.,  Vol.  VIII.  IS-'il. 
p.  109 — also  by  the  same,  A  peculiar  appearance  of  the  tongue  in  Malarious  disease. — Trans,  of  the  Amer.  Med.  Assoc.,  Vol.  XX,  18fi9,  p.  17.'>  [witii 
colored  plate] — and  .4  new  ruriety  of  Malarial  Fever. — New  Orleans  Jour,  of  Med.,  Vol.  XXI,  p.  664.  The  reference  to  a  trespass  of  the  under  on  the 
upper  surface  in  Dr.  BU)^v^;I.I,■H  article  is  a  singular  coincidence,  if  he  was  unaware  of  Dr.  OsBOKX's  paper  published  in  1851,  in  which  occurs  the  fol" 
lowing :  "  The  most  fixed  condition  of  this  symptom  is  an  appearance  of  indentation  or  crimpling.  transversely,  which  is  apparently  confined  to  the  sub- 
jacent tissue,  while  the  su|tcrficial  tegument  is  moist,  smooth,  and  transparent.  In  a  word,  it  seems  to  t)e  a  continuation  or  encroachment  of  the  interior 
surface  upon  the  superior  and  lateral  borders  of  the  tongue,  greater  as  we  approach  the  root  of  the  organ." 


MALARIAL    DLSEASE.  128 

be  attributed  to  tbe  simultaneous  action  of  the  causes  of  the  alvine  fluxes  and  tbe  malarial 
poison.  Where  so  many  men  were  affected  with  diarrhoea  a  certain  percentage  ot  diar- 
rhoeal  complications  was  to  have  been  expected  among  the  remittents,  irrespective  ot  tlie 
action  of  the  malarial  poison  on  the  integrity  of  the  alinuMilary  mucous  membrane.  But 
as  it  is  certain  that  the  coincidence  of  diarrhoea  and  periodic  fever  was  greater  than  could 
be  accounted  for  by  these  considerations,  we  are  at  liberty  to  consider  it  either  as  due 
directly  to  the  malarial  agency  or  as  a  further  illustration  of  the  proposition  that  the  mala- 
rial influence,  other  conditions  being  equal,  is  more  readily  manifested  in  the  debilitated 
than  in  the  strong  and  healthy.  The  diseased  action  as  it  atfect(>il  the  lungs,  excluding 
from  consideration  tlie  supervention  of  pernicious  eliills.  was  not  manifested  by  any  urgent 
or  prominent  symptoms;  it  appeared  rather  to  progress  iiisidiously  as  in  the  course  of 
typhoid  fever.  If  cases  occurred  such  as  were  described  by  AL\nson  in  1857  under  tlie 
name  of  malarial  pneumonia,  and  by  Gaikes  of  Mobile  in  1866,*  who  proposed  for  them 
the  title  of  remittent  pneumonic  fevers,  they  were  not  recorded  by  our  officers  as  mani- 
festations of  malarial  disease.  The  incidence  of  the  disease-poison  on  the  liver  was  very 
generally  manifested  by  bilious  vomiting  and  not  unfrequently  by  jaundice;  in  some 
instances  this  latter  symptom  was  so  strongly  marked  as  to  suggest  the  idea  of  yellow 
fever. +  The  kidneys  did  not  come  into  prominence  in  the  symptomatology.  The  urine 
was  affected  during  the  febrile  condition,  and  in  the  jaundiced  cases  it  participated  in  the 
general  coloration,  but  it  is  not  often  mentioned  as  having  been  albuminous  or  sanguinolent. 
The  following  extracts  from  special  reports  refer  to  tlie  syiujitoms  of  the  intermittents 
and  remittents: 

SurtjioH  M.  R.  (!aue,  25/7i  W'di.  Vols.;  Columbus,  Ky.,  March  31, 1863 :  Bilious  fover,  as  we  have  seen  it  in  our  present 
location,  jiresfiits  tlic  follow  inj;  symptoms  :  For  many  days  before  tlie  i)atient  f^ives  up  lie  conipliiins  of  languor,  bitter 
taste  in  the  mouth,  slight  feelings  of  nausea,  disinclination  for  food,  sometimes  constipation,  and  very  generally  a  con- 
siderable degree  of  heavy,  dull  pain  over  the  eyes.  A  chill,  more  or  less  severe,  generally  precedes  the  attack,  followed 
hy  increased  heat  of  the  entire  surface,  and  slight  or  severe  pain  in  the  lumbar  region;  the  skin  becomes  hot  and 
dry,  the  countenance  flushed,  the  eyes  red  and  watery,  the  pulse  ijuick  and  breathing  hujried;  extreme  irritability 
of  the  stonuich  is  a  frequent  and  distressing  symptom,  and  for  many  days  sometimes,  a  peisistent  accompaniment, 
nearly  everything  in  the  form  of  ingesta  being  rejected.  There  is  commonly  considerable  thirst,  a  marked  decrease 
in  the  urinary  secretion,  which  is  highly  colored  and  has  a  strong  odor,  and  after  the  disease  has  continued  for 
a  time  the  skin  shows  a  yellow  hue,  which  tint  also  extends  to  the  eyes.  An  exacerbation  and  remission  of  the 
fever  takes  place  during  the  twenty-four  hours,  each  succeeding  exacerbation,  perhaps,  ac(iuiring  greater  severity. 
The  symptoms  above  described,  greatly  intensified,  with  a  more  continuous  exacerbation  and  less  distinctly  marked 
remission,  constitute  the  severer  form  of  the  disease.  To  allay  the  pain  in  the  head  and  back,  which  is  often  dis- 
tressing, mustard  applied  to  the  nape  of  the  neck  and  the  snuill  of  the  back,  together  with  cold  applied  to  the  head, 
often  affords  ])rompt  relief.  If  the  suffering  is  intense  and  the  case  more  urgent,  cupping  the  temj)les  and  back  of  the 
neck  is  of  the  first  importance,  and  should  by  no  means  be  neglected  ;  so  also  the  cui)s  may  be  applied  to  the  epigas- 
trium, if,  as  is  sometimes  the  case,  a  feeling  of  death-like  op))rcssion  is  a  constant  and  serious  symptom.  Cathartics 
are  at  once  resorted  to,  the  prescription  generally  used  Iteing  as  follows:  Four  grains  of  podophyllin,  ten  grains  of 
bicarbonate  of  soda  and  ten  grains  of  calomel,  divided  into  six  powders,  one  of  which  is  taken  once  in  two  hours. 
This  combination  ordinarily  produces  very  free  catharsis,  and,  together  with  the  means  already  brought  into  use, 
often  affords  prompt  and  pernuinent  relief,  and  places  the  case  in  a  condition  to  move  through  the  course  of  the 
disease  in  safety,  if  the  latter  is  not  efl'ectually  cut  short.  Bathing  the  entire  surface  in  waterto  which  a  little  soda 
has  been  added,  and  of  such  a  temperature  as  to  feel  comfortable  to  the  patient  during  the  exacerbation,  is  a  matter 


*Rep«jrt  of  O.  F.  Manson  on  Malarial  Pncuinonia. — New  Orleans  Medical  Xewg  and  Hospital  Gazette,  Vol.  4,  1857-i58,  p.  4()0  et  seq.  Malarial 
piipumnnia.  An  Essay  read  l)efore  the  Mobile  Medical  .'Society.  March  .1,  ]8HH.  by  I-',  i*.  (JAINKS,  M.  D. — New  Orleans  Med.  and  Surg.  Jour.,  Vol.  XX, 
p.  V2  ft  seq.  Maxson  describes  this  form  of  pneumonia,  whicii  he  considers  the  prevailing  type  of  the  disease  in  the  .South,  as  a  severe  remittent 
fever  with  piieiuuonie  symptoms  superadded.  The  lungs  become  permeated  with  a  bloiHl-tiiiged  serum  rather  than  citnsolidated  by  exuded  plasnui. 
lie  cimsiders  the  condition  as  one  of  congestion,  for  it  often  occurs  with  (.'old  skin,  Hagging  pulse  and  colliquative  diarrha^a,  manifestations  which  he 
reganis  as  inconsistent  with  the  existence  of  the  inflammatory  process.  TtAIXES  says  that  cases  ushered  in  with  a  severe  chill  are  dangerous,  as  the 
lungs  may  be  overwhelmed  by  the  sudden  congestion;  but  the  fatalit}-  generally  depends  more  upim  the  febrile  disease  than  upon  the  pulmonary  inflam' 
mation  which  accompanies  it.  In  a  few  cases  lie  bled  for  the  sake  of  the  immediate  relief  given  to  the  congested  lungs,  and  he  had  experienced  no  evil 
after-ellects  from  the  bleeding ;  but  cupping  answered  in  the  majority  of  cases.  This  was  followed  by  calomel,  and  if  the  fever  became  high,  by  vera- 
trum  viride.     When  the  remissittn  recurred  large  doses  of  quinine  were  given. 

t  See  Surgeon  TOWLK'S  Notes  cited  supra,  p.  119. 


124  SYMPT()}irATOL0GY    OF 

of  no  HliuiU  moiiifiit,  ami  allonls  a  jilcahaiit  iclicf  Ikjhi  llic  inlcnsc  heat  of  t\u:  skin  and  helps  to  keep  that  great 
(lepurative  organ  in  a  c'ondilion  the  liettcr  to  pcifonii  not  only  its  ordinary  liinctions  Imt  the  large  inerease  of  duty 
now  incumbent  ujion  it.  The  etierveseing  draught,  si)irit  of  niindeierus,  sweet  spirits  of  nitre,  Hoffmann's  anodyne, 
])over's  powder  and  i|>eeacnanha  are  remedies  of  some  imi)ortanee,  and  may  be  administered  with  advantage  l)y  an 
election  of  cases,  and  if  their  exhiliition  be  iirojierly  timed.  Blisters  are  useful  after  the  force  of  tlii^  exacerbation 
lias  been  reduced  in  tlio.se  cases  where  any  consideralile  head,  gastric'  or  pulmonaiy  diHicnlty  remains. 

Nurijtuii  A.  F.  I'Kt'K,  1.-./  2\civ  Mixicn  Miniiilid  ]'iiU.:  Lhh  Luiiun,  Xcw  Mexico,  ^(jil.  30,  18t)2 :  Intermittents  are 
of  the  quotidian  tyjie;  remittents  appioach  very  closely  in  character  to  continued  fever.  The  cold  stage,  so  well 
marked  in  the  intermittent  fevers  of  tlie  different  sections  of  the  United  States,  is  but  slightly  developed  on  this 
river  (the  Kio  (Jrande)  as  far  as  I  have  observed;  it  amounts  to  no  more  than  chilly  sensations  in  different  parts  of 
the  body,  after  which  the  stage  of  pyrexia  supervenes  and  lasts  for  several  houis,  when  the  sweating  stage  begins 
and  the  fever  declines.  Tlie  tongue  is  heavily  coated  with  a  white  fur;  there  is  great  thirst  with  sometimes 
nausea  and  vomiting;  all  disposition  for  food  is  lost;  the  breathing  is  hurried  and  often  irregular,  witli  feelings  of 
weight  and  ojjpression  in  the  epigastrinm;  the  pulse  is  full,  strong  and  frecjuent.  The  nervous  system  is  mncli  dis- 
ordered; there  are  severe  pains  of  a  neuralgic  character  iu  the  l)ack,  loins  anil  extremities;  the  secretions  are  dimin- 
ished, the  skin  being  dry  and  hot  and  the  urine  scanty.  In  the  course  of  a  few  hours  the  sweating  stage  makes  its 
appearance,  when  all  the  febrile  symptoms  gradually  al)ate.  As  it  advances  the  skin  becomes  cool,  the  excitement  of 
the  circulation  subsides,  the  headache  disai)pears  and  the  patient  falls  into  a  calm  sleei>,  from  which  he  awakens 
free  from  fever. 

The  symptoms  of  remittent  fever  differ  iu  many  particulars  from  those  above  enumerated:  For  several  days 
juevious  to  an  attack  the  patient  describes  himself  as  feeling  languid  and  weak,  with  pains  in  the  body  generally, 
epigastric  uneasiness,  deticicncy  of  appetite,  disordered  tasti;  and  slight  soreness  in  different  parts  of  the  body. 
This  state  of  system  continues  until  a  regular  paroxysm  of  fever  makes  its  appearance,  which  continues  with  little 
or  no  abatement  in  the  twenty-four  hours.  In  many  cases  the  only  sign  of  a  remission  is  a  slight  diminution  in  the 
fulness  of  the  pulse,  the  freiiueucy  remaining  the  same,  while  the  pains  in  the  body  may  be  less  violent  and  the  skin 
not  so  hot  as  a  few  hours  before.  The  tongue,  at  first  covered  with  a  yellowish-white  fur,  in  the  course  of  two  or 
thtee  days  assumes  a  dark  and  dry  a])pearance  in  the  ccmtre  with  edges  and  tij)  very  red;  great  thirst;  intense 
j)ains,  especially  in  the  head  and  back ;  sometim(^s  diarrhaja  and  at  others  constipation;  urine  scanty  and  very  dark; 
respiration  hurried  and  diliiiult  ;  skin  sonustimes  of  a  yellowish  hue. 

The  treatment  that  1  adopt  for  tlu^se  two  diseases,  which  are  undoubtedly  identical  in  character  but  different 
in  intensity,  is  as  follows:  If  the  bowels  are  confined  I  give  thre(!  or  four  compound  cathartic  pills  or  half  an 
ounce  of  sulphate  of  magnesia;  if  there  is  diarrluea,  castor  oil  half  an  ounce  with  half  a  drachm  of  oil  of  turpen- 
tine to  be  taken  at  once.  After  the  bowels  are  thoroughly  cleansed  I  give  fifteen  to  twenty  grains  of  sulphate  of 
quinine  morning  and  evening.  If  the  ))atient  has  fever  the  next  morning  I  repeat  the  (juinine,  giving  twenty  grains 
of  the  sulphate  rather  than  tiftcen,  as  I  find  that  this  (juantity  answers  much  better,  given  at  onci?,  than  a  greater 
((uantity  in  divided  doses.  Hy  this  method  of  administration  its  full  sedative  and  fcbiifugc  ctletits  are  jiroduced. 
I  never  have  known  two.  or  at  most  tluee,  twenty-grain  doses  of  the  sulphate  (and  often  much  less  is  required)  fail 
in  this  valley  to  reduce  the  fever  and  produce  complete  convalescence.  In  a  few  cases  I  have  thought  it  necessary 
to  resort  to  alterative  doses  of  mercurials  combined  with  opium  or  Dover's  powder  at  night  to  procure  rest;  and 
if  the  urine  should  be  very  deficient  in  <iuantity  I  give  sweet  spirits  of  nitre,  half  a  ilrachm  to  a  drachm,  three  or 
four  times  in  the  twenty-four  hours.  If  there  should  be  much  jirost  ration  I  give  es.sence  of  beef  witli  wine  or  brandy, 
as  circumstances  may  dictate.  Method  of  administering  sul]ihiite  of  quinine,  w  ith  some  of  its  attendant  results:  I 
never  wait  for  an  intermission  or  a  remission;  if  the  liowels  are  open  I  give  it  at  once,  iu  the  height  of  the  fever, 
in  from  fifteen  to  twenty-grain  doses,  and  repeat  if  necessary  in  three  or  four  hours.  When  the  symptoms  are  of  au 
alarming  character  I  very  often  combine  the  sulphate  with  a  cathartic  and  give  both  at  once,  and  if  in  three  or 
four  Iiours  no  sedative  impression  is  made  I  give  an  additional  quantity.  In  ordinary  cases  I  never  have  found  it 
necessary  to  give  more  than  two  twenty-grain  doses  in  the  twenty-four  hours,  although  I  have  seen  many  cases  iu 
which  I  have  given  double  or  triple  this  (|iiautity  with  the  very  best  results.  The  immediate  results  of  the  admin- 
istration of  the  sulphate  in  large  doses  during  the  fever  are  so  gratifying  that  I  cannot  refrain  from  Tioting  some  of 
them.  In  from  one  to  three  hours  the  sedative  effects  of  the  medicine  liegin  to  appear.  The  pulse,  before  full, 
bounding  and  rapid,  now  becomes  soft,  less  fre<iuent  and  more  regular;  the  skin,  that  before  was  hot  and  dry,  now 
begins  to  be  cool  and  moist ;  the  countenance,  that  was  anxious  and  restless,  now  bears  the  marks  of  composure  and 
rest ;  the  respirations,  that  were  hurried  and  o])pres.sed,  are  now  easy  and  free  ;  the  tongue  begins  to  show  signs  of 
returning  moisture ;  the  urine  becomes  copious;  and  lastly,  the  whole  nervous  system  is  quieted  and  the  patient 
enjoys  sweet  lepose. 

Siii-yt'oii  M.  I).  Benedict,  loth  Xiir  York;  S((tit(i  Uoau,  Fht.,  April  3,  1862:  We  have  had  since  March  1  a  large 
number  of  cases  of  remittent  fever,  mostly  of  mild  type,  although  a  few  have  shown  a  stronger  tendency  to  congestion. 
It  seems  like  a  fever  of  acclimation,  and  in  its  treatment  quinine  is  our  main  dependence. 

Ass't  Surg.  3.  H.  ScHEETZ,  ilth  Pa.  VoU.;  lUaufort,  S.  C,  Augunt  31, 1862  :  Kemittent  fever,  which  prevailed  to  a 
considerable  extent,  was  characterized  by  a  daily  exacerbation  and  remission.  Most  of  the  cases  jjiesentedthe  following 
symptoms:  A  general  feeling  of  lassitude  for  two  or  three  days,  with  partial  loss  of  appetite,  followed  by  alternating 
chills  and  flushes  of  heat,  cephalalgia,  referred  principally  to  the  supraorbital  regions,  sharp  and  lancinating  in 
character,  but  sometimes  dull,  aching  and  heavy;  eyes  generally  suffused;  skin  sallow,  hot  and  dry  during  exacer- 
bation, moist  and  llaccid  during  remission;  tongue  coated;  thirst;  anorexia;  pain  in  the  back  and  extremities; 
bowels  usually  torpid,  but  in  some  disposed  to  looseness;  tenderness  over  the  right  hypochondriac  and  epigastric 


MALAKIAL    JiIPKASE.  12o 

reffioiis;  nausea  frequently  und  tsoiuetiuies  voniitius;;  pulse  fioin  ><.">  to  115  per  luiiiiite:  urin<!  f;(!nenilly  liij^li-cdlored 
and  oeeasioiiiiig  frequent  eoiujilaints  of  scaltlini;. 

The  treatment  found  most  Ivenefieial  was  to  administer  a  mercurial  ])uri;ativo  in  cases  with  torpid  liowels; 
when  nausea  was  present  twenty  };riiins  of  iiiecaiiianha  were  ailded  to  ihe  mercurial.  After  the  cvacuaticm  of  the 
intestinal  canal  <|uinia  in  tive-ixrain  doses  was  niven  four  to  six  tiuu's  daily.  Dianluea  was  treated  w  ith  opium  or 
Dover's  ]>owder  alternating  with  the  quinine. 

Surdcou  (i.  W.  I'niLi.ip.s,  ")//(  III.  I'iiIh.:  I'irriiriUr.  M<L.  Ihccinhcr 'M.  18(i2:  Many  cases  of  miasmatic  disease  were 
coniplic.ated  with  diarrhu'a,  bronchitis  and  luqiatie  ileranucuient .  The  ])aroxysms  in  nuist  of  the  cases  were  not  dis- 
tinct— occurrinf;  at  a  certain  hour,  and  made  up  of  distinct  staijes.  as  of  cliill.  fcxcr  au<l  sweating; — Ipiit  li};ht  chills, 
followed  in  a  short  time  liy  flushes  of  fivci ,  liui  without  siilisr(|ucnt  ]icrs]iiral  ions.  I'hc  fchrih'  act  ion  was  not  hij;h: 
skin  hot  Imt  not  biirnin};:  jnilse  frequent  ami  often  weak  and  small.  A  sense  of  ureal  muscular  luiistration  attended 
all  these  cases:  eonjjestion  of  the  kidneys  was  also  common.     They  were  treati'd  with  free  doses  of  (|uinim'. 

Siirtjion  J.  L.  Moi.I'UHd,  18///  A'.  )'.  )o?».,-  Foil  riil((xl,i,  (in.,  Sipliiiihrr  1,  18()2:  The  ca.ses  of  nuilarial  fever  this 
month  have  been  of  amihl  foiiri.  Tlie  symptoms  are  nause.i  ami  \(imitiiii;.  great  lassitude  and  weakness,  pain  in  the 
back  Jiart  of  the  head  with  a  heaviness  over  the  vertex,  pain  in  thi^  Um>cs,  hi<;h-C(dored  urine,  dark-colored  stools, 
and  slight  pain  in  the  livci-.  In  all  cases  I  think  the  ditiiculty  ai  iscs  from  an  inactive  liver.  The  ticatnient  has  been 
mercurial  purgatives  aiul  castor  oil,  followed  liy  live-grain  doses  of  i|uinim'  in  arouuitic  suliihuric  acid. 

Sunjcun  H .  Eahnkwt  Goodm.sx,  'ZHth  Pa.  I'olx.;  I'oittI  of  Uocka,  Mil.,  Sijittmhrr  lit),  1801 :  I  liave  observed  a  pecu- 
liar disease  among  the  men.  beginning  with  a  dull  headache  for  several  days,  and  then  charaeterizod  by  a  hansli,  dry 
skin,  dry  tongue,  feeble  pulse,  extreme  debility,  no  appetite,  pridiably  a  little  fever  once  in  several  days,  and  with 
more  of  a  tendency  to  constijiatiou  than  diarrlnea.  After  one  or  two  weeks  spent  iu  this  condition  the  patients 
brighten  up,  eat  ravenously,  and  soon  return  to  a  hciilthy  state.  I  have  clas.sed  these  cases  under  the  head  of  remit- 
tent fever;  but  the'  fever  is  seldom  peiceptible  to  the  touch. 

AxH't  Surg.  D.  L.  Hikn'tinoton,  U.  S.  Army;  Fort  Monroe,  Va.jNcptemlwr  30,  181)2:  The  prevalent  diseases  have 
been  those  of  miasmatic  origin  and  those  depending  on  a  deranged  state  of  the  portal  circulation.  The  bilious 
fevers  have  been  mild  and  easily  nninaged.  Interniittents  have  proved  more  obstinate,  and  in  many  cases  have 
continued  a  long  time,  (juinine  having  seemed  to  exercise  l)ut  little  of  its  ])eculiar  power.  In  these  cases  a  resort  to 
Fowler"s  solution  has  been  of  great  advantage.  I  have  noticerl  a  marked  tardiness  of  recovery  in  these  cases  of  mias- 
matic disease,  which  I  have  attributed  |>artly  to  the  fact  that  the  poison  still  remains  in  the  system,  though  held  in 
abeyance  for  the  time,  and  partly  to  the  enervating  etfects  of  the  clinuite.  It  is  i)roper  to  state  that  but  little  of  the 
disease  has  originated  here;  it  was  contra<'ted  during  the  campaign  on  the  peninsula  or  i)revious  to  enlistment. 

Siinjidu  A.  W.  WuiGHT,  58(/i  /'«.  (  o/.f. ;  Suffolk,  Vii.,  Noremhcr  I,  1862 :  We  had  iilso  a  number  of  cases  of  a  peculiar 
tyjxi  of  remittent  fever.  A  nuiii  would  coiuplain  of  a  few  ordiiuiry  bilious  symptoms  for  a  day  or  so,  doing  light  duty, 
when  his  messuuites  would  rei>ort  him  as  crazy.  In  a  day  the  following  symptoms  would  lie  develojied:  Dry  tongue; 
quick  luilse,  110-120;  slight  hetit  of  skin;  good  api)etite:  some  tendency  to  diarrlnea;  wildness  of  expression ;  nerv- 
ousness; constantly  moving  about,  lying  down  only  when  ordered  to;  embracing  every  opportunity  to  escape  the 
care  of  nurses,  and  talking  rationally,  although  occasionally  mildly  delirious.  Tliese  symptoms  lasted  about  two 
weeks,  when  the  patient  suddenly  awoke  to  a  consciousness  of  his  condition.  Convalescence  was  rapid.  I  hiid  six 
cases  of  this  kind,  and  all  recovered  except  Private  Putnam  of  Com])auy  (i,  who  becanu^  insane  and  was  sent  to  the 
Asylum  at  Washington.  The  disease  sometimes  assumed  another  form:  The  man  would  have  a  slight  chill,  then 
fever,  quick  pulse,  dry  tongue,  either  copious  perspiration  standing  in  drops  all  over  the  body  or  great  coolness  of 
surface,  delirium,  great  perspiration  and  death  iu  twenty-four  to  tifty-six  hours.  I  had  two  such  cases  iu  Oak  Grove 
Camp  and  lost  one  of  them. 

11. — The  Peknicious  Fevers. — In  the  form  of  sick  report  used  during  the  civil  war 
the  term  congestive  intermittent  fever  was  employed  as  the  equivalent  of  the  designations 
pernicious  intermittent  fever,  congestive  fever  and  congestive  chills,  to  indicate  that  dan- 
gerous form  of  intermittent,  chai'acterized  especially  by  the  intensity  and  severity  of  the 
cold  stage,  which,  had  long  been  recognized  as  of  frequent  occurrence  throughout  the  mala- 
rious districts  of  our  Southern  States.  Such  attacks  occurred  not  only  in  persons  who 
were  for  the  first  time  exposed  to  a  highly  malarious  atmosphere,  but  also  among  those 
who  had  suffered  more  or  less  from  the  malarial  influence  before  the  supervention  of  the 
congestive  seizure;  indeed  it  is  probable  that  a  majority  of  the  deaths  recorded  by  our 
medical  officers  as  from  simple  intermittents  were  really  due  to  the  occurrence  of  this  per- 
nicious type  of  the  disease.  It  assumed  various  forms,  one  of  which  appears  to  have  been 
observed  with  much  frequency.  In  it  were  presented  grave  symptoms  of  disturbance  of 
the  brain  and  nervous  system;  excessive  headache,  drowsiness,  even  coma,  occasionally 
convulsive  phenomena  and  sometimes  tlelirium,  accompanied  its  onset.     In  some  cases  the 


12fi 


8YMFT0MATUL0(iY    OF 


nervous  disorJer  rnanifestod  itself  in  tlie  form  uf  e[iilc|iliforni  convulsions,  as  obsf-rvcd  liy 
Hur<'-con  Geokge  (Joopkh,  V.  ^.  Army,  wliilc  Mrtlicul  l)ir('(;t(jr  of  tlio  Department  of  the 
Soutli.''"  In  other  instanees  unusual  manifestations  were  recorded,  as  by  Surgeon  (_t.  Rush, 
101st  Pa.  Vols.,  wbo  published  two  eases  of  pernicious  fever  in  wliieli  unconsciousness  and 
insensibilitv  were  associated  with  so  little  disturljance  of  the  oro-anie  functions  that  in  the 
first  case  which  occurred  tlie  patient  was  suspected  of  malingering. f 

Fi'equently  the  severity  and  jirolonged  duration  of  the  chill  or  of  the  condition  of 
collapse  that  followed  it,  corresponded  to  what  has  been  described  as  the  algid  variety  ot 
pernicious  fever.  Dr.  AV'oodwaruJ  mentions  having  seen  at  the  siege  of  Yorktown  a  num- 
ber of  cases  in  which  the  collai)se  was  profound  and  extremely  prolonged.  In  other  cases 
congestion  of  the  kuigs  appeared  to  determine  the  fatal  issue.  Although  vomiting  and 
diarrhoea  were  frequent  concomitants  of  the  sim})le  interinittents  and  remittents,  it  does 
not  appear  that  the  concui'rence  of  these  synip*:.oms,  constituting  a  choleraic  variety  of  the 
disease,  was  often  observed  in  our  pernicious  cases.  When  the  incidence  of  the  disease  fell 
on  the  intestinal  mucous  membrane  profuse  hsemorrhage  was  the  more  common  result,  as  in 
the  cases  described  in  Surgeon  Merritt's  report  submitted  below. §  The  hsematuric  variety 
of  hsemorrhatfic  malarial  fever,  which  has  attracted  so  much  attention  in  the  Southern  States 
since  tlie  close  ot"  the  wai',  does  not  seem  to  have  been  observed  among  our  soldiers.  But  in 
some  of  Mkrritt's  cases  intense  jaundice,  whicli,  with  blood  in  the  urine,  is  regarded  as  the 
characteristic  symptiMu  of  the  luiematuric  variety,  appeared  in  connection  with  the  luemor- 
rhagic  extravasations  from  the  intestinal  mucous  membrane. ||  In  other  instances  the 
beemorrhagic  tendency  was  shown  by  petechi^e  and  vibices.     Dr.  Woodwakd's  cases,  whicli 

*  See  the  n-port  nf  Surg-edii  COOTEH.  p.  231  of  the  Aifpendix  to  Part  I  of  this  work.  Some  iff  the  oases  referred  to  by  Surgeon  D.  W.  HaxI>,  U.  S. 
Vols.,  as  rfceurriii^'-  duriiip;  the  siiimrier  of  iHti.'i  in  the  --.^Tth  Muss.  Vols.,  near  New  Heme,  X.  C  .  must  also  liave  presented  uuirked  cerebral  syrnptotas,  for 
he  says  :   "  I  liave  reason  tu  believe  tliat  snuie  of  these  trases  were  mistaken  for  eerebrosphial  meningitis  by  the  niedieal  otlu-ers  in  attendance."' 

i  In  tlie  I'liiUnh'lpliia  Mel.  antf  Siuy.  Jiiporter,  V(d.  X,  IfiUlS.  page  :«)?*:  Private  C.  of  Co.  V.  and  private  K.,  of  Co.  I,  IDlst  Pa,  \oU.,  who  had  pre- 
sented nothing  unnsiiiil  during  the  niglit  and  previous  tluy,  were  found  on  tlie  mornhig  of  Sept.  25,  ]8t)3,  in  a  state  of  insensibility.  Both  lay  motionless 
and  no  movement  could  be  exeited  in  either  of  them;  their  temperature  was  natural  "or  jierlmps  a  little  higher;"  their  skin  moist  or  perspiring;  pulse  HO, 
reguhir  and  nufderately  tull ;  eountenanee  pUu-id.  The  eyes  were  opcTi  and  looked  natural,  the  pupils  acting  under  tlie  influence  of  light ;  they  wi)ukl  fol- 
h)w  an  object  nu)ved  befi.re  tliein,  and  away  to  a  considerable  distance,  and  chise  quickly  when  a  sudden  movement  was  made  near  and  towards  them. 
Tu  restoic  the  patients  blisters  were  applied  to  the  cervical  and  dorsal  portions  of  the  spine,  and  tiarbonate  of  ammonia  and  ([uinine  were  admiiustered. 
For  thirty-six  hours  they  remained  in  this  uiunoved  condition,  the  pulse  meanwhile  becoming  weaker  and  the  urine  vinded  involuntarily.  Beef-extract 
was  given  as  nonrislniient.  Two  drojis  of  croton  oil  were  put  on  the  tongue  and  (copious  dejections  were  followed  by  improvement  in  both  cases.  Tlio 
hearing  was  somewliat  restonul,  and  when  the  men's  names  were  louiUy  called  they  made  muttering  efforts  to  speak.  Forty-eight  grains  of  tiuinine  were 
administered  to  private  K.  in  twenty-four  hours.  He  recovered.  Private  C  dietl  fifty-two  hours  after  the  attack.  Post-mortcni  examination  found  the 
bnun  and  its  memln-anes  normal.  Plymouth,  N<)rth  Carolina,  where  the  regiment  was  stationed  at  this  time,  is  surrounded  by  cypress  swamps;  90  |)er 
cent.  <»f  tlie  officers  and  men  had  been  affected  by  miasmatic  fevers. 

^  Camp  Diseases  of  the  United  i<tates  Armies,  Philadelphia,  1803,  p.  174. 

§Page  142. 

II  The  following  sketch  of  hiemorrhagic  malarial  fever,  as  it  appears  in  our  medical  literature  since  the  war.  is  of  interest  in  conne4'tion  with  Surgeon 
MekkI'IT's  cases:  In  the  autumn  of  18tJ7  Dr.  T.  C.  OsiiOKN,  of  Greensboro'.  Ala.— iVew  Orleans  Jour.  Med..  IHt;8,  XX,  p.  fi44 — observed  ten  cases  of  ;i 
variety  of  nuilarial  fever  characterized  t»y  ehills,  nausea  antl  vomiting,  followed  by  sudden  bronzing  of  the  skin  and  ha?m;tturia;  five  of  tliese  jiroved 
fatal,  in  some  instances  with  suppression  of  urine  and  ur£emi<!  convulsions.  In  the  recipveries  convales<-'enc<^  was  tedious.  All  the  patients  were  thoroughly 
imbued  with  the  malarial  poison,  having  been  subject  t<t  intermittent  attacks  fr>r  a  long  time  before  the  develojirnent  of  these  unusual  manifestations.  A 
few  months  later  Or.  J.  D.  Ositoit.v,  iu  an  essay  on  Malignant  Congestive  Fever,  read  before  the  Greensboro'  Medical  Soctiety  and  published  in  the 
Nrir  (trJfans  Jmir.  Mrtl.,  Vol,  XXII,  p.  Gl,  added  l>ut  little  to  the  description  of  the  disease  already  given  by  his  father.  Hut  from 'his  ]>apcr  it  is 
understood  that  the  new  disease  had  become  epitlemic.  and  that  the  country  people  called  it  yellow  fever.  His  cases  occurred  during  the  period  from 
September  to  April,  .\bout  the  same  time  Dr.  H.  C.  GilEXT.  of  Port  .Sullivan.  Texas,  in  a  letter  published  in  tlie  Rirhmoud  ami  LnnisriUe  Mf't.  Jour.,  Vol. 
V,  p.  */7l.  described  the  disease  as  it  occurred  in  his  part  of  the  country  in  18t)t)-h7.  and  from  the  recurring  chills,  blood  in  the  urine  and  the  name,  black 
jaundice.  ai>plied  to  the  disease,  as  well  as  its  fatality  and  occurrence  only  in  cachectic  individuals,  it  is  appjirent  that  the  new  malarial  fever  of  Greens- 
boro', Ala.,  was  endemic  in  certain  parts  of  Texas.  The  next  paper  of  importance  which  appeare<I  was  read  by  R.  F.  Mkhkl,  of  Montg<i(nery,  Ala., 
before  the  Medical  .V.'-soeiation  of  the  State  of  Alabama  in  March.  ]8H;>.  In  it  he  defines  the  disease  as  "a  malignant  malarial  fever  following  repeated 
attacks  of  intermittent,  characterized  by  intense  nausea  and  vomiting,  very  rapid  and  complete  jaundiced  condition  of  surface  as  well  as  ino.st  of  the 
internal  tirgans  of  the  biidy.  an  impacted  gall-bladder  and  ha-morrhage  from  the  ki<lneys.  Tliese  phenomena  presented  themselves  in  an  almost  uninter- 
rupted link,  attended  by  remissions  and  exacerbations.  It  is  a  fever  i>eculiar  to  the  Cnited  States."  In  the  record  of  an  autopsy  on  a  case  of  death  from 
this  disease,  contributed  by  Dr.  MirilKI..  the  brain  wns  natural,  its  veins  comparatively  empty  and  its  membranes  jaundiced.  The  thoracic  organs  wer*^ 
yellow -colored  but  otherwi.se  normal.  The  omentum  and  its  fat  were  saffron -colored :  the  stomach  filled  with  dark  grumous  bile  and  its  mucous  mem- 
brane tliii'kened  and  injected,  especially  near  the  pylorus:  the  intestines  normal.  The  spleen  was  firm  and  .solid,  weighed  nineteen  and  a  half  ounces  and 
was  about  three  times  its  normal  size.  The  liver  was  slighrly  enlarged,  firm,  solid  and  of  a  dark  choctjlate  color;  the  gall-bladder  was  filled  with  an 
almost  solid  pasty  [ear-shaped  ntass.  the  smallest  particle  i)f  which  tin«^ed  a  basin  of  water  the  color  of  .saffron.  The  kidneys  were  enlarged  and  of  a 
jifde-reddish  color,  but  dark-greeu  on  section.    Dr.  Mlt'UEL  embodied  the  impacted  gall-bladder  iu  his  definition  of  the  disease,  but  in  subsequent  cases  It 


MALAETAL    DTSEASK.  127 

were  very  fatal,  presented  these  cliaractoristics.  iV-rluips  the  depravation  of  the  bk>od  which 
gave  origin  to  tlie  petechial  blotches  was  due.  as  suggested  by  him,  to  the  concurrent  action 
of  a  scorbutic  taint;  but  tliis  must  be  considered  doubtful,  for,  as  will  be  seen  hereafter,  these  . 


was  found  to  contuin  a  tliick  fjreenish-black  bile,  the  impaction  in  this  case  being  only  an  ag'gravation  of  tho  usual  condition ;  the  spleen  also  has  been 
found  to  bu  more  fn-quontly  softened  and  filled  with  disovfjanized  blood  than  iinn  ami  solid. 

The  new  disease  was  attributed  by  J.  D.  (isuoiiN  to  the  uncared-for  eondition  of  ibo  t-ountiy.  Dr.  \Vm.  A.  OllEEXE.  of  Araericus,  Ga.,  in  the 
Richmond  and  Lfmiaville  Med.  Jour.,  J87-J,  V(»l.  XIU.  p.  l-l!^.  'in  an  anicle  entitled  .Miasmatir-  Ilii'iualnria,  speaks  of  the  almost  entire  neglect  ot 
drainage  eonsequent  on  the  changed  condition  of  agricultural  pursuits  since  the  war.  Dr.  XoRCOM.  of  Edenton.  N.  t'.,  in  his  address  on  Hienn.rrhagic 
Mahu'ial  Fever,  read  before  the  State  Medical  Soeiety  in  1H74.  gave  exjiression  to  simitar  opinions:  "'  Before  the  war.  the  Southi'rn  States  were  in  a 
liigli  state  of  cultivation  and  the  lands  thoroughly  drained,  hence  Tlie  malignant  tbruis  of  malarial  disease,  as  a  general  rule,  were  not  known  except  in 
very  low  V)ad!}'-drained  swamp  lands.  Within  the  jiast  eight  years,  owing  to  so  mucli  hmd  lying  waste,  defective  drainage  and  tlie  general  unsanitary 
('ondition  of  the  country,  tlu'  malarial  poison  has  acted  with  intense  virulence,  and  caused  the  disease  we  are  now  considi-ring.''  In  t'aet  the  morbid  state 
was  generally  regarded  as  malarial  in  its  origin,  but  no  satisfactory  explanation  of  its  evolution  was  jtresented.  Dr.  K.  1>.  MrDAMEl,.  of  Camden, 
Alabama,  (considered  this  ((uestion  in  his  article  on  Ilspnnirrhagie  Malarial  I'i\.r  in  the  Transactions  of  tlie  Statf^  Medical  Assoeiati<m.  IHT-l,  p.  2i)7. 
He  says:  "Why  sln)uld  those  localities  which,  yeai's  ago,  showed  the  most  unequivocal  and  extreme  intluenees  of  malaria  by  animal  aiilunmal 
visitations  of  congestive  or  jieniitcious  intermittent,  remittent  and  psen{lit  contin\ied  nndarial  fevers,  almost  putrid  in  general  intensity,  have  not,  in  those 
times,  presented  with  considerable  fre((uency  and  in  (coTisiderable  numbers  (iases  of  this  now  .justly  dreaded  scourge?  And  wliy  did  those;  same  hu^alities, 
si>on  after  the  earliest  November  frosts,  become  in  old  times  as  liealthfid,  so  far  as  fevers  were  i!oncerned,  as  un)untain  tt»ps,  while  the  insatiate  malaria  of 
to-day  relentlessly  pursues  its  bh^edlng  victims  in  mid- winter,  when  the  air  is  filled  with  snow-tlakes  and  the  forests  are  hung  with  icicles?  And  why  are  some 
places  once  so  salubriims  that  they  knew  no  malarial  fevers  at  all.  or  if  any,  only  tlie  mildest  intermitlents.  then  poi)ularly  regarded  as  tri\'ial  and  almost 
harmless,  now  not  ex<Hnj>t  from  even  this  the  direst  of  all  uudaria!  ills — the  very  sumnuition  of  all  extreme  nnilarial  manifestations?  *  *  *  *  j  iiave 
seriously  pondered  this  wh(de  subject,  and  I  nm  folly  convinced  that  the  grave,  new  order  of  symptoms  now  iicearring  in  nuUarial  fever  in  Alabama  and 
the  adjacent  States,  even  in  localities  not  heretofore  known  as  specially  insalubriiuis,  is  not  due  tit  any  marked  increase  in  the  quantity,  intensity  or  exten- 
sion of  nuilaria ;  for  with  exception,  perhaps,  of  18(^7  and  18fi8,  the  average  numerical  manifestations  of  malaria  have  been  fewer  since  the  advent  of  the 
icterode  lufinorrhagic  period  than  they  were  before  that  period  set  in.  Nor  to  any  allotropitt  or  otherwise  modified  cimdition  of  malaria,  he  this  chemical 
or  dynamical,  orsporoid  in  its  nature;  nor  to  atiy  marked  deterioration  of  the  blood  and  constitution  due  to  depression  of  spirit  or  exhaustion  of  luKiy.  but 
to  a  wide-spread  epidemic  influence."  It  is  to  be  regretted  that  none  of  the  obsei-vers  gave  any  consideration  to  the  character  of  the  water-sujtply  in  these 
virulent  nnmifestations  of  nmlarial  disease.  The  violence  of  the  nmrbid  action  occurring  at  a  time  when  exhalatitms  from  a  malarious  soil  were  not  avail- 
able in  explanation,  and  the  occasional  appearance  of  two  or  nmre  cases  in  the  same  household  indicating  a  local  cause,  in  the  absence  of  contagious  quali- 
ties, are  fads  suggestive  of  uater-infection. 

The  publication  of  the  articles  which  have  been  mentioned  attracted  tlie  attention  of  the  profession  to  the  ha^maturic  fever,  ar.d  a  nund>er  of  jnipers 
on  the  subject  have  since  appeared  in  the  journals  recording  cases  and  discussing  the  pathology  and  treatment  of  the  disease.  Hut  fii-st  it  was  denied  that 
08noux's  new  disease  was  a  hitherto  un<ibserved  expression  of  malarial  poisrming.  I_)r.  .1.  ('.  Facic'I".  in  the  Xew  Orleans  Mttd.  Jour.,  I H6<J,  p.  7(i8,  in 
reviesiing  Miciiel's  paper,  called  attention  to  the  facts  that  this  disease,  although  new  to  the  majority  of  our  Southern  practitioners,  had  been  described  by 
DlTKotE.AU  and  other  French  authoi-ities  as  occurring  in  the  colonies  in  Madagascar.  Cayenne  and  the  West  Indies,  and  that  ho  himself  in  ItTtit  and 
18t)4  had  treated  of  Hemorrhagic  Paludal  Fever,  and  specially  of  its  hjpmaturic  form.  The  hienuitemesie  variety,  he  (contended,  hml  been  fre<iuently 
seen  in  Now  Orleans,  but  bad  been  generally  confounded  by  medical  men  with  yellow  fever.  Indeed.  J.  C.  Cl'M.MlNOS,  of  Monroe.  Ala.,  in  the  A^eic  Orleans 
Med.  \eu\t  and  llnxpl.  Gaz.,  1850-tiO,  Vol.  VI,  p.  811,  records  six  cases  which  dilTi^r  In  no  respect  from  those  afterwards  described  by  OsiKUtN  and  others, 
ami  refers  to  the  prevalence  of  the  <iisease  during  previous  seasons.  KOKCOM  instanced  5IcLeaN'"8  article  on  malarial  fevers  in  Jt'ei/nold's  VraHice.  to  show 
the  familiarity  of  that  writer  with  a  hannorrhagic  variety  of  the  disease.  The  cases  which  are  described  at  length  by  our  Southern  brethren  dwell  U(>on 
the  blood  in  the  urine  and  in  the  serum  which  collects  after  the  application  of  blisters;  but  other  luemorrhages  ai>pear  to  have  been  rare,  although  mention 
is  occasionally  made  of  bleeding  from  the  nose,  mouth  and  stomach.  Dr.  FacieT,  as  already  intimated,  considers  that  haemorrhage  fnun  the  stomach  is  a 
frciiitent  expression  of  the  morbid  action.  "And  when  I  speak  of  large  clots  of  blood,  still  red,  let  no  one  imagine  that  I  then  saw  blood  c.oming  from  the 
nasal  fossa  or  from  the  gums,  swaUowcd.  and,  afterwards,  ejected  before  undergoing  the  intluence  of  the  acid  of  the  gastrii;  juice.  By  no  means.  I  beg 
that  1  may  have  tlie  credit  of  examining  things  closely,  and  that  1  may  ntit  be  charged  with  having  couunitted  an  ern»r  of  so  gnive  a  chanu'ter."  Hence 
Nouco.M  .so  enlarges  the  lines  used  by  Michf;i<  in  defining  the  disease  that  its  name  of  nec<'ssity  becomes  Htennirrhugic  Malarial  Fever  instead  of  Malarial 
Ihematuria  as  giv»'n  by  tlmse  whose  field  of  obser\'ation  had  been  restricted  to  the  one  haeniorrhagic  manifestatit)n.  He  says:  "  .V  malignant  malarial 
fever,  the  result  of  frequent  attat^ks  of  internattent.  or  of  a  prolonged  and  exhausting  remittent.  char.icterize<l  by  ha'maturia.  ha>matemesis.  epistaxis, 
cnterorrhagia,  metrorrhagia  or  hiemorrhage  from  the  gutns  and  fauces,  or  from  two  or  three  of  these  at  the  same  time ;  most  distressing  and  incessant  nausea 
anil  vomiting,  and  complete  jaundiced  Ctindition  (greenish-yellow  hue)  of  body.  The  cold  stage,  though  not  always,  is  generally  well  marked,  and  the 
paroxysms  oftenest  recur  about  every  ten  or  twelve  hours,  but  far  more  frequently  the  fever  is  uninterrupted  by  intermission  or  remission."  A  few  years 
later,  in  1H74,  the  work  of  liEltEXGKli-FEKAUl),  De  la  Fievre  Bilieuse.  Melanurique  dta  I^ai/.s  Chaiids  romparte  ovec  la  Fievre  Jaime.,  and  in  187.'),  his 
chapter  on  Me.lanuric  fever  in  Ins  Traite  Clinique  de.s  Maladies  des  Europeens  au  SeuifJttl.  show  the  existence  of  a  disease  which  correspontls  in  its  general 
features  with  the  Americati  hu-maturit^  fever  with  the  ex<;eption  that  the  daik  color  of  the  urine  is  attributed  to  the  presence  of  a  large  »|uantity  of  biliary 
matters.  lielying  niton  the  aecurticy  of  M.  BEKEN(;ER-I''I^M{Arii'H  observations  and  experiments,  the  writer  of  a  review  of  his  work  in  the  AmericaJi  Jour. 
.Med.  Sciences,  New  Series,  Vol.  I^XI-\.  p.  l(J-3,  tlumvs  doubt  upon  the  htf'muturia  so  frequently  reji^^rted  by  our  American  practitioners,  and  suggests  that 
they  may  have  Iwen  deceived  by  the  biliary  coloring  nnitters  with  which  the  system  is  so  thoroughly  pervaded.  Dr.  Faijet  begged  that  he  miglit  have 
the  credit  of  examiiung  things  closely.  If  our  other  observers  did  not  emphasize  in  like  uumner  it  is  probably  due  to  the  fact  that  they  C'>ald  not  realize 
that  their  testimony  as  to  bloctd  in  the  urine  would  be  <iucstioned.  constituting  as  this  condition  did.  with  the  concurrent  jaunilice.  the  pathognomonic  symp- 
tom of  the  disease  under  observation.  M.  BfiltENGER-FEltACi)  regards  melanuric  fever  as  differing  only  from  other  expressions  of  acute  malarial  poisoning 
in  having  an  excessive  secretion  of  bile  replacing  the  more  usual  perspirations  or  eholeriiic  discharges.  ( )ur  American  writers  allow  the  presence  of  bile  in 
tlie  urine,  as  the  whole  system  seems  deluge<l  witil  it,  but  they  are  jmsitive  as  to  the  jireseiu^e  of  blfHMl  not  only  as  manifested  liy  a  coloration  due  to  the 
dissolved  hsematine  of  disorganized  bloinl  corpuscles,  in  which  case  the  symptom  is  regarded  as  an  effort  to  restore  the  blo<.Hi  to  its  nonnal  constitution 
by  the  elimination  of  the  debris  of  its  destroyed  cttrpuscular  elements,  but  as  shown  by  the  presence  of  the  red  corpuscles  themselves,  and  even  in 
many  cases  by  umnistakable  blood-clots  which  must  be  regarded  as  the  result  of  a  true  hasmorrhage  fnun  ruptured  capillaries  during  a  stage  of  active  con- 
gestion. McDaniel  regards  the  ha^nunThage  as  due  to  interrupted  cutaneous  action  such  as  explains  the  haematuria  in  rheumatic,  catarrhal  and  scarlatinal 
eases.  The  sudtlen  appearjuice  of  jaundice  when  there  is  no  apparent  obstacle  \*t  the  free  passage  of  bile  fn>m  the  system  by  the  alimentary  canal  has 
been  referred  fur  explanation,  by  Professor  JoVNES  in  the  Richmond  and  Louisville  Med.  Jour.,  Vol.  XXIII.  p.  '2±i,  to  the  following  from  NlEMEYElt's 
chapter  on  Ha'inatogencms  Icterus  in  his  Text-Book  of  I^roctiral  Medicine.  Vol.  I.  p.  f!84 :  "  The  views  regarding  the  occurrence  of  jaundice  without  reten- 
tiim  and  reabsorption  of  bile  have  totally  changed  since  the  observations  of  ViKCHOW,  KChnk  and  lIoi'l'E-SEVi.ER  have  shown  that  bile-coloring  matter 
may  be  formed  from  the  free  c4)loring  matter  of  the  blood  without  the  action  of  the  liver;  ami  we  may  indui-e  artificial  jaundice  in  animals  by  injecting 
substances  that  dissolve  the  blood  corpuscles.  There  is  now  no  doubt  that  some  of  the  formerly  enigmatical  forms  of  icterus  are  due  to  the  disintegra- 
tion of  blood  ct)rpuscles,  and  the  transformation  of  the  freed  ctiloring  matter  circulating  in  the  blood  into  bile-coloring  matter.  This  is  particularly 
true  of  those  eases  of  icterus  occasionally  caused  by  poisoning  from  chhtrofnrm  or  ether:  for.  as  experiment  proves,  these  substiiuues  possess  the  power  of 
dissolving  blood  corpuscles This  naode  of  origin  is  very  probable,  though  not  absolutely  proved,  for  other  varieties  of  jaundice,  as  in  that 


128  sym['Toaiatol()(;y  ov 

blotches  in  fulminant  malarial  cases  witc  I'ound  ufteiitimos  in  men  who  had  been  rclaist  and 
healtliy  until  struck  down  by  the  pernicious  influence.  tSurgeon  Jacksux,  lltli  P.i.,  Vols., 
in  a  report,  hereafter  presented,  describes  a  numlier  of  cases  wliicli  occuri'cd  in  a  (^•ommand 
camped  in  and  around  Annapolis,  Md.,  in  the  winter  of  1861.  Some  of  tlie  roi^imcntal 
surgeons  reported  these  cases  under  the  head  of  h/phas  fever,  others  called  them  spotted  J  eerr: 
Surgeon  Jacksok  designated  tliem  at  first  as  iiiaJigniint  congeHtive  fever,  and  afterwards 
simply  as  congestive  fever ,  and  his  re})orts  indicate  tliat  he  looked  upon  them  as  congestivi' 
intermittents  modified  by  the  overcrowded  condition  of  the  buildings  occupied  by  )iis  regi- 
ment as  barracks.  The  petechial  spots,  the  uncoagulated  condition  in  which  the  blood  was 
found  in  the  fatal  cases,  and  the  early  period  at  which  post-7)iortem  putrefactiojj  set  in, 
strongly  favor  the  view  that  the  disease  was  cerebro-spinal  meningitis;  but  the  absence 
during  life  of  the  usual  brain  symptoms  of  cerebro-spinal  fever  is  opposed  to  this  vjew.  In 
many  of  the  i'atal  cases  the  mind  was  clear  to  the  last.  Moreover  the  necropsies  jnade  by 
Surgeon  Jackson  show  that  although  the  cerebral  membranes  were  congested  they  were 
free  from  deposits  of  lymph  or  j>ns.  It  might  be  ui'ged  tliat  winter  is  not  the  §eason  at 
which  cases  of  congestive  intermittent  fever  would  be  likely  to  occur;  but  the  sti\,tistics  of 
the  war  sh<nv  that  as  a  matter  of  fact  congestive  intermittents  did  occur  at  all  se^isons  of 
the  year,  and  in  Jac.'KSOk's  own  regiment  as  well  as  in  other  I'egiments  in  the  vicinity,  cases 
of  ordinary  intermittent  fever  were  occui'ring  side  by  side  with  tlie  pernicious  cashes  under 
discussion  ;  as  indeed  ordinary  intermittents  were  occurring  during  the  same  months  in  all 
parts  of  our  armies.  The  dangerous  hsemorrhagic  fever  since  prevalent  in  the  So^th  is  of 
frequent  occurrence  during  the  winter  months.  The  cases  observed  by  Dr.  J.  D.  Osborn, 
which  formed  the  basis  of  his  paper  calling  attention  to  the  hiemorrhagic  form,  occurred 
between  the  months  of  September  and  April.  Again,  the  mortality  of  the  Annapolis  cases 
does  not  correspond  with  the  usual  mortality  of  cerebro-spinal  meningitis.  The  monthly 
sick  reports  of  the  11th  Pa.  Vols,  show  that  during  January,  1862,  there  were  7  cases  and 
3  deaths  in  the  regiment;  during  February  17  cases  and  1  death;  during  March  2  cases  and 
no  deaths:  in  all  26  cases  and  4  deaths.  During  the  same  period  there  were  13  cases  of 
quotidian  intermittent  fever  and  11  of  remittent  fever,  one  of  the  latter  fatal.  Sui'geon 
Jackson  attributed  the  small  luimber  of  deaths  among  his  j»ete(hial  cases  after  January 
not  merely  to  the  improved  hygienic  condition  of  the  regiment,  but  to  the  fact  that  he  had 
recognized  the  malarial  character  of  the  disease  and  resorted  to  the  appropriate  treatment. 

uccumiio^  lifter  snake-bitfs,  in  tluit  observed  conslaiitly  in  yellow  fever,  quite  often  in  recurrent  (relapsing)  fever,  septicaemia  and  puerperal  fever,  and 
more  rarely  in  other  infectious  diseases,  and  acute  diseases  aceon»i>anied  by  severe  fever."  Commenting  on  this  extract  Professor  JOYNKS  remarks :  "  The 
destructive  action  of  the  malarial  poison  upon  the  blood-discs  is  so  well  proved  that  none  will  question  it ;  and  if  we  admit  that  under  such  intense  and 
concentrated  action  of  the  morbific  agent  as  that  which  induces  an  attack  of  hiemorrhagic  malarial  fever,  this  destructive  effect  is  unusually  rapid  and 
extensive,  the  applicability  of  the  above  view  to  the  icterus  (jccurring  in  this  disease  becomes  at  once  obvious,  and  the  relationship  between  that  syniploni 
mid  the  haMnaturiu  receives  important  elucidation."  Hecent  researches  have  (dcared  away  much  of  the  difficulties  that  surrounded  this  subject.  Thus, 
VOSVU'—HxmogloliiiiKria — Berlin  Klin.  Wor/ifn..  1^93.  No.  2(i— sustains  by  further  experimental  evidence  tlie  view  tliat  the  destruction  of  the  red  cor- 
puscles within  the  vessels  is  the  essential  element  of  the  process.  Having  introduced  lilood  dissolved  by  freezing  into  the  veins  of  an  animal,  he  found 
that  the  remains  of  the  destroyed  corpuscles  were  takifu  up  by  the  si>leen  wliile  the  coloring  matter  was  removed  by  the  liver :  but  when  there  was  an 
excess  of  ha»inoglobine  the  kidneys  participated  in  the  excretion.  When  the  blood  has  been  .so  deteriorated  that  the  action  of  these  organs  is  insutiieient 
to  remove  the  detritus  the  patient  becomes  .jaundiced  by  the  metamorphosis  of  Ineinoglobiuc  into  bilirubin  within  the  current  of  the  circulation. 

The  treatment  adopted  for  the  disease  is  based  upon  the  recognition  of  its  malarial  causation.  Quinine  is  given  in  free  and  repeated  doses,  by  the 
stomach,  if  the  gastrii'  irritation  can  tie  allayed  sufficiently  for  its  introduction  in  this  way.  or  failing  this,  by  the  rectum  or  hypoderniii^  injection.  Many 
practitioners  consider  an  evacuant  doso  of  calomel  of  advantage  jireparatory  to  the  administration  of  (puiiine.  NoucoM  allays  the  vomiting  by  the  hypo- 
dermic injection  of  morphine,  and  refers  to  the  fears  entertained  by  many  lest  the  opium  lead  to  su]iiiiession  and  iiraemic  convulsions,  mentioning  some 
cases  where  uraemic  symptoms,  which  had  already  appeared,  yielded  after  the  exhibition  of  the  morphine.  BERF.NiiKH-FKIi.M'li  also  ajipnivcs  of  the  use 
of  opiates.  Sledication  is  seldom  addressed  sjiec-ially  to  the  ha-inorrhage.  But  5<ime  writers  have  objected  to  the  generally  accepted  methods.  Thus 
.McDa.mKT.  urges  as  the  fust  care  i>f  the  practitioner  in  tliese  cases  the  control  of  the  hitmoirhage  from  the  kidneys  by  the  restoration  of  cutaneous  action, 
which  he  endeavors  to  efl'cct  by  the  application  of  hot  air  and  vapor-baths,  itc.  <jr  by  alternating  these  with  cold  affusions  as  stimulants  to  the  general 
surface.  He  is  doubtful  as  to  the  ticnefit  to  be  derived  from  iiuinine.  and  instances  the  aggravation  or  recurrence  of  the  hseinaturia  under  its  influence. 
( ithcr  practitioners  have  also  claimed  that  (luiiiine  was  iniurious.  M.\I.OXE,  in  the  Misxisijipi  Valli-.ij  Med.  Miinthl!/,  Vol.  I  (IWl),  p.  (G,  while  he  does 
not  believe  thai  quinine  will  produce  the  disease,  tliinks  that  he  has  often  seen  it  precipitate  an  attack  in  those  jiredisposed.  He  regards  the  fever  as  due 
to  the  presence  of  a  micro-organism,  and  claims  great  success  for  the  hyposulphite  of  soda  in  thirty -grain  doses  with  one  fluid  drachm  of  extract  of  buchu 
given  every  three  hours. 


MALARIAL     DISEAr~E.  129 

III.— Ciri;(ixi(;  MALAurAi.  I'ol^on  i.\<;.— Tliosc  s.,l,lioi-.s  who  hud  Ijccn  hjiig  cxpo.sed  tu 
malarial  iiiHuences  iVcqueutly  bt'caiiio  the  suhjects  of  a  poc/uliar  form  of  cachexia  known  as 
chrome  malarial poisonhuj  or  malarial  cac/u-xia.  It  was  ovr.crallv  observed  in  men  who 
had  already  suffered  from  acute  attacks  of  malarial  disease,  but  it  apjicared  also  as  a  primary 
affectiou  in  those  who  had  never  been  attacked  by  fever.=-=  This  chronic  disorder  was  essen- 
tially an  antemia  accomj>anied  by  UKjre  or  less  of  iiepatic  disorder  and  enlargement  of  the 
spleen.  The  complexion  was  early  modified,  acquiring  a  peculiar  yellowish  pallor,  which 
Avas  usually  unaccompanied  by  any  icteroid  tinge  of  the  conjunctiva.  The  skin  became 
diy  and  harsh,  the  lips  livid  and  the  tongue  large,  ilabbv,  pale  or  of  a  faintly  bluish  tint, 
indented  on  tlie  sides,  and  generally  fissured  on  the  dorsum,  which  was  thinly  covered  with 
a  whitish  or  yellowish  coat.  The  i)atient  lost  his  appetite  and  suffered  from  pains  and  aches 
in  the  bones  and  muscles,  and  frequently  from  neuralgia.  In  some,  muscular  debility  was 
associated  with  tremors,  which  prevented  the  individual  from  assuming  the  erect  position. 
Clioreic  movements  and  pai'alysis  agitans  are  also  referred  to  as  having  occurred.  The 
patient  became  dull  in  mind,  dejiressed  in  spirit,  homesick,  indisposed  to  undertake  any 
work  involving  even  slight  exertioii  and  unable  to  carry  it  out  from  physical  disability. 
The  heart  appeared  to  be  early  influenced  by  the  debility  aifecting  the  muscular  system; 
probabl}'  many  cases  of  sudden  death  were  due  to  heart-failure. f  At  first  the  bowels  were 
constipated,  but  generally,  on  account  of  the  conditions  of  camp  life,  diarrhoea  supervened 
and  became  \'ery  intract^ible. 

That  a  notable  alteration  in  the  quality  of  the  blood  was  one  of  the  first  results  of 
malarial  poisoning,  was  manifested  by  the  ana}mic  appearance  of  the  patients.  This  blood- 
change  was  intimately  connected  with  tlie  generally  accompanying  enlargement  of  the 
spleen;  but  the  enlargement  was  not  in  all  cases  proportioned  to  the  cachectic  condition. 
Ill  must  instances  the  increase  in  bulk  of  the  spleen  could  be  detected  by  careful  physical 
exploration,  rnid  in  some  it  was  very  marked.  Disorder  of  the  liver  and  kidneys  could 
also  generally  be  discovered  in  these  cases.  In  many,  oedema  of  the  feet  and  legs,  and  even 
ascites,  appeared,  due  to  organic  changes  in  the  viscera  in  some  instances,  but  in  others,  in 
which  no  organic  lesions  could  be  discovered,  the  serous  transudation  must  be  attributed  to 
the  altered  condition  of  the  blood  and  the  weakness  of  the  circulation. 


IV.— POST-MORTEM  RECORDS  AND  PATHOLOGY  OF  MALARIAL  DISEASE. 

1. — Post-mortem  Rf.cords. — A  full  history  of  the  attack  is  seldom  given  in  these  cases, 
but  ante-mortem  notes,  when  taken,  were  of  the  same  general  character  as  those  already 
submitted  in  the  clinical  records.  The  tongue  was  coated  or  furred,  dry  during  the  fever, 
moist  at  other  times,  occasionally  brown  in  color.  Diarrhoea  was  a  prominent  symptom, 
but   sometimes   constipation   was   present,  with  anorexia,   thirst,   vomiting,  jaundice  and 

*  Sir  Joseph  Fayreu  in  his  Tropical  r/hfascn.  Lntulon.  1H81 ,  j>,  2'3*2.  says :  "  Malarious  eiilargeinent  of  the  spleen,  and  the  attendant  or  consequent 
oaclit.'xia,  are  tVeiiUontly.  hut  b}-  no  means  constantly,  the  result  of  repcateil  reciirrenees  of  malurious  periodic  (»r  remittent  fever  in  those  lon^  e.xitosei!  to 
such  influences  :  and  wlien  the  patient  has  previously  sufl'eretl  from  a^ue  it  is  to  be  expected  that  whilst  the  spleen  remains  affected,  so  lonij  will  the  person 
be  liable  to  recurrence  of  paroxysms  of  fever.  These,  however,  are  not  \\y  any  means  tlie  most  serious  or  obstinate  cases  of  splenic;  cachexia ;  on  the 
(contrary,  they  are  often  more  tra(;table  and  amenable  to  rt'medial  measures  than  others  apparently  of  a  less  formidable  thouj^h  more  chronic  nature, 
which  not  infrequently  present  themselves  in  a  marked  form  where  no  fever  has  previously  occurred." 

t.'^iirj^cou  TOWLE,  of  the  :jOth  Massachusetts,  in  his  jtajier  cited  supra,  jt.  lli),  says;  "  Iti  .\ug'ust,  18t)2,  a  patient  convalescinjf  in  my  regimental 
hospital  from  malarial  fever,  who  had  re(;overed  suHiciently  to  walk  4>ut  of  dmirs.  by  a  mistaken  order  of  his  commanding  otiicer.  was  stripped  and 
waslied  with  water  liruuf^ht  from  the  river.  In  the  midst  of  the  washing  he  fell  back,  gasped  feebly  a  few  times,  and  before  I  reat'hed  him.  though  near 
by,  he  was  dead."  I>r.  Tnwi.K  rcgai'ded  the  fatal  conseiiucnccs  as  due  to  the  inability  of  the  cnfeebleti  and  enervated  heart  to  overcome  the  cheek 
received  by  tlie  circulation. 

MkU.  Hl.ST.,  I'T.  Ill  — 17 


\M)  post-moi;tem   i:1';c()|;i)s  and 

uliiluiiiinal  piiiii.  TIk.'  jmlso  was  t'lvijUi'iit,  ultimately  bocoininM-  iniporceptilile.  Thore  were 
])ains  ill  till'  head,  hark  ainl  liiiihs.  l)ellriuiii.  (■(.)U':'li,  ilvspiKea,  liit'coiiLi-h.  profuse  sweats, 
iiivoluntarv  ilisfliarg<'s  and  eonia  led  to  tlu.i  fatal  result  in  rciniltciit  eases.  (.'(Hivulsious 
were  occa.sionallv  regarded  as  the  manifestation  of  a  ecMvhro-spinal  engoi'geintMit  due  to  the 
malarial  poison.  The  symptoms  in  some  cases  ai'e  of  interest  as  suggesting  the  anfc-iiiortein 
formation  of  heart-clot. 

The  autopsies  in  the  nine  cases,  recorded  helow,  of  death  from  intermittent  fever,  show 
that  the  fatal  result  ilepeiidei]  on  congesti(5n  of  certain  of  the  intcM'ual  organs,  the  liyjiera^mia 
in  some  instances  leading  to  the  formation  of  inflammatory  products.    No  one  organ  appears  to 
liave  been  specially  liable  to  injury  by  the  malarial  influence  ;  for  in  one  or  more  of  these  cases 
the  brain,  lungs,  heart,  stomach,  intestines,  liver,  spleen  and  kidneys  are  reported  healthy, 
while  in  othei's  thev  were  found  in  an  abnormal  condition,  to  which  the  symptoms  observed 
during  life  may  with  proi)i'iety  be  referred.      Tn  case  53  the  force  of  the  disease-poison  was 
expended  on  the  lungs,  causing  fatal  congestion,  and  although  fever  of  a  paroxysmal  type 
had  persisted  for  some  tim(\  and  the  symptoms  had  at  one  time  assumed  a  typhoid  charae- 
ter,   no  diseased  condition  was  observed   in   the  intestines;   the  stomach    was  normal  ami 
tlie  liver  healthy;   the  brain  and  spleen  were  not  examined.      As  there  is  no  clinical  record 
in  b^,\\\e  post-mortem  appearances  must  betaken  in  connection  with  tlie  diagnosis  of  inti'r- 
mittent  fever.      The   stomach  and   intestines   were  healthy,   as   were   the   lungs,    Init   the 
lieart,  liyer  and  especially  the  spileen  were  markedly  altered.      The  recurrence  of  aggra\'ated 
paroxysms  in  55  caused  the  jiatieiit  to  fall  into  an  adynamic  condition  marked  by  sordes, 
imperceptible  pulse,  profuse  perspirations,  hiccough,  stertor,  insensible  pupils  and  involun- 
tary passages;  and  these  symptoms  were  associated  with  congestion  of  the  brain  and  left 
lung,  pericardial  adhesions,  notable  alteration  in  the  liver  and  spleen  and  patches  of  con- 
gestion in  the  ileum.     Jn  5(i,  which  j)resented  diarrl^ra,  vomiting  and  jaundice,  the  small 
intestine  was  of  a  purple  color,  the  stomach  ecchymosed,  the  liver   altei'ed  in  color  and 
the  lungs  congested  in  tluMr  jiosterior  portions;   but  the  brain,  heart  and  spleen  were  normal. 
In  57,  after  the  suppression  of  the  paroxysms,  the  patient  instead  of  recovering  his  usual 
health  became  morose,  apathetic  and  ultimately  comatose,  while  aflected  with  cough  and 
diarrhoea,  symptoms  \vhich  might  be  considei'cd  obscurely  suggestive  of  ty|ihoid  fevei-or  of 
that  fever  as  masked  by  the  presence  of  the  malarial  cachexia.      But  the  autopsy  revealed 
such  indications  of  repeated  congestion  ot  the  brain  as  might   bo  conceived  to  account  for 
the  cerebral  symptoms,  while  the  intestines  presented  no  other  lesion  than  patches  of  con- 
gestion in  the  ileum  and  of  black  pigment  in  the  sigmoid  flexure;   broncho-pneumonia  and 
nutmeg  liver  were  present,  yet  the  spleen  was  normal.     A  special  interest  attaches  to  this 
case,  as  the  manuscript  beai's,  in  Dr.  \\^)Odward"s  liand-writing,  the  words  "Typho-malarial 
fever.     JYote." — as  indicating  that  it  was   intended  to   occupy  a  prominent  place  in  the 
expression  of  his  views  regarding  this  fever.      It  seems  evident,  however,  by  a  reference  to 
the  time  which  elajiseil  between  the  suppression  of  the  paroxysms  and  the  date  of  death,  that 
there  was  no  speciflc  typhoid  element  in  the  case,  else  the  agminated  glands  would  have 
been  found  extensively  ulcerated.     Case  58  is  from  the  clinical  stand-point  an  undoubted 
typho-malarial  fever,  if  such  a  fever  is  susceptible  of  diagnosis.     A  continued  adynamic 
fever  persisted  after  the  suppression  of  the  chills,  but  the  intestines  were  not  altered  from 
the  healthy  condition.     In  59  the  necropsical  record  indicates  that  the  force  of  the  disease 
was  expended  on  the  lining  membrane  of  the  intestinal   canal.     In   60   there  was  latent 


PATHOUmiY    of    MAI.AIMAI.    DIsKASE.  131 

pneumonia,  witli  licart-clot  and  affection    of  tlie   liver,  spleen    and    kidneys;   ami    in  61  a 
coincidence  of  tubercular  disease  and  malarial  manifestations. 

Ca.se  53. — Private  'riidiuiis  W.  I'aikiT,  Co.  K.  lid  Md.  Cav.,  was  a(liiiittc<l  fiDiii  I'liiice  stiet't  prison  October  10, 
1804.  The  |)atieiit  stated  that  he  had  siiiri'icd  toi-  some  time  from  regular  paroxysms  of  a<;ue.  His  eonditioii  on 
admission  indicated  great  nervous  depression.  (Quinine  and  wliiskey  were  prescribed,  and  tlio  bowels  moved  by- 
componud  cathartic  pills.  Six  ila.vs  later  the  fever  assumed  a  typhoid  tyiie,  Iml  this  was  s|ieedil.v  followed  by  an 
im))rovement,  the  tongne  becoming  nn)ist  and  clean,  the  jiiilsi'  S."i  and  the  skin  natnral.  On  the  21st,  after  having 
lieeii  lunisnally  comfortable  and  even  lively  dnring  the  nioining.  he  eoni))lained  in  the  afternoon  of  dyspno'a,  for 
which  connter-irritants  were  applied,  and  as  tliere  was  some  cough,  an  expectorant  mixture  was  given.  At  "i  )>.  .M., 
after  eating  a  uood  nu'al  of  liri'ad  and  milk,  he  was  suddenly  seizi'd  with  inti'Use  dysjinoM  ;  in  the  course  of  half  an 
hour  convulsions  set  in,  and  he  died  shortly  after.  Stimulants,  friction  of  the  extremities,  etc.,  were  tried  without 
etiect.  I'lmt-mortfiii  examination  eighteen  hours  after  di-atli:  liotli  lungs  wen-  much  congested  throughout,  with  the 
exception  of  a  snniU  portion  of  the  anterior  border  of  each:  they  containeil  no  tubercles,  nor  was  any  other  lesion 
oliserved  in  tlieni.  Nothing  abnormal  couhl  be  deti'cted  in  the  st(miaeli  or  intestines.  The  liver  was  health.v.  The 
other  organs  were  not  examined. —  'J'liifd  Diiixhni  lIti«iiUiil,  AUj-tiiiitrid.  In. 

Cask  51. — Private  Patrick  liradley ,  17th  Ind.  I!at"y  ;  age  25;  was  admit  tec  1  ( )ctober  11,  1K(!2,  with  intermittent 
fever,  and  died  Xovember  il.  I'oxt-iiiDi-lciii  examination  :  Tliere  were  pleuritic  a<lhesions  on  the  h'ft  side;  the  pericar- 
dium contained  four  ounces  of  serum  ;  the  heart  was  enlarged  and  fatty.  The  stomach  was  normal  ;  tlie  liver  greatly 
enlarged  and  congested;  the  gall-bladder  distended  and  ulcerated  near  its  <luot ;  the  spleen  uuich  enlarged,  softened 
and  inliltrated  with  l)us  in  its  upper  part.  The  circular  libres  of  the  colon  wen^  strongly  contracted  in  its  entire 
length. — //.  I'ii'ixr,,  Ass'l  .Swrr/.,  1.50/7i  X.  )'.,  Sliwdrl'x  Mdiinioii,  llallimoic,  Md. 

C.^SE  .55. — Private  John  McA'ea,  Co.  P>,  lOth  V.  S.  Inf.;  age  ',i2;  was  admitted  t)ctober  20,  1805,  having  been  sick 
five  weeks,  first  with  diarrlnea  for  two  weeks  and  afterwards  with  chills  and  fever.  He  had  a  chill  daily  at  3.30  p.  M., 
for  which  five  grains  of  (]Uinine  were  ordered  at  8,  10,  12  and  2  o'clock.  During  the  ])arox.ysms  the  patient's  intellect 
was  clouded  and  his  replies  delayed:  he  fainted  on  sitting  up;  passed  his  urine  involuntarily;  had  pain  in  the  head, 
back  and  limbs  ;  the  heart's  act  ion  was  tumultuous;  the  ))ulse  too  rapid  to  count,  and  most  frequent  at  the  ccnninence- 
nient  of  the  sweating.  Some  roughness  of  th«^  heart-soun<ls  were  ob.served.  The  tongue  was  coated,  dry  during 
fever,  moist  at  other  times;  the  bowels  were  open.  On  the  22d  the  i|niniiie  was  repeated,  but  the  chill  an<l  fever 
recurred  in  a  more  aggravated  form.  The  patient  was  very  weak  ;  had  sordes  on  his  teeth ;  pulse  scarcely  jn'rceptiblo 
at  the  wrist ;  urination  involuntary.  WliRkey  was  given  and  mustard  applied  to  the  epigastrium.  Next  day  he  had 
hiccough,  8tertor,profusesweats,  vomiting  of  small  blood-clots,  dy8])hagia,  insensible  ptipils  and  involuntary  passages; 
crepitation  was  heard  over  the  lower  part  of  the  left  side  of  the  chest.  He  died  at  2.30  P.  M.  Po^t-mortcm  exami- 
nation twenty  hours  after  death:  Kight  arm  Hexed  and  rigid:  left  arm  flaccid.  There  was  acpiantity  of  serum  in  the 
ve:itricles  of  the  brain  ;  the  brain-substance  was  of  a  darker  ash  color  than  usual,  and  sections  presented  many  jioints 
of  black  engorged  vessels.  The  right  lung  was  healthy;  th((  lower  lobe  of  the  left  lung  much  congested,  nearly 
hepatized.  The  ])ericardiuni  contained  tliFee  ounces  and  a  third  of  light-pink  serum;  the  apex  of  the  heart  adhered 
to  the  pericardium  by  a  lyuijih-patch  the  size  of  a  shelled  almond;  the  right  ventricle  of  the  heart  was  luuisually 
flaccid,  the  luitral  valve  thickened  and  of  a  dull  yellow  color.  The  omentum  was  thin  and  dark  lead  color.  The 
liver  weighed  eighty-five  ounces;  it  was  of  a  dull  slate  color.  The  spleen  was  pulpy,  weighed  twenty  ounces  and 
a  half.  Some  patches  of  congestion  were  observed  in  the  ileum.  The  kidneys  were  large  but  healthy. — DoityUin 
Hiixpitid,  WiinhhKjtoii,  I).  C. 

Case  56. — Private  Leonard  Bennett,  Co.  D,  199th  Pa.  Vols.,  was  admitted  June  30,  1865,  suft'ering  from  inter- 
mittent fever.  There  was  great  emaciation  with  a  yellow  tinge  of  the  conjuctiva  and  skin,  anorexia,  occasional 
vomiting,  five  or  six  loose  passages  daily  and  restlessness;  the  tongue  was  moist  and  slightly  furred;  pulse  70  an<l 
feeble.  He  died  August  15.  Pont-mortfin  examination  twentv-fonr  hours  after  death:  Body  enmciated  and  ligid. 
Urain  normal.  Lungs  intensel.v  congested  in  their  posterior  i)ortions.  Heart  normal.  Liverof  light  color  superficially, 
blackened  anteriorly  and  below:  bile  yellow  and  granular.  Spleen  firm  and  of  normal  size  ;  pancreas  normal.  Stom- 
ach presenting  blood-spots  in  its  mucous  membrane.  Small  intestines  generally  discolored  and  ver.y  ott'ensive;  jeju- 
num black  or  dark  purple;  ileum  cherry-colored  in  its  upper  part,  darker  below.  Kidneys  large. — Jsn't  Surg.  Gcorije 
AT.  UcGiU,  U.  S.  A.,  Hick's  Hospital,  Baltimore,  Md. 

Case  .57. — Private  James  Hight,Co.  D,  23d  Ohio  Vols.;  age  23;  was  admitted  January  18, 1865,  with  tertian  inter- 
mittent fever.  He  liad  chills  at  irregular  intervals  succeeded  by  profuse  sweating ;  his  intellect  was  unnaturally  dull ; 
he  would  not  eat  nor  try  to  help  himself  though  he  appeared  strong;  he  had  no  pain  ;  pulse  regular  and  compressible. 
Tlie  chills  yielded  readily  to  quinine,  but  he  remained  without  appetite  or  energy.  After  the  first  week  he  de- 
clined graduall.v,  becoming  morose  in  disposition  and  absent-minded,  and  affected  with  cough  and  diarrh(Pa.  On 
February  20  he  was  reported  as  emaciated  and  imliecile ;  he  had  no  diarrlupa  but  passed  his  stools  in  bed.  On  March  1 
he  rallied  so  as  to  answer  simple  questions  correctly;  but  he  ha<l  dyspmua,  much  expectoration  and  extensive  crep- 
itus in  both  lungs.  On  the  5th  he  became  half  comatose  with  <|uick  short  breathing,  and  died  on  the  evening  of 
that  day.  rnst-mortem  examination  thirteen  hoirrs  after  death:  Much  emaciation;  blister  mark  on  back  of  neck. 
There  was  elfusion  under  the  cerebral  membranes,  which  were  not  injected  but  pale;  the  arachnoid  at  the  foramen 
of  Bicliat  was  thick,  opaque  and  white;  the  ventricles  were  distended  with  serum;  there  was  a  cream-colored  spot 
of  softening,  apparentl.v  covered  by  serous  membrane,  on  the  ventricular  wall  formed  by  the  right  corjius  striatum: 
the  middle  commissure  was  remarkably  firm,  as  it  stretched  out  to  nearly  an  inch  in  length  and  so  remained  without 


]32  POST-MORTKM     I:  liiOliDS    AMi 

breaking  across;  tlic  siibstanci'  of  the  ciTclinn]!  was  lianl,  that  oC  tlic  cpiclielluiii  and  cord  soft.  The  anterior  nicdi- 
astiuuin  was  enijiliysciiiatons.  The  lironclii  in  th(  lij^ht  lung  and  in  tlie  lower  lo))e  of  the  left  lung,  esjiecially  behind 
and  below,  were  dilated,  of  a  ilark  j)nrj)le  color  and  tilled  with  a  i)us-like  Unid,  while  the  lung-tissue  around  them 
was  here  and  there  dark  and  solid,  the  affected  lol)es  as  seen  from  the  surface  being  sunken  and  of  a  dark  lead  color. 
The  heart  contained  a  fibrinous  clot.  The  liver  was  large  and  finely  marked  with  nutmeg  foliations;  the  spleen  nor- 
mal. There  were  i)atches  of  reddening  along  tlio  ileum,  and  pigment  patches  in  tiro  sigmoid  lle.xure. — Third  Division 
Hospital,  Alexandriu,  I'ti. 

Cask  58. — Horace  Hill,  a  rol)ust  muscular  man,  age  2i)  years;  colored  ;  was  admitted  November  7,  18U5,  with 
quotidian  intermittent  fever;  tongue  yellow-coated;  appetite  poor;  i)ulse  during  the  intervals  of  the  paroxysm  84,  full 
and  of  good  strength;  bowels  ijuite  regular;  urine  scanty  and  of  high  color;  no  diltieulty  of  breathing;  no  (edema  of  the 
feet  and  legs.  After  treatment  for  two  days  the  cliills  left  the  jiatient.  l)Ut  a  febrile  jiulse  remained;  two  days  later 
sordes  appeared  on  the  teeth  and  lips,  and  the  tongue  becamt^  exceedingly  dry;  mental  torpor  and  slight  delirium 
were  uuinifested.  There  was  fulness  and  slight  tenderness  on  pressure  in  the  right  hypochondrium  and  greater  ])re- 
cordial  duluess  than  natural.  Moderate  vomiting  took  place  about  noon  of  the  13th,  and  in  a  few  minutes  the 
patient  suddenly  and  unexpectedly  died.  I'ost-mortcm  examination  sixteen  hours  after  death:  The  right  ventricle 
of  the  heart  much  dilated;  spleen  gieatly  enlarged  and  softened;  liver  much  enlarged;  kidneys  fatty;  other  organs 
normal. — Surynon  Edwin  lUuthy,  V.  S.  i'oln.,  VOiirerture  HuspHu},  Alexandria,  Va. 

Case  59. — Private  W.  P.  Jones,  Co.  M,  :^d  V .  S.  Arfy,  was  adnutted  September  5, 1863.  and  died  on  the  10th, 
of  intermittent  fever.  I 'out -mortem  examination  twenty-four  hours  after  death:  Both  lungs  were  congested  and 
adherent.  The  heart  was  hypertrophied  and  coated  on  its  exterior  with  a  thick  layer  of  adipose  tissue.  The  liver 
was  slightly  enlarged,  its  coiu'ave  surface  congested  and  of  a  darlc  bluish  color,  which  extended  about  one-eighth 
of  an  inch  into  the  substance  of  tlie  organ.  Tht^  spleen  was  congested  and  dark  colored.  The  intestinal  canal  con- 
tained a  black  mixturi^  of  coagulated  blood  and  mucus;  its  mucous  niemljiane  was  deej)ly  congested  and  :ilnu)st 
black. — Act.  Asu't  Siiry.  J.  A.  Murphy,  Went  End  Honpital,  Cincinnati,  Ohio. 

Casp;  60. — Quartermaster-Sergeant  William  L.  Billmau,  Co.  11,  3d  Pa.  Art'y  ;  age  38;  was  admitted  January  22, 
1864,  with  intermittent  fever  and  died  Maridi  7.  He  was  able  to  w  alk  about  uji  to  the  evening  of  his  death  ;  he  wiis 
present  at  insjiection,  undress(Ml  himself  and  went  to  bed  aitjiarently  feeling  well.  I'ost-nuirtem  examination 
twenty-four  hours  after  death:  lioth  lungs  were  in  the  third  stage  of  pnuemonia;  there  were  aillu'sions  on  both 
sides  and  three  ounces  of  li<|uid  in  the  left  pleural  sac.  The  jjcricardium  contained  four  ounces  of  li(|ui(l.  Tlie 
aortic  valves  were  thickened ;  on  one  of  them  was  a  cousideraldo  quantity  of  adherent  fibrin ;  the  left  side  of  the  heart 
contained  coagula  of  fibrin.  The  liver  was  hypertrophied;  the  spleen  liffge  and  soft;  the  left  kidney  much  larger 
than  the  right,  and  the  pelves  of  both  kidneys  contained  ]ius.  [No.  336,  Medical  Section,  Army  Medical  Museum,  is 
the  heart  from  this  ease.] — Art.  Ann't  Siirii.  B.  IS.Milex,  V.  S.  .1.,  .hirrix  Hospital,  lialtimore,  Md. 

Cask  61. — Private  William  T.  (Jriffej',  Co.  G,  1st  Conn.  C^av.;  age  23;  was  admitted  January  12,1864,  with 
intermittent  fever.  He  died  April  7.  I'unt-mortem  examination:  The  right  lung  was  tuberculous.  The  left  pleural 
sac  and  the  pericardium  contained  effused  serum.  The  liver  was  enlarged  and  tubercles  were  diffused  through  its 
substance;  it  weighed  four  pounds  ten  ounces.  The  spleen  was  soft  an<l  friable;  it  weighed  sixteen  ounces. — Avt. 
Ast't  Surij.  Ji.  li.  Miles,  U.  'S'.  -1.,  •/arris  Ifosjiiliil,  lialtimore,  Md. 

Ill  tlie  next  rase  tlic  iiitcnnissions  disappeared  and  the  patient  became  affected  willi 
remittent  fever ;  yet  the post-'/iiorfem  appearances  did  not  difler  from  tlmse  alrcadv  describi-d. 
The  stomach,  luno-s  and  kidneys  had  sutfercd,  hut  the  other  thoracic  and  alidominal  organs 
were  not  perceptibly  altered. 

Cask  62. — Private  Henry  Morton,  Co.  K,  .56th  Mass.  Vols,  (colored);  age  30;  was  admitted  December  16,  18(!l, 
from  field  hosjiital,  witli  intermittent  fever.  The  jiaroxysms  were  checked  by  (|uinine,  and  the  j)atient  w  as  soon  able 
to  walk  about.  About  IJccember  31  be  had  an  attack  of  diarrlnea,  w  liich  was  leadily  controlh^d  l)y  astringents.  A 
few  days  later  his  ague  recurred,  and  jx-rsisted  in  spite  of  the  administration  of  quinia.  The  disease  assumed  the 
pernicious  form,  the  renii.Hsions  being  but  slight;  the  res|>iration  Ix^came  hurried,  and  delirium  setting  in,  he  died 
January  it,  1865.  J'ost-inortem  examination:  The  left  lung  was  congested.  The  mucous  membrane  of  the  stomach 
was  of  a  dark  yellow  color  and  much  softened.  The  kidneys  were  congested.  No  other  abnormal  appearances  were 
observed.     The  brain  was  not  examined. — .let.  Ass't  Snr/j.  F.  Stoddard,  L'Oiirerture  Hospital,  Alexandria,  Va. 

The  twelve  cases  which  follow  ;ire  illustrations  of  remittent  fever.  In  63,  the  diag- 
nosis, originally  quotidian  intermittent,  was  changed  in  the  progress  of  the  case  to  typhoid 
fever;  but  there  was  no  diarrhoea  during  life,  and  no  intestinal  lesion  was  discovered  at  the 
necropsy;  delirium  was  present,  and  there  was  an  effusion  of  jaundiced  serum  in  the  ven- 
tricles and  under  the  membranes  of  the  brain.  Delirium  is  mentioned  as  having  been 
present  in  one  other  case,  but-  in  it  the  bi'ain  was  not  examined.  The  lungs  were  congested 
in  two  cases,  63  and  72,  tubercular  and  spilenifled  in  one  case,  69,  and  hepatized  and  infil- 
trated with  pus  in  a  f()urth  case,  73;   in  four  c;vses  they  were  unaffected;   in  one  they  were 


PATHOI.OilV    OF    >r.\r.AT;TAL    DISKASK.  133 

nut  exivmiiiuJ,  iUid  in  throe  their  (■(jinhtiou  is  not  statoih  The  heurt  does  not  appear  to 
liave  been  subject  to  notable  alteration  ;  it  is  reported  as  normal  in  six  cases  and  in  the 
others  its  condition  is  not  stated.  The  stomach  contained  a  muddy-green  liquid  in  two 
instances,  69  and  70.  In  all  the  cases  except  63  the  intestines  were  more  or  less  afiected. 
Tn  two.  68  and  74,  both  the  large  and  small  intestines  are  said  to  have  participated  in  the 
morbid  action;  in  five,  64,  65,  67,  70  and  72,  in  which  the  intestines  are  stated  to  have 
been  congested,  inflamed  or  ulcerated,  it  is  probable  that  the  large  and  the  small  intestine 
were  both  intended  to  be  included  in  tlie  statement,  for  in  71  the  inference  that  the  large 
intestine  \pis  afl'ected  is  fully  warranted  b\-  the  phraseology — "the  intestines  were  ulcerated, 
the  ulcers  in  the  small  intestine  beinir  of  lary:e  size.'  In  70  the  mucous  membrane  of  the 
intestine  was  in  part  almost  gangrenous,  the  duodenum  ulcerated  and  the  peritoneum 
inflamed;  in  73  the  intestines  were  congested  and  the  ileum  extensively  inflamed;  in  66 
the  small  intestine  j)resented  signs  of  inflammation,  but  the  condition  of  the  large  intestine 
is  not  recorded  ;  in  but  one,  69,  of  tlie  twelve  cases  is  it  dehnitely  stated  that  although  the 
small  intestine  was  congested  the  large  intestine  was  in  its  normal  condition;  in  none  was 
there  any  affection  of  Peyer"s  glands,  but  the  solitary  follicles  near  the  ileo-ctecal  valve 
were  prominent  in  one  instance,  the  case  last  mentioned. 

The  liver  is  reported  as  normal  in  two  cases;  in  a  tliii'd  case  nothing  is  stated  regai'd- 
ing  its  condition;  in  nine  cases  it  is  variously  described  as  large,  fatty,  pale,  fawn-colored, 
bronzed,  soft,  congested,  etc. 

The  condition  of  the  spleen  was  normal  or  not  stated  in  six  cases;  it  was  enlarged, 
soft  or  dark  colored  in  five  cases,  and  contained  a  purulent  collection  in  one  case,  74. 

Case  63. — Ser>;paiit  Owen  C'rossman,  Co.  }I,  2Stli  Mich.  Vols.;  age  45;  was  admitti-d  February  5,  1865.  Diag- 
nosis— (jiiotidiau  iiiteniiittent  fever,  changed  on  the  Stli  to  t.vphoid  fever.  He  had  suffered  from  chills  every  night 
for  two  wtH'ks,  hut  had  none  after  his  admission.  He  was  much  emaciated  and  depresse<l  in  mind;  had  a  slight  dr.v 
cough  hut  with  easy  and  natural  breathing;  uneasy  feelings  in  the  upper  part  of  the  alxlonien;  darting  pains  in  the 
alxlonu'u  and  thora.x ;  anorexia ;  thirst ;  his  skin  was  dry  but  covered  at  tinu»s  with  a  clannn.v  sweat;  bowels  regular. 
On  the  14th  h<'  had  profuse  ]ierspiratiou,  delirium  and  in  vcduntary  passages.  He  died  next  day.  I'ont-itwrtcm  examina- 
tion twenty-two  hours  after  death :  Skin  jaundiced.  Much  efl'usion  under  arachnoid  at  vertex ;  brain-substance  quite 
hard,  nio.st  of  the  vessels  having  yellow  spaces  between  tracks  of  black  llnid  blood:  lateral  ventricles  full  of  licinid; 
choroid  plexus  showing  bulbs  of  yellow  li(|uid  about  the  size  of  peas  along  its  posterior  lower  edge;  locus  niger  very 
dark  and  broad.  A  little  high-colored  but  clear  serniu  in  the  pericardium:  small  yellow  iibrinous  clots  in  the 
heart.  Kight  lung  so  congested  posteriorly  liy  hyjiostasis  as  to  sink  in  water,  soft,  gray-colored  and  adherent  to 
walls  of  chest  by  nuiny  white  bands;  left  lung  dark  but  crepitant  posteriorly,  firndy  ailherent.  Liver  pale  and 
fatty;  gall-bladder  the  size  of  a  butternut;  spleen  very  large  and  soft,  auwuiic;  kidneys  pale. — Third  Diriniun  Hospi- 
ta],  AlejruiuJrUi.  I'li. 

Cask  64. — Private  .lolin  Cavallence  (connnand  not  stated);  age  27;  was  admitted  Jul.v8,  1863,  from  Alexandria 
jail,  having  lieen  sick  six  weeks  with  bilious  remittent  fever.  From  his  delirious  mutterings  he  was  supposed  to  he 
a  rebel  deserter.  He  did  not  rally  sufficiently  to  converse  rationally,  but  died  on  tlie  12th.  /'(i«/-»(oW(;h  examination 
ten  hours  after  death:  Liver  and  sjileen  somewhat  enlarged;  Biunner's  glands  enlarged;  nnicous  coat  of  intestines 
extensively  inflamed,  but  with  no  ulceration. — .let.  .Ixx'l  Siirfi.  J.  I'.  t'nifl«.  Third  Dirininii  Hnnpitnl,  Alexandria,  Va. 

Ca.se  65. — Marcellas  F.  Dixon,  citizen  of  Missouri:  age  about  20;  was  admitted  December  6,  1864,  with  remit- 
tent fever.  He  afterwards  had  erysipelas,  and  on  recovei.v  from  this  was  attacked  with  diarrlnea  and  laryngitis. 
He  died  January  28,  1865.  rotit-mortnn  examination  four  hours  after  death:  There  was  a  tough  frothy  mucus  in  the 
trachea  and  bronchi;  the  larynx  did  not  exhibit  definite  signs  of  iuflannnation.  The  pericardium  contained  etl'used 
serum.  The  right  lung  was  adherent.  The  bowels  were  congested  but  nof  ulcerated;  the  mesenteric  glands  were 
enlarged. — Jet.  .Ixx't  Siiry.  J.  B.  Young,  V.  S.  ./.,  Uoel;  I-iland  Hospital,  III. 

Cask  (Mi. — Sergeant  Charles  M.  Gould,  Co.  M,  3d  Va.  Cav.:  age  2(t;  was  admitted  June  5,  1863,  with  remittent 
fever.  Quinine  was  administered  with  ai>]>arent  success,  but  during  convalescence  the  patient  being  imprudent  in 
his  diet,  was  attacked  with  diarrhiea,  and  died  June  22.  Vont-mortem  examination  six  hours  after  death:  The  liver 
was  fawn-colored.  The  spleen  was  soft  and  measured  eight  inches  by  five.  The  small  intestine  contained  some 
undigested  food  and  its  mucous  membrane  was  .slightly  inflamed. — Third  Dirinimi  Jfoxpital,  Alexandria,  I'a. 

C^vsK  67. — Private  William  Cornog,  Co.  A,  51st  I'a.  Vols.;  age  34  ;  was  admitted  .\ugust  7, 1861,  with  remittent 
fever.     He  was  very  ill  when  admitted,  and  for  three  days  l)efore  death,  on  the  I8th,  suffered  constantly  from  sin- 


134  I'OST-MOKTEM    KKCUilUS    AM> 

giiltns.  l'oHl-iui>rti'm  fxaininatioii  :  Tlif  limi;s  and  licart  wimc  normal.  The  thoracic  cavity  contained  four  ounces  of 
serum  and  tlie  abdominal  cavity  four  ounces  and  a  half.  The  liver,  spleen  and  pancreas  were  normal.  The  kid- 
neys were  Jarjie  and  white,  weij;hin^  six  ounces  and  a  half  each.  The  intestiiuil  mucous  membrane  was  slightly 
ulcerated. — McDoiiyiiU  I/ospiliil.  Furl  Schui/lir.  X.   )'.  Uarhor. 

Cask  GS. — I'rivate  L.  D.  .Johnson.  2d  Ohio  liattery,  was  admitted  May  10,  lX(>;i,  with  remittent  fever,  havin;; 
been  sick  since  March.  He  died  May  11.  /'«*7-m(»7<«i  exaniiiiation  :  Thoracic  viscera  noruuil.  I^iver  large.  Kidneys 
large,  soft  and  fatty,  weighing  seventeen  ounces.  Mucous  membrane  of  small  intestine  thickened  and  softened: 
large  intestine  congested. — Cilij  Hosjiilal,  .S7.  Louis,  Mo. 

Ca.sk  (iil. — rrivat(!  .John  Ingrahain,  Co.  V,  17th  V.  S.  Infy  :  age  23;  was  admitted  November  23,  1863,  with 
remittent  fever.  He  died  November  2ti.  I'ost-morlvm  examination:  Body  not  much  emaciated;  rigor  mortis  well 
marked.  There  was  some  venous  congestion  in  the  uieuibranes  of  the  brain.  The  right  lung  weighed  thirty-three 
ounces;  its  upjier  lobe  contained  tubercles,  some  of  which  were  cretefied,  and  beneath  these  a  cavity  the  size  of 
a  horse-chestnut  :  the  middl(>  lobe  was  healthy  :  the  lower  lobe  splenitied.  The  left  lung  weighed  twenty-four 
ounces;  it  was  tirmly  bound  to  the  thoracic  jiarietes  by  old  adhesions,  which  also  obliterated  the  division  of  the 
lobes;  the  posterior  portion  of  its  lower  lobe  was  splenitied  and  contained  some  tubercular  deposits.  The  bronchial 
glands  were  large  and  blai'k.  The  right  auricle  of  the  heart  was  greatly  distended  by  fluid  blood;  there  were  no 
clots  in  any  of  the  cavities.  The  liver  was  bronzed  and  weighed  tifty-two  ounces;  the  gall-bladder  contained 
twenty-tiv<'  drachms  of  bile.  The  s|ileen  was  linn  and  of  a  dark  nuihogany  color.  The  jjancreas  was  ([uite  white 
but  not  very  linn;  it  weighed  three  ounci'S.  The  kidneys  were  very  much  congested.  The  stomach  was  enormously 
distended  w  ith  ;i  unnldy-green  li(|Mid.  The  mucous  meml>rane  of  tlu>  snniU  intestine  was  congested  throughout  and 
intensely  purple;  the  valvuhe  couniventes  were  ))i-ominent  :  I'eyer's  patches  wi-re  not  elevated;  the  solitary  follicles 
near  the  ileo-ca-cal  valve  were  conspicuous,  their  sunnnits  being  of  a  deeper  jiiuph'  tliiin  the  adjacent  mucous  mem- 
brane.    The  large  intestine  was  normal. — Axx't  Surii.  Iliinixini  Allni,  T.  .S.  ./.,  lAiuobi  Hoxpitiil,  1f'a>iliin!/l()ii,  J).  ('. 

Cask  to. — Private  Elias  Henderson,  Co.  A,  10th  East  Tenn.  Cav.;  age  4():  was  admitted  Seiiteiidier  11,  1863, 
having  been  sick  in  camj)  five  days.  Mis  skin  was  yellow,  urine  high-coloreil,  bowels  moved  slightly  tliree  to  tive 
times  per  day,  abdomen  somewhat  tender,  especially  in  the  right  hypochondriac  region;  i)ulse  80  and  weak.  He 
was  much  prostrated,  vomited  very  frequently,  and  ejected  food  almost  as  soon  as  taken.  Hiccough  came  on  next 
day  and  continued  with  jaundice,  vomiting,  abdominal  ]iain  and  increasing  i>rostration  until  death  occurred  on  the 
20th.  I'liKt-moiInu  examination  ten  hours  after  death:  The  heart  and  lungs  were  not  examined.  The  stomach  con- 
tained about  six  ounces  of  d.irk  grunu>us  li(|uid.  and  was  highly  injected  lU'ar  the  ]>ylorus;  four  inches  b4dow  the 
pylorus  an  ulcer  three  lines  in  diameter  penetrated  the  coats  of  the  intestine,  which  contained  in  this  locality  about 
an  ounce  of  saiiiotis  jius.  'I'lie  mucous  membrane  of  the  intestinal  canal  was  intianied  and  in  some  parts  almost 
gangrenous.  There  was  some  peritonitis,  evidently  recent.  The  pancreas  was  enlarged  and  scirrhous;  the  spleen 
softened;  the  livei-  somewhat  enlarged  and  its  peritoneal  coat  inllamcd  :  the  gall-bladder  tilled  with  dark  inspissated 
bile;  the  kidneys  normal. — Iloxjiiltil  Xii.  2,  \it>ihrilli'.  Tom. 

Cask  71. — Private  Dallas  Sechler,  Co.  11,  !"2d  111.  \<>ls.:  age  20:  was  admitted  Septembers,  1804,  with  remit- 
tent fever,  and  died  on  the  14th.  ruxt-iiiorliiii  examiiuition  on  ilay  of  death  :  Lungs  and  heart  normal  :  liver  congested 
and  softened:  s])leen  eighteen  ounces;  kidneys  normal:  intestines  ulcerated,  th(^  ulcers  in  the  small  intestine  being 
of  large  size. — I'iiid  HdhjiHhI,  ('liiilliiiKiojid,  Tiiiu. 

Ca.sk  72. — I'livate  p'rancis  I'ellon,  Co.  M.Otli  Ohio  \(ds.:  age  27:  was  admitted  .\ugust  27,  1804,  with  remit- 
tent fever,  and  died  September  23.  l'iisl-mi>rlim  examiii;il  ion  <ui  day  of  death:  Lungs  sonu-what  congested;  heart, 
spleen  and  kidneys  normal :  liver  pale  and  soft :  mucous  membrane  of  intestines  congested,  softened  and  showing 
many  ulcers,  large  and  snuill. — I'iiUI  HoxpUnl,  (liiitttiiioixjii,  Tiint. 

Cask  73.— Private  Orrin  1'.  Tracy,  Co.  H.  3d  Pa.  Arfy :  age  2it:  was  admitted  March  2."),  1864,  with  remittent 
fever,  and  died  April  8.  I'iisl-nKiitiiii  examination:  Extensive  pleural  adhesions  on  lioth  sides:  right  lung  infiltrated 
withi)us:  upper  lobe  of  left  lung  lie|>atized:  three  ounces  of  efiusiou  in  ]ieri<ardium :  liver  four  jiounds  ten  ounces 
and  a  half:  left  kidney  ten  ounces  and  a  half,  right  seven  ounces  and  a  half,  all  iu)rmal  in  appearance.  Intestines 
niucU  congested  and  presenting  extensive  marks  of  intlannnation  in  the  ileum.  No  ulceration  of  Peyer's  patches. — 
Act.  Aas't  Surg.  B.  11.  Alilis,  U.S.  .1.,  Jun-is  Hoxpitul,  Hiiltimorc,  Md. 

Cask  74. — Private  H.  H.  Wade,  Co.  A,  18th  Mass.  Vols.,  was  admitted  August  7,  1862,  in  a  dying  condition, 
probably  from  nuilarial  fever.  Death  occurred  next  day.  I'ont-mnrlem  examination:  L5ody  much  emaciated.  The 
heart  and  lungs  were  healthy.  The  liver  was  sound.  The  spleen  was  moderately  enlarged  and  its  substance 
natural  in  appearance  exccjit  that  a  part  of  the  organ  was  reduced  to  a  thin  sanious  puruloid  li(|uid  forming  an 
abscess  about  as  large  as  a  goose's  egg.  This  al)scess  was  in  contact  with  the  diaphragm,  the  left  extremity  of  the 
stomach  and  the  edge  of  the  left  l(d)e  of  the  liver,  and  was  separated  from  the  peritoneal  cavity  by  adhesion  of  the 
spleen  to  the  })arts  ment  ioned.  The  stomach  was  exceedingly  contracted  but  healthy.  The  nnicous  membrane  of  the 
ileum  and  cohm  was  intiamed,  but  the  agminated  glands  were  natural. — Ait.  Ax-i't  Surg.  J.Lcidy,  Sattcrlee  Hoxpitul, 
Philadelphia,  Pa. 

Ill  the  six  cases,  75-80,  the  fever  became  complicated  with  dysentery,  pneumonia, 
pericarditis  or  j)eritonitis.  The  brain  was  liealthy  in  tlie  only  case  in  which  it  was 
examined.  The  heart  was  natural  in  two  cases  and  unnoted  in  the  others.  Tn  three  the 
mucous  membrane  of  the  intestines  was  conf'ested  or  ulcerated;   in  one  the  duodenum  and 


rATHOl.OOY    OF    MALARIAL    ]')ISEA8K.  135 

pancreas  were  ulcerated.  The  stoiiiacli  contained  a  mud-like  liquid  in  two  cases,  75  and 
79,  and  its  mucous  membrane  was  tliickened  and  slate-colored  in  one  case,  80.  The  spleen 
was  normal  in  one,  unnoted  in  three,  and  enlarged  in  two  cases.  The  liver  was  affected  in 
three  cases  and  unnoted  in  the  others. 

Case  75. — Private  Asa  L.  Patten,  Co.  1, 141th  Ohio  Vols.;  age  24  ;  was  admitted  Fehniaiy  f>,  186.">.  Hilious  mala- 
rial fever,  with  dysentery.  Died  February  8.  r<>si-mnrtfm  examination  six  hours  after  death:  Hody  very  nineh 
emaciated.  Heart  eoiitainins  a  lar-jje  (ihrimius  clot:  liver  enlarf^ed:  stoiiiach  distended  with  almost  half  a  };alloii  of 
a  dark  grnmous  li(]nid;  intestines  congested  an<l  ulcerated;  liluod  watery  and  degenerated — .let.  Ami't  Unry.  II'. 
Bnjitn,  Stunton  Hoxjiitul,  Waxhini/toii,  I).  ('. 

Case  76.— Private  Michael  McCuskey.  Co.  F,  iliii  Oliio  Cav.:  age  IS;  was  admitted  February  22,  1K64,  with 
remittent  fever,  from  which  he  recovered  luit  remained  weak  and  did  not  leave  his  lied.  On  March  25  idcuni-jineu- 
monia  set  in,  and  death  occurred  on  the  30th.  I'oxt-mnrtciii  examination  seventeen  hours  after  death:  The  lower  lobo 
of  the  left  lung  was  liei)atized,  exuding  a  red  frothy  liijuid  on  section;  the  lower  lobe  of  the  right  lung  was  hei)a- 
tized;  tlie  right  lung  was  covered  with  unorganized  lymph;  each  pleural  cavity  contained  twenty  ounces  of  reddish 
serum.  The  lieart  was  healthy;  the  livi'r  presented  the  nutnu'g  apjiearance;  the  spleen  and  kidneys  were  large  and 
congested;  the  mesenteric  glands  cnlaiged. —  Fliixjiitdl  Xo.  X,  XiixhriUf,  Tiiiii. 

C.\SE  77. — Recruit  Casjier  Christenson,  (Kith  >,'.  V.  Vols.;  age  40;  was  ;idiuitted  March  7,  18(54,  with  remittent 
fever,  for  which  quinine  and  brandy  were  given,  but  he  did  not  im]>rove.  'I'wo  days  before  his  death  his  left  leg  and 
ankle  became  enormously  swollen  and  jiainl'ul,  and  next  day  the  right  leg  became  similarly  atfeeted.  He  died  March 
18.  Po»<-»Hor<en»  examination  forty-eight  hours  after  death  :  There  were  old  pleuritic  adhesions  on  both  sides.  The 
pericardium  contained  abouttwo  ounces  of  bloody  serum,  and  there  were  other  evidences  of  recent  pericarditis.  Some 
old  ulcers  were  observed  in  the  intestines. —  Third  Divixiim  Hosjtital,  .llexditdiid,  Id. 

Case  78.— Private  Uriah  K.  McF'arland,  Co.  K,  4th  Ind.  C'av.;  age  3() ;  was  admitted  July  24, 1863,  with  chronic 
diarrheea.  He  recovered  and  was  doing  light  <luty,  when  on  Deceiuber  25th  he  was  attacked  with  remittent  fevor. 
He  improved  after  the  use  of  quinine  for  three  days;  his  appetite  returned  and  he  was  able  to  walk  about,  wlien,  on 
January  5,  1864,  the  chill  recurred  and  was  followed  liy  fever;  bowels  somewhat  constipated.  Three  compound 
cathartic  pills  were  given  at  once,  and  the  (|uinine  was  again  resorted  to  in  six-grain  doses.  Next  day  he  had  a 
burning  pain  in  the  epigastrium,  incaf^ased  by  pressure  and  deep  inspiration,  inc^essant  nausea  and  vomiting,  a  white 
furred  tongue,  feeble  pulse,  130,  and  short  and  liurried  res](irati(ui.  Morjdiia  and  warm  foTueutations  were  employed. 
On  the  7tli  small  and  rejieated  doses  of  calomel  and  opium  were  given,  and  a  l)lister  was  ajiplied  to  the  epigastrium, 
but  the  vomiting  continued,  and  on  the  8th  hiccough,  restlessness  and  great  anxiety  were  added  to  the  symptoms. 
On  the  9th  delirium  supervened  and  the  extremities  became  cold.  He  died  next  day,  the  vomiting  and  hiccough 
liaving  ceased  for  some  hours  before  death.  I'oKt-mortem  examination  eighteen  hours  after  death:  The  peritoneum 
was  much  thickened;  the  omentum  adhered  to  the  intestines  and  anterior  wall  of  the  stomach;  the  serous  coat  of 
the  large  and  small  intestines  was  disorganized;  the  coats  of  the  stomach  were  thickened;  the  spleen  was  twice  the 
normal  size,  softened  and  friable. — Honpila},  Muditoii,  Ind. 

Case  79. — Private  Samuel  Clancy,  Co.  B,  1st  N.  Y.  Vols.  Admitted  July  26,  1862.  Diagnosis — pernicious 
fever.  Died  August  1st  of  peritonitis.  Shortly  before  death  this  man  vomited  a  considerable  quantity  of  a  dark 
olive-brown,  muddy  liquid.  I'oni-morlvm  examination:  The  peritoneum  was  inflamed  throughout  its  whole  extent. 
Pseudo-membrane  was  found  on  the  intestines,  but  they  were  not  agglutinated.  The  stomach  contained  about  a 
pint  and  a  half  of  the  mud-like  liquid  above  mentioned.  The  mucous  membrane  jtresented  a  small  patch  of  inflam- 
nuition,  but  elsewhere  appeared  neither  softened  nor  otherwise  unhealty.  The  mud-like  liquid,  examined  micro- 
scopically, exhibited  an  abundance  of  epithelial  cells  but  no  distinct  appearance  of  blood. — Act.  Jus't  Surg.  J.  Leidy, 
U.  S.A.,  Satttrlec  Ho-ipital,  I'hiludclphia,  Pa. 

Case  80.— Private  Lewis  T.  Fisher,  Co.  K,  149th  Pa.  Vols.;  ago  20;  was  admitted  March  26,  1864.  Diagnosis — 
remittent  fever.  Died  April  25.  Post-mortem  examination  nine  hours  after  death:  lirain,  lungs  and  heart  healthy. 
The  mucous  membrane  of  the  stomach  was  thickened  and  slate-colored.  The  intestines  were  much  congested,  and 
their  serous  coat,  which  was  of  a  slate-blue  color,  was  adherent  to  the  abdominal  walls.  The  upper  half  of  the 
duodenum  was  extensively  ulcerated  and  almost  jierforated  in  some  places.  The  liver  was  much  softened  in  the 
neighborhood  of  the  gall-bladder;  the  spleen  firm  and  healthy;  the  pancreas  somewhat  ulcerated  along  its  attached 
surface.     The  left  kidney  was  enlarged  and  much  congested. — Lincoln  Honpita},  Wushington,  D.  C. 

Typhoid  symptoms  are  spoken  of  in  the  two  cases  which  follow,  accompanying  in  the 
first  case  a  relapse  which  was  complicated  with  inflammation  of  the  parotids,  and  in  the 
other  a  pneumonic  abscess;  but  in  neither  does  the  post-viortem  record  indicate  the  presence 
of  an  affection  of  the  patches  of  Peyer. 

Case  81. — Private  Adam  Hauser,  Co.  G,  38th  N.  Y.  Vols.;  age  25;  was  admitted  October  14,  1862,  with  remit- 
tent fever,  which  assumed  a  typhoid  form,  with  dry  tongue,  diarrhrea  and  low  delirium.  During  convalescence  a 
relapse  occurred,  accompanied  by  inflammation  and  suppuration  of  the  parotid  glan<ls.  He  died  November  21.  Post- 
mortem exanui\a,tiou  eighteen  hours  after  death:  Extreme  emaciation.  The  lungs  were  healthy.  The  pericardium 
contained  about  four  ounces  of  serum.     Nothing  abnormal  was  noted  in  the  liver;  the  gall-bladder  was  moderately 


136  POST-MORTKM    RF'.COJIDS    AND 

filled  with  bil<'.  Tlio  sploon  was  ciilainod  anil  tsoCtciicd.  The  intestines  were  (liniciidcil  with  flatus;  their  poritoncal 
coat  was  liijjhly  iii.jeeted  and  their  mucous  coat  softened.  Tlu^  kidneys  and  bladder  were  healthy. — Third  Division 
Hospital,  Alexandria,  y'a. 

Cake  82. — Private  Louis  Huokmyer,  Co.  I,.S7th  Ohio  Vols.,  was  admit t(><l  October  24, 18()2,witli  chronic  diiirrho-a 
terminating  with  symptoms  resembling  those  of  tyi)lioid  remittent  fever.  He  died  November  13.  I'lint-mnrlem  ex- 
amination: Uody  extremely  emaciated.  Then'  weie  jilen  rifle  adhesions  on  the  left  side  posteriorly,  and  an  abscess  of 
considerable  size  in  the  lowijr  lobe  of  the  right  lung.  The  liver  was  enlarged.  The  mucous  membrane  of  the  small 
intestine  was  injected,  softenisd  and  ulci^rated. — Third  Dirision  I/onpital,  Ahxandria ,  Va. 

In  tlie  next  case  the  patient,  during  couvaloscencc  fruiii  an  attack  of  intennittent, 
appears  to  have  been  taken  with  true  typhoid  fever,  devek>piiig  diarrh«a  and  rose-colored 
spots  at  the  end  of  the  second  week  and  ending  fatally  on  the  sixteenth  day.  The  mucous 
membrane  of  the  small  intestine  was  ecchymosed  and  the  agminated  glands  enlarged  but 
not  ulcerated. 

Case  83. — Corporal  William  T.  Reeves,  Co.  L,  KHh  Ky.  Cav.,  was  admitted  April  23,  1863,  with  intermittent 
fever.  He  had  an  attack  of  hiccough  whicli  continued  for  three  days  with  but  short  intermissions;  but  he  speedily 
convalesced  under  anodynes  and  quinine,  and  on  May  10  was  up  and  walking  about  the  ward.  On  the  12th  he  was 
seized  with  colicky  pains,  ^yhich,  on  the  two  following  days,  became  very  severe,  but  were  relieved  by  cathartics  and 
opiates.  From  the  16th  to  the  20th  ho  complained  of  headache  ami  had  considerable  irregular  fever.  Fiy  the  24th 
diarrhoea  had  developed,  with  tenderness  of  the  bowels  and  some  mental  confusion.  Next  day  the  tongue  became 
dry,  and  on  the  following  day  glazed;  stupor  liad  set  in,  and  there  was  tympanites  of  the  abdomen  with  gurgling 
under  pressure  and  an  eruption  of  rose-colored  spots,  well  marked,  over  the  whole  of  the  body.  He  died  on  the  27th 
after  copious  perspirations,  great  prostration  and  increased  stupor.  Post-mortem  examination  twelve  hours  afterdeath  : 
The  rose-colored  spots,  which  were  very  numerous  on  the  trunk  and  also  on  the  limbs,  presented  a  purpuric  appear- 
ance. The  small  intestine  was  mottled  with  purple,  and  there  were  two  or  three  spots  which  seemed  ready  to  slough; 
Payer's  glands  were  enlarged  and  infianied  but  not  ulcerated.  The  spleen  was  very  large;  the  liver  and  the  thoracic 
viscera  healthy. — Act.Ass't  Surg.  J.  B.Smith,  Washington  Park  Hospital,  Cincinnati,  Ohio. 

In  the  next  case  the  patient,  during  the  debility  consequent  on  intermittent  attacks, 
became  sick  with  fever  which  proved  fatal  about  the  seventeentli  day,  the  tongue  in  the 
meantime  becoming  dry,  brown  and  fissured  Jmd  the  teeth  covered  with  sordes.  Peyer's 
glands  usually  become  ulcerated  at  an  earlier  period  of  the  disease  than  this;  but,  as  in  the 
last  case,  death  on  the  sixteenth  day  did  not  give  ulceration  of  the  patches  as  a  post-mortem 
lesion  although  the  disease  was  apparently  enteric  fever,  it  is  probable  that  the  poison  was 
present  in  this  case  also;  and  in  this  connection  it  may  be  inquired  if  the  occasional  deposits 
of  tubercle  recorded  as  discovered  in  the  ileuin  were  not  typhoid  enlargements  of  the  agmi- 
nated and  solitary  glands.  In  85  the  relapse,  which  was  accompanied  with  typhoid  symp- 
toms, may  perhaps  be  regarded  as  an  attack  of  enteric  fever. 

Case  84. — Private  James  Coady,  Co.  15,  24th  Vet.  Res.  Corps;  age  21;  was  admitted  February  2,  1865,  with 
debility  from  malarial  disease.  The  patient  had  a  haggard  look,  but  complained  of  nothing  but  weakness  and 
inability  to  sleep;  his  tongue  was  slightly  coated  with  white  fur,  bowels  somewhat  loose,  pulse  90, skin  natural. 
He  said  he  had  recently  suffered  from  intermittent  fever.  Wine-bitters  and  quinine  were  given,  with  Dover's  powder 
at  night.  He  slept  well  during  the  following  night,  but  in  the  morning  he  was  feverish,  his  tongue  dry  and  brown 
in  the  centre,  his  bowels  loose,  and  he  complained  of  pain  in  the  right  iliac  region;  there  was  also  some  cough,  with 
pain  in  the  right  breast  and  dulness  on  percussion  over  the  upper  thir<l  of  the  right  lung.  Acetate  of  ammonia  and 
brown  mixture  were  given  and  the  quinine  continued.  During  the  next  few  days  the  typhoid  symptoms  became 
more  marked;  deafness,  fissured  tongue  and  sordes.  Milk-punch  was  ordered.  He  died  on  the  19th.  Post-mortem 
examination:  There  w*re  old  pleuritic  adhesions  on  both  sides,  but  particularly  on  the  right.  The  right  lung  was 
infiltrated  with  tubercle,  some  of  which  was  .softened,  and  there  was  some  intercurrent  pneumonia;  the  mucous 
membrane  of  the  bronchial  tubes  was  thickened  and  of  a  dark-pur])le  color.  The  liver  was  large  and  somewhat 
cirrhosed ;  the  spleen  dark-brown  and  soft.  There  were  patches  of  inflammation  and  occasional  deposits  of  tubercle 
in  the  ileum.     The  mesenteric  glands  were  enlarged. — Third  Division  Hospital,  Alexandria,  Va. 

Case  85. — Private  John  Herman,  Co.  F,  59th  N.  V.,  was  admitted  September  9,  1864,  jaundiced;  convalescing 
from  remittent  fever.  He  was  up  for  several  <lays,  but  a  relapse  occurred  and  the  disease  assumed  a  typhoid  char- 
acter. Diarrhn'a  set  in  with  much  fever  and  tenderness  over  the  abdomen.  Death,  on  October  16,  was  preceded  by 
low  delirium,  involuntary  stools  and  retention  of  urine.  Post-mortem  examination  :  Lungs  healthy  ;  heart  loaded  with 
fat;  liver  of  proper  consistence  but  abnormally  yellowish-brown;  intestines  injected  with  blood;  Peyer's  patches 
somewhat  diseased  but  only  slightly  ulcerated;  kidneys  congested. — Act.  Ass't  Surg.  Henry  Gibbons,  jr.,  U.  S.  A., 
Douglas  Hospital,  Washington,  D.  C. 


?ATIlUlA)(iV    (iK    MAl.AKlAl.     I'lSEASK, 


137 


In  86  a  reference  is  nimle  tn  tvplionl  .-vniptdnis.  anil  the  necropsy  ajipoars  toliave  Keen 
held  with  tlie  iiiteni  to  (hseover  wlietlier  these  clinical  t'eatnres  were  (lep;)iidont  "n  enleric 
fever.  The  cases  87  to  91  are  ajiparentlv  o\'  a  snnilar  character;  no  mention  is  made  ol 
typhoid  symptoms,  hilt  the  anatomical  h'sions  in  lh(>  small  intestine  diller  from  those  ahove 
descrihed  as  present  in  malarial  fever  ami  au'i'i-e  with  those  f  )niid  in  83,  in  which  i.'nteru- 
fever  seems  to  have  seized  upon  a  convalescent  I'rom  malarial  disease.  Alth(iUL:h  these 
cases  appear  to  indicate  that  many  others  giving  a  record  (il  typhoid  symptoms  were  jh-oIj- 
ablv  of  an  enteric  nature,  it  mav  he  noted,  on  the  <ither  hand,  that,  in  cases  o3,  .)•),  •)/  ,  oS. 
63,  64,  81  and  82,  these  svmptoms  were  apparently  unconnected  with  a  spcHMJii-  lesion. 

Case  86.— Charles  Lassell,  Co.  L,  Utii  N.  Y.  Heavy  Arfy;  a>;e  2S :  was  admithMl  .liiiie  ITi,  lS(il,  with  ivmilleiit 
fever.  On  t lie  20th  typhoid  symptoins,  including  diarrlin'a,  were  developed,  iiinl  hi'  died  on  tlie  2Jd.  roxt-iiiortim 
examination  twenty  hours  after  death  :  Some  of  I'eyer's  patches  wereenlarfjeil  and  some  inflamed,  hut  none  ulcerated. 
—  Third  Dlviniuii  Ho«j/ilal,  Ahxuvdria,  Vn. 

C.\.SE  S7. — Private  George  AVillianis,  Uh  Miidi.  Vols.;  agelK;  was  admitted  August  10,  1S()2.  K'emitteut  fever. 
Died  August  11.  roat-morlcm  exaniiuatiou  next  day:  The  body  was  much  emaciated.  'V\w  thoracic  0]gans  were 
healthy.  The  spleen  exhibited  a  remarkable  number  of  the  so-called  Malpighian  liodies,  which  were  of  uniform  size, 
white  and  about  the  size  of  yellow  mustard-seed.  The  liver,  stonuich,  kidneys  and  pancreas  were  healthy.  The 
mucous  membrane  of  the  intestines  was  more  or  less  inflamed  thnuighont,  the  redness  being  moderate;  tlu'  glands 
of  I'eycr  and  the  solitary  glands  were  more  than  usually  prominent. — Act.  AkkU  Snnj.  J.  Lcirly,  SatterUr  Hospiliil,  I'liiln- 
ddjfhia,  Pa. 

Case  8S. — Private  Ananias  Sjjangler,  Co.  K,  20lth  Pa.  Vols.;  age  10:  was  admitted  October  L'S,  1S(!(,  with 
remittent  fever  and  died  \oveud)er  0.  I'ost-morttm  exauiination  nineteen  hours  after  death:  Body  euiaciated;  rigor 
mortis  marked;  suggillation  jxisteriorly ;  nuico-purulent  matter  escaping  from  nostrils;  largo  but  superficial  abscess 
in  perina'um.  The  jduuynx  and  (esophagus  were  normal.  The  larynx  and  tiachea  were  tilled  with  nnico-purulent 
matter,  but  the  mucous  niem1)raue  was  healthy.  The  right  lung  was  adherent  to  the  thoracic  parietes  by  recent 
lymph;  its  posterior  portions  were  infiltrated  with  pus.  The  left  lung,  heart  and  pericardium  were  healthy.  The 
liver  was  darker  in  color  than  usual,  but  Avas  otherwise  liealthy;  the  gall-bladder  contained  six  drachms  of  bile.  The 
sjileen,  pancreas  and  kidneys  were  normal,  as  were  also  the  stomach  and  tlui  greater  portion  of  the  suiall  intestine. 
The  lower  part  of  the  ileum  presented  three  or  four  ulcers  which  appeared  to  be  in  Peyer's  patches;  but  the  ])atches 
were  not  thickened  and  the  ulcers  seemed  to  be  healing.  The  colon  an<l  rectum  were  normal. — Act.  .tux't  Siiry. 
Thomas  Bowen,  Second  Division  Hospital,  Ahxandriu,  T'a. 

Case  89. — Private  Charles  Reed,  Co.  C,  ISoth  N.  Y.  Vols.,  was  admitted  January  17,  18(55.  Diagnosis — remit- 
tent fever.  Died  on  the  2l8t.  Po-tt-mortcm  examination  :  The  right  lung  weighed  thirty-two  ounces;  its  ujiper  lobe 
was  adlierent  and  hepatized;  the  left  lung  weighed  twenty-five  ounces  and  liad  a  sliglit  tubercular  dejjosit  near  its 
apex.  The  heart  weighed  ten  ounces  and  was  healthy;  the  liver  seventy-six  ounces,  pale;  the  spleen  tw<'nty-four 
ounces,  soft;  the  stomach  was  injected  in  spots  and  had  one  ulcer  on  its  posterior  wall;  the  duodenum  ami  jejunum 
were  healthy;  the  ileum  thickened;  Peyer's  patches  and  the  solitary  follicles  enlarged  and  thickened;  the  solitary 
follicles  of  the  colon  enlarged  and  infiltrated;  the  mesenteric  glands  nmch  enlarged;  the  kidneys  normal,  each 
weighing  six  ounces. — Act.  Ass't  Surg.  H.  I.ocwcuthal,  V.  S.  Vols.,  Fifth  Army  Corps  Field  Hospital,  Army  of  PotomHC. 

Case  90. — Private  Perley  J.  Blodget,  Co.  II,  5th  Wis.  Vols.:  age  21 :  was  admitted  October  17,  1801.  Diagnosis- 
remittent  fever.  Died  November  1.  Post-mortem  exanduation  forty-eight  hours  after  death:  Eight  ounces  of  serum 
in  right  and  two  ounces  in  left  pleural  sac,  one  ounce  in  pericardium  and  a  pint  in  the  abdouunai  cavity.  Spleen 
soft,  dark,  weighing  about  two  pounds;  liver  and  kidneys  normal;  Peyer's  patches  in  the  lower  ileum,  and  the 
solitary  follicles  in  the  cieeum  and  ni>per  colon  much  thickened  and  ulcerated;  mucous  membrane  of  colon  inflamed. 
— Second  Division  Hospital,  Alexandria,  Fa. 

Case  91. — Private  Peter  Blair,  Co.  I,  125th  Ohio  Vols.:  ago  21;  was  admitted  Xovomber  17.  ISOIJ.  lutcrmitfeut 
fever.  Died  December  9.  Po.fi!-moc'(;Hi  examination  eighteen  hours  after  death :  Slight  euuiciation.  Lungs  liealthy; 
heart  nine  ounces,  valves  slightly  thickened;  liver  fifty-nine  ounces,  healthy;  gall-liladder  largo  and  distended 
with  bile;  spleen  fonrteen  ounces;  kidneys  seven  ounces  each,  normal;  stomach  healthy;  Peyer's  patches  much 
thickened,  some  ulcerated;  large  intestine  presenting  a  few  superficial  ulcers. — Hospital  So.  1,  Xashrille,  Tenn. 

The  hve  cases  which  follow  come  under  the  heading  of  congestive  c/iills.  In  92  the 
|)atient  died  comatose  from  cerebral  congestion;  but  the  liver,  spleen  and  lungs  were  also 
affected  and  the  blood  was  diffluent.  In  93  the  axlema  and  congestion  of  the  abdominal 
viscera  must  be  regarded  as  the  result  of  tlie  malarial  influence,  for,  had  the  condition  of 
the  heart  been  responsible  for  them,  the  right  lung  would  not  have  been  reported  as  healthy. 
Violent  convulsions  took  the  place  of  the  chill  in  94.  In  95  the  fatal  chill  was  iiccom- 
panied  with  difficulty  of  breathing  ;  but  the  post-mortem  record  declares  the  brain,  lungs, 
Med.  Hist.,  Pt.  Ill— 18 


138  POST-MOIITM.M    liKCOliDS    AKD 

liver,  stomach,  intestines  and  kidneys  of  nomial  si/o  and  perfectly  liealthy;  the  spleen  was 
enlarged  and  there  was  a  thrombus  in  the  right  auricle.  Whether  the  heart-clot  was  con- 
cerned in  the  production  of  the  fatal  seizure  is  uncertain.  But  in  96  deatli  apparently 
resulted  from  the  formation  of  tibrinous  clots  in  the  cavities  of  the  heail.  They  probablv 
originated  during  the  chill,  when  a  tendency  to  stasis  in  the  heart,  increased  by  the  incom- 
petency of  the  valves,  gave  opportunity  for  their  deposit.  The  mufHingof  the  heart-sounds 
must  be  referred  to  an  internal  obstruction,  since  there  was  no  excess  of  liijuid  in  the  peri- 
cardium nor  other  external  condition  to  account  for  it.  The  other  symptoms  described  are 
consistent  with  the  theory  of  the  ante-Tiiorterii  formation  of  the  clots  in  this  instance. 

Case  92.— Private  Henry  Wolfus,  Co.  I,  187th  N.  Y.  Vols.;  age  25;  was  admitted  May  10,  1865.  Dirtf!;n().si.s— 
intermittent  fever  ami  cerebral  congestion.  The  patient  was  quite  cold  and  comatose;  pulse  irregular;  respiration 
noisy.  There  was  no  dulness  on  percussion  except  over  the  ])osterior  and  lowi-r  jiart  of  the  left  lung.  AVarmth  was 
applied  to  the  feet,  cold  to  the  head  and  a  large  stimulating  cneina  was  administered.  He  died  next  day.  I'oxt- 
mortem  examination  eleven  hours  after  death:  Lower  lol)(^  of  right  lung  liepatizi^d;  liver  congested;  spleen  congested 
and  softened ;  venous  lilood  ditilueut ;  cerebral  sinuses  and  veins  turgid  ;  three  ounces  of  serum  in  arachnoid. — Slouyh 
Hospital,  Alexandria,  Vn. 

Case  i>3. — Stephen  McLaughlin,  who  was  discharged  from  2d  T^.  S.  Art'y  August  17,  18()5,  on  account  of  prema- 
ture old  age,  astlima  and  general  deliility  from  twenty  years"  service,  was  admitted  September  11,  confused  in  mind 
and  with  tremors  of  the  limbs  and  voice:  pulse  l^fi:  he  appeared  to  have  lieen  drinking  to  excess.  His  legs  were 
ft'deniatous;  abdomen  full,  tense  and  fluctuating;  auscultation  disclosed  roughness  of  the  heart-sounds  with  increased 
impulse,  the  sounds  being  heard  all  over  the  left  side;  there  was  absolute  dulness  from  a  little  below  the  nipple  to 
midway  between  that  point  and  the  creat  of  the  ileum;  the  respiratory  murmur  was  absent  at  the  base  of  the  left 
lung,  puerile  at  its  sunnuit  and  on  the  right  side:  the  left  side  of  the  chest  was  contracted,  the  right  side  enlarged. 
At  2  p.  M.  on  the  day  of  admission  he  experienced  a  severe  chill,  for  which  brandy  and  quinine  were  given  and 
mustard  applied.  He  recovered,  but  the  chill  recurred  at  2.30  l'.  m.  on  the  following  day  and  he  died  at  7  v.  M. 
rost-mortim  examination  seventeen  hours  after  death:  Body  bloated;  skin  of  the  head  dark  and  livid;  a  thick  greenish 
liquid  flowing  from  the  month.  The  brain  was  normal.  The  right  lung  was  healthy.  The  left  pleural  cavity  was 
partly  obliterated  by  adhesions,  but  contained  in  its  sacculi  serum  and  lymph;  the  lung  was  diminished  to  half  its 
size,  the  lower  lobe  being  very  friable  and  having  its  air-cells  filled  with  a  prune-juice  li<iuid.  The  pericardium 
contained  four  ounces  of  serum.  The  heart  weiglie<l  fourteen  ounces  and  a  half;  the  ventricle  was  hypertroi)lii»!d, 
the  middle  valve  somewhat  thickened  and  the  curved  margins  of  the  pulmonary  and  aortic  valves  hardened.  The 
liver  was  enlaiged  and  softened;  the  spleen,  weighing  twenty-two  ounces  and  a  half,  was  ])ul])y.  The  peritoneum 
was  darkly  injected  and  contained  ten  ounces  of  serum.  The  stomach  and  intestines,  which  were  much  distended 
with  gas,  had  their  mucous  lining  congested.  The  kidneys  were  nodulated  on  the  surface  and  contained  several 
cysts  somewhat  larger  than  a  pea. — DougUin  Hospital,  If'uslunt/ton,  I).  C. 

Cask  94. — Private  Otto  Zlegera,  Co.  0, 1st  U.  S.  Vet.  Vols.;  age  25;  was  admitted  Se])teml)er  13,  18(35,  and  died 
September  19.  He  stated  that  he  had  been  suffering  from  remittent  fever.  On  admission  his  skin  was  of  natural 
temperature  and  perspiring  freely,  but  he  had  headache  and  his  appetite  was  poor,  tongue  furred,  jmlse  intermittent 
and  countenance  anxious.  In  four  days  he  had  improved  so  nnich  as  to  be  able  to  walk  about.  On  the  17th  he  was 
said  to  have  had  a  violent  convulsion,  which  was  considered  as  a  congestive  chill  by  the  attending  medical  ofdcer, 
who  found  the  patient  next  morning  collapsed,  almost  speechless,  and  covered  with  a  ])rofuse  cold  perspiration. 
During  the  day  he  rallied,  but  on  the  morning  of  the  19th  he  had  another  violent  convulsion  and  expired  in  an  hour.* 
Previous  to  death  he  had  been  eating  watermelon  and  Iwiled  eggs.  Postmortem  examination  eight  hours  after  death: 
Kigidity  marke<l.     The  arachnoitl  was  opacjue  and  presented  numerous  white  spots  of  small  size,  chiefly  over  the 


*  A  case  in  wliicli  the  fatal  chill  asstiincd  convulsive  features  is  given  by  Act.  Ass't  Surgeon  HENRY  M.  LYMAN,  U.  S.  A.,  as  havinj^  occurred  in  Hos- 
pital No.  2,  NashviUc.  Tenn.  The  patient  was  admitted  June  liti.  18ti"J,  having  the  appearance  of  being  well  nourished  ;  but  at  the  same  time  there  was  an 
unusual  paleness  of  the  tongue  and  palpebral  conjunctiva.  Prior  to  admission  he  had  complained  continually  of  rheumatism  and  debility.  Quinine  ami  iron 
were  prescribed.  During  the  two  weeks  following  his  entrance  into  hospital  he  was  twice  attacked  by  malarial  fever,  which  was  readily  suppressed 
by  quinine.  On  .hily  17  be  began  to  suffer  much  from  pains  which  he  called  rheumatic,  and  at  the  same  time  his  surface  was  <!ov(!red  with  a  fVetid  per- 
spiration; the  latter  (^ontiinied  thntugh  the  day  and  following  night.  A  scruple  of  Dover's  powder  was  given  during  the  day,  and  next  morning 
a  scruple  of  ({tunine  was  lulniinistered.  .\fter  this  he  continued  well  mitil  the  night  of  the  23tl,  when  the  fu'tid  perspiration  again  api^eared  anil  lasted 
through  the  folhtwing  day.  Ten  grains  (tf  Dover's  [lowder  ever}-  four  hours  were  "ordered  till  the  cessation  of  the  fuitor."  Quinine  was  again  pre- 
bcribed  ;  but  whether  it  was  taken  or  not  was  uncertain,  because  of  the  prejudice  of  the  patient  against  the  remedy.  .Subsequently  lie  expressed  himself 
well  until  the  27th,  when  he  complained  of  pains  in  his  limbs,  of  a  burning  sensation  in  liis  stomach  such  as  he  never  felt  bef()re,  and  of  irisatiable 
thirst.  A  scruple  of  <iuiiune  was  prescribed  for  him.  which,  however,  he  did  not  take.  He  walked  alK)Ut  the  ward  conversing  with  his  comrades  and 
presented  nothing  unusual  in  his  ap[>earance.  He  lay  down  on  hi.s  bed  and  was  S(jon  seized  with  convulsive  movements  of  the  feet,  arms  and  head,  ami 
stertorous  breathing  with  frothing  at  the  mouth ;  his  surface  grew  purple  and  he  died  in  a  few  minutes.  'I'he  }ioM-morUni  exaininatiitn,  five  boui-s  after 
death,  found  considerable  serous  cITusion  under  the  arachnifid  and  about  four  ounces  of  fluid  at  the  base  of  the  brain,  with  much  softening  on  the  lower 
surface  of  its  middle  lobes.  The  lungs  were  healthy:  the  pleura  presented  nothing  of  any  importance  :  the  heart  was  normal ;  in  the  right  ventricle  was 
found  a  small  white  clot :  the  left  ventricle  was  empty  and  contnicted  and  the  right  auricle  enormously  distended  with  black  Huid  blood.  Five  ounces  of 
clear  serum  were  contained  in  the  [KM-icardium.  The  duifdenum  externally  exhibited  a  pinkish  hue ;  the  ileum  and  colon  were  of  a  darker  appearance. 
The  spleen  was  normal  in  size  and  of  a  slate  <;olor.  and  the  liver  of  a  dark  chocolate  hue.  Every  whertt  throughout  the  body  the  blood  was  found  uncoag- 
ulated.    This  caiie  of  congestive  fever  was  presented  in  the  .Second  Part  of  this  work,  p.  239,  as  Case  77tj  of  the  diarrhoeal  and  dysenteric  series. 


PATtR)l.()(iY    OK    MAI.AIMAI.    IHSEASK.  139 

sulci  on  the  right  side  of  the  cerehruin;  the  pia  mater  was  congested.  The  snhstance  of  the  brain  was  of  normal 
consistence;  it  presented  many  pnncta:  the  lining  meniljrane  of  the  lateral  ventricles  was  opaijiie,  hnt  the  cavities 
contained  no  sernm;  the  floor  of  the  fonrth  v(^ntriclc  was  congested  an<l  showed  some  small  ecchymoses.  Both  lungs 
were  marked  in  spots  with  melanic  matter,  the  foreign  substance  of  which  could  be  felt  by  passing  the  linger  over 
the  pleura  covering  it:  the  right  lung  was  congeste<l  by  hypostasis  posteriorly  and  inferiorly,  and  the  substance  at 
the  sunuuit  of  the  left  lung  was  puckered,  tough,  inelastic  and  of  the  sanit^  specific  gravity  as  water.  'I'lu'  heart 
contained  loosely-formed  black  clots.  The  liver  was  normal  in  specific  gravity  and  consistence;  tlu'  si)leen  enlarge<l, 
soft,  flaccid,  weighed  fifteen  ounces  ;  the  pancreas  was  large:  the  kidneys  and  suprarenal  <a])sules  normal.  The  ileum 
and  lower  portion  of  the  jejunum  were  colored  yellow  with  bile;  the  large  intestine  itresentcd  internally  a  blackish 
color  which  was  not  associated  with  softening,  ulceration  or  any  aiipreciabh^  lesion. — (ico.  M.  Mcdill,  .lnn'l  ■Shcj/., 
U.  S.  A.,  Hicks  HonjiitaJ,  Baltimore,  Mil. 

Ca.sk  95. — Private  David  Calvin  Legrone,  Co.  D,  40th  Ala.;  rejected  frontier  man;  age  about  2H;  was  reported 
on  the  morning  of  the  fith  of  December,  W64,  as  having  intermittent  fever.  Five  grains  of  ciuinine  were  directed 
to  be  taken  night  and  morning.  Next  day  he  had  no  fever  and  made  no  complaint,  remaining  up  till  '.•  v.  M.  He 
then  went  to  slee]i,  but  in  about  two  hours  awoke  with  a  chill  and  diHiculty  of  breathing  and  died  in  about  half  an 
hour.  I'ost-mortim  examination  sixteen  hours  after  death;  The  brain,  lungs,  liver,  st(Muach,  bowels  and  kidneys 
were  of  normal  si/.e  and  jierfectly  lu'alfhy.  Ther<'  was  a  thrombus  in  the  right  auricle  of  the  heart  and  about  three 
or  four  ounces  of  serum  in  the  j)ericar<lium.  The  s]>leen  was  about  twice  the  usual  si/e  and  very  soft,  dark  colored 
and  engorged  with  blood. — Jet.  Axx't  Sury.  II'.  li.  Miitthtiis.  V.  H.  .[.,  Hink  l-tldiiil  llospilal.  III. 

Cask  itfi. — Private  (ieorge  Evans,  (ith  Kan.sas  Cav.  (a  Delaware  Indian),  weight  IW)  ])ounds,  was  admitted 
Febrnary  2.3,  18f)3,  with  a  large  ulcer,  of  several  years'  standing,  on  tlm  right  leg.  This  healed  kindly  uiuler  treat- 
ment with  ointment  of  carbonate  of  zinc  and  adhesive  strips.  The  patient,  however,  was  taken  on  .March  M  with 
a  severe  chill  which  lasted  several  hours,  and  was  followed  liy  fever,  with  a  full  and  laboring  pulse,  120,  dyspiuea 
and  great  anxiety  of  expression.  The  fever  gradually  abated  and  with  it  the  force  and  fre(|uency  of  the  pulse;  but 
frequent  palpitations  supervened  with  conse(|uent  loss  of  sleep.  Next  nu)rning  the  juiKse  was  so  small  and  freciuent 
that  it  could  not  be  counted;  there  was  a  suffocating  feelitig  at  the  juiecordia,  with  a  pain  which  extended  to  the 
left  shoulder;  the  countenance  continued  distressed;  the  dyspncea  increased;  frequent  vomiting  of  greenish  nuitter 
occurred  throughout  the  day;  the  sounds  of  the  heart  were  muffled  and  indistinct;  the  bowels  open  and  stools 
healthy;  the  urine  noruuil  ;  the  skin  moist  and  warm;  the  intellect  clear.  The  pulse  became  imperceptible  at  the 
wrist  and  death  took  pla<(^  at  3  a.  m.  of  the  Kith,  forty-two  hours  after  the  accession  of  the  chill.  The  treatment 
consisted  of  five  grains  of  cpiinine  every  three  hours,  with  opiates,  Hoffmann's  anodyne,  nitrate  of  bismuth  and 
mustard  cataplasms,  ront-niortcm  examination  thirty-tive  hofirs  after  death:  Kigor  mortis  well  nuirked.  The  lungs 
were  healthy  throughout.  The  pericardium  contained  one  ounce  of  serum.  The  right  cavities  of  the  heart  contained 
dark  clotted  blood  and  a  large  white  clot  which  ]>roJected  into  the  veins  and  pulmonary  artery;  the  left  cavities 
also  contained  a  fibrinous  clot,  which  extended  several  inches  into  the  aorta;  these  clots  had  numerous  attachments 
to  the  walls  of  the  heart;  the  valves  of  the  left  side  were  thickened  and  incomplete.  The  spleen  was  enlarged,  soft 
and  pulpy;  the  other  abdominal  viscera  were  healthy. — Ilospitiil,  Fort  Scott,  Kansas.* 

The  following  case,  discovered  among  the  record.s  after  the  others  had  been  placed  and 
numbered,  is  inserted  here  as  of  interest  in  connection  with  those  just  recorded: 

Private  Philip  Kiser,  Co.  M,  3d  Ky.  Cav.;  age  20;  was  admitted  November  29,  IKKl,  with  a  gunshot  wound  of 
the  left  leg  near  the  head  of  the  tibia,  received  at  Marietta,  (ia.,  October  f).  1S64.  He  was  put  upon  light  duty  at 
the  liarracks  until  January  1,  186.">,  when  he  was  admitted  to  hospital,  having  had  a  chill  which  was  followed  by 
fever,  nausea  and  vomiting.  When  first  seen,  January  2,  the  vomiting  continued.  A  sinapism  was  applied  over  the 
stomach,  and  mercury  with  chalk,  morphia  and  camphor  were  administered  in  small  doses  every  two  hours.  Next 
day  the  pulse  was  small  and  rapid,  50  per  minute,  the  respiration  thoracic  and  hurried,  35  per  minute,  and  the  abdo- 
men exceedingly  tender,  particularly  over  the  ciecum.  On  the  4th  the  vondting  persi8te<l  and  the  bowels  were 
tympanitic,  the  i)ain  and  tenderness  being  much  increased.  Brandy-toddy  or  milk-punch  was  given  hourly,  and 
friction  and  artificial  heat  were  applied  to  the  feet.  On  the  5th  the  symptoms  were  aggravated;  the  respiration 
increased  to  60  per  minute;  the  pulse  imperceptible  at  the  wrist;  the  e.xtremities  cold  and  the  general  surface 
cyanotic.  Death  occurred  on  this  day.  iVsZ-mor/em  examination  eighteen  hours  after  death:  The  calvaria  was  not 
opened.  The  pericardium  contained  five  ounces  of  serum;  the  pleural  surface  of  the  left  lung  was  thickened  and 
its  apex  intensely  congested  but  not  hepatized ;  the  right  lung  was  healthy;  the  heart  of  normal  size;  firm  clots 
were  found  in  both  ventricles,  attached  in  some  places  to  the  auriculo-ventriciilar  valves.  The  liver  weighed  sixty- 
two  ounces;  its  left  lobe  was  softened  and  crumbled  easily  on  pressure;  the  gall-bladder  was  distended.  The  peri- 
toneal cavity  contained  eight  ounces  of  sanguineo-purulent  serum;  the  omentum  was  inflamed  and  the  surface  of 


*  A  Himilar  case  lias  been  detailed  by  I>r.  JOSEIMI  .fONES:  Tlie  patient  was  sallow,  aiiaetnic  and  subject  to  utta(;ks  of  cliills  and  fever.  He  bad  a 
chill  attended  with  much  embarrassment  of  respiration  on  the  night  tif  January  t'."),  18(>1>.  and  was  adniittett  into  the  Charity  Hospital  of  New  Orleans  on 
ihel'oUowiii^  <lay.  There  was  great  dyspnoea  and  much  restlessness,  but  the  respinitory  miinnur  was  audible  enough.  The  heart's  action  was  irregular, 
rapiil  and  tuniiiltiioiis  and  its  sounds  muffled  :  the  aileriai  circulation  was  weakened,  the  pulse  being  small  and  intermittent  and  the  surface  cold ;  the 
venous  system  was  engorged.  Death  took  place  suddenly  at  1  V.  M.  of  the  "JSth.  The  clot,  consisting  of  distinct  fibrinous  lamin*  free  from  bliKKl 
corpuscles,  was  firmly  attached  to  the  muscular  (columns  and  cords  <jf  the  right  side  of  the  heart ;  it  sent  a  branching  prolongation  intii  the  pulmonary 
arterj'.  I>r.  .tttXES  is  of  opinion  that  the  fortiuition  of  heart-clot  during  life  is  very  oouuiion  in  malarial  fever. — .See  Clinical  Lecture — Heart-clot.  Seiv 
Orleans  Jmr.  of  Med.,  Vol.  XXII,  18t)9,  p.  iii'J. 


\  [()  POST  Mi)r:TT-nr   t;i;cokds  aNI' 

the  intestine  lo.ldt'iicd  :iihI  .•i.iitcd  witli  lyiiipli.  Tin'  <'.ii(li.ic  I'ud  n\^  the  stoinacli  was  liinlily  (•oii.;vste.l.  Tii,.  siilccn 
weighed  fonit.'cn  (iiiiico.s  ;iud  \v;i,s  Noftcncd.  The  kidneys  wciv  Miiiill  aiH^  \K:ihhy.—Acl..U.'i'ti>ui-y.l).  IV.  rUmi,  V. 
S.  Anntj,  Ihiniiititl,  Mudisim,  Iiid. 

Cases  97-99,  from  llioir  i-apidly  Iktal  course  and  tlic  purpuric  blotches  wliicli  cluirac- 
terized  tlieui,  were  retfai'deil  as  cases  of  Hpntfcd  f<'rcr. 

Cask  !t7.— I'liviite  Alonz,,  A.  Liunlicit.  Co.  II.Ttli  Wis.  Vols.;  ajic  li':  wns  udinitted  from  IhuldinKton  Hos- 
pital. Plnhichdidiia,  I'a.,  July  I'ti.  INit.  sntl'ering  fVoni  partial  paralysis  of  the  left  aiiu,  result  in;;-  tVoni  a  gunshot 
wound  received  at  the  battle  of  the  WilchMuess  Ahiy  (i.  The  hall  had  entered  on  the  anterior  surface  of  the  arm 
a  little  below  the  .shoulder-joint  ami  emerged  near  the  sjiine  of  the  ninth  dor.sal  vertebra.  The  jiatient  improved 
under  treatment,  gradually  gaining  the  n.se  of  the  arm,  until  August  U,  when  ho  was  seized  witii  nau.sea,  head- 
ache, weakness  and  pain  in  the  lower  limlis.  Next  morning  he  had  a  chill  followed  by  fever,  pain  in  the  bowels  and 
slight  diarrlnea;  the  nau.sea,  heaihu  he  and  debility  were  increa.sed;  the  tongue  was  coated  with  a  wliite  fur.  He 
was  treated  witli  two-grain  doses  of  .|ninine  ev.-ry  three  hours.  There  was  no  improvement  on  the  lUth;  in  the 
evening  he  voiniti'd  fre(|ueiitly  and  coniidained  (d'  great  weakiu'ss.  Next  day  the  vomiting  continued;  he  was  rest- 
less; his  extremities  were  cold,  face  and  lijis  blMish,  pupils  slightly  dilati'd,  i>ulse  imiiercejitible  at  the  wrist,  but  his 
mind  renuiined  clear.  Circular  purjilish  spots,  which  were  not  elevated,  made  their  appearance  on  the  fac(^  and  right 
arm;  they  disajipeared  under  strong  ])ressure  and  retuiiied  slowly  when  the  iiressnre  was  lemoved.  lirandy  was 
given  freely  and  bottles  of  hot  watei'  ap)ilie(l  to  I  hc^  lower  ext  icmit  ies.  About  11  i>.  y\.  convulsive  movi'ments 
of  the  limbs  occurred,  with  retiaction  of  tiie  head  and  muscular  tv\  itihings  of  tli<'  face.  Death  took  place  within 
half  an  hour  of  the  convulsive  seizure.  /'(ixt-m(irhiii  examinalion  four  hours  after  death:  IJody  well  develoi)ed: 
rigor  mortis  m.nk<d  :  slight  discolored  spots  were  observed  on  the  face,  right  arm  and  lower  extrendties;  there  wa.s 
also  sonu;  suggillation  posteriorly.  The  vessels  of  the  pia  nuiter  were  greatly  congested  and  s(jme  exudation  of 
lymph  marked  their  course,  especially  in  th«'  vicinity  of  tli(>  longitudinal  sinus;  the  brain  was  of  natural  consistency, 
the  puncta  vascuhwa  numerous;  there  was  no  exudation  at  the  base  of  the  brain  nor  etFusion  info  the  ventri(  Ies; 
the  cerebellum  was  less  congested  than  the  cerebrum;  the  pons  and  medulla  appeared  to  be  normal.  The  surface  id' 
the  spinal  cord  in  the  cervical  region  had  a  pinkish  hue,  <lue  to  congestion  of  the  pia  nuiter;  its  substance  was 
natural  in  consistence  and  color.  The  lungs  were  engorged  with  blackish  fluid  blood,  which  exuded  on  section.  I'he 
heart  was  rather  small  and  was  tilled  with  black  lluid  blood,  whi(di  was  frothy  in  the  right  but  not  in  the  left  cavi- 
ties. The  liver  was  of  natural  size,  hut  darker  than  usmil  in  color  and  engorged  with  lluid  blood.  The  spleen  was 
rather  large  and  congested  and  its  parenchyma  firm.  The  nnicous  membrane  of  the  stomach  presented  a  number 
of  ecchymosed  spots;  portions  of  the  small  intestine  were  much  congested  and  the  solitary  follicles  and  glands  of 
I'eyer  were  enlarged;  the  mesenteric  glands  were  engorged  with  dark  blood.  The  kidneys  were  likewise  engorged 
with  blood. — .lit.  .Isn't  Surf/.  Cltartcs  Carter,  U.  S.  ./.,  Tiirnrr'n  Liitic  llonintal,  riiihnhlpliia,  I'll. 

Ca.se  98.— Private  Cliarlea  Octmier,  Co.  G,  Tilth  Pa.  Vols.;  age  45;  was  admitted  May  17,  1805,  with  diarrlnea 
of  six  weeks'  duration,  two  to  six  stools  daily,  but  with  no  i)ain  nor  fever;  his  feet  weie  (cilematous,  which  condi- 
tion was  ascribed  to  hard  man  lung.  Delirium'of  an  acute  character  was  developed  on  the  20th,  the  patient  talking 
loudly,  making  frightful  grirruices  an<l  constantly  seeking  to  leave  his  bed.  Next  day  at  8  A.  M.  his  pupils  wer(^ 
dilated  and  he  was  unable  to  recognize  any  one;  i>ul,se  rapid  and  feeble;  tongue  dry  and  parched;  stools  and  urine 
passed  involuntarily;  a  purple  pcte< dual  rash  a])pcared  over  the  body,  especially  on  the  abdomen.  At  9.30  a.  m.  he 
slept  quietly.  Two  liours  later  he  was  in  collapse  and  gasping  for  breath;  pupils  much  contracted.  He  died  at  1 
p.  M.  Pont-mortein  examination  twenty-three  hours  after  death:  There  was  much  emaciation.  The  lungs  were 
adherent  on  both  sides,  congested  posteriorly  and  contained  crude  tubercle  and  several  chalky  concretions;  the 
apex  of  the  right  lung  contained  al.so  a  snuill  vomica  about  the  size  of  the  thumb-nail.  There  were  two  ounces  of 
yellow  transparent  serum  and  two  yellow  coagnl:i  in  the  jiericardium;  on  the  surface  of  the  heart  was  a  serous  effusion 
which  appeared  around  the  auricular  ai)penilices  as  a  jell}-.  There  were  three  ounces  of  a  turbid,  reddish  liquid  in 
the  abdominal  cavity;  the  mesenteric  glands  were  softened;  the  liver  was  small  and  soft;  the  spleen  semi-fluid;  tin; 
kidneys  normal;  the  stomach  eroded  and  ecchynuised;  Peyer's  patches  exhibited  the  shaveu-heard  appearance;  the 
rectum  was  much  ulcerated:  the  bladder  distended  with  urine. — Dmii/htx  Honpitul,  WiinhliKjton,  I).  C. 

Cask  99. — Private  I.ouis  (Jross,  Co.  H,  9th  Invalid  Corps;  age  42;  admitted  November  19,  18<)3.  On  admission 
this  man  had  much  fever  ami  a  hacking  cough,  with  an  expectoration  of  frothy  mucus.  A  cough  mixture  and  solu- 
tion of  acetate  of  ammonia  were  ordered.  Next  day  at  7  a.  m.  he  had  a  hemorrhage  from  the  bowels;  at  the  same 
time  the  sui>erticial  caidllaries  of  the  thighs  and  abdomen  became  congested,  and  the  capillaries  of  the  whole  surface 
of  the  body  were  soon  affected  in  like  maiuier,  assuming  in  ])atchcs  the  appearance  of  hemoirhagic  extravasation. 
Whiskey  was  administered  every  half  hour,  but  he  sank  rapidly  and  died  at  10  A.  M.  Post-iiiortim  exaniinati(Mi  live 
hours  after  death:  Extravasations  of  blood  over  the  entire  surface  of  the  body.  ]iright-red  spots  on  the  surface  of 
both  lungs;  extensive  pleuritic  adhesions  over  the  left  side.  Right  auricle  and  ventricle  of  the  heart  considerably 
dilated,  the  anriculo-ventricular  opening  being  large  enough  to  permit  the  passage  of  three  fingers;  the  nutral  valve 
thickened  and  feeling  like  cartilage.  Liver  weighing  seventy-two  ounces;  gall-bladder  distended;  spleen  normal. 
Mucous  membrane  of  stomach,  ileum  and  colon  presenting  bright-red  spots  similar  to  tho.se  on  the  surface  of  the 
lungs  ;  the  descending  colon  con  t. •lining  a  large  quantity  of  tin  id  blood:  the  last  twelve  inches  of  the  ileum  presenting 
old  ulcers,  aii<l  the  lower  jiart  of  the  ileum  and  the  large  inti'Stine  gijucrally  much  congested;  kidneys  healthy. — 
Act.  .Iss't  Siirji.  Lliii/d  Oorxii/,  Hun  wood  IlnnpHal,  Washington ,  II.  C, 


TATIli)].n',V    oK    MAI.AIMAI,    lUSKASK.  141 

Til  C(jniif.'c-tioii  With  tlicst'  ('a.ses  tlir  kiUuwiiiu'  iTiKiil;,  art'  dC  intm'crit: 

Sui-iiCiDi  \i.  M.  S.  Jackson,  lltli  J'li.  Vol".;  Ainiapuli'^,  Md.,  Junmirij  'M,  186:.'. — The  cases  of  iinusual  interest  in 
tills  rc-]iort  are  those  of  a  disease  now  popularly  called  upoiti d  fvrcr,  uniX  catalogued  as  mnUi/iKUil  vDiiiirxliir  fvvtr. 
'I'hi'  fiillowinj;:  aic  some  of  the  leadinj;  features  of  the  cases,  all  of  which  presented  ij;reat  unifoiuiity  of  nosoiiiajdiic 
jioiuts,  theie  iieinj;  Ijut  few  premonitory  synipt(nns.  First  a  Severe  cliill  with  extreme  oppression;  violent  pains  in 
the  head  and  limbs,  the  latter  conii)lained  of  as  an  "awful  soreness,"  or  as  ''stinging''  and  "  liuruing;"  expression 
of  Jcrror  and  alarm  in  the  countenance,  particularly  noticeable  in  the  eyes;  cold  skin  ;  most  of  the  cases  pulseless  at 
the  wrist  when  first  examini<l.  !^])oiitaneous  vomitiuf;  dccnrrcd  in  some,  and  in  one  case  constant  inclination  to  go 
to  stool,  with  but  little  or  nothini,'  i>assed  from  the  bowels.  J^pots  apjieared  in  from  four  to  ten  hours  after  the 
attack,  the  patients  dyiujj;  j^enerally  from  ten  to  twenty  hours  after  the  apjicaranco  of  the  spots;  one  case  linfjcred 
three  days.  The  shoitcst  time  from  attack  to  death,  inchidini;  appearance  of  spots,  was  sixteen  hours.  The  spots 
were  of  various  sizes  and  shajics,  tirst  appearinj;  on  the  teet  and  legs;  sonu'  were  of  a  stellated  or  radiating  form, 
luiglit  red;  others  rounilish  and  irregular,  of  a  bluish  color,  and  from  a  mere  i)oint  in  size  to  a  ipiaiter  of  an  inch  in 
diameter.  They  gradually  extended  over  the  whole  trunk,  superior  extremities  and  fa<'e,  at  last  apiK'aring  on  the 
eyelids  as  small  blood  Idisteis.  These  simts.  as  death  aiijiroached  and  after  death,  became  larger,  more  diffuse  and 
of  a  bluish  or  jjurjile  color.  In  some  of  the  ea.ses  there  were  large  blotches  of  the  size  of  th(^  hand  or  larger,  con- 
nected together  irregularly  over  the  body  and  limbs:  in  sonu',  after  death,  the  face  became  of  a  livid  <'olor,  pufV'y 
and  swollen,  the  eyes  protruding,  lii>s  turgid  and  flabby,  a  frothy  mucus  boiling  from  the  mouth  and  a  sanions 
substance  issuing  from  the  nose  and  ears.  IJefore  death  some  of  the  cases  had  the  mottled  ajiiicarance  of  i)ersons  who 
had  been  bitten  by  venomous  rej)tilcs. 

'I'hc  pust-iitoriiiii  a])pearanccs  very  soon  after  death  exhiliited  a  dissolved  condition  of  the  blood  and  a  putre- 
factive tendency  of  the  fluids  and  solids.  Cadaveric  odors  were  emitted  by  some  of  the  bodies  almost  immediately 
after  ileath,  while  the  alxlomen  becanu;  enlarge<l  liy  distending  gases  and  the  face  presented  a  bloated  appearance, 
with  frothy  boilings  from  the  mouth,  already  dcsc  lilud.  The  l)rain  revealed  the  nnirked  ponl-mnrUm  appearance  of 
ilixm)lr((l  or  (letitl  blood;  its  inferior  iiortions  showed  a  gradually  increased  saturation  of  the  membranes  and  cerebral 
snl)stance,  the  bloodves.s<'ls  blackening  almost  the  entire  surface.  The  sinuses  and  large  veins  lieing  imnctured 
dischiirged  their  contents  of  inky  blood  in  a  state  of  jierfect  dissolvedness.  The,  hyjioraMMia  from  hypostasis  was 
paiticularly  maikc<l.  the  blood  a])iicaring  to  sink  from  gravity  by  percolation  like  water  through  the  ti.ssues.  The 
nuiiibiancs  of  the  biain  showed  no  i\  idince  of  inflammation,  only  passing  engorgement.  The  substanco  of  the 
lirain,  exposed  liy  slicing  it  down  from  the  \  ei  tex  to  the  base,  seemed  unaltered  in  mechanical  consistence,  but  darker 
of  hue  in  lioth  incduliaiN  and  ciiierit  ions  substances.  The  cut  vessels  penetrating  the  cerebral  mass  exliihited  the 
sanu^  condition  as  those  of  the  ]icri]diery.  The  ventricles  were  full  of  a  light  straw-colored  serum,  no  doubt  the 
effect  of  a  nu're  mechanical  transudaf  ion  of  the  w.atery  jiortion  of  the  blood  from  relaxed  vesstds  ami  tissues.  It  was 
evident  that  no  inflammation  tuiihl  ha\c  existed  in  (he  biain  or  its  investing  nn-mbranes,  for  the  mental  manifesta- 
tions weic  (dear  in  many  cases  to  the  last.  The  cavity  of  the  alxhinuMi  showed  some  effusion ;  its  contents  j)resenteil 
the  same  general  tendency  to  eechymosis  of  tissue  as  existed  on  the  skin  and  other  organs.  The  stomach  exhibited 
no  evidence  of  iiitlammation,  Imt  the  same  dark  and  mottled  ai)i)earance  ]>redoinimited.  The  inner  surface  was  of  a 
dark  yillo  wish  minldy  color,  as  if  slightly  stalne<l  by  bile,  liut  contained  only  mucus  and  uinligested  nuiterial  recently 
swallowed  in  the  sluipe  of  beef-tea,  brandy,  etc.  The  whole  bow<"l  was  of  a  dark  imdtled  color,  the  large  Intestine 
being  distended  with  gas.     The  liv<'r  was  normal  but  of  .-i  darker  brown  e(dor  than  usual. 

The  tiooi)S  of  this  regiment  caim^  from  Ilarrisburg  on  the  Susiiuehanna  river.  This  Is  a  well-known  malarious 
region,  the  .luniata  and  .Snsi|uehanna  rivers  having  licen  long  initcd  for  their  autumnal  fevers.  Most  of  the  men 
enlisted  had  come  from  districts  of  the  State  where  these  diseases  are  unknown  and  were  thus,  as  is  a  well  ascer- 
t.ilned  fact,  more  liable  to  attacks  of  mi.ismatlc  atieetions.  Before  leaving  }Iarrisl>urg,  where  the  regiment  remaineil 
fidin  the  latter  part  of  August  until  the  27th  Xovember,  18()1,  the  i)rincii)al  diseases  were  clearly  of  malarial  origin — 
intermittent  and  remittent  fevers  assuming  a  tyjihoid  form.  A  number  of  typhoid  cases  were  left  at  Ilarrisburg; 
uniny  of  these  died.  On  our  arrival  at  Annapolis  over  one  hundred  men  were  on  the  sick-list,  nearly  all  of  whom 
were  taken  sick  at  Ilarrisburg.  For  one  month  after  our  airival  at  Annapolis  the  troops  had  lU)  vegetables,  as  they 
couhl  not  be  juocured.  They  were  crowded  into  the  buildings  of  St.  John's  College,  where  many  other  regiments 
had  been  quartered  at  different  times.  These  buildings  had  never  lieen  cleansed,  renovated  or  disinfected  in  any 
way.  The  deleterious  influence  of  over-crowding  was  thus  added  to  the  transported  poison.  Kft'orts  were  nuide  to 
get  lime  and  disinfectants  in  vain,  and  as  the  troops  were  constantly  expected  to  move  from  this  station  no  radically 
icformafory  nu'asures  with  regard  to  the  vicious  condition  of  the  post  were  persevered  in.  *  »  *  When  the  trooj>8 
were  supplied  with  vcgetalih-s  the  scorbutic  condition  of  the  Idood  <d'  nuiny  of  the  men  was  soon  changed  and  the 
he.-ilth  of  the  regiment  was  speedily  im])rove<l.  [( )n  the  monthly  rejiort  of  sick  and  wounded  from  this  regiment  for 
.laniiary,  1S(!L',  signed  by  .'^nrgeon  Jackson,  are  7  cases  an<l  3  deaths  reported  under  the  head  of  other  J'lrers,  and  ou  the 
list  of  deaths  the  three  deaths  are  ascribed  to  febrin  maligna  congestiva.'] 

'  Sitrgcdu  K.  M.  S.  Jackson,  11</(  Pa.  J'oh.;  AnnapoUn,  Alih,  March  1,  1802. — The  cases  of  interest  in  the  accompa- 
nying report  for  February,  1862,  are  of  the  class  of  fevers:  Congestive  17,  internuttent  9,  remittent  8.  The  occurrence 
of  such  a  number  of  intermittent  and  remittent  cases  with  clearly  defined  features  is  significant  as  showing  a 
latioual  gevesia  for  the  whole  class.  The  cases  of  congestive  fever  were  clearly  the  old  form  of  '-spotted  fever."  The 
symptoms  were  the  same,  with  a  slight  modification  in  some  of  the  characteristic  points.  Many  of  the  cases  exhib- 
ited the  same  style  of  maculatiou,  the  same  intensity  of  quickly  locked  and  gorged  congestions  of  the  splanchic 
cavities,  the  same  disposition  to  fatal  first  chill,  etc.     One  striking  niodllication  was  observed  :  Sonu'  of  the  cases 


142  POST  MORTEM    RECORDS    AXD 

w  it  lion  t  s]«its  on  tlip  oxtmnit  ics.  Imt  willi  tlic  same  synijitonis  ol  licruise,  sliowcd  ;i  rcnnirkiililc  swcllinf;  of  the  hilciiii- 
mtnls  iif  thi  hitid  <iti<l  fun  .  Tliis  liluiiti-il  |uiliy  look  \\:is  the  niosl  si  rikiiiu' :iii|ii'Mriincc,  tofit-tlifr  uilli  :i  (linj;y  liliieiicss 
of  the  iiitci;uiiifiit  in  otlu'i'  imils  of  tlii'  hoily.  w  liilc  the  iiijcrlcil  condition  (jf  llic  vessels  of  llie  i-oiijniict  i  v:i  ))ro- 
(luced  11  regular  eheniosis  or  idevateil  ring  aronml  I  he  eonieii.     I  >iilv  one  of  lliese  cases  ])rove(l  fatal. 

The  iiii]ii<)ve(l  eondition  of  the  general  luMlth  of  the  ti<io]is,  from  a  ]iid|ier  siijiiily  of  food  or  mixture  of  vege- 
talile  matter  in  their  rations,  iiecouiits  for  llie  increased  powcf  of  resistance  to  disease;  bloodless  and  scorlnitic 
constitutions  having  become  more  highly  vitalized,  the  surgeon's  etforts  to  arrest  tlip  destroying  powers  have 
bi  en  of  more  avail.  A  i-lear  aj)]ir<'liension  of  the  true  patlndogy  of  the  disease  ha viiig  lieeu  established,  the  remedies 
employed  have  hud  marked  success. 

Sun/ton  SAMfKl.  A.  Sahink,  Hlh  .V.  1'.  .Irl'i/.:  I'nrt  MuiixJhUI.  Md..  t'thntarii  X.  l^lil. — Von  will  observe  in  my  rejioit 
tV>r  January  that  there  have  been  taken  on  the  sick  re])ort  seven  cases  of  coiigestivi'  intermittent  fever,  of  which 
four  have  died.  1  linil  that  the  disease  occurs  most  fre(iuently  among  the  new  recruits,  and  from  observation  I  have 
ascertained  that  the  locality  from  which  they  were  taken  appears  to  have  a  controlling  iuHuence.  A  large  number 
came  recently  from  Onondaga  ('oiinty,  N.  W,  which  abounds  in  malarial  poison  exhaled  from  the  numerous  swamjis 
in  that  portion  of  the  State.  Four  out  of  the  seven  cases  of  ((uigestive  fever  have  occurred  among  these  recruits. 
The  synijitoms  of  this  disease  are  extremely  varied,  indeed  no  two  cases  are  the  same:  yet  a  similarity  exists  which 
enables  the  careful  observer  to  detect  the  same  iiniliiicn  iiiorhi  exerting  its  inlliieuce  with  deadly  ett'ect  upon  thi^  brain 
and  nervous  system.  In  some  cases  the  symjitoms  are  identical  with  those  occuriing  in  the  congestive  fevers  of  the 
West,  while  in  others  there  is  no  ])erce]>lible  chill  from  first  to  last.  Itiit  a  b<-tter  idea  of  the  symptoms  may  be 
obtained  by  re|)orting  a  few  of  the  cases:  — 

1.  John  Hoyer.  Ordnance  Serg't,  17  years  of  age:  married:  in  the  service  seventeen  years;  always  healthy. 
Was  called  to  see  him  alpout  X  i'.  ]\i.  and  found  him  in  a  profuse  sweat,  his  clothes  being  completely  saturated: 
imlse  llo.  small  and  soft;  tongue  clean;  extremities  inclined  to  be  cold;  res]iiration  normal;  countenance  jiale  and 
anxious.  About  ."i  o'clock  he  had  eaten  a  hearty  siiinier,  soon  after  which  he  went  for  a  pail  of  water;  on  returning 
was  attacked  with  faintness,  indescribable  sensations  and  ])ain  in  the  epigastrium  and  right  side  of  the  chest. 
Sinajiisms  were  applied  to  the  extrendties  and  stimulants  directed  to  he  given  at  frecjuent  intervals 'until  the  pulso 
grew  stronger.  1  placed  hini  in  charge  of  a  competent  jierson  and  left  him.  He  soon  became  comfortable;  took 
something  to  <"at  and  drink  during  tlw  night  :  told  his  wife  he  felt  so  well  she  must  go  to  bed.  She  did  so,  and  he 
was  perfectly  <|uiet  and  eoinfoitable  until  ti  A.  M.  when,  while  standing  u]ioii  the  tloor,  he  was  again  seized  with 
the  same  feeling  as  at  first  and  died  immediately.     \o  antojisy. 

2.  Albertus  Cowan;  20  years  of  age;  healthy.  He  was  taken  with  a  chill  on  the  nuirning  of  .January  11 
and  continued  to  get  worse  until  night,  when  he  bt'canie  insensible  and  was  brought  to  hospital.  He  moaned  con- 
stantly, and  when  disturbed  was  violent.  The  juilse  was  (>4  and  intermitted  occa8i(mally ;  it  was  slow  and  had  hut 
little  force  ;  respirations  85  and  some  catching  of  breath  ;  no  stertor;  skin  natural  in  color  and  but  slight  coolness 
of  surface;  jiupils  dilate<l  and  insensible  to  light.  He  could  not  be  aroused  nor  induced  to  swallow  anything, 
liirections  were  given  to  havi'  his  head  shaved  and  blistered.  At  ti  1'.  M.  some  slight  iniiirovement  was  manifest;  the 
pulse  was  stronger  and  the  resi)ijation  improved.  The  blister  had  drawn  w(dl,  an<l  some  beef-tea  and  stimulant  had 
been  given  during  the  evening,  but  the  patient  remained  perfectly  unconscious.  On  January  Hi  there  was  a  decided 
improvement.  He  was  semi-conscious,  and  took  beef-tea  in  suflicient  quantities;  pulse  TO  and  regulai'.  Ordered 
thirty  grains  of  (|ninine  in  two  powders,  four  hours  ajiart.  On  January  17  the  improvement  continued.  It  was 
noticed  that  there  was  a  slight  strabismus  of  tll(^  left  eye.  The  blister  was  ie-iii>plied  to  the  scalp.  On  the  20tli  the 
pupils  had  resumed  their  natural  size  and  the  strabismus  was  entirely  removed.  Aftt>r  this  he  gradually  imjirovcd 
until  the  present  time,  but  has  had  symptmiis  of  remitting  fever.     He  convalesces  slowly. 

3.  (iarrett  S.  Pros.se,  20  years  of  age;  healthy.  He  had  been  in  the  service  but  two  or  three  days  when  he 
was  attacked  in  the  same  manner  as  Cowan.  I  did  not  see  him  until  twenty-four  hours  after  the  attack,  as  the 
men  composing  the  company  were  all  new  recruits  and  their  ofHeers  were  not  notified  of  his  illness  He  did  not 
become  in.sensible  until  about  eight  hours  after  the  chill.  His  juilse  was  60,  slow,  soft  and  with  but  little  force: 
resjiiration  HI  and  sighing.  A  brisk  cathartic  was  given  which  moved  the  bowels  thoroughly;  but  his  condition  did 
not  ini])rove.     He  died  on  the  third  daj-.     \o  autopsy. 

In  all  the  cases  that  recovered  there  has  been  a  tendency  to  remitting  or  intermitting  fever  during  convales- 
cence, which  has  invariably  been  slow. 

tSiinjitiii  David  Mkhhitt.  :">.">//(  /'».  ('d/.v.;  Hiiiitfnrt,  S.  ('.,  Maii  10,  1S63. — We  have  also  had  in  the  regiment  a  few 
cases  of  congestive,  or  as  it  is  termed  by  some  writers,  pernicious  fever.  In  most  of  them  there  has  been  very  little 
time  in  w  liicli  to  do  anything  by  way  of  medication,  .so  rajiidly  has  the  disease  resulted  in  death.  In  these  cases  the 
congestion  has  manifested  it.self  in  various  ways:  In  one  ease  spinal  congestion  was  evinced  by  the  prolonged 
S])asms  which  occurred  with  hardly  any  intermi.ssion ;  in  othercases  spinal  irritation  or  si)inal  meningitis  ;  in  others, 
congestion  of  the  brain  at  a  very  early  period,  with  ol>li(|iiity  of  vision,  sardonic  grin  and  evidences  of  a  dispositio;i 
to  convulsions;  in  others,  intense  congestion  of  the  lungs,  which,  upon  exandnatiou  after  death,  were  found 
engorged  with  dark  venous  blood;  in  others,  congestion  of  the  bowels,  acconii)anied  by  extravasation  of  venous 
blood  from  the  niuc<ms  membrane  of  the  intestine  and  by  softening  of  the  mucous  membrane  to  a  remarkable  degree. 
One  case,  sent  to  General  Hospital  No.  3,  Heaiifort,  S.  ('.,  Ass't  Smg.  F.  T.  Dade,  V.  S.  Vols.,  in  charge,  I  particularly 
remember:  Private  John  Jloyer.  Co.  H,  ooth  Pa.  \'ols.,  came  to  me  after  surgeon's  call  and  aske<l  for  "a  dose  of 
physic,''  as  his  bowels  had  not  been  moved  for  three  days.  He  did  not  appear  to  be  sick.  I  gave  him  at  one  dose 
twenty  grains  of  mercury  with  chalk  and  fifteen  grains  of  powdered  rhubarb.  This  was  taken  at  about  8  a.  m.  At 
2  P.M.I  was  summoned  to  his  tent  and  found  him  in  a  state  of  syncope,  from  which  he  rallied  under  the  adminis- 


PATIIOl.OOY    OF    MAI.ARIAI.     DIPKASE.  143 

tration  of  stimnlaiitfi.  Alioiit  .'i  p.m.  hv  was  rciiuivcil  to  lios|iit:iI.  and  ilicd  tlu'  samr  iiijjjlit  at  about  !•  o'clock  of 
intestinal  ha'moii'ha;;c,  a  pool  of  dark  venous  hlood  beneatli  liini  in  the  bed.  Feisnl]diate  of  iron  had  vainly  been 
given  by  enema,  and  snl])hiitc  of  (juiuia,  cajisicnni,  ether,  lirandy,  etc.,  adniinisteied  internally.  By  invitation  of 
Dr.  Dadk  I  was  jiresent  at  tlie  jiont-iiiortem  examination  twelve  hours  after  death.  Tlie  brain  was  slightly  congested. 
The  lung.s  were  nearly  normal  and  not  noticeably  changed.  The  heart  was  normal.  The  liver  presented  the  nutmeg 
ajipearance;  on  section  it  wa.s  found  to  be  considerably  congested.  The  spleen  was  vcri/  iiiHch  eiilari/cd,  rery  friahh- 
((III/  iiiiicli  ciiiifiCKted.  One  of  the  kidneys  presented  an  extravasation  of  blood  on  its  .surface.  Tlie  stomach  was  xlii/lilhi 
congested.  The  intestines  contained  a  (luantity  of  extvavasated  blood:  Peyer's  glands  and  the  solitary  follicles 
were  somewhat  congested  and  the  mucotis  coat  of  the  whole  intestinal  canal  was  so  much  softened  that  it  was  i>os- 
sible,  with  the  liandle  of  the  scalpel,  to  ncrii))!'  iiff  the  miiciiiix  vuiit  and  leave  the  iniixciihir  coat  denuded. 

Another  patient  died  during  the  chill,  living  only  about  ten  minutes  after  being  brought  to  the  regimental 
lios))ital  on  a  stretcher  from  his  ijuarters,  where,  less  than  three  hours  previously,  he  had  been  joking  with  one  of 
the  drummer  boy.s.  This  was  Private  Edward  Riley,  of  Co.  I).  Another  case.  Private  Philip  Miller,  of  Co.  H,  died 
comatose  a  few  days  after  admission  to  regimental  hospital,  the  whole  external  surface  of  his  liody  presenting  an 
icteroid  hue  beforedeath.  Another,  Private  Irwin  Little,  of  Co.  I,  died  soon  after  admission  to  regimental  hosjiital, 
and  in  this  case  the  .surface  of  the  body  became  Jaundiced  immediately  after  death.  This  num,  lik<^  the  others,  was 
treated  with  ([uinine,  ca])sicum,  brandy,  etc.:  calomel  was  given  with  a  view  to  stimulating  the  secretion  of  the 
liver,  and  mustard  applied  to  the  surface  of  the  body  and  liinlis. 

Siiryton  \V.  M.  .S.viiTir,  85;/(  A'.  Y.  Vola.;  Xew  Berne,  X.  ('.,  Fehriiiirij  2'J,  ]><(w.— Two  men  died  in  hospital  at  .Suffolk 
of  remittent  fever  with  meningeal  complications.  I'ost-iiuii-teiii  examination  showed  that  the  arachnoid  surface  of 
the  falx  cerebri  was  nnich  congested,  hswing plastic  exiiilafioii  at  several  places  on  its  surface.  In  oiie  ease  the  right 
lateral  ventricle  contained  one  ounce  of  turbid  serum  tinge<l  with  blood;  the  left  ventricle  contained  six  drachms  of 
serum  less  turbid  than  bloody.  The  arachnoid  surface  of  tlie  tentorium  cerebelli  and  the  vLsceral  layer  of  the  arach- 
noid covering  the  cerebellum  were  greatly  congested. 

Surgeon  W.  H.  Chimes,  13tli  Kiniias  I'ulx.;  mar  Springfield,  Mo.,  February  2,  1863. — Many  of  the  men  were  taken 
with  high  grades  of  bilious  fever  ami  several  died  of  congestion  of  the  brain.  In  these  cases  the  most  active  treat- 
ment was  pursued:  the  patients  were  bled,  cupped,  blistered;  had  calomel  and  the  bitartrate  of  i)otasli  and  antinmny, 
and  other  remedies  as  the  indications  demanded;  yet  we  were  unsuccessful.  We  began  to  dotibt  our  ])owers  of  diag- 
nosis, l)ut  the  citizens  told  us  that  congestion  of  the  brain  is  a  conniion  disease  In  this  region,  and  that  their  doctors 
bleed  and  give  large  doses  of  calomel. 

Aiix't  Surg.  .T.  W.  Ma.son,  V2th  <'(ir)>s  d'Afrique;  Port  Hud-sou,  La.,  February  2.S,  1804. — Nearly  all  the  cases  that 
cauu^  under  my  obscivation  in  the  months  of  October  and  November,  186.S,  were  the  result  of  zymotic  influences; 
these,  coiiperating  with  the  scorbutic  taint  that  had  been  largely  developed  in  the  regiment,  prodncetl,  in  even  the 
ordinary  incidental  diseases,  an  adynamic  condition  of  the  system.  Many  laboring  under  this  pathological  condition 
were  attacked  with  typho-malarial  or  congestive  fever.  The  tyjiho-malarial  cases  were  in  most  instances  ainemil)le 
to  treatnu'ut,  but  a  large  projiortion  of  the  congestive  cases  proved  fatal.  The  most  prominent  point  of  interest 
developed  in  this  unmanageable  disease  was  a  loss  of  vital  force.  As  an  unusual  thing  the  disease  was  ushered  in 
with  a  slight  chill,  but  generally  this  was  not  apparent.  In  some  cases  the  patients  would  soon  become  cold  and 
l)ulseless:  and  no  treatment,  however  vigorous,  succeeded  in  establishing  reaction.  Death  closed  the  scene  in  a  few 
hours,  or  the  iiatients  lived  for  several  days  conscious  and  without  ]iain,  and  then  died  (juietly,  as  though  they  had 
fallen  into  a  gentle  slumber. 

Lastly,  two  cases  of  chronic  malarial  poisoning  are  given,  with  some  references  from 
New  Berne,  K.  C,  to  this  condition  among  the  troops  operating  there  in  1863.  Tn  both 
cases  the  blood  was  evidently  greatly  altered.  In  one,  the  spleen  weighed  sixty-eight 
ounces  and  the  veins  contained  soft  greenish-white  clots,  while  in  the  other  there  was  dif- 
fluent blood  in  the  ])leural  cavity  and  the  liver  and  spleen  were  disorganized. 

Ca.'*e  100. — Private  Levi  Beech,  Co.  D,  1st  Mich.  Cav.;  age  36;  was  admitted  October  27,  1864,  with  a  contusion 
of  the  left  side  causeil  by  the  kick  of  a  horse.  He  was  feeble:  the  si)leen  was  much  enlarged,  occu])ying  nearly  the 
whole  of  the  left  lumliar  region  and  parts  of  the  umbilical  and  left  inguinal  region.  He  had  suft'ered  from  ague  eight 
years  before  for  fourteen  months,  the  disca.se  intermitting  occasioiuilly  for  about  a  week  at  a  time.  After  admission 
his  appetite  was  variable,  and  he  lost  flesh  although  his  liowels  were  regular.  He  was  treated  with  citrate  of  iron 
and  (|uinia,  stimulants  and  nourishing  diet.  He  was  able  to  be  abont  the  ward  and  out  of  doors;  occasionally  he 
had  sonu-  cough.  About  noon  on  December  31  he  became  speechless  and  unable  to  swallow.  He  died  at  6  r.  M. 
I'ost-miirtciii  examination;  No  rigor  mortis.  The  brain  was  normal;  its  memfiranes  somewhat  adherent  to  the  medulla 
and  pons.  The  right  cavities  of  the  heart  were  distended  and  a  greeuisli-white,  soft,  almost  pus-like  clot  floated 
in  tlie  ventricle.  The  right  lung  was  somewhat  congested  and  adhered  by  old  firm  fibrinous  bands;  the  left  lung 
was  congested  by  hypostasis;  one  or  two  glands  at  the  root  of  the  left  lung  contained  cheesy  and  chalky  matters. 
The  liver  was  large  and  bloodless;  its  portal  veins  tilled  with  soft  yellow  clots.  The  spleen  weighed  sixty-eight 
ounces  and  adhered  to  the  diaphragm  and  stomach;  its  veins  contained  soft  greenish  clots;  a  secondary  sjileen  the 
size  of  an  unhusked  walnut  was  found  at  the  head  of  the  pancreas.  The  mesenteric  glands  were  indurated  and 
about  the  size  of  a  pea.  The  ileum  and  colon  were  normal.  The  psow  muscles  were  softened  and  their  surfaces 
blackened.     The  external  iliac  arteries  contained  blood.     The  kidneys  were  white  and  fatty.     Microscopically  the 


144  rOST-MORTK.NT    JiKCOliDS    AND 

greeiiisli-wliilc  dots  (if  tlir  liciirt  ami  liloodx csscls  cunsislcil  of  j;riiiiiili'.s  anil  iiolyimclciitcd  cflls,  many  of  tlic  latter 
a  little  lai-L;i'|-  Ihan  a  liloo<l  <'or|iuscl<',  Inil   I  he  majorily  much  laij^r]. —  I'liinl  Piii-iimi  Unspitul,  Ahjuinliiii,   \'u. 

Cask  101. — Corjioi-al  S.  Ciniiiioii,  Co.  K,  1 1th  \.  C;  died  June  \'.\,  IMIja.  The  i)atient  had  been  sick  for  some 
time  and  died  su<ldcnl.v  and  unexpectedly.  I'lixl-mortvin  examination:  The  rifflit  liuig  was  adherent  to  the  costal 
jdeiira.  The  heart  was  vcr.v  soft  Imt  contained  no  clot.  The  thoraoio  oavities  on  either  side  contained  three  ounces 
of  uucoagulalde.  hlood,  the  red  corpuscles  of  whi(di,  nn<ler  the  microscope,  were  seen  to  he  broken  down,  stellated 
and  withered,  the  serum  of  a  yellowish-red  color  and  the  white  corpuscles  very  numerous,  seemingly  from  the  absence 
of  the  red.  The  liver  and  spIecMi  were  pnltaceous  and  disorganized.  The  kidneys  were  tiabby. — ./»•«'?  .S'«c;/.  //. 
.tllcii,  U.  S.  J.,  Lincoln  Ho«pil(il,   ll'dxhiii/jluii,  l>.  ('. 

Siir(j(<i)i  V.  J.  D'AviCNON,  iH'illi  .V.  1'.  i'ol.s.;  Xi-tr  lUriie,  .V.  C.  FihrtMrij  28,  18(J3. — The  low  diet,  constant  exposure, 
want  of  rest  and  severe  lal>or  from  which  the  regiment  sntiered  during  the  summer  of  18t;2,  while  before  Kiehmond 
and  at  Harrison's  Landing,  so  reduced  the  vitality  of  the  men  that  the  intlueiice  of  the  miasmatic  atmosphere  of  the 
swamps,  the  intense  In'at  and  the  im])Uie  water  used,nH't  but  feelile  resistance.  It  was  a  common  thing  for  healthy 
robust  men  to  lose  thirty,  forty  and  even  tifty  jionnds  of  tlesli  in  a  few  days;  and  the  sunken  eyes,  emaciated  form 
and  languid  step  demonstrated  the  existence  of  agencies  lieyond  the  inlluence  of  medicine.  The  ordinary  remedies 
for  disease  seemed  of  no  avail. 

Surgeon  Isaac  F.  GM.l.ofi'K,  Ylth  Manx.  I'oln.;  X<  ir  Heme,  S.  ('.,  Fehriiurji  20,  ISfiS. — In  the  latter  part  of  June, 
1862,  intermittent  fever  and  other  malarial  diseases  began  to  ajipear  in  this  comuuind,  increasing  in  severity  and 
prevailing  more  extensivel.y  as  the  season  advanced,  until  Xovemlier,  when  the  regiment  was  (luartered  in  town. 
Notwithstanding  the  extreme  i)revalence  and  severity  of  miasmatic  diseases  but  few  deaths  occurred.  During  the 
months  of  AuguH*  and  Seiitember  several  hundred  cases  were  reported,  but  of  these  only  live  i)roved  fatal.  In  many 
cases,  liowi^vcr,  i)aralysis  agitans,  chorea  and  ascites  resulted.  In  other  cases  the  constitution  was  completely  broken 
down  and  the  men  were  discharged  the  service.  No  treatment  was  of  any  avail  except  by  (|niiiine,  and  this  was  most 
effectual.  When  cinchonism  was  va])idly  j)roduce(l  the  disease  was  promptly  and  almost  invariably  broken  up.  It 
was  rare  that  a  [latient  would  have  a  second  paroxysm  after  coming  under  treatnu'nt. 

I^esiili's  the  relatively  siiuill  number  of  cases  presenteil  above,  it  is  recorded  in  tliirty- 
eiglit  (if  the  cases  embraced  in  the  chapter  on  the  alvine  fluxes  that  the  patients  were 
sufiermg  or  had  recently  suffered  from  intermittent  fever;*  and  references  to  remittent 
fever  occur  witli  equal  tri.'queiicy.  In  view,  however,  of  the  enlarged  spleens  and  other 
more  or  less  chitracteristic  conditions  fouml  at  the  ] lOHt-viortem  examination  of  the  diar- 
rhcjoal  cases,  it  is  probable  tluit  a  much  hirger  number  of  them  than  is  shown  by  the  clinical 
notes  were  coucuri'ently  affected  by  the  malarial  iuHucUce. 

11. — Patholuiucal  Anatomy  and  pATiioLuiiV  ok  Malarial  Disease. — In  summar- 
izing the  patiiological  ap[)earances  presented  by  the  recorded  cases  of  malarial  disease,  it 
seems  proper  to  exclude  the  nine  cases,  83-91,  in  whicli  typhoid  fever  is  suggested  l»y  the 
clinical  history  or  morbid  anat(.)iu\-.  There  remtun  forty  cases  of  death  from  malarial 
affections  m  which  po^f-iiwrfciii  inv(.'stigations  were  held. 

The  Stomach. — In  tweiitu-""*-  of  the  eases  the  (unidition  of  the  stomach  is  not  stated;  it  was  normal  in/jt-e 
and  constricted  in  one.  In  thirteen  cases  a  morbid  condition  Is  sj)e<dlied  thus:  In  /'ohc  the  organ  contained  a  green 
gruuious  or  mud-like  liquid;  in  Iwo  its  niuious  membiane  was  congested;  in  one  softened;  in  one  slate-colored;  iu 
one  thickened,  and  \\\  four  ecehymosed. 

The  Intkstinai.  Ca.\.\i.. — In  hijc  of  the  forty  cases  the  intestines  were  rejifirted  healthy;  in  nine  their  condi- 
tion was  not  stated.  In  thifteen  of  the  remaining  tweuty-tive  cases  the  large  and  small  intestines,  so  far  as  can  be 
ascertained  from  the  phraso(dogy  of  the  reports,  were  both  affected. t  Five  of  these  cases,  59,  til,  65,  TA  and  93,  were 
much  congested  or  iuHanied,  but  not  ulcerated;  in  the  lirst-mentioned,  for  instance,  the  canal  was  almost  black  from 
the  engorged  condition  of  the  ca])illariivs,  and  coagulated  blood  was  found  in  its  interior.  In  one  of  the  thirteen  cases, 
81,  the  mncons  menilirane  was  softened  and  in  serin  ulcerateil:  in  two  of  the  latter,  70  and  80,  the  duodenum  alone 
was  ulcei-ated,  although  the  canal  generally  was  highly  congested;  in  67  the  ulcerations  were  re])orted  as  slight ; 
in  77  as  old;  in  71  and  72  as  large  and  small,  and  in  75  as  associated  with  a  congested  condition  of  the  mucous  mem- 
brane. In  «i.»'  of  the  twent.v-li\  c  cases  the  condition  of  the  small  and  the  large  intestine  is  specifically  stated  :  In  7-1 
both  were  inflamed,  but  the  jiatches  of  I'eyer  were  not  diseased;  in  99  both  were  much  congested  and  ecehymosed; 
in  57  and  94  deposits  of  black  pigment  were  found  in  the  large  intestine,  while  the  ileum  iu  the  former  was  but 
slightly  congested  and  in  the  lattermerely  stained  with  bile;  on  the  other  hand  the  patches  of  Peyer  iu  98 presented 


*  St>fl.  in  the  .Sjwiir.d  I'art  of  tliis  iviirk,  cases  9.i,  l(i:t,  104.  171.  18'l.  191.  1!)4,  HMl.  i43.  StiO.  -JT-J,  :i(l.">.  :.!HI,  ;l7:i,  381).  3',«;,  401,  410,  43:!,  517,  SS,  (iOl, 
614,  fCW.  fiSti.  704,  7:i."i,  738.  74:2,  747.  7.')S,  77(i.  S09,  852,  854.  857,  858,  8.59. 

t  III  .Vlj^eria,  wliere  the  French  tntiips  were  expnsed  to  inftuetiees  siniilar  to  thnte  alTeotin^  our  soldiers  in  the  insiUirious  distriets  of  the  .South,  the 
lesions  of  ehronie  dysentery  were,  iieeording  to  Laverax,  eonstantly  found  in  eases  offerer  when  death  occurred  a  lonjr  time  after  the  eoniinenceiiieut  of 
the  malarial  alTcctioii. — Hfcui'it  dr  MhuKin-A  iff  Meiifcinf  dc  Chiruri/ie.  ft  dr  I'liarmacif  Mitiluirfs,  1  scrie.  t.  LXl,  184"„',  p.  83, 


PATHOI.UUY    OK    MALAWI  A  I.     MsEAsE. 


145 


the  |ii};iui'iil<'il  flppearaiife,  whili'  flit-  icctimi  Wiis  nlc<'ratc(l  :  in  tix  t  lir  ihiicuun  riiruiliraiii'  of  tlic  iiriiiii  was  softeueil 
and  tlii('koiic<l,  tliat  of  tlie  colon  confjcslcil.  In  the  remaining- xij"  of  tlif  twentv-livf  cases  the  small  intestine  or 
ileum  only  was  att'ected :  In  55,  66  a  nil  it?  it  was  I'ongested,  and  iu  the  last-mentioned  case  the  jiatclies  of  Peyer  and 
the  s(ditaiy  }j;hiud.s  weie enlarged ;  in  X2  it  was  ulcerated  ;  in  (>9  congested  to  a  imrple  color,  which  presented  a  deeper 
tint  in  the  apices  of  the  solitary  glands,  although  the  jiatches  of  I'eyer  were  unaffect<'d ;  in  5(!  also  there  was  a  deeply 
colored  congestion,  which  was  specially  marked  throughout  the  jejunum. 

In  two  of  the  cases,  7S  and  79,  in  which  the  coiulition  of  the  umccuis  lining  is  not  stated,  there  was  peritonitis, 
and  in  two,  70  and  80,  in  which  the  niuccuis  lining  was  congested,  tlierc  was,  iu  addition  to  ))eritoiieal  inllammation, 
in  one  ulceration  of  the  duodenum  and  in  the  other  ulceration  of  the  duodenum  and  i)ancreas.  ISiune  serous  etfusion 
was  found  in  the  peritoneum  iu  two  other  cases,  aud  iu  several  there  was  imue  oi  less  injection  and  darkeuing  of 
the  serous  coat  and  omentum. 

It  would  appotir  fruHi  these  records  that  although  intlainrnatory  tcudeucies  in  the  intes- 
tinal canal  were  not  an  invariable  conse(|Uence  of  niahirial  disease,  they  uccurn-d  with 
more  frequency  than  might  reasonably  lie  referred  to  the  concomitant  action  of  diarrha'al 
causes  as  distinct  from  the  malarial  })oison  ;  and  further,  that  the  incidence  of  the  disease 
was  not  localized  on  any  particular  part  of  the  tract,  l)ut  atfected  alike  the  larg(>  and  the 
small  divisions  of  the  gut.  The  slight  preponderance  of  cases  in  which  tlie  small  intestine 
was  affected  may  be  referred  to  diarrliceal  causes,  as  in  Maillot's  cases,  given  below,*  the 
preponderance  seems  to  have  been  due  to  the  inclusion  uf  typhuid  fever. 

In  this  absence  of  partiality  for  a  particuhrr  region  of  the  intestine  as  the  site  of  its 
manifestations,  the  malarial  poison  ditfers  essentially  from  the  typhoid.  The  lower  part  of 
the  deum,  as  will  be  seen  hereafter,  was  the  site  of  typltoid  developments  when  no  other 
part  of  the  canal  was  affected;  and  when  a  greater  extent  of  the  canal  was  involved  this 
part  of  the  ileum  was  more  intensely  affected  than  others.  But  in  the  cases  at  present  under 
consideration  the  duodenum,  jejunum  and  colon  were  found,  one  or  all,  to  l)e  at  times  impli- 
cated witliout  a  corresponding  intensity  of  the  inflammatory  action  in  the  ileum. 

Another  and  striking  diffei-ence  will  be  observed  between  the  action  of  the  malarial 
poison  and  that  of  the  typhoid  disease  on  the  intestines.  In  the  latter  the  intiammatory 
action  was  circumscribed  and  its  force  expended  on  the  closed  glands  of  the  ntucous  tract, 
which  were  destroyed  by  ulceration  or  sloughing,  while  the  general  surl'ace  was  not  neces- 
sarily involved.  In  the  former,  on  the  contrary,  the  action  was  general  over  the  parts 
of  the  intestine  implicated  and  not  contined  to  a  particular  anatomical  component  ;  and  if 
the  closed  glands  were  affected  they  were  not  specially  so,  but  only  as  forming  a  part 
of  the  congested  tract.  Moreover,  while  in  the  typhoid  cases  the  mucous  lining  of  the 
intervals  between  the  glands  was  sometimes  darkened  or  reddened  with  congestion,  the 
engorgement  was  never  so  diffuse  or  intense  as  in  the  malarial  cases  in  which  the  intensity 
of  the  congestion  was  often  manifested,  as  in  97-99,  by  ecchymoses,  or  as  in  59,  by  the 
escape  of  blood  into  the  canal  fi'om  its  engorged  and  blackened  membrane. 

'^  Tlie  fitUowinj^  suiniiiiiry  of  Maii.lOT's  ol)servati()i]S  ure  ^iveii  fur  comparisun  witli  tlie  te.vt. — See  Traite  des  Fih-ii t^  liitermitttutes.  Paris,  18:lti,  ji. 
'283  I't  .s'f/.  Aiium^^  tlie  oltservutiuns  tliat  I  liave  eii!le(;ted  and  reported  there  are  t went j^-eiif lit  eatJes  uf  po,-it-tiiui-tein  inijutry.  In  all  tliese  the  digestive 
organs  were  exatiiined;  in  a  single  ease  the  head  was  not  opened,  and  in  another  ease  the  eliest;  in  twenty-one  eases  tlie  eonditioii  of  the  si»inal  eord  is 
recorded.  The  dilferent  (iri^aiis  i>resented  the  foUowinir  abn'innifies :  Di;/eMire.  f)y(/atis. — Twenty-seven  times  the  iiuieoiis  nieinlirane  of  the  stomacrh 
ottered  sonielhino:  worthy  of  note;  only  onee  was  it  in  a  nonnal  stale.  The  alterations  were  ;  ( Iray  slate-eolored  softening,  willumt  veriiiilion-eolored  injec- 
tion, five  liiiies:  ifray  slate-eolored  softening,  with  iniiietated  verinilioii  injeerion.  in  a  ease  of  quotidian  fever  whieh  became  ty)ihoid;  dirty-gray  softening, 
u  ith  \  ennilioii  injeetion,  eleven  times  :  <lirty-gray  softening,  without  \eiiiiilion  injection,  in  a  ease  in  whieh  death  did  not  oeenr  until  after  twenty -three 
days  of  aiiyre.\ia;  russet -eolored  softening  four  times:  red-hrown  softening  twiee;  Idaekish  softening,  without  injeetion.  one*':  in  a  ease  of  rupture  of  the 
spleen,  the  mucous  inemhnine  of  the  stomach  presented  only  a  very  slight  recent  injeetion  with  a  gray  tint:  tinaily.  in  a  ease  of  typhoid  fever,  there 
was  found  that  red  eolor,  with  softening,  iieculiar  to  iie-ute  gastro-enteritis.  'lh^>  sinall  hifislini'  presented  the  following  ehanges :  Fifteen  times  soften- 
ing with  a  gray,  brown  or  slate-eolored  tint  with  or  witliout  recent  injeetion  ;  nnee  tin'  red  softening  of  acute  enteritis :  twelve  times  vestiges  uf  honey- 
eonilied  patches,  of  whieh  three  jiresenti'd  the  shaven  beard  appearanee;  eleven  times  an  ainiornial  de\  elopment  ot  ilie  sylitary  follicles:  twiee  the  circular 
wiiitish  Jiatehes  depressed  :  onee  only  ulcerations :  twiee  intussusceptions  without  reduces  :  t'oiir  times  there  \M'ro  no  lesions,  and  onee  the  condition  of  the 
small  intestine  w:is  not  recoriled.  The  httyf  itilt^HiK-  pivsenlcd  anatoinieal  lesions  li->s  trciiti'iiliy  than  ihc  si,Mn;ich  and  the  small  intestiii'-.  In  el.ven 
eases  it  ottered  nothing  of  note  ;  in  three  its  eomlilioii  was  tint  incntiund  :  its  changes  i.f  le.vtiire  aiul  color  \vcrc  similar  to  tliosc  in  the  small  iiili-sline 
with  the  exeeption  of  the  lioney-eoinlied  pat<.-lies.  which  cannot  he  Inrmc.l  there. 

Mkd.  Hlst.,  Pt.  Ill- 19 


14G  r(>sT->[i»i!Ti';M  rI'Iccjim^s   and 

TIic  coiiilitHJii  (if  tli(^  I.IVKH  WHS  nut  .sl:itL-(l  in /V»iii- (jf  tlic  cases;  in  <"*«//i/ i(  was  vcpoitnil  normal.  I'.nlarge- 
nient  in  niciitioneil  in  si.vtei'H  cases,  of  wliicli  oiiv  was  I'ciiorti^d  in  addition  to  lie  pale  and  witli  soft  yellow  clots  in 
its  viswels,  oik:  conKeMt<'<l,  "««  soft,  inic  t nliercnlai',  one  lilui.sli,  iiiic  slate-coloicd  and  «(((■  as  |)iesentinj;  iiutnief{  folia- 
tions. In  on«'  tli(^  liver  was  conijested,  in  one  coniiesled  and  s(jftened  anil  in  tiro  softened:  in  o)ie  it  presented  the 
nutinej;  api>eaianco;  in  on«'  it  was  fatty,  in  one  pale  and  soft,  in  one  fawn-colored,  in  one  |>artly  blac  Icened,  in 
one,  bronzed,  in  otie  dark-c<dored  and  enj;ori;ed  with  thud  lilood  and  in  one  pnltac(!OUH.  In  ont^  case  the  f^all-blad- 
tlor  was  fonnd  to  be  ulcerated. 

Dr.  Btkwaedson,'^'  after  <a  sories  of  necropsies  in  cases  of  remittent  fever,  came  to  tlie 
conclusion  tliat  a  change  in  tlio  color  of  the  liver  from  a  reddish-brown  to  a  mixture  of 
gray  and  olive  was  the  anatomical  characteristic  of  the  disease  in  the  series  wliich  he 
had  studied,  and  probably  also  in  all  eases,  as  this  scries  was  made  up  of  cases  extending 
over  three  successive  seasons,  and  originating  not  in  a  single  locality  but  in  different  and 
widely  separated  places.  The  organ  was  described  in  individual  cases  as  of  the  color  of 
bronze,  of  a  mixture  of  bronze  and  olivc  or  of  a  dull  lead-color  externally  and  bronzed  with  a 
reddish  shade  internally.  Fost-morte/n  records  antedating  Stewardson's  observations,  made 
occasional  mention  of  an  engorged  and  dark-colored  liver  in  cases  of  malarial  fever;  and 
in  1847  MKCKELf  referred  the  coloration  to  piguient  in  the  blood,  where  it  was  found  later 
by  other  investigators. 

Fkkeiciis,J  in  185-4,  during  an  e])idemic  of  fever  in  Silesia,  resulting  from  an  overflow 
of  the  Oder,  observed  deposits  of  pigmt-nt  in  the  liver  and  spleen,  and  frequently  in  the 
brain  and  kidneys.  The  liver  was  steel-gray,  blackish  or  chocolate-colored,  sometimes  pre- 
senting brown  insulated  figures  on  a  dark  ground.  Tlie  pigment  to  which  this  coloration 
was  due  consisted  of  granules,  larger  masses  and  true  pigment-cells  in  the  capillary  net- 
works of  the  })ortal  and  hepatic  veins,  and  in  many  cases  in  the  arteries.  It  was  noticed 
also  that  while  there  was  enlargement  from  congestion  in  acute  cases,  the  organ  was  fre- 
quently diminished  in  size.§  Home  yetirs  later  Dr.  J.  Forsyth  Meigs ||  made  a  series  of 
observations  in  the  wards  of  the  I'enusylvania  Hospital  which  he  presented  as  attesting 
the  accuracy  of  FivKkiciis'  views. 

Tlie  posf-morfe/ii.  notes  given  above  show  such  variety  in  the  color  of  the  organ  that  it  is 
impossible  to  consider  the  bronzed  or  gray  and  olive  liver  as  a  constant  pathognomonic  lesion. 
Maillot ][  and  E.  Collin  ='"'=  show  simihir  autopsical  results;  and  Dl'tkoulau,  while 
regarding  congestion,  with  augmentatiiin  of  volume  and  consistence,  as  the  prominent 
condition,  refers  also  to  fatty  degeneration  and  changes  in  color  from  altered  secretions,  and 
especially  from  the  presence  of  pigment  formed  in  the  liver  itself  or  derived  from  the  spleen. i"]- 

The    SPLEENJt  was  normal   iu  K<?reH  cases,   while   in  riffht  its  condition  was  not   reported.     There  was 

*  Scf.  Observatimis on  Hemillent  FrrrrfnuHikil  upau  etisisoh.trrreil  in  tin-  rinnsylrania  JZospitul.    Am.  Jovr.  Zletl.  Sciences,  Vol.  I,  X.  S.,  1841,  p.  289. 

t  H.  3IECKEI. —  i'lhrr  sclunirzcs  I'ii/ment  in  <.'■  r  //i7--  iiii'l  lUm  Ilhile  cluer  C.  isteskrankcn.  Ally.  Zcitschr.fiir  I'/i/chiulrie..  H<1.  IV,  !?47.  S.  198 — 
first  observed  t.tnck  pigment-roll.;  in  tlic  1)I<i(k1  of  nn  insiuie  j»iitiont  uiio  tliod  of  plitliis^is  :  it  is  not  known  wtietber  he  liatl  intermittent  fever.  The  spleen, 
liver  and  briiin  wen-  rii'h  in  I'igmcnt.  VntcilOW — Xur  path.  I'Ini.iioloyii:  ik,^  Blids.  Airliii;  lid.  II,  1849,  S.  SS7 — observed  pijjfinent-cells  in  tlie  bliiod  of 
the  heart  of  a  man  dead  of  malarial  eaehexia. 

^A  Cli.-i'-ul  Trcatiseon  l/isca.?es  nf  t!ie  Lirrr.     New  Syilenham  Soe.,  Loiubni,  13G0,  A'ol,  I,  p.  317. 

§"In  all  the  cases  which  terminated  fatally  (IJ8)  the  liver  eontainod  a  quantity  of  pii^mont ;  in  ten  it  appeared  enlarged  and  conge.«ted  and  in  eight 
atrophied;  in  nine  r;-se8  the  eells  contained  mueh  oil ;  lardaeeon..;  matter  enuld  b:}  detected  iti  three  eases,  but  only  iu  stnall  quantity.  Except  in  one  oa.se, 
pigment  was  alwavH  found  in  t!ic  jplcen;  three  times  this  organ  was  lardaceous,  and  in  thirty  eases  its  vcdnme  exceeded  the  usual  limit."     Op.  rif..  p,  3LJ4. 

II  On  til  I  Vitlhological  Appearance.^  presented  in  Marsh  Ferer.    A  :n.  Jonr.  'led.  ic/.,  Vol.  l,.  N.  .S..  1805,  p.  3U5. 

lIThus  MATT.l.or;  In  five  instances  the  condition  of  the  lirer  was  not  indicated:  in  live  it  presented  nothing  abnormal ;  nine  times  it  wa>  !•;. digested; 
three  times  Iriabie;  once  hrillle;  three  times  yellowish,  pale  and  soft :  onci'  -rreenish-yollinv,  and  (nice  it  Iiad  tlie  aspect  of  a  cake  of  chocolate. 

•**  111  eol-I.IN's  .'.^  cases  of  pernicious  fever  the  liver  was  normal  in  size  in  si.'C  cases  and  hypellrophied  in  forty-six  ;  in  ten  of  the  latter  it  tv;i-s  softened 
and  in  two  indurated.  'I'lie  color  was  altered  in  nineteen  cases  to  such  tints  as  ilark-brown,  clioeolate.  bistre,  fawn-color  and  earth-color;  but  lie  notes  his 
failure  to  observe  the  morbid  coloration  mentioned  by  .STEWAKLisox  in  his  Pt.jusylvauia  Hospital  cases. — Reciceil  de  Mcmovres  de  Mcdecine  de  Citiritnjit 
et  de  Pharmacie  Militaires,  'J«  serie,  t.  I\',  1848,  p.  l'J8. 

tt  DUTROULAt'. — Traite  des  Maladies  des  Euvopeens  dans  les pays  chauds.    Paris,  1864,  p.  196. 

**  Maillot  speaks  of  the  spleen  thus :  In  five  cases  its  condition  was  not  indicated  ;  in  one  only  it  appeared  normal ;  twenty. one  limes  it  was  larger 
than  usual,  iu  one  instance  without  change  of  color  or  texture;  thirteen  times  it  was  of  the  color  of  the  dregs  of  wine  ;  seven  times  choeolate-eolored  ;  in 
one  ease  it  was  broken  and  reduced  to  a  wine-colored  I'ulp,  and  in  one  iu  which  it  resembled  a  cake  of  chocolate,  its  fibrous  membrane  was  easily  detached 
and  crackled  like  a  sheet  of  parchment. 


PAIMiOLUGY    OK    MALARIA  I.     DISEASE.  ^47 

fiilargemont  in  niitefeeu  ciiscs.  ai-Cdiiiiianii-d  in  hrilvc  with  Miltciiiiij;-  m  |iiil|iiiicss,  '  in  two  with  coii^'cst  iuii. 
iiioMewith  abscesst  and  in  one  with  iiitiltiation  (if  pus.  One  s]>\rvn  was  coiijrcstiMl  and  si>t'tfncd,  oiu- cun^'cst.-d 
and  daik-eolored,  one  soft  and  small,  one  scniillnid.  one  ]>nlta<i'(nis  and  one  lirin  and  of  a  dark  niahof,'any-c(il(Pi-. 

The  connection  between  enlarii-einent  of  tlit>  splcrn  tuul  porioJie  levers  has  lu^en  rceoo;- 
iiize(]  from  tlie  earliest  times,  but  as  late  as  lS2S  M.  Gkndrin  noted  tlie  fact  that  lunlieal 
authorities  maybe  searclied  in  vain  for  a.  thonniu'li  tlcscri|)tion  of  the  clianges  in  the  sj>leen 
in  subjects  dead  of  intermittent  fevei'.  llu  endeavored  to  determine  the  anatomieal  charac- 
ters of  these  changes  by  massing  and  comparing  the  isolated  facts  reconled  in  special  pajters 
and  works  on  pathological  anatomy.  His  results  showed  that  tlu^  spleen  was  eitlier  tumefied, 
witl;  or  without  induration,  or  softened,  with  or  without  tiuvK^action.j;  iM.  Neppi.k..§  in  1841, 
arrived  at  similar  conclusions  t'nim  a  study  of  cases,  btit  he  added  also  tlud.  tlie  stagnation 
of  the  blood  in  the  spU>en  tended  to  hypertrophy,  acute  and  chronic  iiiilammations,  soften- 
ing and  degeneration  of  tissn(>,  which  were  often  fatal.  Mor(^  receiitlv  DrTROUhAi^H  sum- 
marized the  alterations  in  the  sj)leen  as  simple  congestion  causing  augmentation  of  vohnne, 
hypertrophy  of  tissue  from  rej)eated  congestions,  and  changes  in  tlie  contained  blood  involv- 
ing diffluence  and  accumulation  of  pigment,  witli  disoi'ganization  of  the  splenic  tissue  when 
the  blood  has  attained  an  extreiue  degree  of  dyscrasia.  The  ctises  jn'esentcd  by  our 
medical  officers  during  the  war  illustrate  the  vaiious  splenic  conditions  from  the  normal  to 
disorganization  without,  and  occasionally  with,  the  intermediation  of  inflammatory  action; 
l)ut  no  mention  is  made  of  pigmentary  dei>osits  in  the  organ.^  as  the  microscope  was 
seldom  used  in  their  j<o.s-/-»;or/r/;Mnvestigations. 

Medical  writers  generally  consider  the  changes  in  the  spleen  as  the  most  frequent  and 
characteristic  of  those  occurring  in  malarial  fevers.  In  all  of  I^averan's  cases  the  spleen 
was  enlarged  and  more  or  less  softened, •'=*  Tn  hut  one  of  Maillot's  cases  was  it  normal. 
Nevertheless  in  the  cases  presented  by  our  medical  records  there  are  seven  in.stances  of 
normal  spleen  in  thirty-two  cases  in  which  its  condition  was  rep<H-t(.'d.  Piorry-)-}-  found  it 
healthy   in  six  of  twenty-seven  cases   of  intermittent  fever.     HaspelJJ  also  observed  it 


*  ROKIT.i.NSKI  in  his  I'atlwlngical  Atiatomii.  B.  HI,  K.  381.  says  tliat  in  (il)striictiiin  .if  tlip  I'irculaticHi  llic  blimd.  ai't-uinulalpcl  anil  ii'taiiipil  in  iXm 
spii'cii.  cieatps  a  Odniiitiiin  (if  iiyperainiic  tnrKcscpncd  witli  a  darli-rcl  cdldr  of  llic  iirgan,  and  by  its  Cdnliniiancc  iinidiiccs  liyiicrlnipliy  iif  lli(>  Hlm.iis 
lissiies  as  well  as  (if  the  pulpy  substance.  'I'liis  tiirgesocnoe  is  always  clKiractoiizcd  by  smne  increase  in  consistence,  firmness  and  density.  Tlie  chanjres 
(if  tissue  f.illiiwing  such  turgescence  may  be  very  different,  inasmuch  as  they  depend  (in  tlie  Cdnstitutiiin  nf  the  bl.iiid.  and  theref.ire  may  snmetimes  iiccur 
as  an  induration  and  sduietimes  as  a  Sdftenintr. 

t  CiM.I.IX— ifecufiZ  lies  Miiiinires  tie  Meil.  Mililairts.  -J'  s6rie,  185.'i,  t.  XV—Huiitiires  ile  la  yi'«^;— considers  that  external  violence  often  acts  as  the 
determining  cause  in  the  production  of  suppurative  inflainmation.  Til.,\;>c  also,  in  his  Altscis  ile.  la  rale  dans  la  cachejrie  paluili'enne.  Paris.  187!!,  .•igrecs 
with  Cni.l.ix,  as  enlarged  sjileens  are  so  common  and  abscess  so  rare  in  malarious  subjects,  and  especially  since  the  |i..ints  where  absitcss  is  deter- 
mined are  those  most  exposed  to  violence  from  without  or  from  the  traction  caused  by  the  weight  of  tlie  enlarged  organ.  These  points  are  the  sniierior 
extremity,  the  externtd  face  and  the  anterior  margin;  Init  the  organ  may  be  converted  into  a  capside  filled  with  jiiis.  in  which  case  it  is  impossible  to 
determine  the  piiint  of  initiatinn. 

;The  following  is  a  rendition  (if  M.  (IKMUilN's  lonclusioiis:  1.  The  spleen  is  frequently  alTectcd  in  intcrmitl.nt  fever,  and  tliis  atfection  has 
for  its  princijial  characteristic  an  augmentation  of  volume,  i.  The  aiigment.itioii  of  volume  is  always  .somewliat  large  and  freinienily  considerable. 
;i.  The  tumefaction  is  sometimes  carried  so  far  .is  to  incommode  mechanically  the  functions  of  the  digestive  organs.  1.  Tlie  augmentation  of  volume  extends 
in  all  directions,  but  particularly  in  length.  ,">.  The  tissue  of  the  tumefied  spleen  is  aiurmented  in  density,  but  there  is  no  alteiiilion  in  its  texture;  its 
vessels  remain  permealile.  (i.  The  tumefied  .spleen  may  experience  a  certain  degree  of  displacement  by  its  nwii  v.-eigli(.  ', .  The  softening  is  the  imme. 
diate  effect  of  Certain  intense  periodical  fevers  or  the  result  and  termination  of  some  old  splenic  engorgement,  s.  The  softening  is  of  two  kinds  :  1st.  Idiir 
pathic.  (irmit  seemingly  dependent  (in  any  movllid  affection  of  a  dilVerent  nature:  id.  Inllammatory.  and  dciiendent  upim  the  iiill  ■."imation  of  the  organ, 
I',  There  seems  to  exist  a  direct  relati(ni  between  certain  lesions  of  the  s]>lecn  and  certain  alterations  of  the  lilood.  I  i.  The  engorged  and  softened  spleen 
in  fevers  may  be  ruptured  by  causes  directed  against  it  and  operating  against  its  tissue  mechanically  or  through  aug  in'iitation  of  the  congestion  of  which 
it  is  the  seat.  11.  The  rujitiire  may  be  spontaneous  from  the  simple  progress  of  the  malady.  13.  The  (.'lironic  engorgement  f  inc  spleen  following  inter- 
mittent fever  is  a  freipient  eau.se  of  fatal  gastrointestinal  lueuiorrhage.  KS.  When  this  accident  occurs  the  siileen  is  softened  and  engorged  with 
blood,  more  or  less  black,  as  if  it  were  ruptured:  the  ga5tro-s]ilenie  veins  are  dilated,  varicose  and  sometimes  ruptured.  14.  The  siileen  is  directlv 
and  immediately  emptied  liy  hieinorrhage  into  the  digestive  passages  from  the  gastro-splenic  vessels.  1.5.  This  disgorgement  may  be  salutary,  because 
it  may  destroy  the  morbid  condition  of  the  spleen.— ./()?/r?j«/.  G-'neral  ile  Med..  Paris,  ls-27.  i.  (',  p.  3(i. 

^Journal  deM-'dfcine  lie  Lijftn.i. I.  1841.  ji.  ;tli7.  \\ilp.rif..  p,l!i."i, 

ir  ri;l-;ill(lls  (h'scribes  the  spleen  as  lihiish  black  or  dark-brown  in  color,  cither  nnif..nn  or  speckled,  from  dep(.sited  pigment.     Op.  ci/.,  p.  318. 

*'I,.4VF.Il.vx.  Diiriimeii/.i  iioiir  sfrrlr  a  I'Uhlniri  drs  Maladii.t  ilii  .Xunt  ili  r.l/i/./Hi.     Me,mnire.v  ile  Mid.  .WiUliiires.  I'ser..  t.  LU.  184-J.  p.  8.'). 

tt  r.-a^illr  .flediriih  ,h  l-ari.'.  18:!3,  p.  3n8. 

;;H.\sim;i.,— .lAita(/(>,v  de  I'Ahjrrie.  Paris,  isiii,  t,  11,  \\.  :il8. 


148 


T'OST-MORTl'.M    Rl'',(i  JlMts    AST) 


occasionally  in  its  normal  condition,  ospecially  wlioii  tho  fatal  lever  liad  not  been  of  long 
•  luration.  Indeeil,  he  considers  the  absence  (jf  splenic  lesions  in  pernicious  fevers  as 
frequent  and  remarkable,  referring  to  IVvilia' and  .Iaix^tot  for  illustrations.  Dutroulau 
believes   the  spleen   to  l)c   normal  in  20  per  rent.  <>['  the  endemic   fevers  of  hot  climates. 

Tlio  KIDNEYS  \v<  1"  ■Diuui!  ill  nine  cases  icoordpd  by  our  niedica!  ol'licers,  and  not  mt'iitioned  in  si.t'tcfii.  Tlioy 
were  lai^je  in  firo  cases ;  larfjc  and  wliite  in  one;  coiifjested  in /»«■«■,•  tatty  in  f#ire<>;  tlal)l)y  in  one;  pale  in  one; 
in  one  case  they  contained  cysts  and  in  iinother  i)ns.'' 

'Die  condition  of  the  iik,vht  was  not  slated  in  ttrentu-one  of  tlie  cases;  it  was  recoriled  as  normal  in 
ten  cases,  leavin;;  only  nine  for  special  mention — thns :_  1  lypeitrophy  in  one  case,  dilatation  in  one,  eiilarj;'e- 
nient  and  fatty  defjeneration  in  our,  tiaccidity  in  owe,  softness  in  inic  and  valviilai  lesions  in  . /'««)•  cases.  Whitish 
tibrinons  clots  were,  noted  in  th»^  cardiac  cavities  in  six  instances,  ehietly  on  the  ri^ht  side;  in  one  case  f^reeiiish 
clots  were  found  on  the  rijjht  side,  in  another  loosely  formed  lilaek  clots  on  both  si<les,  and  in  another  black  llnid 
blood,  which  was  frothy  in  the  rifrht  hnt  not  in  the  left  cavities.  The  rKUiCAKDiiiM  was  partially  adliereiit  to  the 
heart  iu  one  case,  and  in  twelve  cases  there  was  an  effusion  of  from  one  to  four  ounces  of  serum,  which  was  tinged 
with  blood  in  two  cases  and  in  one  instance  contained  yelhnv  coagnla. 

According  to  the  French  observers"}"  changes  in  the  muscular  tissue  of  the  cardiac  walls 
are  frequently  noted.  Dutroui.au,  indeed,  regards  the  alterations  in  the  heart  as  second 
in  importance  onlv  to  those  in  the  sph^cn.  M.  Vali.in  J  conceives  the  alteration  to  consist 
of  a  primary  transformation  of  the  intcrlibrillar  pr(.ito|)!asm  into  albuminous  granules  which 
cloud  the  striip,  cause  swelling  and  end  in  fatty  degeneration. 

The  l.UNdSiJ  in  tho  recorded  cases  were  normal  in  nine,  tubercular  in  three,  more  or  less  congested  in  ten, 
intlamed  in  seven  and  ecejiyniosed  in  one;  in  ten  their  condition  was  not  mentioned.  There  were  adhesions  in 
four  of  the  cases  in  which  the  state  of  the  lung-tissue  was  not  recorded,  and  a  small  jileuritic  effusion  in  one  in  which 
tho  lungs  were  normal.  Tho  jileura  was  adherent  also  in  three  cases  in  which  the  lungs  were  congested  and  in  four 
iu  which  they  were  inHame<l,  and  there  was  effusion  in  two  of  the  pnciimonitic  and  one  of  the  tubeicnlar  cases. 

The  itHAiN  in  firenfu-eif/lit  of  the  forty  cases  was  ]irol)ably  not  examined  liy  our  medical  oHicers,  as  no  men- 
tion is  made  of  its  coiKlition.  An  examination  iu  tireire  instances  showed  a  normal  condition  in  Jive.  In  »»('  ease 
there  was  venous  congestion;  in  llinc  cases  the  liruiu  was  engorgeil  with  blood  and  presented  effusion  under  the 
nieinbranes  or  in  tho  ventricles;  in  one  of  these  tlie  seinui  was  jaundiced,  the  blood  black  and  the  cerebral  tissue 
tirin,  and  in  another  the  brain-substance  was  of  a  darker  asli -color  than  usual.  In  three  cases  there  were  indici.tions  of 
inflammatory  action,  in  one  injection  of  the  meningeal  vessels  with  some  exudation  near  the  longitudinal  t.nus,  in 
another  a  similar  injection  with  opacity  of  flu-  arachnoid,  and  in  the  third  case  thickening  of  the  luembiaues.  effusion 
and  circnmseribed  sottcning  of  the  cerebral  tissue. 

MaillO'K  found  the  Ijrain  all'cctcMl  so  frcqucntlvH  that  he  regarded  malarial  fevers  as 

*  DrTItori.Al'  Sliys  nf  tin's*'  urifiuis.  tli:tl  wln'ii  l)lninl  :i[i<l  iillitiiiitn  Iiavt'  lii't'ti  nbscrx  rtl  in  t\w  urine  wild  snnu'  iMTsistcin-e  tin'  jut.-it -mortem  exuunna- 
tion  Blniws  citln'r  [lijfnn'nlutiini  of  the  eurtieni  sul)stanee  or  ii  hmlueenus  (ieifenenilinn  witli  un  ueeinniilatiuii  nf  pijfnient.     <t//,  t-iL,  p.  II'T. 

I  'I'lius  M  AU.I.or :  'the  heart  in  si.v  cases  was  flabby  ami  pale  :  (nn-e  Mabliy  with  yellowisli  eulnration  ;  om'e  Habby  witll  dihltatinn  nt"  lln'  left  veiitrieh'. 
and  fimr  times  the  walls  nCthis  ventricle  were  hypcitrnphied.  I.AVKUAS — 'riie  lieart  was  of  iliniinished  consistence  in  nine  of  fourteen  cases.  <>/;.  rit.,  p. 
HI.  Col,l,l.N"ri  experien<;c  ;dso  shows  the  heart  us  t'retpielttly  ailected.  In  liis  lilty-two  cases  tif  pernicious  fever  it  was  norruul  in  twofiftlis:  its  volume 
was  aujfniented  in  three-tenths,  ami  in  one-half  it  was  tlaccid  and  of  a  dull  livid  color.  These  characters  were  even  more  prominent  in  the  chronu-  cases: 
In  sixty-one  cases  the  physiological  condition  was  noted  only  in  one-fourth,  Haceidity  with  a  4lull  or  onitni-pcel  color  ui  twti-thirds  and  au^nienteil  volume 
in  four-ninths,   o^j.  fit.,  p.  139. 

t  M.  E.  Vai.I.IX,  Drs  alterations  Hutotnifit^ufx  tin  cfeitr  rl  ttes  Musclta  Volontairi'^  rlaux  lt\i  Jiprre.'<  /tpraicieusef!  (t  remitteutfs,  Ufiteil  tie  Memoires 
de.Mefi.  J/t7i7airf/{,  3""  ser..  t.  X.VX.  Paris.  If7-1.  p.  \'i  ft  sefj. 

§  Maili.ot  continues:  In  one  ease  the  chest  was  not  i)pened :  in  one.  also,  it  ofFcre4l  nothing  abnorytal.  Thirteen  times  the  pleura  presented  old 
adhesions,  but  the  lunf^s  were  sound;  in  one  case  there  was  liepati'/.ation  of  the  ape.x  of  the  right  lung,  and  in  another  some  spoonfuls  of  russet -colored 
serum  in  the  left  cavity.  I.AVEHAN  says  that  in  his  cases  the  lungs  were  always  engorged  and  the  bronchial  tubes  oftentimes  fille<l  with  blood-tinged 
mucus.  Oy».  cit.,  p.  8."i.  In  Coi.blN's  fifty-two  pernicious  cases  the  lungs  were  normal  in  only  two  instances :  they  were  deeply  congested  in  the  majority 
;ind  splenified  in  one-fifth  ctfthe  subjects.    Op.  cit.,  p.  IS."'. 

11  M.vll.bo'l's  sumnniry  is  as  follows  :  Membrane.^  of  the  liroin. — Five  limes  the  arachnoitl  was  i^enerally  4ipa(iue  (once  this  genertil  opacity  t:oincided 
with  the  devehipment  of  I'aci'hioni's  glaiuls :  once,  with  the  same  alteration,  there  were  adhesions  to  the  ilura  mater  and  a  gelatinous  subnracinniid  infil- 
tration); three  times  the  opacity  was  confined  to  the  sulci  between  certain  <'onvolutions;  in  one  case  of  algid  icteric  fever  the  arachimid  had  a  yellowish 
tint;  in  <nie  case  of  quotidian  fever  which  had  beconu'  typhoid  there  was  a  eoUet'tion  of  jmrulent  serum  in  the  cavity  of  the  arachnoid.  In  eleven  cases 
the  pia  natter  wiis  more  or  less  vividly  injected,  the  arachnoid  not  being  so ;  i:i  six  other  cases  the.se  membranes  were  simultaneously  the  seat  of  a  vermil- 
ion-<Mjlored  injection ;  in  the  nuijority  of  the  cases  the  superficial  vessels  of  the  ein-ephalon  were  markedly  ct>ngestcd:  several  times  the  injection  of  the 
different  membranes  was  sulliciently  fine  to  torm  more  or  less  extensive  patches  of  an  intense  ami  brilliant  red.  Brain. — Twenty-two  times  the  brain  was  mtire 
or  less  injected ;  generally  of  a  density  and  firmness  which  seemed  much  more  jironouuced  than  initural.  Ordinarily  it  showed  li  closely  jmnctated  red 
coloration  ;  in  some  cases  of  comatose  and  delirious  fevers  the  cerebral  mass  was  .so  intensely  congested  that  on  compressing  it  the  blood  issued  from  its 
cut  surfece  as  if  from  a  saturated  cloth.  Eight  times  we  noted  a  dark  coloration  of  the  gray  nnitter,  whii-h  in  five  eases  was  even  blackish  ;  six  times  the 
choroid  (tlexus  was  of  a  dark  red  color:  ten  times  the  ventricles  containeil  :i  sanguinolent  serum.  In  a  conuitose  fever  the  brain  was  soft,  although  much 
injected:  in  a  c;(se  of  algid  icteric  fever  it  was  slightly  injectc<l.  of  ordinary  consistence  luid  yellowish  in  color;  in  three  other  cases  it  was  also  slightly 
injected,  but  without  change  of  color  ttr  consistence.  The  nervous  substiuice  tif  the  cerebellum  prest-nted  less  frequently  than  its  membranes  alterations 
imalogous  to  those  iu  the  brain  and  its  membranes.  .Meinhraties  of  tlie  .•<pinal  t-ord. — Fourteen  times  the  spinal  pia  milter  was  the  seat  of  a  vermilion 
injection;  five  times  the  anu'hnoid  ;uid  the  pia  mater  were  sinuiltaneously  injeetetl;  in  a  case  of  idgid  ii'tcric  fever  both  had  u  yellowish  color;  in  iuiother 


PATHiiljKiV     OF    MAT.AIMAL     I'lSEASE.  149 

due  to  an  irritation  liavinp:  (ov  its  aiiatoiniral  ('liaractor  a  livpememia  of  the  nervous 
matter  and  its  ni.Tnitraues.  '[In-  dark  culiral  imh  of'  tlir  lirain-suhslain'r  was  observed  bv 
liiiii  and  iitlaa'S.  esjicriallv  liv  l>i:iii!rr/-'  wIim  illr.^U'att-il  tln'  condition.  Iomlj;  Ijet'ore  FRKiurils 
drew  attentimi  to  it  and  connecti'(l  it  witli  oilier  piLi'iumtatioiis  m  malarial  cases.  Mure 
reeently  HAM.\roN'li  lias   susi'irestcd  the  pr)ssiliilitv  ot'  rcc(i'j:iiiziii'j;  this  condition  during  lil'c.-l- 

lu  one  of  tlie  forty  iccoideil  oases  the  I'AlioTin  (il..\NliS  wiic   inllauu'd,  :iii(l    in   (Hic   tlic   I'so  i:   MCsci.v.s  wimo 
lilackenod  and  disorf;auizi'd.t 

Tlie  liKXKKAi,  MASS  OF  TliF.  r.i.oou  is  siii'dally  lucntidiii-d  in  twn  cases  as  haviiij;  uiulovj;(iiie  cluingo;  in  (me  it 
was  diffluent  aiul  in  the  otlier  watery  and  ilef;eneiated.  In  a  lliird  lase  Idodd,  \vlii<-li  liad  esea]ied  into  the  iileuial 
cavities,  was  uncoafjiilable,  its  red  coipuseles  liioUen  down,  stellateil  and  witliered.  its  while  eorpuseh's  rohitively 
nnnieious  and  its  seinni  ofa  ieddish-yelU)\v  ('(dov.  But  an  alteved  eonditinn  of  the  lihiod  is  sufif^ested  hy  the  reeords 
of  many  other  oases:  as  l),v  tlie  occasional  blooil-tiniie  shown  b.v  tlie  ell'nsion  into  tlie  ))ericai<liiini;  the  U)o»e 
lihick  (dots  in  the  lieart ;  tlie  black  blood  with  wliicdi  the  ceiebral  veins  and  occasionally  tliose  of  other  orfjans  wen- 
loaded,  tlni  vessels  in  one  instance  Iiavinj;  presented  yellow  8i)e(dis  between  tracts  (d'  l)la(k  Ihiid  blood;  the  soft, 
jrreenish,  pus-like  coagulation  which  had  taken  jilace  in  the  heart  and  portal  veins  of  one  subject,  the  fibrinous  heart- 
dots  of  several  cases,  and  the  freiiueiit  S(d'teninfj  and  occasional  defieneral  ion  of  the  liver  and  sideen,  aiijiarently 
unconnected  with  intlaininatory  processes.  l'nfortnnat(  ly  the  inicroscoiie  was  scddoin  used,  and  the  records  therefore 
jjjive  but  little  iuforniatiou  as  to  the  details  of  this  altered  condition.* 

their  etind  iiui  was  not  stated.  Mfthtlfary  subxlavce. — In  four  (m>('>  tlio  corii  was  ^nii'rall.v  iii.ioctcd  iiiid  iiioro  Uian  oniiiiaril.v  tiria  :  in  otic  ca-se  it  was  It-ss 
tina  than  natural ;  in  one  the  iii.icction  was  ver.v  slijrht;  tlir«M'  times  it  jtresi-nled  a  normal  coasistenry  witlnmt  inieetinn  ;  in  two  rases  IIh*  injection  was 
general,  but  imu'h  more  nairked  in  the  eervieal  ami  Innil)ar  rejrions ;  in  oim  it  was  of  a  \ellowisli  tint  witlnmt  other  trhange  ;  in  four  there  was  jftManal 
injpetion  with  red  dorsal  softening:  in  three  the  softeninjr.  dorsal  also,  was  wliitr:  in  anoiher  the  white  sttfteninjj;  had  its  seat  in  the  eervieal  reirioa: 
finall.v,  in  ont!  rase  the  injection  of  the  ^ray  matter,  generally  nmre  pronounrcd  than  that  of  the  white  matter,  wjis  ver.v  intense  in  the  eerviejd  arch,  and 
exteialed  to  the  red  softeniniif  in  the  dorsal  portimi. 

*Bluiail' — Kfjiorts  of  Medical  Cases,  London,  IHSl.Case  CI,  Vol.  11,  p.  -JIT.  I'h.tos  XVIl  ami  XIX.  The  cortieal  suhstanoe  <.f  the  brain  was  almost 
of  the  eolor  of  black  lead,  and  the  miiuite  eireidation  of  the  eineritioiis  substaia'e  was  so  loaded  with  venims  blood  as  to  ^ive  (»ne  ^ener.il  purple-jrray 
eolor.  The  mednllar.v  matter  wiis  id'  a  uniform  dead  ffra.v-white  eolor.  which  appeared  to  be  given  by  imntrnerable  fine  ^jray  specks  and  short  hair  like 
vessels  resemblinpf  the  appearance  produced  hy  scrapingthe  naj>  of  fine  cloth  npr)n  a  sheet  of  paper. 

tin  an  article  on  lUgmentarii  Deposits  in  the  Jiruiu  result  iiifi  from  Mntariol  Poistrniln/,  in  the  Trans.  Amer.  Xeitrtilof/irnl  Assoriation,  IHTS, 
Dr.  W.  A.  Hammond  pointed  (mt  that  in  affeetitnis  of  the  nerviuts  sj-stern  havinj^  a  inahirial  «n-igin,  and  in  which  prestnnably  there  are  cerchnd  pigment- 
ar.v  depifsits.  similar  formations  may  often  he  detected  in  the  retina  b.v  ophtlialmoscfipie  examinatitm.  See  idso  a  eontrihution  to  the  stiaiy  of  the  nature 
and  ctinseqiienees  of  nuilarial  pois<niinij, — St,  Louis  Clinical  Record,  \'oI.  IV,  \ini,  p.  I'Jlt. 

^  ^I.  VAI^riN  discovered  cloud.v  swelling,  obseuratitm  of  striae  and  tatty  degeneration  in  the  fibres  of  the  recti  muscles,  especially  towards  their 
lower  part.     .See  article  already  referred  to  in  connection  with  changes  in  the  muscular  tissues  of  the  heart. 

§  The  altered  C(mdition  of  the  bUpod  was  studied  by  IlI-:ciil'KKEI,  junl  Uoiin-at — Recherclies  relatives  d  la  composition  du  Sanfj,  dans  Vital 
de  sanli  et  dans  I'i'tat  de  maladie,  Compt,  rend..  Paris.  IH-l-l,  XIX,  j>.  Ill8:i;  and  hy  Til^;oN".\in»  ami  I'(H,KY  in  184.") — Rerueil  de  Mem.  de  M-d.,  tf-c, 
Milituires,  X.  LX.  T'he  latter  reporters  made  niuilys(-s  of  the  blood  in  sixty-six  cases  of  Algerine  fever.  Their  residts  show,  p,  U'l.  a  watery  condition 
due  to  dtunnuti(m  of  globules,  albumen  and  inorganic  constituents  of  the  serum,  without  augmentation  of  fihrin.  unless,  as  in  nire  cas(^s.  the  congcstitm  of 
the  organs  had  developed  into  iuflainmation.  Ilr.  .losKi'M  .IONI';s  gives  the  following  as  the  results  of  his  investigation  into  the  diameter  of  the  changes 
in  the  blood:  '•  I .  In  malarial  fever  the  specific  gravit.v  of  the  blood  and  serum  is  diminished.  The  s)tecific  gravity  of  the  blood  ranges  in  this  dis(^ase 
from  lOIJO,.'*  to  1042.4,  and  the  specific  gravity  of  the  serum  from  1018  to  10"-!:l.ti,  In  health,  on  the  other  hand,  the  specific  gnivity  of  the  blood  varies  from 
105.")  to  I0(i3,  and  the  specific  gravity  of  the  serum  from  1027  to  lli;t2.  2.  In  malarial  fever  the  colored  blood  corpuscles  are  greatly  diminished.  In  health 
the  dried  corpuscles  may  var.v  frcun  120  to  1.10  parts  in  the  1,000  of  blood,  and  the  moist  lilood-corpu-scles  from  4H0  to  tiOO.  In  malarial  fever,  on  the  other 
hand,  the  dried  colored  corpuscles  range  from  .'il.ilH  parts  to  107,81.  and  the  moist  hlood-corpuscles  from  207.92  to  323.03.  The  careful  eoinparisnn  of  tliest* 
analyses  of  malarial  blood  with  each  other  reveals  the  fact  that  the  extent  and  rai)idity  of  the  diminution  of  the  colored  corpuscles  corresitonds  to  the 
geverity  and  durati<ni  of  the  disease;  a  short  hut  violent  attack  of  congestive  or  of  remittent  fever,  in  its  severer  forms,  will  accomplish  as  great  a  dimi- 
nution of  the  colored  blood-corpuscles  as  a  long  attack  of  intermittent  fever,  or  the  prolonged  action  of  the  malarial  iMiison.  3.  In  malarial  fever  the 
relation  between  the  cidored  corpuscles  and  liquor  sanguinis  is  deranged.  Thus  in  healthy  blood  the  relative  proportions  of  moist  hlood-corpusr-les  in  the 
1,0110  parts  and  liciiior  sanguinis  may  vary  from  480.00  to  COO.OO  of  the  former,  and  from  520.IK1  to  4IK),00  of  the  latter:  whilst  in  malarial  fever  the  globules 
vary  from  207. '.12  to  323.(13,  and  the  liqnor  sanguinis  from  7I'2.08  to  676.37.  4.  The  fibrin  of  the  blood  is  diminished  to  a  marked  extent  in  some  cases  of 
malarial  fever,  and  is  altered  in  its  properties  and  in  its  relations  to  the  other  elements  of  the  Idoitd  juid  to  the  hhwKlvessels.  .5.  The  <irganic  matters  of 
the  lifjuor  sanguinis,  and  especially  the  albumen,  is  diminished  in  malarial  fever.  Thus  the  s(.lid  matters  of  the  serum  n'ny  vary  in  health  from  !K)  to  10.'); 
whilst  in  malarial  fever  they  vary  from  62.78  to  80.22  parts  in  the  1,00(1  parts  id'  blood," — Medical  and  Suri/ical  Memoirs.  New  Orleans,  1876,  Vol,  I,  p. 
586.  Dr.  JONKS  makes  no  mention  of  pigment  in  the  blood  although  aware  of  FitF.KIlIls'  views,  which  he  discusses  in  connection  with  the  autopsies  of  his 
cases  of  chronic  malarial  poisoning,  in  both  of  which  the  liver  and  spleen,  and  in  one  the  brain,  were  densely  loaded  with  black  pigment.  American 
pathologists  do  not  ai>iiear  to  have  prosecuted  the  study  of  the  blood-changes.  IIUTCHIXSOX,  in  an  article  on  a  case  of  enlarged  spleen,  w  ith  remarks  on  the 
nmlarial  cachexia,  in  the  Med.  Xevsand  Abstract,  V(d.  XX.WIII.  1S80,  p.  449.  reports  a  microscopnal  examinatimi  of  the  bli>odas  follows  :  •'  The  red  corjius- 
cles  are  irregular  in  shape  and  .size,  and  form  themselves  poorly  into  rouleaux.  Most  of  them  show  a.  tendency  to  .liter  in  slmiw — to  become  <hmble  con- 
vex. The  white  corpuscles  also  vary  in  size  and  are  slightly  increased  in  numher.  a  few  mole  of  them  being  seen  in  a  field  than  in  health,  but  the  hhxMl 
is  not  leucocytha-niic.  There  is  no  evidence  of  pigmentation.  "  Dr.  ■RicHAltli  llKxcni.—  i'e.her  fiiimrnlbildunii  iiach  Febris  intermittens.  Zeitschr.  der 
lais.  kiin.  GeselUchaft  der  Aerzle  zu  Weill,  Bd.  I.  18.'>0.  S.  338— describes  the  i.igment  as  consisting  partly  of  divrk-browu  and  partly  of  dark-violet  Inidies 
about  as  large  as  blood  corpuscles,  some  enclosed  in  cells  and  the  others  isolated  or  adherent  in  masses  of  Iwr-*'-  or  thirt.\-  granules,  generally  lying  close 
to  the  coats  of  the  vessel.  A  subsequent  article — Ueber  das  Wechseljieber  und  die  cnpillaren  Blntungen  in  d<r  -Vi  lanamie.  Oesterreicltische  Zeit.<chrift 
fiir  Prakti.iche  lleilkuude.  Weill,  Bd.  VIII,  18i!2.  S.  810  et  seq. — gives  among  others  the  following  conclusions :  The  peculiar  pigment  of  intermittent  fever 
comes  neither  from  an  arrest  of  blood  in  the  vessels,  which  VIHCHOW  holds  as  one  of  the  conditions  of  its  occurrence,  nor  from  haemorrhage,  but  from  the 
coloring  matter  of  the  blood  leaving  the  blood-corpuseles.  The  coloring  matter  is  communicated  to  the  coats  of  the  vessels,  and  may  there  lie  found  at 
first  as  a  reddish,  and  later,  oftentimes  as  a  dark -brown  substance :  while  the  corpuscles  not  entirely  deprived  of  their  coloring  matter  continue  to  circulate 
with  the  rest  of  the  hhwid  as  small  reddish-looking  bodies.  The  principal  seat  of  this  pigment-formation  in  severe  ensea  is  the  brain,  and  in  mild  cases 
the  liver  or  spleen.  This  peculiar  hue  of  the  colonng  matter  of  the  blood  is  due  to  the  action  of  malaria,  as  it  is  observed  only  in  cases  of  disease 
arising  from  this  cause.  Dr.  .III..  Pl.ANKH — I'eber  das  Vorl,-ommen  eon  Pigment  im  ISlute.  Zeitschr.  der  k.  k.  lies,  der  Aerzte  zu,  Wien,  1854.  Bd.  I,  S. 
126  el  seq, — found  pigment  in  the  spleen,  liver  and  brain  of  the  subjei:ts  of  intermittent  fever.     Bhsid  taken  from  the  living  subject  contained  a  multitude  of 


150  post-mokte:m  kkcords  and 


The  varying  and  sometiiues  liculthy  (.•uiKlitiou  of  oacK  of  tlie  organs  presented  in  these 
records  gives  assurance  that  no  one  of  tlieni  is  entitled  to  have  its  changes  from  the 
normal  state  regarded  as  pathognomonic  of  malarial  disease.  The  opinion  of  Maillot  con- 
necting the  disease  with  a  hypenemic  condition  of  tlie  nervous  matter  and  its  membranes, 
that  of  Btewardson,  holding ^the  bronze  coloration  of  the  hver  as  essential,  and  that  ot 
many  French  writers,  associating  the  febrile  manifestations  with  enlargement  of  the  spleen, 
are  rendered  equally  untenable  by  this  one  consideration.  Maillot  considered  the  liyper- 
iemia  to  be  the  cause  of  the  fever  and  not  simply  an  accompanying  anatomical  fact. 
Stkwardson  was  content  to  regard  the  liver-change  as  pathognomonic,  without  insisting  on 
its  being  the  cause  of  the  morl)id  })lienomena,  since  there  was  no  evidence  that  it  existed 
at  the  commencement  of  the  fever  and  the  early  symptoms  could  not  be  traced  to  it  as  their 
source.  The  enlargement  of  the  spleen,  so  long  known  to  be  associated  with  malarial 
disease,  and  the  softening  and  occasional  inflammatory  appearances  presented  by  it  are 
undoubtedly  suggestive  of  an  intimate  relationsliip  between  the  fevers  and  the  changed  con- 
dition of  tbe  orii-an,  Audouard'^'  held  the  tumefaction  to  be  the  effect  of  a  congestion 
wliieli  prectMled  an<l  determined  the  fever.  At  that  time  medical  opinion  generally  considered 
malarial  fever  as  an  aflPection  of  the  nervous  system,  the  particular  seat  of  which  remained 
involved  in  obscurity,  while  the  affection  of  the  spleen  was  regarded  as  connected  with  an 
obstacle  to  the  circulation  in  the  portal  system  not  pertaining  exclusiA^ely  to  intermittent 
fever.-}-     Following  Audouakd,  Piorky  concluded  that  the  tumefaction  was  essentially  a 


brown  and  blank  inasso.s  similar  to  those  4iftRii  hct-n  in  2>'*st-inortem  Muod.  But  cell-like  pifjincnt  bodies  were  constantly  found.  Dr.  PLANER  admits  that 
the  subject  of  pignnMit-inrmatiun  is  as  yet  lar  from  being  understimil  to  its  full  extent,  and  that  there  is  nothing  in  liis  observations  to  enable  us  to  decide 
u|>(m  the  manner  or  j>la*'e  <>£  its  fiirtnation,  FKKllHilH  describes  the  pigment  found  in  the  blood  as  usually  in  the  form  of  small  rounded  or  angular  gran- 
ules, sometimes  Rharply  defined  and  at  tithers  surrounded  by  a  brownish  or  pale  margin.  They  are  oeeasionally  isolated,  but  more  frequently  held 
together  in  small  a g|ij rogations  by  a  pale  hyaline  eonne<'ting  sul)StiMiee.  The  groups  are  rounded,  elongated  or  irregularly  branched.  True  jngment- 
eells  are  also  observed,  although  in  smaller  numhers  than  the  granule^i!  anil  granular  nuisses.  The  color  is  usually  deep  blaek,  more  rarely  brown  or 
ochre-eolored,  and  least  frequently  reddish-yellow.  The  pigment  exists  in  greatest  abmidanee  in  the  bluod  of  the  pt)rtal  veins.  He  regards  it  as  formed 
chiefly  in  the  spleen,  as  the  si)indle  and  club-shaped  cells  with  rounded  nuclei  in  thti  blood  resemble  those  which  are  found  along  with  free  granules  in 
the  sjfleeti.  Hut  he  conceives  that  the  liver  also  mny  be  etuieerned  in  the  j>roduetion  of  the  pigment,  as  in  one  case  of  death  after  a  protracted  quartan  the 
spleen  was  enlarticd,  lardaceous  and  completely  free  from  piiftnent,  while  the  liver  contnined  considerable  quantities.  A.  KELisCil — Contrihution  ii 
f\4nat.  Path,  ties  Mnladies  I^nlKxtres  eiKfemi'/ins.  Arrhices  tie  I'hya.  uonmih'.  et  path.,  1*''  s6rie,  t.  II,  1875,  p.  tiUl.  This  investigator  counted  the  number 
of  b!m>d-corpuscIes  in  seventy  cases  of  acute  nnd  chnmie  nuitarial  poisoning  at  the  hospital  at  lMiillii>eville  in  IST'l-.'i  and  found  an  invariable  diminution 
in  the  number  of  the  red  (corpuscles  (oligocytha-niiat.  Twenty  to  iliirty  days  of  simple  remittent,  quotidian  or  tertian  fever  n^duced  the  nurnljer  fntm  five 
millions  lo  one  million,  or  even  as  low  as  half  a  million  per  cubic  millimeter.  He  observed  that  a  quotidian  or  remittent  fever,  on  its  first 
invasion,  would  reduce  the  number  of  globules  ns  much  as  two  milliims  p4'r  cubic  millim(;1re  in  four  days  or  even  one  million  in  a  single  day.  But 
usually,  as  S(M)n  as  the  oligocjtha'niia  was  estiiblished.  at  one  tt)  two  million  globules  i>er  cubic  millimetre,  it  remained  stationary  or  nearly  so.  The  white 
globules  were  also  generally  diminished  in  number,  and  proportionally  even  more  than  the  red,  notwithstanding  the  enlargement  of  the  spleen;  their 
number  was  one  to  one.  two  or  three  thousand  red  :  but  there  were  excejitions  to  this:  in  a  few  cases  the  white  corpuscles  were  relatively  more  numerous 
than  in  health.  He  c«)unted  in  i>arti<'ular  instances  1  to  192,  118  or  even  112  red.  These  bluod-chiinges  are  more  rapid  during  the  first  few  days  of  the 
fever;  they  continue,  but  more  slowly,  for  a  longer  period,  and  then  remain  stationary  or  nearly  so.  AVhiie  the  red  corpuscles  were  found  to  be  diminished 
in  number  their  transverse  diameter  was  increased,  in  some  instances  tt)  11,  V2  and  even  13  micromillimetres ;  the  smallest  mean  in  fourteen  cases,  in  each 
of  whi<'h  <»ne  hundred  globules  were  measured,  was  7.^80  and  the  largest  mean  'J.42D  micromillimetres.  In  pernicious  fever  there  is  a  rapid  diminution  in 
the  number  of  the  red  corpuscles.  ann>unting  to  from  half  a  million  to  a  million  a  day  at  the  In^ginning  of  new  cases  ;  but  in  those  that  supervene  on  previous 
malarial  anieniia  the  decrease  is  less  rapid,  from  IdO.OOO  to  20().()IH)  a  tlay.  In  these  cases  tlie  white  corpuscles  are  relatively  and  absolutely  increased  in 
number ;  there  may  be  as  many  as  1  to  200  or  even  70  red,  in  this  respect  diffeiing  from  the  blood  in  ordinary  agues.  He  observed  pigment  in  the  white 
corpuscles  of  the  blood  twenty-four  times  in  twenty-four  cases  of  pernicious  fever.  In  forty-seven  chronic  oases  he  had  twenty -one  negative  and  twenty- 
six  positive  results  ;  of  the  latter  twelve  were  observed  during  life,  the  otliei-s  after  death.  He  never  found  pigment  in  the  jteripheral  vessels  unless  the 
|K>rtal  and  splenic  veins,  the  liver,  spleeu  and  bone-marrow  were  eatunited ;  on  the  contrary,  in  fourteen  autopsies  he  found  it  in  these  internal  parts, 
although  there  was  none  in  the  peripheral  vessels.  In  eight  cases  of  <irdinary  ague,  on  pricking  the  finger  imme<iiately  after  a  paroxysm,  he  found  the 
pigment  five  times.  Iti  a  later  paper — XnuveUe  Coutrihvtion  d,  I' Anal.  Path.  fJes  Maladies  Palustres  endhniqiie.s.  Archires  tie.  I'hys.  normale  e.t  path.,  2* 
H^rie,  t.  IH,  187(i,  p.  lOI — KElxir  states  that  during  the  interniittent  attack  the  leucocytes  diminish  in  g-reater  proportion  than  tlie  red  corpus(;les.  The 
diminution  is  rapid  and  continuous,  reaching  as  low  as  one-half  cr  one  third  of  tlieir  number  before  the  attack.  One  or  two  days  are  required  for  their 
re  establishment.  The  swelling  of  tiie  spleen  is  coincident  with  their  disappearance  ;  but  tiiese  phenomena  are  not  proportionate.  In  the  cachectic  cases 
the  leucocytes  are  diminished,  but  not  in  projHirtion  to  the  splenic  eidargement. 

*Jour.  Gen.  de.  Mid.,  t.  T.XXXIII,    Paris,  1823,  p.  24.5. 

f  At  a  later  date  Dr.  ElHEXM.WN,  in  an  article  on  the  proximate  cause  of  enlargement  of  the  spleen  in  intermittent  fever  and  fevers  generally,  in  the 
Archiv/ur  die  gesammte.  Medicin,  H.  V,  Jena.  1843,  S.  401.  refers  tlie  tumefaction  of  the  spleen  to  the  chill.  He  was  led  to  this  opinion  by  reading  the 
histories  of  two  eases,  one  of  hepatic  phlebitis  brought  <m  by  a  fish-bone,  whii^h.  in  its  progress  from  the  stomach,  had  transfixed  the  superior  mesenteric 
vein,  and  the  other  a  ca.<e  of  rupture  of  a  metastatic  abscess  into  one  of  the  hepatic  veins.  In  both  there  w(Te  repeated  irhills  with  splenic  enlargement. 
He  considere,  therefore,  that  sin<'e  we  have  tumefaction  (tf  the  spleen  in  varieties  of  fevers  which  in  their  origin,  nature  and  indications  are  wholly  difTer- 
ent,  we  may  enqiure  whether  this  enlargement  does  not  belong  to  the  fevers  as  such,  originating  in  the  febrile  movement,  no  matter  on  what  cause  the 
latter  is  dependent.      l>uring  the  rhill  tht*  capillaries  arc  greatly  contrar-tcil  and  ihi-  hlood  partly  or  wholly  exi-luded  from  theui,  in  oouBe<iuence  of  whicli 


PATHOLO(iY    OF    MALAIUAL    DISEA.'^E.  151 

congestion,  altliougli  infliuniautdiy  clianu;!'^  niiu-lit  in  proiiTt'^s  of  time  appear,  and  was 
incliiRMl  to  view  the  fever  as  connected  witli  the  condition  of  tin-  spk>(,'u.'--  NKLi-:Tf  strength- 
ened tliis  view  by  reporting  a  case  in  wliirh  an  inlhinuriatioii  of  tiie  spleen  caused  l>y 
external  violence  was  inmiediately  loUowed  li\-  intcrnnttent  fever  which  was  eured  by 
quinine.  Cohadox]!:  in  his  thesis  argued  in  fiehalf  of  i'loiuiY's  tiieory,  that  interniittents 
ari'  due  to  a  [lathoiogiral  condition  of  the  spleen  and  of  the  portions  of  the  nervous  system 
vvhicli  correspond  witli  that  organ.  Ffy.KKAT,^  however,  was  tlie  most  outspoken  advocate  of 
the  view  that  intermittents  are  due  to  an  inllanimation  of  tlie  s[ileen.  His  principal  argument 
was  the  existence  of  tumefaction  and  pain  in  the  organ,  but  it  was  shown  by  XKi'i^hK,|| 
NiVET^f  and  others,  that  while  this  pain  is  ahsent  in  many  intermittent  cases  it  is  present 
with  tumefaction  in  other  diseases,  as  typhoid  fever,  in  which  tlu're  are  no  intermittent 
symptoms.  The  very  character  of  the  fever  was  an  obstacle  to  the  acceptance  of  Pkzerat"s 
views,  as  the  tendency  of  inflammation,  once  established,  is  to  progress  not  to  intermit. 
Moreover,  Gendrin  had  already  shown  tliat  the  tumefaction  occurs  without  inflammation 
or  other  material  change  in  the  intimate  structure  of  the  organ.  The  enlargement  was 
therefore  held  to  be  the  effect,  not  the  cause,  of  the  febrile  manifestations.  Finally, 
DuTROULA  Lr''"^'  argued  that  while  the  state  of  the  spleen  is  the  most  frequent  and  marked 
characteristic  of  malarial  fevers,  and  sonietimes  one  of  the  causes  of  grave  symptoms,  it  is 
neither  the  point  of  departure  nor  the  seat  of  the  febrile  phenomena. 

But  before,  and  during  the  continuance  of,  this  contest  as  to  the  connection  of  splenic 
engorgement  with  the  intermittent  phenomena,  there  was  an  underlying  idea  that  the  con- 
dition of  the  blood  stood  in  a  peculiar  relation  to  the  organ  and  occasioned  its  congestion. 
One  of  Gendrin's  conclusions  points  to  vitiation  of  the  blood.  NrvET  held  that  in  inter- 
mittents, as  in  scurvy  and  typhoid  fever,  in  which  also  there  is  engorgement,  the  disease  is 
general  and  the  blood  probably  altered.  Even  Piorry  regardcvl  a  change  in  the  blood  as 
antecedent  to  the  pathological  condition  of  the  spleen.  Some  light  was  thrown  upon  this 
jtoint  by  the  discovery  of  the  pigmented  condition  of  certain  of  the  viscera  in  malarial 
fevers.  Feerichs  considered  that  the  disorganization  of  the  blood  was  effected  in  the 
spleen,  suggesting  in  explanation  that  during  the  stasis  which  takes  place  in  the  blood- 
current  as  it  passes  from  the  arterial  system  into  the  splenic  sinuses,  a  stasis  which  is  aug- 
mented in  the  congested  state  of  the  organ  consequent  on  malarial  fever,  conglomerate 
masses  of  blood  corpuscles  are  transformed  into  pigment,  which  is  afterwards  arrested  in 
the  capillaries  of  the  liver,  brain,  kidneys,  cfec.  The  spleen,  however,  could  not  be  consid- 
ered the  only  organ  actively  concerned  in -the  disorganization,  as  much  pigment  had  been 
found,  in  one  case,  in  the  liver,  while  there  was  but  little  in  the  lardaceous  spleen.     But 

tlio  larj^er  vessels  ami  heart  become  overloaded.  In  this  turgescenre  tlie  spleen  has  a  great  share,  as  it  seems  designed  for  the  reception  of  blood  in  a  dis- 
ordered state  of  the  circulation,  to  obviate  thereby  tlie  dangers  arising  from  such  disturbance.  He  alludes  to  the  fact  that  splenic  enlargement  may  arise  from 
disonlered  circulation  resulting  from  heart  disease,  as  shown  by  Bkkka — (Rappoyto  della  clinira  di  Padova,  IHI'2,  p.  V2} ;  NAH8E — {H-^rns  Archu  ,  ISiy, 
August,  S.  liO),  and  SOUCHOTTE.  (Mim.  dt  la  Soc.  de  Med.  J'rat.  de  Himljiellier,  t.  .\X,  p.  243-2.54) — and  inquires  why  there  should  not  be  an 
overcharging  of  the  spleen  with  blood,  and  a  consequent  enlargement,  in  a  disturbance  of  the  circulation  due  to  spasm  of  the  capillaries  in  the  chill 
of  fevers.  He  concludes  that  since  all  the  facts  and  direct  observations  indicate  that  the  chili  causes  the  splenic  engorgement,  this  ctmdition  will  be  found 
in  every  fever  which  begins  with  a  chill,  and  will  be  most  marked  in  intermittents.  because  in  them  the  chill  is  not  only  more  severe  than  in  other  febrile 
diseases  but  more  frequent  in  its  recurrences.  .St)  also  in  the  fever  arising  from  purulent  infectitni,  where  the  chills  return  frequently  the  enlargement  of 
tilt!  spleen  will  lie  marked  :  but  in  those  having  only  a  single  chill  the  augmentation  naturally  cannot  be  so  great.  Besides  the  character  of  the  fever  the 
ttnie  of  the  tissues  seem  tti  have  an  influence  on  the  enlargement ;  for  in  atiynaniic  fevers  in  whi(!h  the  tissut^s  have  lost  their  tone  the  spleen  will  make  less 
resistance  to  the  bltitKl  forced  upon  it  in  the  cold  stage,  and  in  time  will  have  less  ptiwer  to  remove  the  accumulated  blood,  than  in  sthenic  cases  in  which  the 
tissues  remain  vigtirous.  In  irritative  and  inflammatory  fevers  the  splenic  enlargement  need  be  st)ught  for  only  while  the  chill  lasts,  and  no  great  increase 
need  be  expected,  while  in  asthenic  forms  it  is  nt»t  only  great  but  t>f  longer  duration. 

*  Memoire.  stir  Vital  df  la  rate  datislesjievres  intermittentes.     Gazette  Medicate,  \?'X\.  p.  rtti:!, 

\  Archives  Generates  de  Mi'decine,  2"  serie,  t.  V,  1834,  p.  137.  ;  COIHIiON— CW/ecdon  des  Thises.  Paris,  1847,  t.  Ill,  No.  31. 

§  Archires  (Ihierales  de  Medechie,  2'-  s6rie,  t.  V.  1834,  p.  199.  ||  SF.n'I.E— Gazette  Mtdicale,  t.  IV,  183:1,  p.  613. 

^NIVKT— Annates  de  Mid.  Beige,  t.  II,  1838,  p.  2').  **  Op.  cit.,  y.  195. 


152  POST-MURTKM    RECORDS    AND 

the  viiluiiblc  rosciirflics  of  Kki.scii  in.ipcar  t(j  waiTiini  liis  couclusiou  that  the  i)i>i;iiient  is 
foriiu'il  iti  the  iiiiiHs  of  thi;  eii'ciihitiiM''  IjKjuiI  ami  is  dcpositod  therotVoiii  iii  the  substance  of 
those  organs  when  a  stasis  In  the  circulation  affords  comhtions  favorable  for  sedimentation. 
He  n^gards  the  splenic.  iiK^lanosis  as  secondary  to  the  appearance  of  tlie  pigment  in  the 
Idood  because  in  two  of  his  cases  there  was  little  deposit  in  the  spleen  while  the  blood  was 
charged  with  masses  of  pigment,  ami  because  the  deposition  of  this  melanaemic  pigment  is 
conducted  in  the  same  manner  as  that  of  other  matters,  such  as  cinnabar,  which  have  been 
artificially  introduced  into  the  circulation.*  In  a  later  paper  KELsciif  concludes  from  his 
many  observations  that  the  presence  of  this  pigment  in  the  blood  is  a  pathognomonic  sign 
of  acute  malarial  poisoning;  that  it  is  not  i'ound  in  chronic  cases  in  the  absence  of  febrile 
accessions,  and  that  it  is  ;in  int«M'mittent  phenomenon  allied  to  the  other  intermittent  mani- 
festations of  acute  impalu(bsiii,  with  which  it  appears  and  disappears. 

Tn  summaiizing  tiie  jiud-viortem  records  left  by  our  medical  officers  it  is  evident,  not 
oidy  that  the  condition  of  no  one  organ  is  tlie  cause  of  malarial  manifestations,  but  that 
these  ai-c  due  priiiiariK'  to  a  morbid  condition  of  the  blood.  Jii  this  way  only  may  death  be 
accouiiteil  for  in  cases  characlerixed  b\-  alteration  of  the  bK)od  with  Imt  little  enlargement 
of  the  liver  ()!■  spleen.  in  this  wav  also  may  be  ex))lained  the  |,)igmentary  deposits 
asso(;iated  with  stasis  of  the  blood,  iVom  engorgement  as  in  the  spleen,  or  from  congestion  or 
inflammatory  conditions  in  other  oigans  as  the  liver,  brain  or  intestinal  canal. 

The  change  in  the  blood  is  presented  as  of  two  different  characters;  one  in  which  it 
was  thin  and  watery  witli  a  tendency  to  effusion  and  separation  of  fibrin;  and  the  other  in 
which  it  became  black  and  dlsoi-gaiiized.  The  former  was  its  condition  in  intermittent  and 
chronic  cases,  as  indicated  b\'  such.svmptoms  as  ana'mia,  debility  and  effusion,  and  by  the 
post-mortem  appearances  in  those  cases  in  which  death  occurred  less  from  the  intensity  of 
the  j)oisonous  influence  than  Ironi  some  accidental  circumstance,  as  heart-clot  in  cases  95 
and  96,  or  from  the  effects  of  some  complication,  as  in  case  75.  The  latter  was  its  condi- 
tion during  jiernicious  attacks.  These  changes  were  pnjduced  in  the  blood  by  the  operation 
of  the  malarial  infiueiu^e.  If  they  arc  regai'ded  instead  as  due  to  the  action  of  the  enlarged 
or  solteni'd  spleen,  which  was  so  lVe(juentlv  pivsent,  the  disorganization  of  the  blood  would 
be  projiortioned  to  the  splenic  alteration.  But  the  presence  of  blood  capable  of  continuing 
life  in  a  patient  whose  spleen  weighed  sixty-eight  ounces,  case  100,  is  inconsistent  with  the 
idea  of  the  participation  of  this  organ  in  the  disorganizing  process.  In  other  cases  death 
occuri'ed  from  altered  blood  although  the  spleen  weighed  only  a  few  ounces  more  than  usual. 
The  notably  eidargcd  spleen  is  a  characteristic  of  clironicity;  it  corresponds  to  a  mildness 
of  the  poison,  as  where  the  disease  occurs  in  temperate  climates,  or  to  an  accommodation 
of  the  svstem  to  pernicious  doses,  where  it  occurs  in  liighly  malarious  localities.  On  the 
other  hand,  in  some  of  the  fatal  remittents  the  spleen  was  found  to  be  unaffected.  Instead, 
therefore,  of  regarding  this  organ  as  an  active  agent  in  the  disorganization  of  the  blood,  its 
action  may  plausildy  be  considered  as  conservative,  preventing  dangerous  congestions  in 
other  organs  by  its  eidargement,  and  preserving  the  blood  from  that  diffluent  and  black 
condition  which  is  the  concomitant  and  probable  cause  of  the  more  dangerous  pyrexial 
manifestations.     It  may  be  that  the  action  of  the  spleen  is  mechanical :  as  suggested  by 

*La.nzI  and  Tkkkici — fl  miasma  jKifiisfr^,  Hniiia.  1875 — oonnoct  malarial  cHseascs  with  oerlain  dark-colorpd  granules  found  in  the  cells  of  niicro- 
sropir  al^se,  which  in  the  winter  cover  tlie  Roman  Canipagna,  but  die  under  the  heat  and  dryness  of  the  summer  and  are  converted  into  a  dark-colored 
humus.  The  dust  i)articles  from  thi.s  are  aftinned  to  be  identical  with  the  blat^k  [ligment  <)f  malarial  disease,  and  to  act  as  a  fermest  when  introduced  into 
the  human  system. 

I  .\.  KULscll  — 0,«/,-i7;i((/..,i  «  riiLiliiht  iirs  n,iil,i,U,s  jHilnslns—lir  la  Mrln iinitii —An:hh-es  (irii,  ilr  .Veil.,  '•'"  .serie,  t.  VI,  1880,  \i.  38.'». 


PATHdT.OiiY    OF    MALAHIAI.    lilSEASE. 


153 


Kklsch,  the  ]iii;-iJioiit-iniissfs  ]ii;i\-  lie  ruindXiMl  irniii  llic  cii'dilntiii^  blood  l.iy  a  process  ot 
sedimentation;  but  the  livpertrophv  wliieli  is  sd  rre(|Uentlv  found  in  chronic  cases  appears  to 
indicate  tliat  there  is  a  vital  action  iiivolveil  in  the  removal  of  the  malarial  poison  trnm  the 
blood  and  in  the  reireneration  ol'  the  latter  after  its  disuriranization  bv  the  morbitlc  asivnt. 


Y._CAUSATIOX  OF  MALARIAL  DISEASE. 

The  following  exti'acts  from  sanitary  re])orts  have  been  selected  from  many  of  a  similar 
tenor  as  indicatino-  the  views  of  our  mcilu'al  ofHcers  on  the  causation  of  malarial  ilisease: 

Siiryeon  V.  L.  Dimu.K.  [\th  Conn.  \'tAx..  Duwfn^kic  Ixlmid.  S.  ('.,  March  SI,  ISty. — Tlic  rej;imciit  romaiiiod  at  Hilton 
Head,  S.  ('.,  (luriiij;  tlie  first  twenty  diiy.s  of  .lainiiiry,  l><li'J.  wlieii  it  was  ordcicd  to  I'liilvaik — alioiit  >*00  utronji — on 
the  steamer  ('Diiiinjiolitiiii.  'f  lie  boat  at  best  was  not  eaiiable  of  acconiiiiodatiiif;  o\  i-r  four  liundred  men  for  any  leiii;tli 
of  time.  From  some  iiiiexi>lained  cause  tlie  coniinand  was  Vcept  on  tlie  crowded  transport  for  live  days  in  tlic  liarbor 
of  Port  Royal  and  for  fifteen  more  in  Warsaw  Sonnd,  when  it  was  ordered  to  eiicamii  on  Warsaw  Island,  (>a.  The  side 
of  the  island  where  tlie  troops  were  landed  did  not  afford  sutlicient  dry  land  to  lay  out  a  rcfjular  encampment,  and 
the  tents  of  the  men  were  huddled  together  without  lej^ard  to  order.  What  we  saw  of  the  island  was  one  vast 
swamji.  Tlu!  climate  is  nearly  the  same  as  at  Hilton  Head,  generally  mild  and  <'(|uable.  'J'lie  disease  that  ]iarticu- 
larly  atiected  the  regiment  at  this  jdace  was  the  congestive  or  pernicious  fever  of  the  coast,  which  raged  for  the  first 
five  days  after  we  landed  with  almost  incredible  violence.  Of  the  fatal  cases  not  more  than  two  lived  twenty-four 
hours  after  the  commencement  of  the  attack.  While  at  Warsaw  Island  the  only  duty  exacted  of  the  troo](s,  besides 
the  usual  guard  and  picket  duty,  was  about  three  hours  daily  drill.  The  command  remained  on  shore  about  nine 
days,  when  it  was  ordered  to  re-eml)ark  on  the  little  transi)ort,  and  there  we  lay  lazily  at  anchor  for  the  eleven  suc- 
ceeding days  in  Warsaw  Souiul.  At  the  expiraticui  of  this  time  General  Sherman,  hy  advice  of  the  Medical  Director, 
ordered  the  return  of  the  regiment  to  Hilton  Head.  It  should  be  stated,  however,  that  when  the  order  came  to 
return  no  fatal  case  had  occurred  for  the  jirevious  twelve  days.  For  the  next  twenty  days  the  regiment  remained 
at  Hilton  Head,  wlien  it  was  ordered  to  the  support  of  (iencral  Viele  at  Dawfuskie  Island,  S.  ('.  [The  rejiort  of 
si(^k  and  wounded  from  this  regiment  for  the  iiuarter  ending  Marcli  'M,  Wii'2.  gives  a  mean  strength  of  93li  oHicers  and 
iiicn,  aiiKUig  whom  were  22  cases  of  congestive  fever  with  11  deaths.] 

Siiryioii  .l.\s.  H.  TiiOMrsox,  V2ih  Me.  FoU.,  3'ew  Orleans,  La.,  October  1,  1862. — The  vicinity  in  which  the  above- 
mentioned  comiianies  were  stationed  is,  if  possible,  more  marshy  and  unhealthy  than  the  rest.  The  marshes  are 
iriegnlarly  intersected  with  deep  sluggish  bayous  and  lagoons;  this  fact,  in  connection  with  the  effluvia  from  the 
canals  or  sewers  before  menti(uied,  explains  the  large  number  of  intermittent  and  continued  fevers  reported. 

Sunjeon  James  Hryan,  V.  S.  VoU.,  opposite  Vick»hury,  June  27,  1863. — The  vicinity  of  the  great  swamjjs  near  the 
Mi.ssissipjii  ])ermitted  the  malaria  to  be  borne  by  the  prevailing  winds  to  the  locality  of  our  hosj)itaI,  an<l  convalesc- 
ents and  jiatients  from  this  cau.se  were  liable  to  new  attacks  and  relapses.  The  only-  efficient  iireventive,  Judiciously 
administered,  was  (|iiinine.  This  was  found  a  sure  inophylactie:  but  becoming  scarce  we  had  to  resort  to  cinchona, 
which,  in  larger  doses,  we  found  to  lie  eciually  etfoctual  both  as  a  prophylactic  and  a  remedy. 

Surgeon  S.  K.  Tovvi.E.  30//i  Mans.  Vols.,  December  31,  1862. — July  1,  1862,  the  regiment  was  in  bivouac  on  the 
swampy  point  ojiposite  Vickeburg,  wliere  it  had  been  about  ten  days.  This  whole  locality  had  just  emerged  from 
an  overflow  of  many  weeks'  duration,  and  was  still  barely  passable  through  mud  and  water  from  ankle  to  armpit 
deep,  the  8lo])e  of  the  level  being  the  only  place  upon  which  the  men  could  sleep.  Aliout  the  10th  the  bivouac  was 
changed  to  alongside  the  canal  or  cut-off  being  dug  across  the  l>endof  the  river  through  a  heavily  wooded  swamp — 
thus  adding  the  deleterious  iiifiuence  of  large  quantities  of  fresh  soil  of  vegetable  origin,  daily  thrown  uj),  to  that 
already  exjjerienced  fnuu  the  thick  dejiosit  of  the  long  flood.  This  position  was  occupied  to  the  end  of  the  mouth, 
when  the  jilace  was  evacuated.  During  this  time  the  men  had  no  tents,  luit  were  re(|iiired  to  build  booths  of  branches 
as  a  partial  protection  from  rains  and  heavy  dews,  and  to  construct  platforms  of  jioles  two  or  three  feet  high  upon 
which  to  sleep.  Moreover,  the  duties  were  very  severe.  At  first,  on  account  of  the  mud  and  water  in  laying  out  the 
canal  and  cutting  the  trees  from  its  course,  many  of  the  men  were  wet  day  and  night:  after  this,  digging  the  cut-off 
entailed  similar  hardships  and  exjiosiires.  There  were  also  freiiuent  alarms  at  night  and  nuich  guard,  jiicket  and 
scouting  duty,  exposing  them  greatly  to  l)oth  dew  and  sun.  Drills  were  also  ordered,  after  the  first  few  days,  from  5 
to  7i  A.  M.  (practically  liefore  breakfast)  and  again  for  two  ami  a  half  hours  in  the  afternoon.  The  diet  was  exclu- 
sively, as  it  had  been  with  but  slight  exceptions  since  leaving  .Ma.ssachusetts  in  January,  salt  meat  and  hard  bread, 
and  many  of  the  men  exhibited  in  consecjiience  the  preliminary  symptoms  of  scurvy.  All  the  circumstances  lended 
to  depress  the  spirits,  and  there  was  no  prospect  of  any  change  for  the  better  unless  the  entire  object  of  the  expedi- 
tion was  abandoned. 

As  the  immediate  result  of  this  long  exposure  to  intense  malaria  undc  tircnmstances  tending  to  still  further 

increase  disease,  a  malignant  form  of  remittent  fever  Ijecame  very  prevalent,  with  a  strong  tendency  to  take  on  the 

congestive  type.     Out  of  the  eight  hundred  i)icked  men  (one  hundred  and  fifty  feeble  and  second-rate  men  had  been  left 

behind)  eighteen  died  in  the  swamp,  while  at  the  time  the  regiment  left  that  position  more  than  half  of  the  entire 

Med.  Hjst.,  Pt.  Ill— 20 


154  CAUSATION    OF 

force  \va«  on  tlio  sick  list,  two  hiiiidied  liein;;  in  hospital  and  nioic  than  that  number  sick  in  (Hiaiter.s.  The  hospital 
accoinniodatioiiH  were  ne^^ro  huts  and  steainlioat  decks,  with  no  beds,  beddiuf^,  stores  or  provisions  other  than  rations, 
obtainable  excepting  b_v  seizure. 

Dnrinji;  Au<;ust  tlii'  reijiinent  was  at  Baton  IJouge,  La.,  where  on  the  5th  it  took  part  in  the  battle,  losing  four 
killed  and  ei^ihteeu  wounded.  The  sick  list  durinj;  this  month  was  never  below  four  hundred,  almost  entirely  from 
lualariiil  diseases,  chietly  remittent  fevers.  In  .Se[)tember  and  October  the  regiment  was  encamped  near  Carrollton, 
La.,  on  the  so-ealhsd  Metairi<^  ridj^e,  lu-ar  the  swamp  extremity  of  the  fortifications  defending  New  Orleans  from 
attack  from  ui>-rivei'.  This  ridge  at  tlu^  point  of  encami>uient  is  but  a  few  feet  above  the  heavily  wooded  swamp 
within  gunshot  on  either  side,  and  with  the  exception  of  the  fresh  deposit  of  decaying  vegetable  matter,  was  l)ut 
little  if  any  improvement  over  the  swamp  oppo.site  Vicksburg,  producing  the  same  class  of  diseases,  although  some- 
what less  pernicious  in  type.  At  ISaton  Kouge  and  Carrollton  the  men  got  vegetables  enough  to  eradicate  the  scor- 
butic symptoms,  and  the  laboi-  and  exjtosure  were  less;  but  the  sick  list  did  not  fall  at  any  time  nmcli  below  four 
hundred,  and  generally  three  hundred  were  in  the  hospital.  Nearly  all  those  who  had  remittent  fever  from  the 
exposure  at  ^'ieksl)urg  liad  repeated  attacks  at  Carrollton,  and  of  the  few  who  had  escaped  up-river  not  one,  officer 
or  jiiivate,  escap<'d  illness  from  the  effect  of  malaria  at  the  latter  locality.  Although  the  g<'iu'ral  type  of  malarial 
disease  was  somewhat  less  severe  at  Carrollton  than  at  Vicksburg,  the  men  had  become  so  deliilitated  by  repeated 
attacks  that  the  mortality  was  no  less.  There  also  resulted  a  class  of  chronic  eases,  with  diarrluea,  anasarca  and 
anjcniia,  tending  apparently  irresistibly  to  death  by  exhaustion  of  the  vital  powers.  Hospital  accommodations  were 
much  better  than  while  up  the  river,  and  gradually  became  quite  good,  while  the  facilities  for  a  proper  diet  were 
also  miK'li  improved. 

In  Noveml>er  and  December  the  regiment  was  quartered  at  the  II.  S.  barracks  four  miles  below  New  Orleans, 
where,  with  but  nominal  duty,  little  exposure,  good  diet,  dry  airy  quarters  and  a  generally  cheerful  and  contented 
feeling,  the  men  have  steailily  improved  In  health  and  strength.  But  while  this  has  been  true  in  general  terms  of 
the  regiment,  there  have  been  many  relapses,  and  in  many  cases  the  system  has  seemed  so  thoroughly  poisoned  by 
long  exposure,  under  the  most  unfavorable  circumstances,  to  malarious  influences  as  intense  as  could  be  found  in  the 
South,  that  no  resjionse  would  f(dlow  the  exhibition  of  stimulants  or  the  most  nutritious  food,  but  death  would 
inevitably  occur  from  (■xhaustlon  or  debility  alone. 

The  treatnuMit  followed  has  liccn  simjile  from  necessity,  if  not  from  choice;  for  the  majority  of  the  cases  have 
been  treated  In  the  regimental  ho8i>ital  with  only  the  limited  variety  of  supplies  furnished  for  field  service.  Sulphate 
of  (|uinine  has,  of  course,  been  the  great  reliance,  and  in  no  case  of  intermittent  fever,  in  which  anything  approaching 
a  fair  trial  could  be  had,  has  it  failed  in  effecting  a  prompt  cure.  Cases  of  malarial  fever  treated  in  houses  (contrary 
to  the  results  of  my  exi)erience  with  typhoid  fever  on  the  Potomac)  have  progressed  much  more  favorably  and  rapidly 
than  those  in  tents,  and  cases  in  Sibh^v  tents  have  proved  less  tractable  and  more  liable  to  a  relapse  than  those  in 
wall  tents  with  a  fly.  Indeed,  in  tliis  climate,  in  sunnner  a  fly  is  indispensable  for  comfort  either  in  the  hot  sun  liy 
day  or  the  heavy  dews  at  night.  Capsicum  has  i)roved  of  great  value  in  conjunction  with  quinine,  especially  in 
cases  reciuiring  stimulants,  as  after  the  first  most  of  them  did.  Mustard  in  the  form  of  large  poi'ltices  was  more 
useful  than  when  aiqdied  with  b.itlis,  and,  especially  in  the  congestive  cases,  was  of  the  first  importance.  Of  stimu- 
lants, ale  was  the  most  universally  beneficial,  and  but  few  instances  were  noted  in  which  it  failed  to  act  kindly. 

The  total  mortality  in  the  regiment  during  the  six  months,  in  general  as  well  as  regimental  hospitals,  was 
two  hundred  and  two,  or  one-Jiftli  the  aggregate  strength  July  1,  which  was  one  thousand  and  eleven.  Of  these  lit 
died  during  the  (luarter  ending  Sei)tembor  30  and  88  during  the  last  quarter.  The  aggregate,  December  31,  1862,  is 
seven  hundred  and  thirty. 

Surycoii  J.  M.  Ai.lex,  MIIi  I'd.  I'oh.,  Mmj  31,  18()2. — The  regiment  is  on  duty  in  the  valley  of  the  Potomac.  This 
region  of  Virginia  is  jirovi^rliial  for  almost  every  variety  of  miasmatic  fever,  and  when  the  peculiar  nature  of  the 
climate,  hot  days  aiul  cold  nights,  is  taken  into  consideration  in  connection  with  fre<|uent  overflows  and  rank  under- 
growth, the  cause  nuiy  be  easily  e,\i)lained.  The  <liseases  Incident  to  the  vicinity  are  remittent,  intermittent,  typhoid 
and  congestive  fevers,  pneumonias,  diarrhu'al  and  bronchial  affections. 

Sitri/foit  Robert  Morris,  9th  X.  1'.  Voln.,  Key  Went,  Fla.,  April  1,  1862. — The  ponds  in  this  vicinity  are  a 
fruitful  source  of  disease:  for  the  rains  wash  into  them  a  large  quantity  of  vegetable  matter,  which,  during  the 
process  of  decomposition,  evolves  so  much  malaria  or  bad  air  that  the  odor  is  very  offensive,  particularly  when 
the  wind  blows  over  them  towards  the  camp.  One  of  these  ponds,  that  nearest  the  encampment,  has  recently  been 
filled  up,  and  no  doul)t  the  salubrity  has  been  thereby  much  increased. 

Surgeon  A.  W.  AVooi)nri,i,,  9th  X.  J.  Voh.,  CaroUnti  Citi/,  X.  C,  June  1,  1863. — Some  of  the  posts  at  which 
portions  of  this  regiment  have  done  picket  duty  have  been  extremely  unhealthy.  Particularly  is  this  true  of  Have- 
lock,  a  post  on  the  railroad,  eight  miles  from  Newport  barracks  and  sixteen  miles  from  New  Berne,  N.  C.  It  is 
situated  in  a  low  wet  swamp  on  the  border  of  Sloeum's  creek,  which  is  here  dammed  for  water-power.  In  the  spring 
of  1862  the  dam  washed  away,  leaving  a  large  extent  of  surface  which  had  been  covered  with  water.  This  place 
became  extremely  unhealthy,  developing  intermittent  and  remittent  fevers  in  great  abundance.  The  record  shows 
that  98  per  cent,  of  the  men  of  this  regiment,  who  had  been  stationed  there  more  than  ten  days,  were  attacked  by  one 
or  the  other  of  these  fevers.  For  a  time  they  were  kept  subdued  by  administering  daily  portions  of  quinine,  but  the 
supply  being  suddenly  cut  of!',  they  reappeared  with  greater  i"re<iuency'  and  increased  severity.  It  is  believed  that 
a  sufficient  supply  of  quinine  will  jjrevent  at  such  places  the  prevalence  of  these  fevers  to  any  serious  extent. 

Surgeon  X.  W.  McClukk,  4</i  /oica  Car.,  near  flelena,  Arl:.,  Septeml>er  30,  1862. — On  July  1  we  were  encamped 
on  the  White  river  at  Jacksonport,  Ark.,  perhaps  the  most  malarious  locality  in  the  State.     Our  fevers  were  then, 


MALAEIAT.    DTSKAf^E.  155 

an  t  liev  had  buoii  for  some  iiiontlis  )  ire  v  ions,  of  a  uialiijiKint  iliararlrr.  ( )n  thr  lit  li  we  moved  down  the  river  on  Kliort 
I'atioiis.  Miasmatic  fevers  prevailed  to  a  eonsideralde  extent,  Imt  of  a  mild  eliaiai'ter.  Aliout  tiie  last  of  July  we 
reached  this  jilace.  Our  brigade  has  since  heen  encamjied  six  miles  west  of  the  town  in  a  position  as  saluhrious  as 
any  in  this  vicinity,  although  the  low  cotton-lands  extending  to  the  south  atford  fertile  soil  for  the  production  of 
nnilaria,  anil  cnir  men  have  not  been  proof  against  its  withering  intluence.  Ixtermittent  and  reuntteiit  fevers  have 
readily  yielded  under  the  use  of  (|ninine:  but  the  atmosphere  is  so  impregnated  with  |>oison  that  thereexists  a  strong 
tendency  to  ii  return  or  relapse.  After  a  repetition  of  the  attacks,  or  even  after  a  severe  and  protracted  first  attack, 
diarrluea  has  supervened,  attended  with  cachexia,  and  we  have  fouml  it  necessary  to  ren\ove  the  patients  to  northern 
hospitals;  nearly  all  such  cases,  however,  have  recov<red  by  being  thus  removed  and  put  upon  a  liberal  diet. 

Siiryt'iin  IT.  F.  ('oxkai>.  17I//i  Pa.  Vols..  Hi'iiiiforl,  N.  ('..  Ajiril 'AO,  1Si>'-i. —  The  cam])  we  now  occupy  is  sittiated 
on  Port  ]{oyal,  one  of  the  sea  islands,  a  sandy  ])lain.  Innnediately  in  the  rear  of  our  location  passes  an  inlet  from 
(,'oosaw  river.  This  inlet  is  about  one-fourth  of  a  mile  wi(b>.  When  the  title  is  in  it  is  filled  with  water,  but  is  left 
bare  when  the  tide  receih's.  Long  swam]i  grasses  cover  its  bed,  giving  rise  to  an  increased  miasmatic  influence 
from  the  decomposed  vegetation.  As  the  warm  weather  advancis  a  still  greater  (iinintity  of  the  niiasmatic  poison 
will  be  generated.  Tlie  prevailing  disease  is  intermittent  fever,  w  hicli  has  increased  considerably  witliiu  the  last 
two  weeks,  and  is  generally  of  the  ([uotidian  ty|>e.  It  has  so  far  readily  submitted  to  active  treatment.  I  generally 
conunence  with  a  purgativt^  dose  of  calomel,  followed,  if  necessary,  by  a  dose  of  oil,  rhubarb  or  salts.  I  tlien  put  the 
patient  on  sulphate  of  quinine,  from  twelve  to  twenty  grains  daily,  divided  into  three  or  four  doses.  This  seldom 
fails  to  check  the  jiaroxysms;  yet  I  generally  continue  the  ((uinine  for  some  time  to  prevent  the  recurrence  of  the 
disease.  I  observe  that  it  requires  larger  (itiantities  of  <]uinuic  to  act  efficiently  in  this  climate  than  in  our  northern 
States,  no  dotibt  from  the  miasmatic  influences  being  more  powerful  in  this  region  than  in  the  north.  I  have  not 
as  yet  had  any  case  of  bilious  remittent  fever,  but  anticipate  its  prevalence  as  the  summer  months  advance. 

Siiriicoii  S.  N.  SllEli.MAN,  Sitli  X.  T.  Vols.,  Siiiicn  J/i7/.s-,  Md.,  (Iclohcr  1,  IStll. — (hills  and  fever  have  resulted,  but 
only  in  those  doing  guard  duty  on  the  river:  and  of  those  attacked  few  fail  of  a  rapid  recovery  when  quinine  is 
liberally  used  and  strict  confinement  to  cam])  enjoined.  With  the  ajiproach  of  the  fro.sts  of  autumn  the  number  of 
attacks  decrease  and  the  recoveries  are  mor<'  sp(<e<ly.  But  for  diseases  of  malarious  origin  the  hi'alth  of  the  regiment 
would  l>e  good. 

Axxt.  Siiry.  .Tamks  B.  IIuntkr,  OOth  Tiui.  Viil.<<.,  on  ihc  coixJition  of  certaiti  nuimt'iits  ««((/■  Thihodcaux,  La.,  August  31, 
lHti4. — It  is  worthy  of  renuirk  that  the  sick  reports  of  the  IStli  N.  V.  Cav.  and  4th  Iowa  Bat.  show  a  nmch  larger  per- 
centage of  cases  of  inti'rnnttent  fever  than  those  of  the  Kith  and  (iOth  Ind.  Vols,  for  the  same  time  and  under  nearly 
similar  circumstances  as  far  as  camps  and  duties  are  concerned.  The  question  suggests  itself  whether  the  dift'ereuce 
in  fa  vol  of  the  last  two  regiments  is  not  due,  at  least  in  part,  to  the  fact  that  they  are  using  the  wedge-tent  while  the 
other  commands  have  only  the  imiierfect  ))rotection  of  the  shelter-tent,  in  which,  in  bad  weather,  the  men  cannot 
keep  tlieir  clothing  or  blankets  even  t(derably  dr.v,  and  under  which  they  are  constantl.v  exposed  during  the  night 
to  currents  of  air  ]irol>ably  charged  with  malarious  ])oison.  [In  another  regiment,  the  33d  111.,  in  which  intermittent 
and  remittent  fevers  have  Ijcen  the  prevalent  iliseases,  proj>hylaxis  has  been  attempted  with  fair  success  by  the 
administration  to  the  portion  of  the  command  most  exposed  of  a  spirituous  infusion  of  willow  bark.] 

Amt.  i'w(v/.  Alexander  Ingram,  V.S.Armi/,  2d  U.  S.  Car.,  Skarpshurg,  Md.,  Septemler  1,  1862. — The  iirst  two 
months  of  the  ijuarter  were  jmssed  on  the  Peninsula,  where  the  nuMi  were  exposed  to  excessive  heat  and  miasm.  Add 
to  these  agencies  the  influences  of  water  tainted  with  alluvial  and  animal  matters,  and  the  exhalations  from  the 
various  unwholesome  accumulations  incident  to  a  crowded  camp,  and  the  essential  causes  of  sickness  in  the  command 
will  be  comprised.  These  various  causes  resulted  in  irregular  malarial  diseases,  nearly  every  case  being  benefited  by 
the  administration  of  quinine. — intermittent  fevers,  remittent  fevers  and  diarrhoeas  characterized  by  torpidity  of 
the  liver.  That  the  malarial  fevers  did  not  assume  a  typhoid  type,  as  was  the  case  in  many  commands,  I  attrihtite 
to  the  superior  cleanliness  of  the  men  in  person  and  camp,  and  temperance  in  diet  and  drink,  they  being  old  and 
disciplined  soldiers. 

Surgeon  Charles  J.  NounguiST,  8'3d  N.  Y.  ('«/«.,  near  Shdrpxhiirg,  Md.,  October  10, 1862. — On  October  21, 1861,  the 
command  was  ordered  to  the  scene  of  the  Ball's  Bluff  disaster,  and  while  at  Conrad's  ferry  it  was  exposed  to  a 
drenching  rain-storm  for  eighteen  hours.  The  men  were  without  shelter  of  any  description,  and  remained  in  their 
wet  clothing  for  fort.v-eight  hours :  this,  in  connection  with  the  insanitary  conditions  of  their  camp  at  Muddy  Branch, 
decaying  vegetable  matter,  a  clayey,  moist  soil  and  muddy,  brackish  water,  caused  a  marked  change  in  their  health. 
Remittent,  intermittent,  l)ilious  and  typhoid  fevers  prevailed  to  an  alarming  extent,  and  fully  one-third  of  the  regi- 
ment succumbed  to  the  evil  influence  exerted  on  their  systems  by  the  above-mentioned  causes. 

These  reports,  as  also  occasional  references  in  those  published  in  the  first  part  of  this 
work,*  indicate  the  belief  of  our  medical  officers  in  the  identity  of  origin  of  all  the  so-called 
malarial  diseases  from  simple  languor  and  loss  of  strength,  with  slight  splenic  enlargement 
or  hepatic  derangement,  to  the  congestive  fevers  which  were  so  speedily  fatal.  The  essence 
of  these  various  and  clinically  dissimilar  morbid  phenomena  was  conceived  to  be  an  emana- 
tion from  certain  soils,-  especially  those  which  were  rich  in  vegetable  matter  undergoing  the 

*See,  for  iustaiici!,  in  tlict  Aiiin'iiilix  tho  reports  of  Teiplkr,  p.  40;  Cooper,  ]i\>.  2:!2-3;  Itisn,  \i.  £il);  t'RiNK,  p.  318,  and  Whitehill,  p.  334. 


156  CAUSATION    OF 

natural  process  of  decomposition  untler  the  conibiued  intiuence  of  heat  and  moisture.  Hence 
swamps,  marshes,  i-iver-l)ottoms  lialde  to  flood,  bayous,  lagoons,  ponds,  dams  and  canals 
wei'e  (h.'cmed  sufficient  to  acHiount  for  the  presence  of  disease,  especially  towards  the  close 
of  the  sunniier  season,  when  the  heat  was  believed  to  opei'ate  indirectly,  by  lowering  the 
water-level  and  exposing  larger  surfaces  of  moist  soil,  as  well  as  directly  in  promoting  the 
generation  and  evolution  of  the  malarial  miasm. 

The  disease-cause  was  recognized  as  moving,  cloud-like  upon,  and  for  some  distance 
along,  the  slopes  which  faced  its  marshy  source ;  and  as  capable  of  being  carried  in  danger- 
ous concentration  for  considerable  distances  by  winds  passing  over  such  extensive  swamps 
as  are  found  in  the  Mississippi  bottom.  Its  greater  concentration  or  more  malignant  char- 
acter at  night  was  illustrated  by  the  frequency  with  which  men  were  seized  while  on  night 
duty.  ])r.  Hunter,  indeed,  refers  to  the  greater  prevalence  of  the  disease  among  men  who 
slept  in  shelter-tents,  the  open  ends  of  which  gave  free  exposure  to  the  air,  than  among 
those  who,  other  things  being  equal,  were  better  protected  by  the  wedge  or  'A'  tents. 

It  is  manifest,  however,  that  the  presence  of  ab.solute  swamps  or  marshes  was  not  con- 
sidered essential  to  the  development  of  the  miasm,  as  it  was  attributed  to  cotton-lands  and 
other  soils  where  vegetation  was  raidv.  Frink  noted  the  prevalence  of  intermittents  in 
some  regiments  camped  in  a  strip  of  timber  on  rather  low  ground.  The  cutting  down  of 
trees  for  firewood  or  for  the  building  of  huts,  corduroy  roads,  breastworks,  bomb-proofs, 
abatis  and  other  military  works  was  frequently  followed  by  the  development  of  mahirial 
fevers.  As  in  civil  lif(>  sunilar  consequences  have  often  been  ascribed  to  the  clearino-  of 
tind^eved  lands,  the  exposure  of  the  soil  to  an  increased  solar  heat  was  regarded  as  the  cause 
of  the  newly  developed  insalubrity.  And,  as  in  the  inception  of  agriculture  in  a  new  country, 
the  removal  of  undergrowth  and  the  upturning  of  the  soil  are  so  frequently  followed  by  mala- 
rial manifestations  or  the  aggravation  of  pre-existing  diseases,  it  seems  likely  that  no  incon- 
siderable proportion  of  such  diseases  in  our  annies  may  have  been  owing  to  the  clearing 
of  the  surface  and  disturbance^  of  the  soil  incident  to  the  process  of  going  into  camp.  It  is 
certain  tliat  many  of  our  medical  officers  recognized  this  possibility,  and  were  as  e;irnest  in 
their  efforts  to  preserve  the  natural  integrity  of  a  camp-site  which  appeared  free  from 
malarial  factors,  as  to  drain  and  improve  one  which  was  manifestly  insalubrious. 

But  a  soil  capable  of  evolving  malaria  under  the  theory  of  organic  decomposition  was 
reputed,  in  one  exceptional  instance,  as  exercising  no  injurious  effect  on  the  health  of  the 
ti'oops  camped  near  it: — 

AssH  Sitni.  (iEORiJK  H.  HouN,  2d  Cal.  Car.,  Camp  Indepemknce,  Ow&n's  VuUcy,  Cal.,  April  1,  1863. — The  great 
ext»int  of  swainp-liiiid  might  he  supposed  to  einise  miasmatic  disease.  No  case  has,  however,  heeii  known  to  arise. 
All  tlie  causes  favorahle  to  the  development  of  such  diseases  exist.  Their  absence  can  only  he  accounted  for  l)y  the 
extreme  dryness  of  the  atmosphere  and  the  quantity  of  saline  materials  in  the  soil  and  water. 

It  is  proliable,  however,  that  the  swamps  of  Owen's  Valley  are  as  malarious  as  those 
of  the  river-bottoms  in  Arizona,  where  the  climate,  soil  and  vegetation  are  of  a  similar 
character,  and  that  the  absence  of  malarial  manifestations  reported  by  Dr.  Horn  was  due 
to  the  absence  of  exposure.  After  the  establishment  of  Fort  McDowell,  Arizona  Tcrritorv, 
on  the  <lrv  mesa  sloping  towards  the  Verde  river-bottom,  the  garrison  ]X'main('(l  free  from 
malarial  disease  for  over  a  year.  At  the  end  of  this  period  Indian  hostilities  called  detach^ 
ments  of  the  garrison  into  the  field,  and  coincident  with  their  exposure  in  temporary  camps 
in  the  rivei'-bottoms  malarial  fevers  appeared  among  them.  Gamp  rndependence  was 
established  three  miles  from  Owen's  river,  on  high  ground  bearing  only  scattered  patches  of 


MALARIAL    DISEASE.  1-37 

liuncli-grass  mij  sayx-busli.  At  tlio  time  Dr.  HoK^"  nuuli'  his  report  tlie  post  luul  not 
been  gurrisoned  t'(.ir  more  than  a  vear.  Its  hiter  records  show  tlie  presence  of  mahirial  I'eNTi's. 
On  the  other  hand,  malarial  diseases  of  a  pernicious  character  are  reported  in  one 
instance  where  the  surroundings  are  said  to  have  been  inconsistent  with  the  theory  of 
organic  decomposition  : — 

Siivijeou  W.  ^V.  Kiuiwx,  7//i  N.  H.  f'oh.,  Fort  Jefferson,  Tortuynn,  Flu.,  June  30,  1X()'_'. — Tlicve  seeiiis  to  be  no  cause 
for  iiiuhiiial  disease,  as  tlie  waters  of  tlie  Atlantic^  Ocean  constantly  batlie  tlie  walls  of  tlie  fort;  yet  tliree  or  four 
cases  of  very  severe  and  iualii;nant  congestive  fever  occurred  in  rapid  succession,  though  nothiiiff  of  that  character 
has  since  apiieared. 

The  records  of  Fort  Jeilerson  show  the  jirevalence  of  mahirial  ailoctions  ;'='  but,  akhoiigh 
there  is  little  siu'face-growth,  the  absence  of  organic  mattei'  in  the  sdil  may  not  be 
admitted.  ( )n  tlie  contrary,  the  soil  apj.iears  rich  in  the  eliMnents  of  vegetable  growth; 
for  id  Key  West,  where  a  similar  coral-sand  is  raisc'd  a  few  feet  above  the  salt-water  lev(d, 
it  is  covered  with  a  thick  cha|)arral,  and  produces  under  cultivation  nearly  all  the  tropical 
fruits  and  vegetables.^ 

A  review  of  the  observations  bearing  on  the  relation  between  vegetation  tuid  malarial 
disease  appears  to  indicate  that  the  poison  of  the  disease  is  elaborated  during  the  reduction 
of  nitrogenous  oriranic  matter  into  the  inortranic  t'orm  in  which  it  is  available  for  absorption 
by  growing  plants,  and  evolved  tVom  the  surface  as  malaria  when  the  living  vegetation  tails 
to  absorb  all  tlie  richness  of  the  prepared  nutritive  material.  Thus,  in  the  diurnal  changes, 
malarial  exhalation  ceases  when  the  vitality  of  the  plant  is  at  its  ma.Kimum  under  the 
influence  of  the  sun's  li<j;ht  and  heat,  and  becomes  active  durino;  the  night,  the  period  of 
vegetable  repose.  Our  spring  fevers  occur  when,  with  the  northward  advance  of  the  sun. 
the  earth  liecomes  heated  before  its  surface  is  covered  with  the  new  vegetation.  During 
the  summer,  when  vegetable  life  is  in  full  activity,  malarial  diseases  do  not  increase  in 
proportion  to  the  increasing  heat  of  the  season.  In  the  autumn  the  hot  sun  and  occasiontd 
rains  continue  the  processes  going  on  in  the  soil,  but  the  natural  decay  which  succeeds  to 
the  fructification  of  the  annuals  interferes  with  absorption  and  malarial  diseases  assume  an 
increased  prevalence  and  malignancy. 

The  association  of  autumnal  fevers  with  vegetable  decay  led  to  the  belief  that  the 
putrefaction  or  decomposition  of  vegetable  tissues  was  directly  connected  with  the  febrile 
occurrences.  But  it  is  well  known  that  free  exposure  to  the  effluvium  li-om  decomposing 
vegetable  masses  does  not  develop  malarial  affections.  It  is  only  when  this  vegetable 
matter  has  been  mixed  with  soil  and  is  undergoing  the  fermentative  processes  which  result 
in  the  nitrification  of  organic  ammonia  that  the  presence  of  malaria  is  manifested.  Sea- 
sonal observations  made  in  the  tropics  give  testimony  agreeing  with  that  of  the  temperate 
zones.  The  dry  season  is  the  analogue  of  our  winter;  but  while  with  us  soil-fermentation  is 
held  in  check  by  cold,  in  the  tropics  moisture  is  the  lacking  factor.  With  the  first  showers 
of  the  rainy  season  some  cases  of  fever  occur.  AlibertJ  explained  these  sudden  develop- 
ments bv  enunciating  his  sixth  proposition:  "Rains  which  fall  in  very  hot  weather  may 
contribute  to  the  production  of  malignant  intermittents  by  setting  at  liberty  putrid  vapors 
which  had  been  confined  beneath  the  hardened  surface  of  the  earth."  But  they  corre- 
spiond  to  our  vernal  intermittents,  and  may  be  referred  to  the  same  cause,  the  })resence  of 
the  conditions  needful  to  soil-fermentation  and  the  absence  of  growing  vegetation.     As  the 


*  '*  Tile  i>n-\itiliiiy  diseases  are  niuliiriul  fevers,  usually  mild,  and  eatarrlial  alTeetidiis." — ihj'jWnit  »/  the  I'.  S.  Artny.     Circular  No.  8,  S.  O.  0.,  Waah- 
iiigtuii,  1).  ('.,  IST.'i,  p.  140. 

t  Work  last  quoted,  p.  144.  ^Alibekt — A  TreatUv  on  MultijmuU  iuU't-mUteiits.     Caldweirs  translatiou,  PbiladelpUia,  18UT,  p.  182. 


158  fArsATION    OF 

niiiis  i-i;iit imii'  tlio  cDimtrv  lircoini'S  cdvcri'il  willi  uii  oxiiborant  vonlun',  aiid  ilic  niulurial 
iiiiuiil'csliitiuiis  are  Icssciicil,  hiit  dulv  td  lnTiik  out  with  iiicroasod  virulence  wlieii  tliiw 
annual  growth  wilts  and  docavs  al  llio  end  of  the  rainy  season."'' 

^ralaria  may  thereforo  be  eoiisidei'od  due  to  a  want  of  relation  between  tlie  nutritive 
cleincnts  of  till'  soil  and  its  living  vegetation.  AVhen  thus  viewed,  malarial  developments 
following  a  i-eiiioval  of  the  natural  growth  in  the  preparation  of  the  ground  for  agricultural 
purposes  are  readily  explained.  Their  subsequent  disappearance  when,  by  drainage  and 
cuhivation,  a  pi'oper  i-elatiiaiship  has  been  established  between  the  soil  and  its  crop,  is  an 
obvious  (•(jiisequence.  Exhalations  from  a  jiarched  soil  bearing  n  withered  vegetation,  as 
noted  hv  Fkrguson  in  rorkv  ravines,  river-bottoms  and  bare  open  liollow  lands  in  the  Iber- 
ian Peninsula,  are  also  understood,  as  well  as  his  remark  that  a  healtliy  comhtion  of  soil  in 
these  pestiferous  regions  was  infallibly  regained  Ijy  the  restoration  of  the  marshy  surface 
to  its  utmost  vigor  oi'  vegetable  growth."!"  There  wasunderlving  moisture  in  these  rocky 
ravines  and  temporarily  dried  up  water-courses.  So  at  Fort  Jefferson,  Fla.,  a  rich  organic 
soil  with  underlving  moisture,  a  high  temperature  and  absence  of  living  vegetation  may 
be  accepted  as  the  conditions  whieh  permit  of  malarial  exhalation. 

Oftentimes  men  in  the  full  vigor  of  health  were  struck  down  by  the  miasmatic  influence, 
but  in  general  the  operation  of  predisposing  conditions  was  recognized.  These  are  variously 
enumerated,  but  all  undoubtedly  acted  by  lowering  the  vital  powers  and  rendering  the  sys- 
tem less  able  to  withstand  the  influence  of  a  superadded  miasm.  Most  of  the  conditions 
affecting  the  soldier  on  active  service  were  of  a  depressing  or  exhausting  tendency.  He 
was  often  hungrv;  his  food  was  not  unfrequently  poorly  cooked;  the  issues  of  hard  bread 
and  fresh  meat  at  times  occasioned  diarrhfEa;  the  sameness  of  diet  developed  a  scorbutic 
taint.  One  reporter,  indeed,  regarded  the  ration  as  the  most  powerful  of  the  predisposing 
factors,  the  excess  of  its  carbonaceous  elements  inducing  a  congestion  of  the  portal  svstem 
which  opened  the  way  to  malarial  attacks. J  While  generally  warmly  clothed,  the  soldier 
was  often  chilled  at  night,  or  after  jM'ofnse  perspiration  or  exhaustion  from  fatigue.  He 
was  exposed  to  rains,  and  had  to  remain  in  his  wet  clothes  for  days  at  a  time,  sleeping  (.)n 
the  Wet  ground  without  shelter.  At  other  times  the  exhaustion  was  consequent  on  forced 
inarches  or  excessive  labor  under  an  op]>ressive  sun.  The  water-supply  was  generally 
surface  collections,  often  foul  naturally,  and  usually  tainted  by  the  inflow  of  the  surface 
washings  and  drainage  of  neighboring  camps.  Lastly,  a  state  of  mental  depression  arising 
from  absence  from  home,  domestic  concerns,  impending  personal  or  public  danger,  etc.,  was 
considered  as  adding  to  the  predisposition. 

Hot  days  and  cold  nights  are  mentioned  by  Surgeon  Allen  as  predisposing  the  system 
to  malarial  attacks;  but  Oldham's  theory,  that  malaria  is  chill, §  is  sufficientlv  disproved 
by  Dibj5Lf/s  report  from  Dawfuskie  Island,  li.  C,  where,  in  a  mild  and  equable  climate, 
the  command  became  subject  to  some  of  the  most  malignant  of  the  malarial  affections. 

The  influence  of  pr.'disposiiig  conditions  in  determining  the  type  of  the  fever  is  suggested 
by  a  study  ot  Talde  XXXI 1 1,  where  tlie  indicated  prevalence  of  congestive  and  remitt(mt 
(;ases  in  the  I'otomac  Department  seems  explicable  only  on  the  assumption  that  the  fatigues, 
exposures  and  privations  of  the  troops  operating  between  AVashington   and    Richmond 


*Fur  ,111  cxcollcnt  ck'scription  .if  the  sc;isiiii:il  occurrpnrc  nf  tlicsi'  fi'vors  at  SiiTni  Lii>n>!  iiiul  iwighliDrinK  imiiits  uii  tlii^  .Mrii-aii  coast,  si'c  ISovi.k 
on  thf;  IMsm^'s  <,/  IWi'lcnt  Afriru,  Ivnlninii,  1H:J]. 

t  0,1  thr  .\icli„i-  iiwl  HMoni  <,//>„:  Mursl.  I'umm.     Trans,  ilmjid  lyirieli/,  E<linl)ur(r,  182:1,  Vi.I.  IX,  \i.  27.'i. 

XF&lSK—AppeiulU  (u  Part  Fimt  u/ this  Work,  p.  318.  j  WTud  is  Malariaf  by  0.  F.  Oldium,  Loniluli,  1»71. 


MALARIAL    PLSEAPE.  159 

ivinlcfeil  iIk^iii  iiiotv  lialilr,  wlirii  fxpusfil  to  tlic  iiialariiil  influence,  to  bccomo  affeoteil  willi 
an  aLi-gnivatfil  type  ol'  tlir  disease  than  men  who,  tliough  exposed  to  more  concenti-aled 
miasms,  wrre  in  lietter  coiuhtioii  to  resist  their  prostratinii;  influence. 

Hevei'al  nt  tlie  reporters  reter  tu  impuritv  in  tlic  driidving-water  as  occasioning  a  pre- 
disposition to  malarial  affections.  In  the  early  history  of  medical  science  paroxysmal  fevers 
and  enlarged  spleens  were  referred  to  the  action  of  impure  water.  But  as  the  doctrine  of  an 
aerial  miasm,  enunciated  by  Lanclsi,  explained  many  things  which  had  been  obscure,  it  met 
with  general  acceptation,  and  the  possibility  of  water-infection  was  forgotten  bv  tlie  ])rofes- 
sion  although  it  contiimed  as  a  strong  belief  in  the  minds  of  the  uneducated  in  all  malai'ious 
countries.  This  theory,  however,  of  an  air-borne  swamp  poison  failed  to  account  for  all  the 
cases  that  occurred,  unless  on  the  supposition  that  the  evolving  surface  was  sometimi's  so 
minute  as  to  be  readily  overlooked.*  Meanwhile  an  occasional  instance  was  reported  in 
which  the  disease  was  apparentlv  due-to  the  drinking  of  an  infected  water,  as  for  example 
the  well  known  case  of  the  iVi'go.f  But  as  malarious  waters,  supposing  them  to  exist,  are 
usually  and  for  obvious  reasons  found  in  localities  presenting  all  the  conditions  needful  to  the 
evolution  of  an  aerial  poison,  the  disease,  when  it  did  occur,  was  referi'ed  to  the  lattei'  as  a 
matter  of  course,  while  the  existence  of  the  former  remained  unsuspected.  The  recognition  of 
water  as  an  agent  in  the  transmission  of  malarial  disease  has  been  gradually  effected.  Pro- 
fessor Parkes,  giving  weight  to  a  number  of  cases  which  he  mentions,  accepted  the  theory 
and  speculated  on  the  connection  between  the  disappeai'ance  of  malarial  fevers  in  England 
and  the  coincident  use  of  purer  supplies  of  drinking  water.J  Professor  Leon  Colin,  from 
his  experience  in  Algiers,  denies  that  marsliy  waters  produce  intermittent  fevers;  but  as 
the  troops  under  his  observation  were  operating  in  a  notoriously  malarious  country  the  ditK- 
culties  in  the  way  of  arri\-ing  at  a  positive  conclusion  must  have  been  very  great.  His 
testimony  cannot  be  considered  as  authorizing  a  stronger  statement  than  the  denial  of  the 
occui-rence  of  cases  which  might  not  be  plausibly  referred  to  malarial  exhalations. 

A.  country  where  malaria  is  not  exhaled  from  the  soil,  at  least  in  quantity  or  concen- 
tration sufficient  to  produce  interinittents,  would  seem  necessary  to  relieve  observations  on 
malarious  waters  from  the  objection  caused  by^  the  alleged  presence  of  the  aerial  pioison,  and 

*Tlnis  Maccvlloch,  in  Lis  Fastiy  on  Malarui,  Philadeli)Iiia,  1829,  p.  28  :  *'If  it  is  acknowledged  or  proved  that  niarsh  or  swaniji,  wliether  fresh  or 
salt,  is  {generative  of  malaria,  it  is  also  a  very  coinnion  opinion  that  a  certain  extent  of  thi.s  soil,  and  g:iMierally  a  coiisidenible  one,  is  iieeessary  to  the 
priKiuction  of  disease.  This  is  an  error;  and  it  must  he  classed  among  the  dangerous  ones,  as  being  prLHiuctive  of  false  security.''  lie  then  advi-rts  to 
the  anahigy  between  malaria  and  contagion,  arguing  that  the  tjuantity  of  malaria  necessary  to  jiroduce  its  iieculiar  disease  or  diseases  must  be 
inilefinably  small,  for  it  is  w^ell  known  that  often  from  a  very  limited  sjiot  the  jioison  will  prcK-eed  through  the  air  or  on  the  winds  to  distances 
of  throe  or  four  miles,  exhibiting,  notwithstanding  the  dilution  which  must  take  place  in  transit,  almost  as  much  virulence  as  in  its  native  ma r>li ; 
and  he  cites  the  hills  of  Kent  as  infected  by  emanations  from  the  marshes  of  Erith,  Northfleet  and  Gnivesenil.  "The  conclusion,"  he  says,  "is 
obvious;  and  there  is  nothing  in  it  which  seems  to  admit  of  dispute,  since  it  is  almost  a  question  of  iirithmetic.  If  the  produce  of  a  hundred  stpiare  feet 
or  acres  or  of  any  scale  ami  number  (»f  jarts  can,  under  a  dilution  of  one  thousand  or  ten  thousjmd  times,  excite  di.sea.se,  then  must,  in  the  inverse  ratio, 
th"'  produce  of  the  one-thousandth  or  the  ten-thoustindth  portion  of  that  space  be  cajiable,  before  dilution,  of  prmlucing  the  same  effects ;  or  a  single 
blade  of  grass  acting  on  water  (if  this  be  the  cause)  may  be  as  eflicacious  as  an  acre  ;  supposing,  of  course,  that  it  is  actually  applied  to  that  luirt  of  the 
body  which  can  suffer  from  its  action."'  Tommasi-Crudeli  holils  that  malaria  maybe  generated  in  ipiantities  sufficient  to  produce  intermittent  fever 
by  the  ganlen  mould  of  flower-pots  kept  in  bedrooms,  an<l  on  the  authority  uf  Professor  vo-n  Kr-uwam»,  instances  the  case  of  a  liussiau  lady  whose  aguish 
relapses,  having  been  referred  to  this  cause,  were  rterinanently  cured  by  the  removal  of  the  Hower-pots. — Pnirtitioner,  Vol.  XXVII,  pjt.  3ST-8. 

fPAUiiES  in  his  Practical  Uii(jieue  summarizes  and  remarks  tni  this  case  as  follows  :  "The  case  of  the  .\rgo,  recorded  by  BorniN, — Tt-ait'' ile  tii^'tjraphie 
et  <le  Sfttti^iijue  ^rrdicule^,  ISoT,  t.  I,  p.  14'2, — is  an  extremely  stniug  one.  In  ly:J4,  H)mj  soidi''rs  in  good  health  embarked  on  three  vessels  to  iKi.ss  fmm 
liona  in  Algiers  to  ^lars  'illes.  They  all  arrived  at  Marseilles  the  same  day.  In  two  vessels  there  were  tJSl)  men  without  a  single  sick  man.  In  the 
third  vessel,  the  .\i-go,  ther.-  had  bei-n  120  men  :  thirteen  die<l  during  the  short  passage  (time  not  given),  and  of  the  loT  survivors  no  less  than  9s  were 
disembarked  with  all  forms  of  jialudal  fever,  ami  as  lJorni\  hiinsidf  saw  the  men  there  was  no  doubt  (*f  the  diagnosis.  The  crew  of  the  .\rgo  had  not  a 
!  ingle  sick  man.  .Ml  the  soldiers  had  been  exposed  to  the  Siiine  influences  of  atmosphere  before  <-mbarkatiou.  The  crew-  and  the  soltli«'i-s  of  tlu-  Argo 
were  exposed  to  the  satne  atnlosi»heric  conditions  during  the  voyage  ;  the  influence  of  air  seenis  therefore  excluded.  TloTe  is  no  notice  of  the  fo(»d.  but 
the  production  (jf  malarious  fever  from  fo(Kl  has  never  bijen  suggested.  The  water  was,  jiowevi-i-,  different — in  the  two  healthy  shi]is  the  water  was 
good.  The  soldiers  on  boarvl  tlie  Argo  had  been  sniiplied  with  water  from  a  marsh,  wbicli  had  a  disagreeable  taste  aorl  .,d<.r;  the  crew  of  the  .\rgo  had 
jiure  water.     The  evidenci'  seems  heri!  as  nearly  complete  as  could  be  wishcil.'' 

J  "  Is  it  not  possible,"  he  says,  "  that  the  great  decline  uf  agues  in  Kiigland  is  pai-tly  doe  to  a  purer  drinking  water  being  now  used  ?  Formerly, 
tltere  ciin  U-  little  doubt,  when  there  was  no  organized  supply  and  much  fewer  wells  existed,  the  jjeople  must  have  taken  their  supply  from  surface 
colb.-ctions  and  dit<-hes.  as  they  do  now,  or  did  till  lately,  at  E»lieerness," 


160  TArsATIOX    OF 

till'  iciiilriirv  In  rrl'd'  ;ill  iii'irliiil  | ili( 'in >i iiriia.  lo  lis  i nil iii 'iii-c.  Till'  wnli'i'  \v;is  al  one  inne 
siaiiiiiii'il  in  siidi  -a  roiinirN-.  at  l'"iMl  HhiIlici'.  dh  llie  iiurtlicrn  A(_>\u-  (,['  ilic  I'inlali  Moanlaiii^ 
in  \W-i.iiiinL:  Tv.  wlni-i'  inliTiniitcnts  \V(jiv  ninlouLtrdly  iin|ioi-liil  (lisuiiises  wliicli  IciiJrd 
to  ioiiuvi-  intcrxals  and  nllimalc  ivc(>\cry.'^'  .\c\-ci-llii'lcss.  in  lliis  nMUiUy,  a  ivinittent  U:vr 
was  Well  rci'oo|ii/f(|  as  iniliiicnous.  Il  was  kiu^wn  lo  tliu  settlers  as  nuiu nldinh'rcr.  am] 
altlionuli  in  niosL  cases  rei-o\-ci-v  was  lapid  iiinlei'  inerennal  purges  ami  (|uinine,  the  palieut. 
if  no|  siil»)erle(l  to  simmmHi-.  trealinent,  would  i'all  into  an  advnamic  eiMidition  to  which  the 
nainc  nf  h/nlniid  or  /i/j,li')-ni((J(i ritil  was  oecasioiially  apjilied.  Th;il  tliis  tever  was  malarial 
in  its  (H'i^in  was  the  L;eni.-i'al  opinion  of  the  medical  men  familiar  with  it.  although  the 
source  (jT  the  exhalation  was  not  evident  and  although,  more<Jver,  the  disease  did  not  cori'c- 
spond  in  its  periuil  of  prex'aleiice  witli  the  remittents  ol'  notoriously  malarious  regions.  h 
(.tccairi'eil  with  greatest  I'reipieney  during  the  months  of  May,  June  and  -luly.  hut  aj>peared 
(jccasionallv  in  all  the  wther  months  e.ri-<'iit  September  and  October."!"  the  months  ot  s])ecial 
prevalence  of  the  onliiiMi'V  autumnal  Icver. 

This  i-emitteiit-  was  trace(l  by  the  wi'itei'  to  the  use  of  the  liver-water  constituting  the 
supply  (jf  till'  ]>ost.J;  lie  found  that  this  water  contained  a,  larger  ijuantity  of  organic  mat- 
ter than  was  usual  in  eood  river-waters,  and  that  the  maximum  and  minimum  of  the 
prevalence  of  the  fevei'  corresponded  in  time  with  the  maximum  and  minimum  of  the 
organic  impuritv  in  the  water-siippK'.  During  the  period  of  incrcasetl  impurity  the  bed  ot 
the  stream  was  moi'e  or  less  Hooded  and  the  water  turbid  from  the  spring  rains,  and 
especiallv  I'rom  tla;  melting  of  the  snows  on  the  mountains.  As  the  post  was  seven  thou.sand 
feet  aliDVe  the  seadeVi'l,  and  on  \\\i'  northern  exposure  of  the  mountain  range,  its  springs 
wei'e  late,  the  tliaw  begininng  only  towaixl  the  end  of  .\pril  ami  lasting  well  into  July. 
L)ui-ing  the  pi'i'iod  of  dimiidshi'd  im[(urity,  as  scarcely  any  I'ain  fell  on  the  mountains  wdiich 
at  this  lime  Were  free  iVoui  snow,  the  small  volume  of  clear  water  which  ran  in  the  bed  of 
tile  stream  niii>t  bi_'  I'egai'ded  as  jiercolated  waters  contributed  bv  the  mountain  spriuiis. 

This  led  to  a  more  extended  survey  of  the  history  of  mountain  fever,  wliicli  developed 
in  everv  instance  a  similar  ivlationship  to  organic  impurity  in  the  water.  Thus  hunters, 
millers,  cattledierders,  surveying  parties  and  soldiers  on  scouting  dut\',  who  made  use  of  a 
surface-water  supply  chargeil  with  \-egetable  impurities,  were  more  frequently  aft'ected  with 
remittent  le\ei'  than  (lermatient  settliM's  who  had  provided  themselves  with  a  pure  siipplv 
from  wells  and  springs.  That  the  remittents  which  alFected  these  nomads  were  not  directly 
due  to  malarial  exhalations  was  manifest  from  their  occurrence  when  the  ground  was 
Covered  with  snow  and  the  temperature  far  Ijelow  the  freezing  point.  At  Camp  J)ouglas, 
Utah,  such  remittents  were  observed  only  among  soldiers  who  had  been  absent  from  the 
station  on  scouting  duty.  On  account  of  the  small  size  of  the  stream  on  which  this  post 
depended  lor  its  water-supply,  and  the  possibility  of  its  diwing  up  at  times  during  sum- 
mer, a  storage  resei'Voir  had  been  liiiilt.  This  was  large  enough  to  pei'init  of  an  efficient 
sedimentation:  but  to  j>reVent  the  unnecessary  rilling  up  of  the  basin  by  the  intrusion  of 
solids  the  instnictioiis  ti;  the  niaii  in  charge  h)oked  to  the  admission  of  water  only  when 
it  ran  without  turbidity  in  the  stream.  Tlie  exclusion  of  the  snow-waters  and  heavy  rainfalls, 
thus  effected,  ga\e  a  coniparati\ely  pure  spi'ing-water  at  all  times  for  the  use  of  the  post. 
Moreover,  the  gradual  disappearance  oi'  these  mountain    remittents  with   the  progress  of 

*  ;%iV,i.  „/  M.   I  .  S.  Ariini.  —  ri,:,,!,,,-  N,,.  .s.  s.  11.  (I..  l.sT.-,.  p.  :||i,). 

fSi-.-  «i.ik  hi-t,  it..,l.  |..  :;-ii.  ivhcp  ii  i;il.l..  ,,|i, ihiy  M.-k  nit.><  is  |.iv«iMit..l.  .■iiiliraciiii;  tli.-  c-i^'lit  .vours  lSfiO-7:i. 

lH>l.Mi\.~'M3Lniiilui„  i;.,ef  •iwl.  Mithirir.H^  Wains.     Am.  .J;ii,:  .lA ./.  Sri.,  Vnl.  I, XXXV,  lt<7fi,  pp.  1-'J7. 


MALARIAL     MsKASK.  lC>] 

sptrlfiriiMit  was  mI  ,.,,i,|,  wi-iulii  m  tlir  ar-uinr-nt.  In  llir  carlv  davs  of  traiis-conini.'ntal 
ti-av.'l,  whi'ii  the  uvfi-laml  j.uiniry  iiiipli.d  niontli.-  i>\  wi-ai'v  iiiaivlnn.^  aii,l  a  wat.T  .-ii|.ply 
Iroiii  ri\(is,  |>oiuls,  dams,  vtL-.,  the  disrasc  was  (-(11111111,11  and  danjivroiis  ;  l.iu  wlicii  tlic 
'pairncy  was  accomplished  by  steam  in  a  few  days,  and  tlic  settlements  lurni.-lied  with  a 
hcltcr  water-supjily,  the  remittent  occurred  only  in  those  whose  mode  of  lit'e  im]H»e(l  ,,n 
them  the  conditions  common  to  all  in  the  (\u'lier  (lavs. 

Soldiers  on  scouting;  duty  are  iiarticiilarly  liahle  t((  this  remittent.  Idiev  are  exposed 
to  climatic,  influences,  over-fatigue,  loss  of  sleep,  anxieties,  insulllcient  and  hadlv  c.i.ik.Ml 
hjod  and  iinpiu'e  water.  These  are  })recisely  the  harmhil  agencies  to  which  our  trodps  weiv 
subjected  during  the  civil  war,  except  that  in  the  latter  instance  there  was  in  addition  an 
exposure  to  malarial  exhalations  which  was  considered  the  etlicient  cause  of  all  malarial 
matdfestations.  But  since  the  troops  on  Indian  servit-e  in  ^Vyonung  and  otliei'  Territories 
ai'e  liable  to  a  remittent  which  may. not  be  attributed  to  emanations  from  the  soil,  it  is  pos- 
sible tliat  some  of  the  remittents  which  afllected  our  soldiers  dui-ing  the  war  mav  have  been 
due  to  other  causes  than  an  airdjorne  malarial  i)oison.  And  if  so,  this  cause  must  have 
been  an  impure  water;  for  the  troops  at  Fort  Bridger  were  also  ail'ectetl  by  the  renutt(>nt, 
and  they  had  nothing  in  common  with  the  soldiers  on  scouting  duty  except  the  water-sup- 
ply from  the  running  stream,  at  times  charged  with  vegetable  impurities.  They  were  well 
led,  well  clothed  and  sheltered,  ami  had  no  exposures  nor  fatigues  other  than  those  borne  by 
their  comrades  at  posts  where  there  were  no  remittents,  but  where  there  was  at  the  same 
time  a  better  water-sup[)ly. 

In  view  of  these  facts  and  considerations,  to  which  may  be  added  a  few  instances  of 
l>robably  malarious  waters  more  recently  recorded,'-'  it  seems  not  uidikely  that  a  certain 
percentage  of  the  malarial  diseases  which  alTected  our  armies  was  due  to  the  introduction  of 
the  malarial  poison  into  the  system  bv  means  of  tln'  drinking-water. 

The  writer  was,  and  is,  inclined  to  bidieve  that  the  eases  dii(.:  to  waterdm[iregnation 
were  included  among  those  characterized  by  adynanuc  tendencies,  liecause  renutteiits  instead 
of  iutermittents  occurred  at  Fort  Bridger,  and  these,  when  neglecteil,  assumed  a  typhoid 
(diaracter.  It  may  readily  be  allowed,  Innvever.  that  where  the  water  is  strongly  charged 
with  the  p(jison  the  morbid  develoiunents  mav  he  rapid  and  pernicious,  as  m  the  cases  on 

*  See  Sm.\iit  uli  H'o/tr  Aiialum,  in  thi^  Aimiial  Itepnrt  of  the  Salumnl  Hoard  of  lluMi,  \Vii..<lii(i(.'lcir(,  l>.  ('.,  IKSd,  p.  .^(l■2,  wiicrc  Rimiilr  Nn.  I\  mkI  Ii.v 
l)r.  <;.\iNKs  of  >!i>l>ili-.  on  iiccodiit  of  malarial  rcniittc?it.s  having  occiirn-d  jimotip  the  ih-ixoks  uKiiij;  it,  was  fpund  to  coiitaiii  .;i.">  |iart  or^ratiic  arintionia 
per  niilliuii.  No.  -1(1  of  tile  same  report,  from  a  fistt-ni  in  a  well-i»avcri  and  non-nialariotis  section  (»f  New  ()rl(>aris,  was  fnrnished  h.v  l»r.  C.  H.  Wmiti:, 
M('di<al  Itirector  of  tiie  Citizen's  .\iixiliary  Sanitiiry  Association,  that  lead,  if  i)resetit.  niifiht  N-  detected,  as  the  persons  nsinj:  the  water  had  been  affected 
with  man.v  anoniato([s  ..syni]'to[([s.  No  lead  was  found,  but  the  inipurit,v  of  the  water,  .70  of  orpinic  ammonia,  was  sncji  that  the  anal.vst  helieved  him- 
self dealiiiK  with  ewamp-water  furnished  for  the  jmrpose  of  testing  his  results,  reiidini;  tin!  anai.vsis  a  severe  cas<'  of  remitledt  fever  was  ilcvelo|M'd  in 
the  house  in  the  [H-rson  of  a  woman  who  had  not  t(een  in  a  malarious  nei;:lihori(«H»d  for  man.v  noxiths.  Suspicion  was  aroused  in  the  minds  <»f  the  [x-ople 
and  the  cistern  was  closed.  When  the  analyst  reported  the  water  as  a  veritahle  swamp-water,  the  occurrence  of  this  fever  was  made  know  n  to  him. 
.\(cordin);  to  the  Ii,p„rl  <i/ ll„  Xnli-'wil  Hoard  of  Htallli,  \sx-l,  p.  att,  Dr.  K.  1>.  ('((((M.KV,  of  .Mariners  Ilarln^r,  Staten  Island,  S.  Y.,  was  called  on  a  Wed- 

nes4lj(y  to  see  tile  cas(>  of  a  pirl  six  years  of  ape  who  died  after  a  convulsive  seizure  whi<di  had  I n  prcecdi'd  l»y  Iwcnly-four  hours  of  chill,  headache 

and  vomiting.  No  autopsy  was  hi  Id.  (ni  the  foUowiUK  Sunday  another  child  of  the  same  faniily  had  a  chill  foll.meil  l,y  (ehrile  excitement.  Th.-  .hill 
recurred  next  da.v,  and  death  took  place  after  didirium  and  convulsions.  .\s  the  reupaininn  cidldren,  three  in  nundier,  were  now  show  in^  symplouis  of 
fon.ttestive  fever,  l>r.  l'((oxl,K\  ordered  the  family  to  move  into  another  hou.se  alioul  thirty  nMlsdistanI  and  siKnited  upon  higher  ground.     The  ground  on 

which  the  V(Mated  I .se  stn(«l  was  so  low  that  .«-casionally  it  was  surrounded  hy  lhi.  tide.     Tie-  well  was  only  ahout  six  feet  d.-.p,  and  al.out  a  month 

hefore  the  death  of  the  first  child  it  was  completely  tilled  hy  a  very  high  tide.     This  «a-  li^d.d  out.  and  afterwards,  when  the  waPr  .anie  into  the  widl, 

a  green  siuin  was  noticed  on  the  surface  of  it.     The  door-yard  was  kept  in  a  lillhy  condition.     This  was  II nly  water  u.si-d  fioni  the  lime  the  well 

was  baled  out  until  the  s ml  child  died  :  and  the  mother  stated  that  these  two  children  drank  a  go.»l  deal  of  the  water.     The  remaining  children 

promptly  hegan  t'»  rei-over  under  siM-citic  treatment  and  wen-  fully  n'st(»red  to  health.  I>r.  CooXLr.v  refem-d  the  ea.ses  to  the  use  of  the  widl-waler.  The 
analyst's  report  on  this  sample,  the  history  of  which  was  uiiknuwn  to  hiin,  may  he  summed  up  in  the  remarks  ap}H-(ided  to  tlie  analytieal  details—"  Iwid, 
(indiahly  ditch-water."  See  also  the  lirilM  iledkal  .lovrwd,  Novemtsr  S,  ISM,  to  which  .Mr.  Wll.vl.i.KV,  a  memlsr  of  the  Indian  Civil  .S'rriie,  contriliuted, 
p.  '.iI'J,  an  interesting  memorandum  concerning  the  i»roi>agation  of  malarial  fevers  hy  impure  driiikiiig-waliT.  .\Iong  the  base  of  the  Himalayas,  in 
the  northwestern  provinces  of  India,  lies  a  helt  of  marsh  and  forest  called  the  Terrai,  which  for  many  .veai-s  has  heiii  uniuhahitahle  owing  to  the  malarial 
fevers  which  prevail  then'.  Cimtiniioiis  efforts  have  heeu  made  hy  the  government  of  the  pnivinci'S  to  nrlaim  and  poimlate  this  tract,  hut  w  ith  (mly 
partial  success.  The  strife  hetween  enterprise  and  malaria  is  continually  carrieil  on,  l.nt  at  the  cost  of  a  fearful  .sacritic'-  of  human  life.  The  |M>ople 
have  for  age^  hrlirM.I  ill  (he  transnlis^ion  of  the  fever  hy  meaUB  of  the  drinking-wati  r,  and  this  hi  lief,  it  is  staled,  has  at  last  been  accepted  in  its 

Mki>.  Hlst.,  Pt.  111—21 


162  CAT-SATrOX    OF 

thf  Argo  an.-l  in  those  reeorderl  hy  Dr.  Coonley.*  The  occurrence  of  lirematuric  Ipvhv  in 
the  winter  inontlia  is  suggestive  of  a  water  origin,-|-  as  are  also  the  congestive  chi'il>  whicli 
0(;('nr  in  some  instances  without  an  aitparmtly  adequate  exposure  to  cuiicentrate.l  miasms. 
These  cases  may  not  be  all  referred  to  differences  in  tho  i)hysiological  condition  of  tln' 
individual,  due  to  variations  in  nutrition  or  hygienic  surroundings,  since  differences  iii  thr 
type  of  the  disease  are  manifestly  less  dependent  on  such  idiosyncratic  conditions  than  on 
s(>ason  and  locality,  and,  as  in  the  case  of  the  mountain  fever,  on  the  natui'e  of  the  poison 
or  on  its  mode  of  int,ro<luction  into  the  system. 

The  a"-encv  of  the  water-sunplv  in  the  transmission  of  the  malarial  poison  lias  an 
important  practical  bearing.  A  water  free  from  vegetable  organic  matter  is  indicated  as  a 
means  of  prevention.  But,  in  addition,  a  study  of  tlie  data  collected  concerning  the  effects 
of  impure  water  shows  that  while  surface  waters  have  malarial  possibilities,  filtered  or 
percolated  waters  have  not  been  suspected  of  causing  paroxysmal  fevers. J  Filtration 
appears  to  remove  the  malarial  poison.  The  conditions  of  active  field  service  do  not  always 
admit  of  well-ditminti  or  systematic  artificial  filtration,  and  hence  the  occasions  are  ol  ire- 
quent  occurrence  when  an  extemporized  filtration  by  the  regiment,  company  or  individual 
would  probably  ])revent  much  sickness,  disability  and  death. 

Although  the  connection  between  vegetable  matter  in  a  water  and  a  possible  malarial 
character  of  the  latter  has  been  established,  there  is  no  ground  for  assuming  that  the  vege- 
table impurity  is  the  cause  of  these  remittents.  Infusions  of  putrescent  vegetable  substances 
have  been  taken  into  the  stomach  without  the  production  of  malarial  symptoms. §  But  as 
malaria  is  generated  in  soils  rich  in  vegetable  matter,  a  water  contaminated  by  the  one  will 
be  likely  to  be  charged  with  the  other,  whether  that  water  is  stagnant  on  the  surface  of 
the  malarious  soil  or  an  air-cleansing  precipitation  on  a  non-malarious  region.  It  is  not 
difficult  to  understand  the  absorption  of  malaria  by  moisture  in  swamps,  marshes  and 
other  localities  where  exist  the  conditions  recognized  as  needful  to  the  generation  ot  the 
poison.      It  seems  probable,  however,  that  the  processes  of   nature  result  in  a  general 

(■ntirot.y,  tliiiuRli  lifsitiitiiiKly,  by  most  (if  tlic  nii'dioil  iiruremiiili  in  Iiiilia.  Tlio  iIlu«tration»  given  liy  Mr.  Wll.iLLEV  am  (•(mvinciiiji :  "A  iiarty  iif  wdik- 
iilon  wore  sent  twii  i.r  three  years  ajt.i,  in  tlie  ninTith  of  Oetiitier.  to  repair  a  bri.lp-  over  a  stri'ani  ealleil  the  Chnk.l,  anil  they  were  depeiulent  en  the 
stream  for  their  drinliing-wab'r.  Out  i>f  the  thirty  men  only  three  es<-a|x>d  fever,  anil  several  ilieil  Sinee  then  a  deep  masunry  well  has  Iieen  runstructeil 
at  a  few  hiiuilri'il  yards  distanee  from  the  liriiljie  ;  and  the  forest  (rnards,  whi)  are  liK-ated  there  and  ilriuk  only  the  water  of  the  well,  find  the  station  a.s 
healthy  as  any  other.  Ajtain,  a  villat;e  named  lialirwa,  two  or  three  miles  from  the  forest  honler,  where  the  supply  of  driukinsi-water  was  ohtaiTied 
from  shallow  wells  fed  hy  the  intiltnition  of  the  surface  drainage,  had  heen  reiK>atedly  settled  and  deserted,  owing  to  the  fatal  eharaeter  of  the  fever 
whieh  pri'vailed  there.  Six  years  ago  the  landlord  went  to  the  expense  of  eoiistrneting  a  masonry  well  forty  feet  deep,  reaehing  down  to  the  spring 
level,  and  ido.sed  all  the  shallow  wells  previously  used.  Sinee  then  the  village  has  hi'eomo  known  as  one  of  the  healthiest  villages  in  the  ueighhorliood. 
The  Forest  Department  now  constrnets  deep  masonry-wells  at  all  the  forest  stations,  and  hy  this  preeantion  is  enaliled  to  maintain  a  penuanent  staff 

of  guarils  at  stations  when'  formerly  th n  were  invalided  and  had  to  he  relieved  every  fortnight.     Jloreover,  the  villagers  in  the  viiinity  show 

their  appreriation  of  the  measure  hy  resorting  to  these  wells  lor  their  supply  of  drinking-water  during  the  malarious  season.  There  seems  therefore  to 
he  little  douht  that  in  this  trait  the  ehiefeanse  of  malarious  fever  is  the  drinking-water,  whieh  has  heen  exposed  to  some  poisonous  aetion  ahove  ground. 
The  streams  whieh  enjoy  the  most  deadly  reputation  all  take  their  ri.se  in  the  dense  forest,  and  are  overliung  for  a  portion  of  theireonr.se  hy  a  thiek 
screen  of  overarching  trees  ami  hushes.  Streams  whicli  are  lionlered  liy  sand  or  honlders  are  generally  innocuous.  Unhealthy  villages  are  found  mostly 
along  the  shallow  depressions  which  convey  the  surface-water  of  the  fori'sts  to  the  rivers.  lioth  facta  seem  to  point  to  the  conclusion  that  the  malaria 
contained  in  the  wah'r  is  generated  liy  the  decaying  vegetation ;  and  the  fact  that  the  malarious  season  liegins  in  Ajiril  and  hecomes  most  ileadly  in 
October,  which  has  been  used  to  e.stablisli  another  theory,  dws  not  militate  against  this,  for  these  perioils  are  coincident  with  the  iwriodswhen  the  forest 
trees  shed  their  leaves.  But.  however  this  nmy  lie,  there  is  no  iiuestion  that  many  places  mited  for  malaria  have  now  Iiecome  healthy,  and  the  change 
has  liceu  sharply  marked,  ami  lontemporaneous  with  the  construction  of  ma.sonrv-well.s."  Surgeon  E.  G.  Ri-.sSEl.l.,  Betigal  Medical  Service,— .Wi/i«  in 
aiul  liiJiu-ieK  of  th'  Sple*'ii,  Calcutta,  ISKd, — also  gives  from  his  experience  in  India  many  instances  of  the  association  of  malarial  diseases  with  the  use  of 
water  draining  from  jungles,  terrais  or  marshes  at  the  base  of  mountain  ranges,  and  their  disapfK'araiicc  on  the  substitution  of  a  tietter  water-sup]ily. 

*See  last  note. 

f  See  note  uiprii,  ]i.  12li. 

J  The  purer  sujiply  which  in  all  countries  has  succeeded  the  use  of  impure  surface  collections,  and  wliich  has  coincided  with  the  iliminished 
prevalence  of  malarial  disease,  has  lieon  in  the  first  instance  derived  from  wells  or  springs.  The  water  of  tliesii  has  ofU'li  been  convicted  on  more  or  less 
positive  evidence  of  the  propagation  of  typhoiil  fever;  but  in  no  case  has  a  well-water  been  arraigned  for  the  causation  of  malarial  disease  unless  there 
lias  been  an  evident  inflow  of  surface  washings.  In  Professor  M.\llet's  investigation  into  the  value  of  the  processes  of  water  analysis — .Unntnl  //cjioi-/ 
of  the  yaliomil  linitnt  nf  Hmltfi,  Washington,  1SH2 — nineteen  natural  waters  were  reported,  in  each  of  which  there  seemed  fair  ground  for  believing  that 
disease  had  actually  been  caused  in  the  (hm-sous  of  those  drinking  them  ;  but  of  these  l)r.  Coh.m.ev's  case,  noted  above,  is  the  only  instance  of  a  well-water 
susiK'cted  of  malarial  infection,  and  in  it  a  surface  inflow  was  clearly  established. 

gSee  exiwrimeuts  of  rAREM-DocHATELET  and  Andkai.,  noted  in  the  Second  Tart  of  this  work,  p.  610. 


MALARIAL     lUSKASK.  U-)3 

rlitrnsioii  of  inalarin  in  the  .-uri'atT'  wat^'i's  (>!'  tli«'  carlli.  If  malarial  <'xlialatinii>  Im-  not 
(iHsti'i>\a''l  l'\'  al  iiin>|.|]r']-ir  a-'Mirios  tli.^v  inust  arcuiiiiilal r  as  a  part  ol  tin-  li('tt'rou;i'nr"iLs 
materials  wlm-ii  woiil*!  rnllr.-t  to  a  sut]'i)ratiiii:'  turlM<lily  in  tli«'  aerial  ocoan  lait  lor  tla'ii- 
nrpi'ipitat  inn  iVoni  time  tn  tiuio  with  the  I'ain  ah<l  snow.  The  lo^s  or  mists  wliirh  u'ather 
over  marshes  arc  known  to  he  speeiallv  permeinns  tnan  the  t'ondeiisat  it.m  nr  eoneciitral  mn 
of  evolved  malaria  ae<-(im[)anvini^  the  fine  preeijuLat mn  nf  the  atnios])herie  nier-inre.  It  is 
but  a  stet)  further  to  assume  its  eonikaisation  and  [»r<MM|)itation  with  the  j-ainfa,il  and  snow.''' 


^^  Pr.  MiM.i.uAiM'.  in  ,■»  not"  mi,  |.,  i;|m  ni  tlir  Sf.nnti  r;nt  of  lliis  work.  .si.v<  lli;ii   \\>-  will  \v.i\r  nrr.i^ioii  Ii.Tr;ittiT.  w}i.>n  (lis<-ussin,i:  the  rti..lnf;y  <if 
nmiitriiti  frv^rs,  to  n-W-v  t>-  ilir  ;iruiiinrnts  lirniii:li t   tnrwjir'i  l-v  \h    Smaim'  in   Ijimt  •'[  the  pi'uli;i1>|.'  pivH^ncr  <>i  m;ilari;i  in  tln'  siicw,     TImmt  i.-  thus  [ir-'- 

SeiltC'l   tn   tlir    W  ritiT  ill"  ilriir;it(     t;i>U    mI   i   li  I  ir  i>j  11  -    Ills  uW  II    \V..|U   Jttnl   (ipi  Minns   fl  '  UN    In.    WMnliU   \i;|.'.-.   |H>ill1    nf  \  irU  .        r.irtUnat.'Iv  IliHiirticl.'   Ull   M.Ht„(„in 

Fer,',-  <f,i>l  M.ihirioHs  ir.//.,>,  i,H.  .l.;>r.  M"l.  >-/',/...  .lull..  l^Ts.  was  -iil.Tniri..i  \\]]\]'-  in  iiianiiMripI  t..  Dr.  \\  mmw  \i:i>.  who,  in  a  Ii'tt«Tto  Assi«tunt  Snr^ifon 
C-ii'-i-al  *'.  H.  I'KANF,  Vs.  A.,  ilalf'.i  :\l;i\    I.  1^77.  i-nIiTr.|  luM.l.irct  inns  In  t  Im'  IlinTV  :    !>!.    "  l.rt  nit'  |u>int  niit.'"  In'  wivs.  "tliat  if  Pr.  Sm.vht's  aim!  v.-i.'s  an* 

rnrrrrt.  Hi.-  .-now  thai  iails  a  I  i  ani|.  r»oii:ila>  innlain>  a>  imuli  ori;anii'  amnmnia  a^  \\  \\Kl.\  N,  wln.sc  pinrss  I ni|tlnys.  fouuil  ill  thi-  Thatiics  at  Lninlnn 

Bridgp.  and  inoit-  than  lir  fninid  in  soni"  nl"  ihr  unrst  London  diirdiin;:-\vati  r.  I  loiif.^s  it  «  asirr  lor  ui>-  to  ludicvf  ttuit  I»r.  Smart  Ints  fiillcn  into  soint^ 
orror  in  his  riiaMipnIations  than  tn  hidiiv  this.  '\'h--  prucrss  is  afknnwli'il-cH  to  Im>  nm'  of  rxtn'nir  (hlirary,  in  ^vtiirh  it  is  easy  fttran  inrxiH-ricnct'd 
manipulator  to  fall  Into  error,  so  thai  I  raniiot  h.Ip  suspfi-tiiip;  the  extraordinary  n-siilts  ohtainrd."  Ur.  WnnnwAKns  want  of  lailh  in  llic  iircnrary  of 
till'  uiiulytical  rrsnits  pri'viiiti-d  him  from  Kiviny:  thf  siil'.j''il  riiat  i-onsidcration  which  it  wouM  othcrwisr  lijivn  n-roivt'd  from  liiin  ;  tlius  only  may  we 
acruunt  for  thf  hasty  and  siip'-rli.ial  virws  on  whiih  his  fiirthrr  ..hjfctions  w-V'  liasrd.  'Jil.  "  Nor  am  I  l"'(tr>r  siitisticii  with  tin-  hypothi'sis  hy  wliirh 
Dr.  Smart  acronnts  f^'r  th-'  ptisinrr  of  .-^o  nmi  h  ors^anic  niiitt'i"  in  Ihc  air  of  th^  KocKy  >|outitaiii  rctrimi.  'I'lit'  prt'vailing  winds  of  thr  cotitirn-nt  an- 
from  the  we.st  to  the  >-.\>t,  iU>-  ;;ii'al  majoiily  of  ihr  storms  nmvr  in  that  diin  tioii.  and  tiny  oti^ht  to  rarry  tin'  nrganir  inatt'T  l)Iown  with  the  iiir  from 
thi-  purfaci-  of  tin'  .Tiiitiiirnf  'nrn;i  fn.ni  tin-  llorky  >Innntaiiis  iustrad  uf  towards  tlnni.  ;'.d.  Mon-oviT,  if  Dr.  Smart's  hypothoHis  is  rorrect,  thr  i-fnial 
itih'rmittpnts  in  th"  l.'<.rky  llonntain  n'i;ion  ouuhl  to  pndoniinat*-  in  nnnihrr  and  s.-vrrity  over  iUe  jnitnmnal  oiu'H.  So  far  as  I  know,  Jiowevcr,  thf 
n.'versp  is  tin-  casi'.  Tlir  >l;iti>tirs  of  th<'  I'arifi.-  n-.i;ion,  inrliniinj;  tin-  station.s  iti  New  Mcxini.  Tolorado  and  the  wlopi-  hctwi-i-n  tlio  Rocky  Mountains 
and  the  Pacilir  Ocean,  show  nialariai  diseases  to  he  as  distinctly  autumnal  as  in  llic  other  rey;ions.  Ith.  Kvcn  Dr.  Smart's  p<)st  of  Caiup  Douglas  is  no 
exception  to  this  rule.  The  annual  j  nun  tier  nf  cases  of  intennitfent  and  remittent  fi'vor  tn'tuirring  at  it  is  usually  very  small,  hut  in  IStlG-'t)!),  '71,  ""I'l-Ti 
and  '74  there  were  a  j;oiid  niaiiy  cases.  Tlmse  nf  ISHit  were  all  imported  from  Florida  ;  tlin  others  originated  on  thc>  spot,  and  give  a  distinctly  autumnal 
curve  in  every  year  except  isT  1,  in  w  hieh  the  vernal  fevers  jiredominateii.  fith.  As  to  mountain  fever,  I  have  never  seen  a  case,  and  know  it  ouly  from 
the  testimony  of  otiiers.  Krnm  what  I  have  thus  learned  I  am  ohliged  to  conclude  that  Dr.  Smart's  oh-servatiouH  refer  to  certain  mild  venud  epidemics, 
and  are  heuc)*  partial  and  incomplete.  The  more  severe  epidemic  ohservod  h.y  Dr.  Vollum  tn  1871  at  Camp  Douglas  was  an  autumnal  one,  and  as  his 
account  of  it  is  interesting  and  ditlers  in  many  n'spects  fnun  that  of  Dr.  Smart,  I  suhmit  a  copy  of  the  remark.-*  on  his  sick  report  for  Septeniher,  1S71. 
*  *  *  '  During  this  niontli  an  epidemic  of  intermitlent  and  remittent  fever  accompanied  hy  diarrliiea,  dysentery  ami  tonsillitis  has  pn.'vaileil  at  this 
place  and  in  the  indghhoring  settleuuMits.  Tln^  otTicers"  and  soldiers'  families  were  cliieily  affected,  hut  the  (severest  cases  occurred  among  the  troops. 
The  nunilx'r  (d' cases  among  the  families  was,  inti-rmittents  '2'.\,  typhoid  fever  4.  Annmg  tln'  women  and  cliildren  symptoms  resemhling  hysteria,  often 
appeared  and  teuiled  mmdi  to  disguise  the  cases.  In  many  of  these  cases  there  was  a  strong  tendency  to  sink  into  a  typhoiil  coii.iitiou  ;  and  (he  typhoid 
rases  repoited  among  the  troojis  commeneed  as  intermittent.  Among  the  officers'  and  soldiiT.s'  families  there  were  four  cases  of  typhoid  fever  that  coiti- 
inenceil  in  the  same  way.  'I'liis  epidemic  is  styled  hy  the  resident  physicians  as  the  mountain  fever,  the  tendency  c»f  which  seems  to  lie  to  pass  on  from 
the  symptoms  of  a  simple  intermittent  fii  those  of  true  typhoid  fever.  Its  hahits  in  tlie  interniittent  or  remittent  stage  an-  similar  to  malarial  fever 
elsewhere  in  the  United  States,  and  it  is  controlled  hy  (luinine  if  juislied  in  ten-grain  rioses  three  times  a  day  for  a  week  or  ten  days.  I  have  a  hidief 
that  if  this  treatment,  accompanied  hy  good  noiirisliment  and  moderate  stimulation,  were  adopted  early  enough,  the  tyjihold  symptoms  would  he  pre- 
vented and  the  case  kept  within  the  htiunds  of  intermittent  or  remittent  fever.'  " 

In  reply  to  these  arguments  the  writer  submits: — 1st,  That  an  exj^.-rience  of  many  years  in  th'*  priK-essi's  of  water  aualysl.s,  iinduding  numerous 
examinations  of  rain-water  and  snow-falls  in  various  parts  of  the  country,  warrants  a  heli(d'in  the  .suhshintive  existence  of  the  vegetuhic  matter  report<'d 
by  him  in  the  river,  rain  and  simw-wators  of  Fort  Iiridg(T,  Wyoming  Territory,  ami  <'auip  DougIa.s,  I'tah  T<'rritory.  lid.  That  the  pn-vailing  winds 
an*  from  the  west  to  the  east  is  ackimwledged  ;  but  this  cannot  he  considered  as  proof  that  the  niin  and  snow-falls  in  the  R«Mky  Mountuins  are  esper-ially 
free  from  organic  matter,  when  they  are  known  hy  direct  exj>eriment  to  contain  an  unusually  large  ijuaiitity.  There  are  currents  and  counter-eurn-nts 
in  the  air,  as  in  tin-  ocean,  and  we  cannot  ]iredicate  what  may  he  going  on  in  the  higher  strata  of  the  aerial  ocean  from  the  direction  of  the  currents  at 
its  bottom.  'M.  There  are  many  malarious  valleys  in  the  Rocky  ."Mountain  region  and  in  the  vast  section  id'  country  known  as  the  Military  Division  of 
tlie  Pacific,  where  intiTinittents  are  produced  l>y  exhalation  as  in  other  swamp.y  districts;  and  as  these  predominate  so  greatly  over  the  mountain  fever 
cases,  malarial  iliseases  in  the  Pacific  region  may  he  oxj)ected  to  l)e  as  distinctly  autumnal  as  they  are  in  tlie  Mississippi  Valley.  There  is,  indeed,  no 
general  sea.son  for  mountain  fever.  Its  appearance  in  a  given  locality  is  due  to  local  conditions.  At  Fort  Uridger  it  is  vernal  in  its  visitations,  .-lince 
that  is  the  season  during  w  Inch  the  stream  is  si)0cially  coutjiminated.  On  aciHinnt  of  the  high  elevation  and  northern  exposun^  the  immens*-  masses  of 
snow  which  choke  up  the  mountain  gorges  during  the  winter  take  a  long  time  to  melt  and  drain  off,  during  which  periiMl  the  river  is  swollen  to  two  or 
throe  times  its  average  size  and  its  waters  am  discolored  and  turbid.  At  Camp  Douglas,  however,  the  conditions  are  wluilly  difterent.  The-  stream  Is 
small,  it  htdug  one  of  a  dozen  which  run  a  short  course  down  the  mountain  side  to  a  main  stream,  the  .Ionian  river;  the  exposure  is  southern,  the 
altitude  h)wer,  and  the  winter  climate  much  less  seven-  than  on  the  mountains  above  Fort  Bridger,  ho  that  snow  does  not  accumulate,  but  falls,  melts 
and  is  carried  off  several  times  during  the  course  of  the  season,  from  Xovemher  to  May,  rendering  the  stream  swollen  and  turbid  for  a  week  or  two  at  a 
time  ;  and  so,  during  the  summer  and  autumn,  a  thunder-tdoud  creeping  along  the  mountain  range  will  llood  th(^  creek  fora  liay  or  two,  or  if  the  mountain 
showers  are  repeated  at  short  intervals,  for  a  week  (^ir  two,  thus  disseminating  the  jiruhahle  cause  of  mouTitaIn  fever  all  ovi-r  the  spring,  sununer  and 
autumn,  if  the  turbid  and  impure  waters  are  used  as  a  drinking-sujiply.  Hence  the  time  of  visitation  at  Fort  Itriilger  may  not  he  tin'  time  of  visitation 
at  another  station.  The  time  corresponds  with  the  fltMMling  of  the  stream  with  snow  and  rain-wati'r,  and  not  with  any  s|K'cial  mouth  or  season  of  the  year. 
Nor  can  this  time  he  ascertained  from  the  reconl  of  the  rainfall  at  a  post,  as  it  is  the  fall  <in  the  radicles  of  tlie  stream  which  is  in  (piestion  ;  the  stream  at 
Camp  I>ouglas,  for  instance,  is  not  unfrequently  turbid  from  nn)untain  showers  while  the  post  and  its  vicinity  an*  dusty  and  parched  for  lack  of  niin.  4th. 
Tlie  annual  niiiuber  of  cases  of  malarial  disease  occurring  at  Camp  Douglas  is  usually  very  small,  but  in  certain  years  there  were  ago(«l  many.  In  isri\i 
the  intermittents  were  imported  from  Florida,  and  in  tlie  other  years  clnira<-terized  by  thtdr  |)restmce  thi-re  were  very  notable  changes  in  the  consti- 
tution of  the  garrison.  Thi'  statement  that  the  cases  which  (K'curred  in  these  years  originated  on  the  spot  is  not  sustained  by  a  chwe  insiH'ction  of  the 
history  of  the  post.  Some  of  them  originated,  to  the  knowledge  of  the  writer,  whih.'  the  men  W(;re  absent  on  Indian  service.  From  the  impossibility  of 
distinguishing  in  many  instances  the  imported  from  the  indigenous  malarious  cases  among  those  which  ajipt-ar  on  the  n'cords  of  fnrnn-r  years,  it  cannot 
be  iletcnnined  that  the  latter  are  vernal  or  autumnal,  nor  which  is  of  nmre  im|Kirt.ance,  that  tliey  do  or  do  md  correspond  with  the  imjiure  condition  of 
the  water-supply,  .^tli.  Dr.  Volum  attributed  his  cases  in  1S71  to  rotting  wood  in  the  old  barrack  quarters,  anil  to  dampness  and  want  of  veutihiticm 
and  sunshine,  factors  which  certainly  do  not  enter  into  the  causation  of  many  uniloubted  cases  of  uiouiitain  fever.  An  imiintvement  in  the  health  of 
the  garrison  was  coincident  with  the  construction  of  the  water-re.servoir  ;  but  as  at  the  siime  time  new  and  commodious  ([uarters  were  built,  tlie  writer 
did  not  admit  tliis  increased  healthfulness  of  the  post  into  his  original  argument  in  favor  of  the  transmission  of  malaria  by  the  water-supply,     Iiiasmucli. 


l(>t 


CArsATION    OK 


Mal;ii-in,  is  not  :in  nmUihlo  ors^miic;  ,^as,  lor  were  it  so  its  .lissipaliun  in  tlu;  <ur  would  l>o  lol- 
lowr.l  1)V  lis  acstniction,  aii.l  its  subsoiiueiit  coiuleiisatioii  in  the  marsh  mists  w.-uM  l>o 
ii.i|K.ssil)lo.  It  has  thcrotore  a  certain  stabihty,  and  its  presence  in  the  rain  may  be  as 
rra<lily  accepted  as  its  presence  in  the  mists,  it*  the  same  morbid  plienoniena  foUow  tlie 
in,-;rstion  ol'  tlie  rain-water  as  foUow  an  exposure  to  the  mists.  This  stabihty,  in  view  ol' 
tiic  (>xi(U/.ing  influences  of  the  air,  is  suggestive  of  a  vital  resistance  on  the  part  of  the 
miasm,  and  lends  countenance  to  the  views  of  those  who  regard  as  the  essential  of  malarial 
disease  a  specific  germ,  which  will  be  eventually,  if  it  has  not  been  already,  identified/^ 

Rki,ai\^ks. — In  some  instances  in  which  the  individual  had  already  suffered  from  the 
disease  the  so-called  predisposing  causes  operated  so  strongly  as  to  be  apparently  the  deter- 
mining cause  of  a  relapse  or  recurrence.  It  was  observed,  in  commands  affected  by  the 
malarial  poison,  that  a  suddenly  developed  increase  in  the  number  of  the  intermittent  cases 
frequently  resulted  from  exposure  to  chill,  as  from  wet  clothes,  weather  changes  or  incau- 

howcvor,  aK  Dr.  ■U'r>oi)WARD  Iuik  l)rc.uKlit  the  cpidomu-  fnrwanl  hi  tliiw  rdiuuTtinn,  it  nuiy  Iw  imiiitcil  nut  that  wliilr  tlic  local  conditiuns  nn_'utiiUMMi  l»y 
Dr.  Voi.n'M  may,  and  uiiit'>iilit''"lly  Iiad  lln'ir  iiitlui'in-c  <>n  tln'  rhjiraitiT  iitnl  prn^^n'sis  of  ttic  disf'asi'.  tlicy  wen*  not  tin'  essential,  fnr  lie  ('Xpri'ssly  states 
that  til''  *'pi'l<'inii-  was  iiiit  ((inHm-il  to  tlif  pnst,  hut  implicated  \hv  Tifit;lilmriri;;-  scttlcTncnts.  all  of  wliicli.  it  may  ln>  n-markr'd.  made  nso  of  water  from 
lilt'  <  'amp  hou;;las  fitrtani  or  froTii  others  niriniiL^  a  parallel  course  and  suhjr't-t  In  tin'  same  contaminating.'  influences. 

*Tht'  latest  attempts  at  identiticatioTi  have  hcen  l>y  Ki.Kif;;  and  ToMMAsi-('itri>KM—W"f/( -■*»//'(  .\<itin<t  <lf'lln  Malmi'i.  Kc.ma.  I  NTH.  The.se  eM  in  vij;atoi.j 
ann<iunced  the  discovery  of  a  hacilhis  \vhi<h  they  found  constantly  present  in  the.  swanip-niud  of  the  l{oman  marshes.  This  hacillus  was  susi-eptihli'  of 
cultivation  in  tish-j;elatine,  ami  wIhmi  injected  into  ralihits  pmduced  a  fever  similar  to  that  which  occurs  in  the  human  suliject  when  expo-seil  to  paludal 
exhalations.  It  consisted  of  short  nxls  ^^  to  |()  niicruniilliinetres  in  lenj;th  wiiich  evcdved  into  tortuous  fllanu'iits,  jointed  hy  the  forniati<in  of  clear 
i*[Hice«  at  repular  intervals  in  tlieir  jirotophisni ;  spores  wen-  develop^^d  in  tlie  centre  (»r  at  the  extreniiti<'s  of  the  joints.  They  considered  this  microphyte 
as  the  cause  of  malarial  fever,  and  named  it  H.  malarias  Hut  other  ohserverH  have  faih'd  to  identify  it.  .Steknhkki;,  who  was  sent  hy  the  National 
BtKird  of  HejiUh  to  inv<'stiKate  this  subject  in  the  mahirious  environs  of  New  Orleans,  fimnd  in  the  niarsh-niuii,  ann)n^  many  other  bacterial  forms,  some 
which  .seemed  to  answer  (he  description  piven  of  the  H.  malaria',  but  similar  forms  were  found  in  dust  fnun  the  city  s<|uares  of  New  Orh-ans,  ancl  also  in 
culture  exjMTimerits  at  Baltimore,  where  malaria  wns  not  in  question.  Moreover,  the  inoculation  c-xiieriments  on  rabbits  won'  hold  by  him  to  be  incon- 
clusive, an  the  teni|K*rature  curve  in  the  nibbit.i  ojH-nited  on  had  in  no  case  a  distiiietly  i«»roxy8mal  character,  while  healthy  rabbits  sometimes  showed 
as  marked  variations  in  tenii>erature  as  thosi'  delineated  in  the  charts  of  Klf.rs  and  ToMM.\si-CKrnELi.  The  chanfjes  in  the  spleen  which  these  exj)eri- 
menters  found  at  the  autopsy  of  the  inoculated  nihbits,  and  attributed  to  the  malarial  influence,  were  shown  by  Stkrnbkrg  to  occur  in  death  fnun 
septica'uiia  produced  by  the  iiKwulation  of  human  saliva — HPe  Snppleweul  No.  14,  Nathnal  Hoard  of  Jli-nlth  HnllHhi,  Washin^tfUi,  1881.  We  must  therefore 
conclude  with  him  that  the  evidence  on  which  Ki.F.iis  and  ToM>iAsi-('Rri>Ki,i  based  theirclaini  to  a  discovery  is  not  (satisfactory.  Xevertheh'ss  Dr.  Jri.irs 
ItRKScuKiKi.P,  I'res.  Microscopical  Section,  Mamlu^t'-r  Medical  S<K-ie{y,  exhibited  at  one  of  the  meetings  of  the  section  s[K'cimeiis  <»f  blood  taken  from  a 
sailor  sutTeririj:  from  ititrMinittinn  attacks  of  fever.  The  Idood  c(uitained  bacilli  of  exactly  the  sanu-  character  as  those  desr-ribed  hy  TomMASi-Cii(i)p:i,i. 
Iturin^'  Hie  intermissions  the  bacilli  disappeared,  but  their  spores  <ould  be  readily  di.><tinjiuished.  -Hritish  }h;i.  .hmr..  Vol.  I,  ISM,  p.  \k\'L  While  I.anzi 
atitl  TKumot  (sec  note  supra,  p.  l.'i'J)  rejiard  the  pi{;mr-nt  };ranules  in  tin-  IdoiMl  of  malarial  caws  as  resnltinj;  f'rotn  a  fermentative  action  produced  by  ^iruilar 
frratiules  derived  from  the  decomposition  of  jiri  .I/./.i  iiii'isninlira,  I.avkhan — Xutnrf  I\ir<isU(iirf  ihs  Airidmfs  ih-  I'  Imjufhiilisnif,  Paris,  IHHl — insists  that  these 
pig;meut  ^;ranules  are  connected  with  Hie  life-jiist'.ry  of  a  niicroparasib'  whic-h  nourishes  in  thi-  bloo<l  and  which  has  heretofore  been  ret;arded  by  Kf.i.scu 
and  others  as  a  pigment-bearing  h-ucoivtr.  In  e\amitiations  of  the  blotMl  in  sixty  malarial  rases  ilurin;;  his  servii-e  hi  .Mgiers  Lavkkan  found  the  pij;- 
nieiit  gninules  in  forty-two  cases.  The  lary;e  pr>>portion  of  iiepttlve  ri'sults  was  due  (o  pndonj;ed  treatiu-nt  in  thes:'  instances  by  the  sulphate  of 
quiuine.  Hut  the  interest  in  his  observations  attat  lies  to  the  eelluhir  envelniM'  en<dosinj;  the  pij;ment  jxranules.  It  was  distiiti;uished  under  threo 
forms,  which  he  has  figured.  In  the  liri-t  the  cells  are  elongated,  somewhat  pointed  at  their  ends  and  often  ineurvi;<l  (baiiana-sha|K'd) ;  sometimes, 
however,  they  are  oval;  the  pijrmeni  jirains  are  Ioos<'ly  ajjKre^ated  or  ilispi>sed  in  an  annular  form  toward  the  centre  of  the  c-ell.  In  the  second 
the  cells  are  spherical,  and  in  size  sometimes  even  lartier  than  a  red  blood-corpns(de ;  the  pigment  jj;rairis  an-  usually  arRinj^ed  in  a  ring  concentric 
with  the  circumference  of  the  cells.  Thcsi-  spherical  bi»dii's  Jire  furnished  with  three  or  four  slender  filaments  each  about  three  tin.et)  as  louj;  as  the 
diameter  of  a  ivd  bloixl-corpuscle.  Whi'U  in  nipid  mi>tiou  the  filaments  undulate  like  the  an^nillula  and  their  action  impresses  a  moveoient  on  the 
neighborinj;  corpuscles.  In  the  third  form  there  are  various  deviations  from  thi-  spherical  (uitline  ;  the  cells  are  larger  than  those  of  tl.e  filamenti'd 
series,  and  while  the  contained  pigment  graiiis  are  irregularly  disposed  the  annular  arrangement  is  sometimes  noticed.  I.avkrax  reganis  these  thr<'e 
kinds  of  cells  as  representing  ilifferent  ithas*'s  of  the  evolution  of  the  siime  panisite.  the  serond  form  furnished  with  nmbile  tilainents  Icing  considen-'l 
the  i«'rfect  stati'  of  the  orgiinisni.  while  the  third  form  is  reganh-d  as  the  cadavers  of  the  iwrasitic  idenients  and  as  identical  with  the  jiigmented  elenietits 
found  in  the  organs  of  persons  who  liave  dii'd  of  |«'rnici(.iis  fevers.  Uecently  T<immasi-('rt  pei.i,  Marcuiavava  and  Cf.lli— />«/tV(*j  Mfhrid  iin::''tt'\  Vol. 
•  XXI.  p.  7,  Calcutta.  .Ian nary.  iSHi;— have  shown  that  the  a pjH-a ranees  legarded  by  Lavkkan  as  due  to  an  exotic  oi-ganism  in  the  bhuMi  are  in  reality  th^ 
result  of  degenenitive  r-hanges  in  the  red  blood-ctprpusdes.  The  globular  pndoplasm  ap|K'ai-s  to  become  absorbed  or  converted  into  a  hyaline  material 
phowing  amo'boid  changes  of  form,  itiid  the  luenioglobin  is  transfornu'd  into  melanotic  iwirticles  which  exhihit  oscillatory  inoveiuents  in  the  intfri')r  of 
the  corpuscle  iiou  represented  by  a  diaphanous  spherule.  The  nn>bile  filaments  of  Lavkras  have  been  observed  by  these  Investigators,  but  are  believed 
to  consist  of  globular  protoplasm  luiKlified  in  a  way  as  yet  iinkiioun.  The  corpuscles  ultimately  become  djshitegrated  and  the  black  pjirtides  in  various 
degn-es  of  aggregation  are  set  free  in  Hie  current  of  the  circulation.  Camim.o  (ioi.ni — Fortnchrittp  (h'r  Mfdiiin,  B.  IV,  1SSC»— has  also  seen  changes  in  the 
blooil  similar  to  those  dewribed.  consisting  of  the  de\elopm  -m  of  colorh-ss  plastnic  bi Miles  in  the  red  bhxKi-corpuscles.  .\s  these  Ixulies  enlarge  melanotic 
jiarticles  are  found  siatt^Ted  within  their  substance.  All  trace  of  the  nonnal  ciuistitution  of  the  Idocul-corpuscle  becomes  lost  in  its  tninsformation  inti* 
a  cidftHess  globule  contahiing  particles  of  pigment.  The  latter  ultimately  tend  to  the  centre  of  the  globule,  appearing  as  a  dark  nucleus  around  which 
the  eidorless  substance  und<-rgoes  fission  In  radiating  lines,  the  resulting  cellules  presenting  a  si-inblance  to  the  rays  of  a  coinpositi'  flower.  When  this 
Htuge  »)f  tieveUipnient  has  been  reached  a  febrile  attack  is  imminent.  Afterward  the  cellules  and  the  centnil  mass  of  pigmented  matter  are  liberated  into 
the  curn'iit  of  the  blood.  At  I*avia,  (Joun  examined  forty  cases  with  negative  results  in  two  only.  Most  of  liis  fevers  were  (piartans ;  and  he  claims  that 
the  long  intervals  between  the  [>aroxysms  affonled  time  for  tlie  complete  develuimient  and  fission  of  the  alten-d  corpusch-s,  results  which  are  not  observed 
in  fevers  which  have  shfirter  intervals.  Whether  the  destruction  of  the  red  bloiMl-corjiuscles  ami  the  assix-iated  jtignieiitary  changes  result  from  tho 
action  of  the  bacillus  malaria'  or  of  the  alga  of  Lanzi  and  TF.RRior,  or  are  independent  of  both,  d(M's  not  ajiiK-ur  to  have  been  determined ;  hut  Tomma.si- 
Cridfi.i  regards  them  as  of  great  practical  importanie  in  the  diagnosis  of  obscure  cases  of  malarial  infection  in  continued  aufl  subiontinued  fevers. 

.\-:  the  genu  thi'ory  of  malarial  di.sease  <'xplalns  so  many  of  the  nioridd  phenomena  and  is  at  the  sjuue  time  consistent  with  what  is  known  of  the 
natural  history  of  the  ditieasc-esKcnce,  there  is  a  strong  tendency  to  accept  it  iu  advance  of  the  isolation  and  identifitatitm  of  the  specific  micro-organism. 


MALAKTAT.    DlSKAsE.  165 

tious  rooling  after  the  perspirations  of  lali^'ne  <luty.  Tliat  tlicse  attacks  were  not  du.'  t.) 
Iresli  arcL'ssions  (i|  tin*  poisr^ii  was  t^'vnltah'tMl  hv  lluar  occurrtaice  alter  llt<-  t<'nnM)i-;n-\-  rliill  ul' 
a  l)al  li  undertaken  as  a  Inxurv  t»r  in  the  intt-rt'st  of  personal  cleanliness.  !!< 'lapses  wciv  also 
ottentiiiies  releiTetl  to  ei'i'ors  (^1  diet.  Tliey  oeeui'red  at  anv  time  at'ter  the  .priinai'v  attaek- 
but  ill  eases  in  wlneli  tlu^  (tpt-ratmn  nl  a  pi-edisposin^  eaus.-  was  not  nianitest  a  ti-ndt-nev  to 
recurrence  at  weekly  intervals  was  u'enerallv  conceded:  tlnis  Mkimmtt  speaks  t)f  wai'dino- 
oft  the  liehdoinadal  eliill  hv  arsfUite  ol  p"">tasli.'=*  Xo  ohsei'N'al inns  wepi'  recorded  ^n  this 
point:  nor  were  lhf\-  possiMe  on  an  ext»'nd*_'d  scale,  as  treat  nieuL  interfered  with  ihi-  natural 
progress  of  tlie  inurbid  pheiuMneiia.'f' 


VI.— PREVENTION  OF  MAF^ARIAL  DISEASE. 

Gkneral  Constdkkations. — From  what  lius  heen  said  uiuh^r  the  head  of  causation,  it 
is  clear  tliat  the  protection  of  the  troo])S  from  the  malarial  intluence  is  the  alhimportant 
preventive  nh.'asui'e.  It  is  tvvn^  that  on  active  service*  the  imperative  military  necessity 
often  rerpiires  the  sacritlce  of  life  hv  disease  in  the  occupation  of  an  important  Itut  unhealtliy 
locality,  as  it  calls  lur  expitsure  to  death  nu  the  line  of  hattle;  hut  in  hoth  instances  a 
thorough  knowh?dge  of  the  ground  may  j)erinit  it  to  be  lield  with  a  minimum  of  loss.  Dr. 
WooOHUi.L  sjiows  that  the  disease  in  the  9th  N.  J.  Vols,  was  due  to  the  oc(aipation  of  acami) 
near  a  broken  dam  jiresenting  a  large  extent  of  bottom  hind  as  a  niakarial  exhalent.  ^Flie 
(>th  ( 'oim.  Vols.,  in  Dmu^.lk's  report,  became  seriously  damaged  hy  its  camp  in  tln^  swamps 
ol  ^Vai'saw  Islauih  These  and  various  other  reported  instances  may  have  been  unavoidable 
results  of  tlie  military  necessity;  but  it  is  certain  that  tlie  health  of  many  commands 
suft*ered  fi'orn  the  occupation  of  unhealthy  camp-sites  which  were  afterwards  abandoned 
altlioughthe  inihtary  conditions  remained  unchanged.     Thus  we  find  Dr.  Tripi.er  effecting 

*Sc<'  Merritt's  report,  in/m,  p.  180. 

fFuRRv  ill  liis  CUimiie  iif  tin-  I'liUfil  SfnU'ity  New  York,  1842,  p,  283,  says:  "That  iuterinittcnt  U-xcr  Ii.-ik  a  t<-Tni»'Tirv  to  a  sfptenarv  n-vuliitinii  is  a 
fact  tliat  was  frf.|u<'ntl.v  vcrificil  in  Florldii  luiih'r  tlic  author's  observation  ;  and  this  too  in  a  niatim-r  so  uncquiv<KaI  that  it  attnirtfil  the  atti-iitiou  of 
till'  (omriinn  wdlilicr.  At  these  Ht'ptciiarv  jM'riods,  afti-r  t!ic  seventh,  fourti-enth  or  twenty-tirst  iKintxvsni,  the  disfuse  has  a  (iis|Mtsiti(pn  t.i  terminate  spon- 
taiu'diisjy.  It  is  at  tliese  iKTiinls  that  fchrifuj^e  remedies  act  with  the  jirreatest  success  ;  aucl  as  repinls  relapses,  it  is  then  too  tliat  a  vast  majority  <K'cur, — 
a  circuuistaiice  of  sucli  fretpu'iit  (K'currence  in  Florida  that  soldiecs  would  voluntarily  come  to  the  hosjiital  to  ohtuin  medicine  to  prevent  its  i*etuni." 
'I'liise  statements  are  somewhat  luiracloxical :  The  influenees  o|H'ratinff  at  the  septi-nary  iwriiMls  nut  only  cause  the  sulisidence  of  an  attack  In  i>uv  wlio  is 
sntfertni;,  Imt  liave  power  to  deteruiliie  the  (x-curnMice  of  an  attack  or  relapse  in  one  who  is  not  sufferiuf;.  The  d<K'trine  of  u  iK-riinlicity  iie|K'udent  on 
lunar  intluence  has  heen  lon^  entertained  hy  ahle  fihservers,  esix-cially  in  India.  r>r.  Francis  Halkoik  in  his  Tvnl'm'  on  Putrid  lifmittimj  Inte!</itial  /■l».-js, 
Kdiuhur^h,  ITiHi,  develi>])ed  the  theory  of  sol-luiuir  influence.  In  accordance  with  liis  vh-ws  daily  remissions  aiul  afrtiravations,  septenary  n-turns  and 
seasonal  j.revalence  were  due  to  the  comhined  intluence  of  the  sun  and  moon,  the  fehrile  state  hi'ln^f:;reater  at  the  diurnal  meridional  iK'ri<Mls  than  durint; 
the  inti-rmeridional  intervals;  at  the  uovi-lunar  and  pleni-lunar  (M'riods  tlum  durin>^  tlie  iutervi'tiiuj;  iwritxls,  and  ♦■s|M'cially  at  the  hmar  imtiimIs  of 
the  equinoxes  as  coni|>ared  with  those  of  the  interM-ipiimxtial  intervals.  He  stat«'s  that  the  sol-liinar  iuflueiu-e  in  fever  is  felt  at  Ilonaris  and 
(dher  places  not  less  tlian  three  huudred  miles  distant  from  the  n'acli  <tf  tlie  tides,  and  that  cuusecpiently  Lind's  idea  that  these,  and  not  the  agencies 
hy  which  they  are  caused,  are  ctmnected  with  the  jiro^rn'ss  of  fever  is  suflrtciently  refuted.  Sir  J.  K.  Martin  in  his  lutliifnr,'  *,/  7V<.jn>*i/  Cliitintf.%  London, 
IsCl,  quotes  the  observations  by  which  Mr.  Francis  Dai.v,  of  the  Maitras  army,  arrived  at  the  conclusion  that  there  is  a  s«d-luHar  intluence  as  arj^ued  by 
I>r.  Bai-focr  ;  and  W.  Moore  in  his  I)u*mses  of  In'din,  London,  1801,  pji.  H7-8,  says :  "  Indeed  a  very  short  piuctice  in  the  tr<»pics  will  convince  the  most 
sceptical  that  individuals  who  have  suffered  froTu  malarious  feven*  are  more  or  less  affected  at  either  the  full  or  chaiij^^e  of  the  moon.  Many  exiM-rience 
return  of  fever  at  these  times;  others,  feelings  of  uneasiness  or  nialais4',  but  not  amounting  to  actual  ague  ;  and  this  |)redispositiuu  tolwcome  periodically 
aifected  may  remain  for  months  and  ev^'U  years,  and  may  reiur  at  uncertain  periinls,  the  intervals  being  (Hissed  in  perfect  health.  That  the  inoou  ;<*>;■  w 
has  any  effect  in  inducing  this  state  may  well  be  questioned  ;  but  that  the  amount  of  mud  surface  exjiosed  by  the  low  ebb-tides  and  the  consequent 
greater  exhalation  taking  place  may  act  as  an  excitant,  is  at  least  jirolmhle  in  the  ueighborhotKl  of  the  sea-<H«ist.  In  far  inlanii  districts  some  t)ther  solu- 
tion of  the  mystery  is,  however,  requisite;  and  Morehkad  inedines  to  the  opinion  that  when  the  coincidence  of  febrile  diseaw  and  lunar  phase's  is  ruited, 
there  will  generally  be  found  pres(_'ut  an  appreciable  atmospheric  change  of  temivniture,  of  moisture  or  (»f  direction  of  winds,  wliich  he  apprehends  i,-  the 
deteiTUining  cause  of  the  febrile  disturbance."  Nevertheless,  in  the  AunaU  *>/  MilUnrif  and  Sand  Sunjertf,  ih:,  London,  IHiMi,  I>r.  H.  (iiRAin,  on  page  184, 
states  that  the  want  of  ivliable  evidence  on  the  subject  of  the  moon's  influence  on  iH'ri^Mlic  fever  liaving  been  brought  to  the  knowledge  of  the  comiuander- 
iu-ohief,  orders  were  irtsue<l  requiring  that  the  records  of  iKiroxysms  should  1k'  kept  in  every  medical  charge  in  the  Bombay  Presidency  during  the  year 
ISfil,  with  a  view  to  deteiinine  the  question.  The  result  showed  ori,17."i  jiaroxysms  as  iM-curring  in  14)>  medical  charges  at  U  stations,  4ind  it  is  concluded 
from  these  that  pantxysms  of  fever  do  not  txcur  lUtire  freipieutly  at  tin'  springs  than  at  other  j^'riiMls  of  the  month. 


166  TRKVKNTIOX    OF 

the  nMiioval  of  the  troops  from  tlie  fiiits  iiciir  Arhagtoii,  Yn.,  to  tlic  liigher  grounds  beyoiul 
the  first  ri(lg<'  overlooking  the  Potomac  river,  that  they  loigliL  liave  the  jtroti.'ction  ol  its 
crest  from  tlie  malarious  currents  n|ii'isiiig  from  the  hottoni  lands/-' 

The  predisposing  conditions  or  so-called  causes  were  also  unavoidable  in  many 
instances,  but  not  in  all.  E.xposures  to  excessive  heat,  cold,  rain,  fatigue,  etc.,  might  not 
be  avoided  in  the  face  of  the  enemy,  but  their  influence  was  at  times  unnecessarily  i'elt  in 
camp.  At  one  period  the  men  of  tlie  Army  of  tlie  Potomac  were  turned  out  f(ir  duty 
long  before  sunrise  and  breakfast,  but  Dr.  Triplkr,  recognizing  that  this  had  much  to  do 
with  the  prevalence  of  malarial  fevers,  obtained  an  order  that  reveille  .should  not  be  sounded 
until  after  sunrise,  and  that  hot  coflfee  should  be  issued  immediately  after  roll-call. 

A  dry  camp-site,  good  water  and  food,  suitable  clothing,  the  avoidance  of  unnecessary 
drills  and  fatigues  during  hot  weather,  and  of  exposure  to  nocturnal  chills,  particularly  when 
the  troops  are  fasting,  will  not  only  lessen  the  prevalence  of  malarial  diseases  in  commands 
wliicli  have  uidbrtunately  been  exposed  to  the  miasmatic  influence,  Ijut  when  combined 
with  temperance,  cleanliness  and  that  I'cgularitv  <^f  life  which  old  and  well  disciplined 
soldiers  find  to  be  not  inconsistent  with  active  service  in  the  field,  will  probably,  as  sug- 
gested by  Ass't  Burg.  Ingram,  prevent  the  development  of  typhoid  syniptoms  in  the  mani- 
festations which  do  occur. 

The  experience  of  our  medical  officers  is  opposed  to  the  idea  of  an  accommodation  of 
the  system  to  the  malarial  poison  with  the  concurrent  retention  oi'  a  normal  degree  of  health. 
The  febrile  accessions  might  fail  to  recur,  but  the  patients  continued  aiuemic,  weak  and 
languid,  if  they  did  not  become  subject  to  the  more  active  manifestations  of  chronic  malarial 
poisoning,  so  long  as  they  remained  exposed  in  the  malarious  country.  Medical  Inspector 
W.  H.  MussEY,  U.  8.  A.,  touches  this  subject  in  a  report  of  an  inspection  of  the  Depart- 
ment of  North  Carolina,  dated  April  18,  1868: 

Much  has  been  said  upon  the  subject  of  accliuiiition,  which,  in  these  localities,  would  be  nothing  more  noi' 
less  than  a  conijilete  saturation  of  the  system  with  malaria,  so  that  intermittent  fever  would  be  the  nornuil  condition 
of  those  acclimated.  But  there  must  be  acclimation  to  the  new  life  of  the  cam]>,  and  this  is  important.  It  is  es.sen- 
tial  to  keep  the  soldier  up  to  the  highest  point  of  resistance  to  the  malarial  influences.  Care  in  the  ([uality  of  the 
food,  the  proper  mixture  of  vef^etabh'S,  the  cookery,  the  administrati<ni  of  proi)hylacticM,  attention  to  cleanliness, 
raising  the  bed  above  the  ground,  avoiding  unnecessary  exposure  in  the  night,  wearing  tlauncl,  and  the  administra- 
tion of  cotfee  and  a  lunch,  are  the  best  means  of  securing  this  resistance. 

PR0PHYL.\CTIC  USE  OF  QuiNiNE. — The  attention  of  the  medical  otficers  of  our  armies 
was  directed  to  the  prophylactic  use  of  (piinine  at  the  very  outset  of  the  war.  fn  the  Rales 
for  preserving  the  heaJtJi  of  ilie  soldier,  prepared  by  Dr.  Wm.  If.  V.\n  Buren  of  New  York, 
for  the  United  States  Sanitary  Commission,- and  issued  July  V.),  1861. f  the  ilaily  use  of 
quinine  was  recommended  in  localities  wheie  ague  and  fevers  wei'e  prevalent.  Later  in 
the  year  a  pamphlet  by  the  same  author  J  was  also  issued  giving  a  digest  of  the  evidence 
on  which  the  recommendation  was  founded. 

This  embraced  the  personal  experience  of  the  author  in  Florida  during  April,  1840,  that  of  his  friend  Dr.  J.  8. 
Newberry  on  the  Isthmus  of  Panama  and  elsewhere,  a  letter  from  President  David  Hoadley  of  the  Panama  railroad 
company,  setting  forth  the  beneticial  results  of  an  issue  of  ([uinine  in  wine  to  the  crews  of  merchant  vessels  visiting 
.\s))inw-all,  a  letter  from  William   l.airil  of  Liverpool,  relating  the  successful  use  of  ciuinine  as  a  prophylactic  by  the 


*  ApfHiiidix  to  Part  First  of  this  work,  ii.  46. 

fU.  S.  Sanitary  r'omniiasi,>ii  Dim-.  Nd.  17,  reiirintetl  in  MiUtanj  MkI.  ami  Siiry.  Emu/g,  edited  for  the  ronimission  hy  Win.  A.  jrAsiHONn,  Pliiladelphia, 
1864,  par.  2.'i,  p.  16S ;  "  It  is  wise  and  prudent,  wlien  ague  and  fevers  are  prevalent,  tliat  every  man  sliouiii  taki^  a  dose  of  quinine  hitters  at  least  once 
iu  twenty-four  lionrs.  This  will  snridy  serve  as  a  Siifeguard  against  an  attack  of  disease  ;  it  has  heen  practised  in  Florida  and  elsewliere  with  undouhted 
heuetit." 

J  Wii.l.iAM  II.  Van  lilKKS  —  Qiiwiin'  .1-  .1  I'n.pluilwlir  ,i,,,il,isf  .If.i/iirejiis  iluieiise.  Sanitary  Conunission  Dix-.  31,  New  York,  1861,  reprinted  up.  <U., 
last  note,  p.  !«  el  se.j.     From  a  note  ap|«-uded  to  the  .jrigiual  pamphh-t  it  api»ars  that  this  essiiy  was  approved  for  puhlieation  Septemhcr  30,  1861. 


MALARIAL    DT8EASK.'  167 

crews  (till  ]\ne  of  stcamerH  plyiuj?  l>etween  Liverpool  and  the  coast  of  Africa,  the  testimony  of  Hryson  *  and  Ilayuet 
of  the  Kn-^lish  >  a\y.  Dt*  Saussnre  i  of  Ciiarleston,  8.  C,  and  of  several  African  travellers, '^S  hesides  sundry  favorable 
<»]»ini(>iis  and  recoiiiinendations  from  various  sources  showing  the  conlidcnce  with  which  the  nirasun'  was  regarded 

iu  various  (|uartcrs.|| 

It  was  elt.'clarod  to  be  a  fact  well  established  in  the  experience  of  American  physicians, 
that  the  daily  use  of  three  to  six  grains  of  quinine  by  those  who  arc  exposed  to  the  danger 
of  malarial  {>oisoning  will  in  most  instances  avert  an  attack,  or  failing  this,  will  render  the 
disease  milder  and  prevent  the  development  of  the  malarial  cachexia. 

In  accordance  with  these  recommendations  quinine  dissolved  in  whiskey  was  fro- 
(juently  used  as  a  prophylactic  by  our  medical  officers,  but  no  systematic  records  of  the  results 
wcrt-  kept;  nor  docs  it  ap|>ear  that  the  metliod  was  anywhere  employed  with  persistence 
on  a  consideral)le  scale.  Tlie  difficulty  of  transporting  the  whiskey  needed  for  the  purpose 
often  interfered  with  the  continuance  of  the  experiment,  and  at  other  times  the  quinia 
itself  could  not  be  obtained  in  sufficient  quantity.  Many  medical  officers  w^ere  led  by 
their  observations  to  form  a  favorable  opinion  of  the  efficacy  of  this  prophylactic  method, 
and  in  the  Sanitary  Commission's  Memoirs  may  be  found  the  testimony  of  Sui'geons  Isaao 
P.  (Ialloupe,  S.  B.  Titkall,  F.  H.  Milligan,  S.  W.  AnnoTT,  W.  S.  Wij.lks,  II.  Z. 
Gill  and  Professor  Paul  F.  Eve.T[     Moreover,  Dr.  Flint  expressly  states  that  no  testi- 

*  Ai.F.XANDKR  Bkvson — <hi  thf  Prnjilif/hftUr  injlneii>:c  »/  Quinine.  MoL  Times  ami  <liiz.,  l«r»4,  Vul.  I,  ji.  () — refi-rs  tou  Htiiiidiiig  rule  in  tlu*  Navy  fnjuim'd 
l>y  till-  '.itli  iirticli'  of  tin-  Snrj^eoiis'  [iistrurtioiiF:,  that  ineii  sent  un  uhon*  in  trupicat  cliiiiatrH  shoulil  t;ikt>  daily  in  tin-  niuniinga  dnu-hni  uf  |)owdt>rt>d  hark 
in  \\  iiic  ns  a  prupliylartii-,  and  stattjs  that  thin  nu-asriri-  had  fal!i*n  into  ilisns*'  iKirtly  on  aioonnt  of  tht-  doubts  of  tint  nii'ditral  ofihrcrM  and  imrtly  Itt'caiiw 
of  the  iiitusi-iMis  churactiT  of  the  dos*".  Hi'  thi'U  Hi^-aks  favorably  of  tlu^  iim  of  aniorpboiirf  iininiru'  in  wine,  citing;  thf  rfports  of  a  niunlM-r  of  iniHlirul 
ortirci'.-*  on  the  African  station  to  tin-  ffFcrt  that  biKitu'  cri'ws  nsing  this  prtiphylactit'  ♦■itln^r  wholly  fsra|H'd  or  luul  milder  attacks.  He  admits  the  (Hca- 
hional  faihirc  of  (jninirit'-winc  as  a  pre  vent  ivi-  of  fi-vi-r,  but  holds  that  it  has  been  of  nnist  essential  servien.  Jle  had  prcvioiisly  n'coninit' tided  its  us<',  and 
givi'ii  Sunn-  evil  if  nil-  in  its  favor  Ju  his  H'-port  mi  the  Cliiiiute  nnd  Prtmipid  DistaseH  uf  the  African  ntatu>n.     London,  1H47,  p.  21S, 

I  I,.  .1.  II  \\sv.~<hi  the  Eudemie  jW'-rx  nf  Afrira  and  the  I'ioi>hijUietir  use  of  Quinine.  Med.  Tin»c^  and  <Jtr..,  l^-'jo,  Vol.  I,  p.  28() — cites  the  case  nf  a  ImhiI's 
.  r-u  .x)..,-..!  on  the  I'oiiga  rivi-r  for  twu  <lays  and  nights  :  ;i2  otticers  and  men  who  used  tlie  jprophylai-tic  daily  had  hut  four  Hliy;ht  cases  of  fever.  As  a 
roiiini^r  tu  Ibis  be  instances  the  exposure  for  woven  or  eiglit  days  on  the  Lagoon  at  Lagos  of  'M  otticers  and  men  wlio  only  took  the  quinine  every  other 
il;i  \ .  ;i  tid  li;ol  seventeen  seven?  eases ;  whili-  an  olticer  and  man  on  sliore  at  Sierra  Leone  for  eight  days  took  mi  qniniue,  ami  both  had  i-emittent  fever, 
lloi  ir  will  ln'  observed  that  the  nam  wlu»  snfteri'd  least  had  b<'en  exposi-d  the  shortest  time,  ami  that  the  liHalities  wen-  not  the  sjinie. 

I  11.  \V.  1)K  ^MSSXRF.—  Qulnini'  an  u  I'tophijhuile  vf  InlennUtent  and  liemittent  f<'fvis.  (Jhnrlrstnn  Mt-d.  J<nir.  and  Hfi-ien\  Vol.  XV,  !HC.)l,  p.  4:i:i -l"stili<-s 
t>'  til--  siic'iss  nf  lliis  measure  on  the  rice  plantations  and  els<'where  in  South  Carulina,  citing  tin-  Knglish  naval  exiwrieiice,  and  contrasting  the  fiit;ility 
of  K'tiiitretit  I'rver  III  the  tirst  Niger  exploring  e\[>edition  with  the  cuni]ianit)ve  good  health  of  the  .second  ex|M>dition,  in  which  ipiiniiie  was  used  as  a 
pntpliylactic.  An  account  of  the  first  has  been  given  by  ,1.  ().  McWil.l.l  am^.IM/.  ///n/.  •>/  the  Kip^'iHtion  to  thf  Xi'jer  dniimj  the  ijt'ars  I«41-2,  riini/>yisinij  an 
ovi.nnut  11/  thf  J'ti'fr  iihuh  led  la  its  ahrnpl  (ennination.  London,  184;i.  The  «*-cond  liaH  been  chl'onichMl  by  WiLI.IAM  Halfoi'h  BaiKIE — \arnitive  of  an 
tlijihiiiuij  I'l.ijihjf  Hit  thf  rii'ns  Kirt/ni  and  Iti'itne  (eantnumh/  hnaim  <ia  the  Niger  ami  Tmddit)  in  1854.  London,  iSTitl,  See  Appendix  '»',  p.  4r>2,  and  uUo  au 
article  by  the  siinit^  author — (hi  lifniitlfnt  f^rfr,  fXfieeiall;/  (W  ('/  appears  on  thr  TIV**/  nnmt  of  Afri^-a^  fir.      Edinhnrtjh  Mfd.  Jinir.,  Vol.  II,  IH/^fKT,  p.  HU:!. 

i;Sucb  as  W.  li.  JlAiKiK,  rtee  last  note.  T.  .1.  IIi''i'cifiNSON — Inipres^inns  of  llWcra  Aft'ira,  Lomlon,  IMftS,  p.  22it.  The  artich*  on  Inlerniillent  f'-nr  in 
the  Emtjilopudia  Hritannica,  and  l>i'  < 'II Aii.i.r— A'f/<"i/"r»(/  Afrua^  Chap.  -Will,  p.  WWW — to  which  the  eilitor  has  added  a  reference  to  the  observations  of 
Moi  AT  among  the  Andaman  Islands — Anmd"  of  Mditanj  and  Sarul  Snn/erfiaml  Tropiral  Mrdivine,  *-tt:,  London,  IWU,  p.  VX\. 

II  He  cites  (iKoitiJK  H.  Wool) — .1  Treatitte  on  Thrrapt-idirs^  etr.^  Philadelphia,  IH.'»f'i,  Vol.  I,  p.  '2t)<) ;  and  also  the  recinnuiendationa  of  several  Knglish  army 
medical  otticei-M  of  high  position  and  reputation,  whow  views,  however,  do  not  apiM*ar  to  have  been  carried  far  enough  ti»  yield  definite  pnictical  results. 
The  first  id'  tliese  is  the  letter  of  Direetor-fJeiienil  A.  S.MiTH  of  the  Army  Medical  Deiuirtna-nt,  .Inly  27,  IS.m.  to  the  InsjH-ctor  (leneral  of  Hospitals  in  the 
Crimea,  leeunimending  the  prophylactic  use  id'  ipiinia,  and  remarking:  *' Having  now  at  command  sulticlent  of  this  drug,  sjH'cially  provided  for  that 
service,  to  furnish  tive  gniiiis  jht  diem  to  every  member  of  a  force  of  :t,''.,(H.)0  men,  i  iM-g  you  will  take  8Ucli  measures  as  you  think  proper  with  u  view  to 
induct-  the  medical  officers  to  employ  that  remedy.'" — Report  if  thti  t'ontniinfiionfru  appointi-d  to  imjnire  into  thf  lietjnlntionii  affeetiny  the  SanUary  condUton  of  the 
Arnifi,  etc.,  LuniloU,  iH")?;!,  Aj>J>endix  7H,  p.  TO.  The  Mfd.  and  Siirtj.  Uintorrj  of  the  Jiriti.sh  Armit  n'hirh  serr^d  in  Tnrkeij  and  thf  Crimea,  etc.,  London,  1858^ 
nialies  no  mentii)ii  of  tho  adoption  of  this  measure;  but  in  the  apiK-ndix  to  Vol.  I,  p.  r)(>4.  Sir  Jon.v  Hai.l,  lusjM'ctor  tieneral  of  Ho.'-pitals,  in  reply  to 
un--  of  the  queries  of  the  Director  <ienei-al,  wrote  in  January,  1H.')7,  that  '*  In  malarious  ilistricts,  ipiinine,  or  tinimiiiUiie  in  solution,  which  is  preferable 
trom  the  form  it  is  in,  givi-n  as  a  prophylactic  in  either  wine  or  spirit,  is  very  beneficial,  but  soldiers  do  not  like  it,  and  I  have  lu-ard  them  declare  that 
it  had  occasioned  the  complaints  they  were  laboring  under  at  the  time."  Tht'  second  is  the  recommendation  of  l>ireotor-(ieueral  J.  B.  Gibson  of  the 
Ainiy  .Medical  I»ei^«irtnient,  submitted  to  the  Minister  of  State  for  War  during  the  piv|Kiration  for  hostilities  in  China  in  tHr>'.»,  that  a  sto<_-k  of  <iuiuine- 
wine  be  provided  for  issue  during  the  unhealthy  months,  or  when  tlje  soldiers  are  retpiin-d  to  pnx'eed  np  rivers  or  to  encamp  in  the  vicinity  of  marshy 
ground, — with  the  instructions  to  n.se  quinine-wine  <ontained  in  ii  8  of  the  New  Medical  Kegulations  for  Field  Service  issued  tt)  the  Kxpeditionary  Army 
(in  China)  iluring  the  sjime  year, — .inni/  Med.  bfpartmfnt,  Stntixtiml,  Sunilar//  tun!  Mfilicid  Reports  for  the  year  ISftSt,  London,  1S61,  p.  iHl.  But  in  the  volume  of 
the  same  reports  for  lW)(l,  London,  1802,  p.  ;iit:t,  is  found  an  otticial  sUitenielit  of  the  Prartival  rennlts  hearimj  on  thf  Mediral  hrpurtnienl  deducible  from  the 
opi-iatlons  in  China,  from  which  wi>  learn  :  "  That  the  ex|>eriinent  of  quinine  as  a  prophylactic  against  malaria  was  not  tried  iu  this  campaign  on  a  nufti- 
ciently  extended  wale  to  wariunt  reliable  results."  It  is  true  that  Wm.  K,  E.  Smart — Qfm.  on  thf  Climatoloi/ij,  Topoi/raph'j  and  hisea.-ifs  <f  Hong-Kong  and  the 
i'anton  rirvr  station,  Tnins.  Epidem.  Soc.,  London,  Vol.  1,  IHWH,  p.  'I'M — s|)«'aks  of  the  "coinimnitive  exemption  "  tjerured  by  quinine  fur  the  crews  of 
the  gunboat  flotilla  on  the  Canton  river,  hut  he  gives  nothing  mure  precise*  than  the  statement  that  "they  seemed  not  to  suffer  disproportioually  from 
malarious  fevers,  excepting  those  of  the  intermittent  type."  It  would  appear,  too,  from  his  remarks  that  the  quinia  was  given  "on  the  slightest  o^.'ca- 
sious  tif  indisposition  "  rather  than  to  the  well  men.  The  last  of  these  citations  is  a  mere  suggesti«.m  for  the  use  of  this  measure  by  II.  C.  Reau£ — 
Rfntark)'  on  thf  Topoyraphf/  of  tfif  MUiUiry  .ttatiuni*  in  Ilritiah  GnUma,  etc.,  Vtdunie  for  185!!,  cited  snpra,  p.  :^4;i. 

^j  Sanitary  Memoirs  of  the  War  of  the  RfMlioH,  voUretfd  and  pnhlinhed  hij  thf  U.  .S.  HanUary  Commission.  Medical^ — edited  by  AUSTIN  FLINT,  New  York, 
1807,  p.  I.t4.  See  also  an  aiticle  headed  Qninine  as  a  Precentief  of  Malarial  disetutf.  tktn.  Lk/m.  Bulletin^  Vol.  I,  1804,  p.  215;  also  Amer.  Med.  77nfett,  Vol. 
Vlll,  1804,  p.  :i48,  ill  which  the  inspector  of  the  Sjinitary  Commission  in  the  Department  of  North  Carolina  and  Virginia,  J.  W.  Page,  reports  great  benefit 
from  the  issue  of  a  quinine  ration  to  regiments  iu  the  vicinity  of  New  Berne,  N.  C. 


168  FREVKNTIOX    OF 

inony  adverse  to  tliis  metlioil  (if  [U'oplivlaxis  hml  heoii  rpcei\'0il  bv  tlio  Coinmi^sion. 
R<'jiorts  f;ivonil)lo  to  tlio  issuii  ol' i[Hiiiiiii'  wrre  made  to  the  Surgeon  Gi'iicral  s  (  )tlicc  liy 
certain  medical  officers,  and  some  communications  were  received  by  L)r.  W'uoinvAKD  in 
i'es|)onse  to  a  letter  requesting  information  on  tlie  subject.      These  are  herewith  submitted. 

Siirt/ion  C.  N.  ('IlA^^u•:lU.AI^•.  lo//,  .I/m.s.v.  J'dIs.,  WdsUiiKjtou,  ()<t(ilin-  1,  l«(il. — The  fevers  were  of  a  liilions  remit- 
tent type,  sdiiie  rapidly  asmiiiiiiif,'  :\  typhoid  form.  At  tirst  tliey  were  of  a  very  severe  eliaracter,  and  four  treated  in 
onr  regimental  li()Mi)ital  jiroved  fatal.  One  became  eonvale.sceut  and  left  the  hospital  for  his  ([uarters,  hut  owin;;  to 
iinprndence  he  suffered  a  fatal  relapse.  Another  was  delirious  from  the  first,  his  skin  literally  covered  with  peteclii:e 
andvihices;  lie  had  severe  congestions  of  the  head  and  bowels,  and  sank  after  an  illness  of  ten  days.  'I'ho  third 
and  fourth  had  all  the  phenomena  of  ordinary  typhus  fever,  and  both  ditMl  of  severe  and  repeated  hemorrhages  from 
the  l)owid8.  As  the  epid<Miii(-  juogressed  the  tyi>e  of  the  disease  beeauu-  milder,  although  we  still  have  oeeasionally 
cases  of  a  severe  (diaracter.  The,  treatment  employed  has  been  usually  a  mild  laxative  of  castor  oil  and  oil  of  tur])en- 
liiui,  often  preceded  by  live  grains  of  liliu'  ]iill:  full  dose^j  of  (luinine,  and  an  occasional  Dover's  i)owder,  after  tlie 
ojieration  of  the  cathartic.  This  has  sulliced  to  arrest  very  promjitly  the  large  j)roportion  of  the  cases,  while  it  miti- 
gated the  others,  excepting  the  few  cases  more  emphatically  typhoid  in  their  tendency  which  ended  fatally. 

After  witnessing  tlu^  salutary  effects  of  ([uinine  as  a  remedy,  I  determined  to  employ  it  as  a  propliylactic,  pro- 
vided a  BUtlieient  <|iiantity  could  be  procured.  An  api)cal  to  the  Sanitary  Commission  secured  twenty-three  gallons 
of  whiskey  containing  tliiec  grains  of  (piinine  i)er  ounce  of  li(|Uor.  The  nuui  W(!re  allowed  to  takc^  daily  one  or  two 
ounces,  and  I  was  happy  to  witness  its  results  in  reduiing  the  morning  report  of  the  sick  from  lifty  or  sixty  to  twenty 
daily.  After  the  supply  was  exhausted  the  rejiorts  exhibited  an  increase  of  the  disease.  I  am  prepared  to  recom- 
mend eniph.itically  tlu^  use  of  i|iiinini^  .-IS  a  i)ro]diylactic  under  circumstances  paralhd  to  our  own.  A  .second  snuill 
supply,  furriished  also  by  the  Sanit;iry  Conniiission,  has  been  of  great  service. 

Miilicdl  Iiiijiiftdr  .Joii.v  Wii.so.v,  C.  S.  A.,  Jriiiii  of  the  I'otiimuc,  OctohtrSl,  18G1. — The  ordinary  endemic  diseases  of 
the  region  have  touched  the  Army  of  the  I'otomai'  [before  Tetersburg]  with  unwonted  gentleness  duiiug  the  usually 
sickly  autumnal  mouths.  This,  at  least  in  a  measure,  is  due  to  the  vigilant  surveillance  kept  ovei'  the  ]iolice  of  thi^ 
cani]is  and  the  cleanliness  of  the  person  of  the  soldier,  and  also  to  the  excellent  manner  in  which  tlit^  aiiny  has  lieen 
fed  and  clothed.  In  the  more  malarious  localities  occupied  hy  our  troops  during  the  months  of  .Sejitemlier  and  Octo- 
ber, a  ration  of  whiskey  and  <|uinine  was  given  daily  with  excellent  effects  as  a  prophylactic. 

Aunt.  Surg.  Alkkeii  A.  WooniltM,!,,  U.  S.  A.,  in  charge  of  lidtfalion  of  2d  and  lOth  U.  S.  Infantry,  Scjifcmlxr  30, 
IXG'2. — The  whiskey  ration  that  was  at  one  tinu-  attempted  is,  in  my  opinion,  not  only  uiiprotitable  but  absolutely 
detrimental  when  it  is  issued  indiscriminately,  even  under  the  worst  aspect  of  military  life  on  the  Chickahominy. 
It  is  nni)ro(itable,  becau.se  on  those  occasions  when  it  would  be  of  service,  if  at  all,  it  is  often  impracticable  to  issue  it. 
If  useful,  it  is  chiefly  in  the  depression  and  exhaustion  induced  by  wet  and  cold,  immediately  after  a  fatiguing 
march;  but  as  these  are  the  very  times  when  th<(  wagons  are  not  up,  it  is  impossible  to  obtain  it  until  the  occa- 
sion for  its  use  has  passed.  The  transportation  of  the  recjuired  amount  would  greatly  burden  the  Quartermaster's 
department,  an  item  In  the  nu)vemcnts,  ami  <'onse(|uently  in  the  health,  of  the  army  not  to  he  overlooked.  Its 
habitual  issue  would  uiKiuestionably  tend  to  the  jiroductiou  of  intemperate  habits  in  some  and  foster  those  of  others 
that  a  campaign  might  otherwise  dissiiiate.  While  accustoming  men  to  a  stimulant,  to  be  deprived  of  at  those  times 
they  would  most  need  it  (as  indicated  abov<'),  would  be  doing  a  double  injury.  The  addition  of  quinine  does  not 
seem  to  counterbalance  the  evil,  and  so  great  a  consumption  of  that  valuable  drug  appears  to  be  a  waste  which 
nothing  but  the  nu)8t  certain  henetits  should  authorize.  To  leave  the  issue  of  <|uinine  to  the  legitimate  channel  of 
the  medical  de])artment  is  nuudi  more  rational  than  its  indiscriminate  administration  liy  battalions.  ( )f  course  these 
remarks  refer  to  the  circumstances  of  the  Army  of  the  Potomac,  and  not  to  those  cliimites  where  perpetual  ciuchon- 
ism  is  the  condition  of  life  to  the  white. 

Snrijiun  J.  (i.  Hkadt,  2(\th  Musn.  f'oln.,  Xcw  Orleans,  La.,  March  31,  18G3. — The  rainy  season  continued  through 
the  last  (|uarter,  and  ]irohably  had  an  effect  ujion  the  health  of  the  regiment,  as  shown  by  a  considerable  increase 
in  the  number  of  cases  of  intermittent  fever.  Wet  days,  followed  by  sudden  changes  to  warm,  muggy  weather, 
have  invariably  increased  the  j)revalence  of  this  fever;  but  all  the  eases  occurred  among  men  who  had  previously 
suffered  from  the  disease.  I  consider  that  the  ('ity  is  comparatively  free  from  the  miasm  to  which  malarial  fevers 
owe  their  origin,  and  that  these  fresh  casi'S  are  nu'iely  the  reappearance  of  an  old  trouble  which  had  been  lying 
dormant  in  the  system.  To  test  the  value  of  whiskey  and  quinine  as  a  prophylactic,  I  procured  fifteen  gallons 
of  whiskey  and  added  one  ounce  of  (luinine  to  the  gallon.  This  mixture  was  served  out  to  the  guard  at  night  at 
the  rate  of  one  ounce  per  man.  In  wet  weather  a  ration  was  also  served  out  at  midnight.  I  am  positive  that  it 
prevented  a  great  numl)er  of  attacks  of  chills. 

Surgeon  1)A^■I^)  Mkkkitt,  't'^lh  I'a.  Xoh.,  Beaufort.  S.  ('.,  May  10,  1868.— The  issue  of  a  ration  of  whiskey  and 
quinine  while  the  regiment  was  on  Edisto  Island  was  of  great  service  to  the  health  of  the  command.  At  Heaufort 
the  ration  has  only  been  issued  to  the  men  on  picket  duty.  I  am  a  strong  advocate  of  the  measure,  ami  the  oral  testi- 
mony of  other  medical  officers  corroborates  my  opinion. 

Ax^t.  Surg.  E.  A.  Thomp.son,  1l'//(  .Me.  fnls.,  llatun  llouge,  La.,  Fehruarg.  181)3.— Most  of  the  cases  (d'  intermit- 
tent fever  which  occurred  during  the  winter  were  observed  in  the  companies  that  were  exposed  to  malaria  during 
last  sumnu^r  while  on  detached  service  at  Lake  Pontchartrain.  We  are  now  issuing  rations  of  quinated  whiskey  to 
the  men  on  picket  and  extra  duty  with  marked  benefit. 


MALARIAL    DT^f'.ASR.  1G9 

Medical  Inspector  E.  V.  Vollfm,  r.  .s'.  .(..  Liuairinc.  Kif.,  Dcccmlicr  HI.  1S03. — I  liave  to  state  that  fiom  my  t-xjio- 
rience  with  i|uinine-\vhiskey  as  well  as  witli  simple  (Hiiiiiiie.  I  am  le<l  tci  believe  that  it  is  a  ]iro]>hyla('tie  against 
malarial  fevers.  When  tmojis  are  about  t<i  enter  or  abidi'  in  a  region  well  known  to  lie  malarious,  I  would  advise 
1  lie  modiMate  u.se  of  i|niiiiiie-whiskey.  to  lie  eontinned  in  diniinislii'd  i|iiMnt itii-s  as  Ion;;  as  il  is  evidrnt  tlial  the 
troops  are  in  danger  of  attack  ;  but  I  would  diseoiiiiteManee  its  ;,'eneial  issui'  except  at  such  seasons  and  in  such 
rei^ions  as  are  markedly  malarious. 

Medicul  Jii-fpectiir  A.  C.  Hami.in,  J'.  S.  .1.,  Wanhinfitfin.  !>.('.,  S'ni-imlicr.  1M(!;{. — My  observations  have  not  been 
coiuluoted  on  an  extensive  scale,  but  the  results  have  eonviuced  me  that  the  use  of  i|ninine  wliisk<'y  in  projihy lactic 
doses  produces  a  prompt  and  energetic  action,  and  sujiports  the  ori^anic  forces  in  resisting;  the  |iernicions  intluence 
of  malaria  and  nentralizinj;  the  iialiulal  poison:  liut  when  paludal  lachexia  is  once  faiily  estalilished  the  adminis- 
tration of  (|ninine  seems  to  be  w  ithont  mmdi  force.  1  will  also  state  that  I  consider  the  licst  mode  of  admiuisterinj; 
this  dm;;  to  be  in  solution  in  the  red  wines,  by  reason  of  their  tonic  etl'ect  upon  the  muscular  tilire:  and  1  believe, 
with  the  distiu;;ui8hed  chemist  Ileniy,  that  the  red  wines  of  Knrgnndy  are  best  adapted  to  the  puriiose, 

*S'«/y/coM  A.  1',  MAVi.f.i:  1 .  f '.  .^■.  lo/s..  I.imisriU,-.  I\i/..  \iin}iil>(  r  \,  IXIi!!. — I  think  that  the  issue  of  i|ninine  or  some 
antiperiodic  as  a  projihy  lact  ic  would  be  not  only  hnmaiie  liiit  an  iMimomical  measnre  for  the  (iovernnn'ut.  Alcohol 
is  d<iu  lit  less  tin-  liesf  nienst  luiim  tor  its  ad  mi  nisi  rat  ion.  and  pnre  obi  \\  hiskcy  t  he  licst  form  of  alcohol :  Imt  inasmuch 
as  it  wonld  be  im])ossible  to  obtain  the  latter.  I  w<iuld  recommend  that  diluted  rcctitied  spirits,  i.  c.  pun>  diluted 
alcohol,  be  used  for  this  ]iurpose.  I  regard  alcohol  when  prolierly  administered  as  |irophylact  ic  to  a  limit<'d  extent, 
but  when  iui]iroperly  used,  as  is  too  often  the  case,  its  effei't  is  donbtles.s  the  reversi\  I  would  therefore  recommend 
that  in  any  such  combination  the  alcohol  sliouhl  bear  as  small  a  )iro|iortion  to  the  antiperiodic  as  may  be. 

Surgeon  T.  II.  Haciik,  V.S.  I'lih.,  Il'iishiiij/loii,  H.  ('.,  Xnreinlier  ',i.  IXIi:!. — I  know  (|niniue-\vhiskey  is  of  great  use 
as  a  projihylactic  against  nuilarial  fevers.  However,  I  am  o)iposed  to  the  mixture,  ami  think  its  geueial  issue  wduUl 
can.se  nuich  harm,  owing  to  the  fondness  of  many  foi  whiskey.  I  am  in  tin  or  of  a  inixlnre  without  whiskey,  though 
I  w<iuld  in  some  cases  have  recourse  to  whiskey  its  well  as  to  i|ninine. 

finrgcon  K.  Swii'T,  U.  S.  J.,  I'henter,  I'li.,  \oreinher  '2'2,  \X{>'.i. — In  ,Iune,  1817,  at  \'era  Cruz,  Mexico,  I  recom- 
mended two  grains  of  snljihate  of  ijuinia  in  about  two  ounces  of  whiskey,  to  be  taken  by  the  otlicers  every  morning 
at  the  moment  of  rising.  'J'his  could  not  be  administered  to  the  tiwn  for  want  of  a  sulHeient  siijjply  of  the  li(|Uor. 
The  army  was,  however,  generally  healthy,  and  I  did  not  discover  any  marked  ditference  between  otlicers  and  men. 
In  Texas  I  fre(|Uently  recommended  this  prophylactic  in  malarious  districts,  and  credited  it  with  an  iiiHuence  in 
warding  otf  disease.  So  fully  convinced  was  I  of  this  that,  as  Medical  Director  of  the  Army  in  Kentucky  in  Dccem- 
bei .  ISIil,  I  urged  (ieneral  Mitchell  to  apiirove  a  daily  issue  of  (iiiiniiie-whiskey,  but  the  advance  of  the  tirmy  into 
rennessce  pie\  enteil  me  from  making  satisfactory  observations.  In  a  circular  iinblished  to  the  Army  of  IhoCnm- 
li  rland  by  older  of  (General  Kosecrans,  I  lind  the  following  directions,  viz:  "Hot  colfee  should  be  issued  to  the 
solilier  immediately  after  rising  in  the  morning,  and  in  inclement  weather  (|uiniiie  and  whiskey  in  the  evening." 

FiiVdi-alilc  testimony  is  also  found  in  some  of  the  reports  |>riiili'il  in  the  A|i|M'n(li.\  to 
t!ic  Fii-st  J'art  of  tliis  work,''' tinJ  in  certain  articles  )uililisli<Ml  \>y  annv  nicilical  (itlicffs  in 
the  medical  journals. f  Unfortunately  this  testiiiKJiiy  is  in  no  instance  bascil  upon  .statistics 
showing  the  comparative  etl'ect  of  like  exposures  upon  commands  using  the  quinine  and  oliiers 
not  using  it.  Un  tlie  other  haml  no  reports  condemning  the  prophylactic  use  of  (|uinin(' 
Lave    been    published. J    although    doubts    liavi;    occasionally    b(>en    expressed    as    to    its 


*Ri*(',  ftir  iiistiUK'c,  tlii*t  iif  Siirj^eon  C.  S.  TltiCLKlt,  Mt-ilinil  Dln*''tor,  .\riii.v  tif  tin*  l^ntumuL-,  pp.  47-S,  in  wliicli  lu'  .stuti-H  tliat,  Iiiiviii^  n-cfivi'il 
favorable  n-pnrts  ut'  tlic  I'ilt-ctH  uf  (Hiininc  and  wluskt*>  as  tin-  ri-snlt  i)f  an  ■•\|ii-riiiiciital  i.ssin-  inadf  by  iiis  m.-diral  otlircrs,  lii-  rt'ctmiriK'TKlcd  its  nwi-  ti» 
tliiisi'  ri-triinc'iits  «liiw  ciliclitiiai  si'i-ini-d  niiwt  t.i  drniand  it.  and  was  indiu-ed  tliiTi'al't  r  tc.  ki'i'p  it  i. instantly  un  liand  in  tlic  l>Mivi>y<ir's  stun-.  Si'.'  alsn 
p.  Im,  wlii-ri-  Snrgi-on  .1.  H.  I!K"WN,  .Mi'dital  Din-rtcr.  4tli  Aniiy  ('(.ips,  ixpn-ssi-s  liinisi-lf  sitisH.d  tliat  liad  a  lili.Mlil  supply  ..f  <|uinin<'  \nvu  ubtainabb' 
fur  proiiliyhutii-  pnrjiiist's  and  tn-atlni'nt,  unc-lialf  iil'tln"  sickness  that  pri'vailt'd  in  bis  cuniinand  durint;  tln'advaiu'i-  un  Willianisbiirjr.  V.a..  in  lS(i-.i,  wniiM 
liave  ln'1-n  pn-vi'iiti'd.  -Msm.  un  pp.  7S-H,  Assistant  Snry:t'un  Hahvk^  K,  liuuwN,  I'.  S.  Army,  states  tliat  bis  re;rinient,  the  Tctb  N.  V.  \'uls.,  wliile  u  i 
tbe  l^•uiusnla.  was  seriunsly  tbreatelled  with  intermittent  fever,  bnt  tiiat  a  lib.-ral  adininistratiuri  uf  ipilnine  ili.ss.ilved  in  whiskey  tu  IIk-  whule  euln- 
niand  cheeked  tbe  jiruKress  uf  the  diseas*'.  .\lsu,  on  ]ip.  2.'12-:l,  Snriieon  ih:<t.  K.  euupKit.  f.  S.  Army,  after  r.'ferrin;r  tu  tbe  generally  received  upiniun 
that  white  men  c(nild  nut  live  un  ttie  luw  marsliy  grounds  borderinff  the  rivers  uf  the  snntlieastcrn  euast,  and  tu  tlie  feeling  uf  anxiety  eiaiseqnent  un 

tlie  issue  uf  urilers  to  eun.striiet and  jiarri.sun  furtiticatiunsun  these  liottom  lands,  states  tliat  :  '•  t'li liial  ullieers  on  rinty  in  the  liatteries  were  instrnrted 

tu  issue  to  the  men  qnlnine  and  whiskey  a.s  a  propbylaetie ;  and  witli  beneficial  etfect  it  was  used,  as  the  statements  of  the  medical  oHicer-s  jnfurnied  me. 
Wliile  referring  to  tlie  propbylaetie  iisi-  of  quinine,  t  would  state  that  in  such  easi-s  as<-anie  nnder  my  own  uliservatiun  I  s;iw  lunch  ^utHi  resulting  from 
it.  .Many  men  who  seemed  to  be  imperceptibly  almost  sueeumbin;;  to  the  malarious  poison  wen-  in  a  short  time  ^rivilifr  indications  of  perf -ct  health. 
I  wonld  strongly  recommend  its  use  in  all  malarious  districts,  for-  tlionirb  the  expense  is  eoiisiilerable  the  l.enetU  bdlou  iny;  will,  I  think,  mi»re  than  com- 
pensate for  the  outlay." 

t  Sec  letter  from  Itrijrade  Snrjreon  (;f.o.  II.  I.vmas — ll'istnn  M*''l.  nuil  Sunj.  J"iu-..  Vol.  t.X  V.  isf.ii,  p.  lifj — in  which  the  prophylactic  use  of  quinine  is 

liiuhly  commended  :  see  also  the  Kime  Junrnal.  I, XIX,  lsil:l,  p.  lll'.i,  where  Surs: iliKuuiii;  Hkioit, -j:!'!  Mass.  Vols.,  relates  his  experience  with  tbisdrui; 

in  bis  rejiinieiit  at  New  llerne,  N.  ('..  and  vicinity,  and  strone-ly  eonimends  its  use  as  a  prophylactii-. 

{  If  w.-  except  the  following:  A  b.jard  of  surireons  i-oiisistiri';  of  llrs.  C.  II.  (Iav.  C.  II.  IIomans,  li.  M.  Honors,  specially  detailed  by  the  (;,.vern..r 
of  Massachns.'tts  to  inspect  the  i-ondition  of  the  Massaidinsetts  regiments  of  tb.-  .\rmy  i>f  the  Potomac,  then  before  Yorktown,  visited  that  army  dniiny: 
April,  Isl'i'J,  and  made  a  report,  Kon^.ii  Mnl.  nml  Siir<j.  Jmir..  Vol.  LXVI.  ts(,-i,  j,.  ;i.',4.  to  thi'  Surp'on  Cenenil  of  tin' State,  in  whiih  they  remark  :  ■'.Malaria 
was  said  tti  be  actiiij;  powerfully,  and  therefore  quinine  must  be  administen'd  in  lariie  doses.  The  ill  etlect  from  this  larp'  dosinjr  was  found  to  he  much 
^M-eater  than  that  from  any  supposed  malarial  intluence.     The  inipl-ovement  in  every  instance  wlii-i-e  the  quinine  was  either  entirely  stopjR-d  or  y;iveu 

in  greatly  reduced  i|uantities  was  t larked  and  too  continued  to  leave  a  shadow  of  a  doubt  as  to  the  exciting  lause  of  the  in'rsisteut  headaibe  and 

diarrhu'a.     The  ^ood  effect  of  stimulants,  bnuidy  en-  whiskey,  was  immediately  sen  when  we  had  some  t-'  trive."     This  paratrraph  is  cited  Iiy  tlie  editor 

Med.  Hist.,  Pt.  111—22 


17<^  PREVENTION    OF 

value/''  In  view  of  the  genCTal  tenor  of  the  testimony,  it  must  be  allowed  that  quinine 
exerciseil  a  protective  influence.  Nevertheless,  as  the  practice  of  administering  it  for  its 
prophylactic  virtues  was  generally  abandoned  in  the  later  years  of  tlie  war,  it  must  be 
conceded  that  the  rcsidts  achieved  did  not  equal  the  expectations  wliich  were  at  first  enter- 
tained. Hut  a  consideration  of  the  well-known  temporary  action  of  the  drug  on  the  system 
will  readily  explain  its  failui'e  to  protect  where  the  exposure  in  a  malarious  country  was  so 
pndonged  as  during  our  civil  wai'.  An  intermission  in  the  use  of  the  quinine,  by  leaving 
a  command  exposed  to  the  miasm,  necessarily  put  an  end  to  the  prophylactic  experiment. 
The  sickness  of  those  who  became  affected  by  the  malarial  influence  and  the  idiosyncratic 
immunity  of  others  under  similar  exposures  rendered  unnecessary,  in  many  instances,  the 
further  expenditure  of  quinine  as  a  preventive,  and  led  to  the  gradual  abandonment  of  the 
method  by  our  medical  officers.  Practically,  therefore,  the  prophylactic  use  of  quinine  in 
our  armies  was  a  failure;  but  it  does  not  follow  that  the  method,  so  far  as  employed,  was 
not  of  value.  On  the  contrary,  all  who  adopted  it  give  positive  evidence  on  this  point. 
Men  were  saved  from  attack  and  preserved  in  perfect  health  for  the  active  service  of  the 
time-being  liy  the  use  of  the  drug.  That  it  did  not  coiitiiiuo  to  save  them  after  its  use  was 
intermitted  does  not  detract  from  th(>  value  uf  the  prot,ection  already  rendered.  That  it  did 
not  save  from  attack  every  one  to  whom  it  was  adnainistered  is  no  argument  against  its 
pi'ophylactic  use.  Its  efficacy  even  as  a  remedy  is  unequal,  some  cases  requiring  more,  some 
less,  for  the  suppression  of  the  morbid  phenomena,  and  in  certain  instances  in  which  the 
morbific  influence  is  overwhelming,  Cjuinine,  although  well  known  to  be  of  remedial  value,  is 
unfortunately  of  no  value.  Its  efficacy  as  a  preventive  may  not  be  supposed  to  be  more  equable 
than  its  remedial  power.  The  malarial  influence  may  be  so  overpowering  that  the  prophy- 
lactic dose  maybe  as  inefficient  for  ])rophylaxis  as  the  remedial  dose  for  cui-e.  Prom  these 
considerations  it  would  seem  that  the  quinine  which  was  used  with  a  view  to  prophylaxis 
was  of  value  in  preserving  health  temporai'ily,  and  that  the  disuse  of  the  method  was  due 
not  to  a  rt-cognition  of  its  want  of  value,  but  to  the  ditficulfy  attending  its  successful  prose- 
cution in  cases  of  prolonged  exposure,  especially  as  the  periods  of  active  service  which 
led  the  troops  into  dangerous  bivouacs  and  surrounded  them  with  predisposing  conditions 
Were  precisely  those  in  which  there  was  the  greatest  liability  to  a  failure  in  the  issue  of  the 
prophylactic  doses. 

Nor  must  it  be  forgotten,  in  a  discussion,  of  the  prophylactic  value  of  (piinine,  that 
although,  owing  to  conditions  of  continued  exposure,  the  attem|;)t  to  protect  whole  com- 
mands was  given  up  during  the  later  years  of  the  war,  the  protection  of  individuals  li-om 
relapses  continued  to  be  practised  to  the  last,  not  by  issues  of  (quinine  and  whiskev,  but 
by  the. administration  of  the  drug  in  repeated  doses,  covering  several  days  at  a  time, 
or  by  larger  doses  given  at  specified  periods.  The  success  of  this  mode  of  treating 
relaj)ses,  really  a  prophylactic  use  of  the  drug,  bears  strongly  on  its  value  when  used  under 
favorable  conditions  for  the  pi'otection  of  healthy  men  from  the  miasmatic  influence. 


of  till'  'hiiiiifn  Meili<:nl  Juitnml,  Vul.  Xl.\,  Isd'.;.  |i.  -111'.,  w  liu  r.'iiiark.s ;  "Is  nut  this  luiiustruiis  'quiuiut'  proiihyliixis  noiiseii.se  about  iilii.vi-il  itut'.'  The 
woril  uf  its  pruiiiise  is  nut  even  kept  tu  the  ear,  an>l  the  hnnihng  jiruveji  ilauit-ruus  as  well  us  expi'nsi\e."  The  i-eport  of  the  Massaeliu-etts  physicians 
is  nut  iiialerstui'il,  liuwever,  tu  refer  siH'eitieally  tu  tlie  use  *>f  qiiinia  as  a  pruphylaetie,  hut  rather  to  its  alleged  abuse  in  tlie  treatment  uf  tlie  siek. 
The  pruphylaetie  use  is  prubably  ubjected  tu  in  the  remarks  ui  \\.v.\,  Lf.  B.  Munkuk- -/.eWiv  /<-  tU>-  Sunjfon  tlnx'rul  of  thf  Sluti-  o/'  .Wa^Mn7u(.^-7/s,  li,inf,,„  M,<l. 
and  Siinj.  Juiir.,  \'v\.  LX\  11,  18(i"2-;i,  p.  21 — whu,  writilif^  uf  a  brief  tour  uf  duty  in  the  .\rniy  uf  the  l*utumae  iluriui;  .huie  and  .Inly,  IHU'^i,  says  :  ■■  We  fuund 
H  great  many  iiatients  who  had  suffered  from  uver-dusinj^  with  ipiinine  administered  in  whiskey," 

*  J.  J.  AVottDWARD — OiUUiiex  of  the  chiff  fuiup  bim-usea,  etv.,  Philadelphia,  ls(i:i,  p.  llis  e/  ,vey, — siM'aks  lUnibtiugly  of  the  pruphylaetie  value  uf  quinine, 
ttrst,  on  at'couut  of  its  failure  to  become  an  accepted  method  of  prevention  in  the  uriny,  and  secondly,  on  the  claim  thtit  its  continued  use  i-stablishes  a 
tolerance  of  the  remedy  by  which  its  curative  powers  are  to  a  great  extent  lust.  "  'I'he  general  u.se  uf  quinine-whiskey  as  a  preventive  of  malarial  disease 
is  therefore  to  be  regarded  as  unadvisable.  *  *  *.■  Qninine  should  be  reserved  foreniploynieut  as  a  therapeutic  measure  in  the  treatment  of  the  actual 
symptoms  of  malarial  disoi-ders  when  they  ap^K-'ar  in  individual  cases." 


MALARIAL    BTSEARE.  171 

The  experience  of  tlie  war  appears  to  teach  that,  when  a  command  is  to  be  temporarily 
exposed  in  a  speciallv.daiigerous  locahty,  quinine  shoukl  be  issued  for  the  sake  of  such  protec- 
tion as  it  may  give;  l>ut  that  wlien  the  command  is  to  lie  stationed  for  a  long  time  in  a 
malarious  section,  prevention  should  be  attempted  by  the  judiciuus  selection  of  famp  sites 
and  the  avoi<Lance  of  predisposing  causes,  while  (piinine  is  reserved  for  remedial  exhibition 
on  the  first  manifestations  of  ilie  malarial  poison  in  the  system,  and  for  special  pru[ihylactic 
doses  under  conditions  of  unwonted  ex}K:)sure  or  in  anticipation  of  relapses. 

The  whiskev  ration   is  brought  incidentally  into  question   by  its  connection  willi  the 
quinine.     Dr.  Wookiu'll  has   expressed   the  prevailing  sentiment  of  our  inedical  officers  ' 
with  I'egard  to  it.      As  a  matter  of  fact,  tlie  (■am])aigns  of  the  civil  war  were  made  on  hot 
coffee,  with  a  rare  issue  of  whiskev  under  special  conditions  of  fatigue  or  discomfort.      The 
sanitary  reports  are  therefore  generally  silent  on  the  subject  of  the  whiskey  ration  jx'v  se. 

On  the  Confe(h-i'ate  side  attention  was  directed  at  an  early  period  of  the  war  to  the 
prophylactic  use  of  quinine  by  Dr.  JosKPH  .Tones,  who  cited  in  support  of  his  favorable 
opinion  the  accounts  of  its  successful  employment  by  English  naval  vessels  on  the  .\friean 
coast. '='  This  essay  was  sul)se(iuently  embodied,  with  some  additional  matfiM',  in  a  rep(n't 
made  by  Jones  to  the  Surgeon  General  of  the  Confederate  Array  in  August,  LSG-l.t 

From  this  report  it  appears  that  quinia  had  not  been  employed  as  a  prophylactic  to  any 
extent  in  tlie  Confederate  Army  chiefly  because  of  a  scarcity  of  the  drug.  Nevertheless 
it  had  been  used  on  a  small  scale  with  decided  benefit  in  certain  malarious  localities. 
Ass't  Surg.  J.  N.  Warren,  2r)th  South  Carolina, J  stationed  on  James  Island,  S.  C,  gave 
four  and  a  half  grains  daily  to  two  hundred  men  of  his  regiment,  from  April  to  October, 
1863.  Four  cases  of  malarial  fever  and  one  of  tyqihoid  occurred  among  these  men.  The 
remainder  of  the  regiment,  between  three  and  four  hundred  men,  did  not  take  tlie  prophy- 
lactic, and  over  three  hundred  cases  of  paroxysmal  fever,  with  twenty-three  of  typhoid, 
occurred  among  them.  Surgeon  Samuel  Lo([AN,§  chief  surgeon  of  the  2d  and  3d  Military 
Districts,  Department  of  South  Carolina,  (leorgia  and  Florida,  tried  quinia  in  four-grain 
doses  daily  as  a  prophylactic  during  the  summer  and  autumn  of  1863,  in  portions  of  several 
small  commands  stationed  in  malarious  districts  of  South  Carolina.  The  coast  line  is 
indented  with  numerous  bays,  inlets  and  salt-water  creeks,  which  contribute  to  the  form- 
ation of  a  series  of  islands  consisting  of  light  sand  supported  by  a  clay  stratum  a.  few 


*  Jo.«EPH  Jones — Sulvhate  of  quima  mbamistereil  In  atiiaJI  dosten  ifitnuij  health  the  be.<*t  means  of  prereuthiij  dull  ami  fever,  and  BiUoiis  ferer,  and  Oriaentii-e  ferer, 
in  Ihoae  eyp<jsed  to  the  nnhealthij  climale  of  the  rieh  lunhinds  anil  sn-anijt^  of  tlie  S^nthein  <  'loifedenieij.  f^ontlien,  Med.  and  Sniy.  Jonr.,  Vol.  XVIII,  .\uj;iist,  18(jl, 
II.  flit:!.  ••  Uiiiler  tlu'Sf  I'xoosiiri's  I  liavu  fuuu.l  tliut  suliiliiiti^  of  qiiiiiiii.  tiikeu  in  fioni  :l  tii  ■'>  graiii.s  tuiui-  during  the  da.v,  would  in  most  rases  iirevent  the 
oeiunence  of  malarial  fe-er,  and  if  it  lailed  to  wanl  it  ott  enliii'lv  tin'  attack  would  he  of  a  very  .slii,'ht  character."  In  support  of  this  position  he  cit.'s  the 
prevalence  and  fatality  of  malarial  fevers  anions  Europeans  in  Africa  hefore  tin'  introduction  of  the  use  of  qninia  as  a  prophylactic,  and  contrasts  this 
with  the  compai-ittive  immunity  in  the  case  of  certain  Knglish  naval  vessels  on  the  west  cimst  of  .\frira  during  iH.'iti  and  \^nl. — See  Stalistiral  re^tort  of  the 
heallti  <f  the  Itoijat  Sarii  for  Hie  ijear  ISfili,  London,  IS.'iS,  pp.  llHJ  to  11(1 ;  al.so  tin-  same  for  the  year  ISfiT,  Loudon,  18.".ll,  pii.  TS-Sfi. 

t  Qninine  as  a  Pi-ophtilact'w  atjainM  Malarial  ferer:  beinij  an  apjiendijr  to  the  Third  reptnt  on  Ttiphoid  and  Malarial  ferer*,  delivered  to  the  Snrgeon 
denerul  of  the  late  t'.  S.  .1.,  Ani/ntit,  18(H.  Nashville  Jrnir.  ,f  Med.  and  Sanj.,  Vol.  II,  18i;7,  p.  441  el  mj.  Dr.  .loSES  adverts  to  the  great  prevalence  of  inter- 
mittent and  remittent  fevers  in  the  command  statioueil  in  and  around  Fort  .Jackson  on  the  Savannah  river.  This  command  had  a  mean  strength  of  878 
men,  and  during  the  twelve  months  "  from  Octoher,  180'i,  to  Novemher,  18«:i,  'iSllS  cases  of  malarial  fever  were  treated."  He  assumes  that  these  men 
might  have  been  protected  at  a  c<ist  of  S4,:5',Kl  hy  each  using  an  ounce  of  quinine  during  the  p*'riod  stated.  On  the  other  hand  he  supposes  that  had  no 
propliylactic  been  used  the  proj^r  treatment  of  the  cases  reported  would  have  reouired  on  an  average  ot>  grains  of  quinia  each,  or  about  liiM)  ounces, 
costing  at  So  I'er  ounce  fl,.'!!*!.  Tlie  additional  cost  of  the  quinia  rei|uirert  for  proiihvla.\is  would  thus  be  $-2.8V)0 ;  but  against  this  he  offsets  the  pay  of 
the  men  on  the  sick-list,  .\ssuming  IK)  men  to  be  constantly  otf  duty  in  the  unprotected  command,  their  pay  per  annum,  estimati'd  at  S1:!,-2W1,  would 
give  a  balance  of  f  ln,:!10  as  a  saving  to  the  Confederacy  by  usitig  the  quinia  as  a  prouhylactic.  Besides  the  reports  of  Surgeons  \V.\rren  and  Logan, 
ULeiitioned  in  the  text,  Pr.  Joxes  reprints  a  report  by  Surgeon  Oitavivs  White,  dated  .lames  Island,  S.  C,  May  7,  18i;2,  in  which  the  writer  refers  to 
the  Kuglish  naval  experience,  and  recommends  the  prophytaetir  ubi-  of  (piinia  by  the  troops  on  .lames  Isl.-ind  and  in  St.  .\mlrews  Parish  :  also  a  letter 
fiom  Dr.  I).  Df  1're,  dated  N'ashville,  Tenn.,  May  1",  181",  mentioning  the  case  of  six  individuals  exposed  to  malarial  influences  who  attributed  their 
eseajK'  from  fever  to  the  use  of  quinia. 

J  Surgeon  Wakren's  observations  were  made  at  the  instant.-e  of  Dr.  .loSES. 

g  Samuel  Logan,  P.  A.  ('.  S.—Pniphi/lactii'  ejects  of  iiuinine.  L'oufed.  Stale.-:  Med.  and  Svrg.  Jaur.,  Vol.  I,  p.  81.  This  article  was  republished  by  its 
author  in  the  Rithmond  Med.  Jonr.,  Vol.  II,  ISGO,  p.  412. 


172  PRFAT.XTIOX    OF 

feet  below  tlio  surface.  Towards  the  interior  tlie  liglit  sea-island  soil  gives  place  to  level 
tracts  of  stiffi'i'  I'mi h, sandy, but  mixed  with  red  clay,  on  which  th(.>  undergrowth  is  extremelv 
luxuriant.  '^Fliese  lowlands  are  intersected  by  swamps,  some  bearing  rice,  and  all  c(im[instMl 
of  an  alluvium  on  blu(>  clay.  Beyond  this  the  pini>  barren  I'egion,  a  dry,  porous  sand  with 
i-lay  underlying  it  at  a  considerable  deptli,  becomes  gradually  changeil  into  the  rolling 
ground  which  leads  up  to  the  mountain  slopes.  Malaria  prevads  in  the  sea-islands,  in  the 
low-levels  and  in  the  lower  pai-t  of  the  pine  barrens.  The  higher  parts  of  the  last,  and 
some  of  the  first  ari;  exempt  t'rom  fevers;  l)ut  as  the  Union  troops  occupied  all  the 
healthy  portions  of  the  shore,  the  rebel  lines  of  defence  ran  tiu'ough  the  uniii-ahhy  low- 
lands just  within  the  belt  of  sea-islands.  Dui'ing  the  sununer  months  most  of  the  troops 
were  moved  to  the  healthy  pine  lands,  but  some,  chieHy  cavalry  commands,  were  retained 
for  outpost  tluty  in  the  sickly  low  grounds.  To  these  quinine  was  admimstenMl  as  a  prophy- 
lactic; but  it  was  not  taken  by  all,  although  all  were  exposed  to  similar  iiiHuences.  This 
failure  on  the  ]iart  of  some  to  make  use  of  the  rpiinino  gives  a  value  to  Dr.  Log.vn's  statis- 
tu'S  liy  pemiittrng  a.  (•(Jinparison  to  be  made  l.x'twei'n  the  sick  I'ates  Irom  malarial  disease 
among  those  who  did  and  those  who  did  not  use  the  drug.      Ilis  results  were  as  follows: 

'I'dtuI  iiiiiiiher  who  took  no  (|uiiiint)  2'M)\  liad  fever  1S4:  ratio  per  1,000  of"  fever  cases  to  jiatieiitN  ."i82.(>0,  or  I  in 
everv  1.71  patieiits;  ratio  per  1,000  of  severe  eases  to  total  eases  313. JS,  or  1  in  every  3.19  eases.  Total  iiunilier  who  took 
(|uiiiiiie  irrei^nlarl.v,  24t);  had  fever  Itt!;  ratio  i)er  1,000  of  fever  cases  to  patients  390.21,  or  1  in  every  li.oti  ))atients: 
ratio  per  1,000  of  severe  eases  to  total  cases  291.t)t),  or  one  in  every  3.71  cases.  Total  nnnil)er  who  took  qninine  re<;iilaily 
,^)0(i;  had  fever  98;  ratio  per  1,000  of  fever  cases  to  patients  193.67,  or  one  in  every  5.11!  patients;  ratio  per  1,000  of 
severe  cases  to  total  cases  321). 53,  or  1  in  every  3.0(5  cases.  It  wonld  seem  from  these  statistics  that  altlionfjh  not  an 
absolute  ])roidiylactic,  the  dej;ree  of  i)rotectivt^  jiower  possessed  by  the  aj;ent  fully  warrants  its  use.  If  four-tilths 
of  the  fe\er  cases  are  prt^veiited,  it  should  surely  be  used.  It  may  he  well  to  explain  that  under  the  head  of  iniiiihi-r 
1(7(0  ioiik  (jiiiiiinc  irreguJarlji  are  included  tliose  who  wonld  for){et  or  nefjlect  to  take  it  some  three  or  four  days  in  the  week, 
or  take  it  one  day  and  forget  it  the  next,  or  omit  it  for  a  week  at  a  time. 

Oil  the  other  hand  it  has  been  stated  by  Dr.  IIkrrick  of  Louisiana,  that  quiuia 
was  issued  in  a  spirit  ration  to  tlio  crews  of  the  Confederate  Heet  in  Mobile  l^ay  during  the 
summer  of  1863,  by  order  of  the  Confederate  States  naval  commandant,  but  the  result  of 
the  trial  was  not  satisfactory  and  it  was  soon  discontinued.* 

It  is  not  difficult  to  add  to  the  list  of  authorities  brought  forward  by  V.\N  Burkn  and 
JoNKS  in  sup[)ort  of  the  prophylactic  virtues  of  quiuia.  On  this  side  of  the  question  may 
be  cited  the  paj)ers  of  MKimirr,  RooKRS,  Hkrrick,  Bartholow,  Vivknot,  Jilek  and 
Hamilton,  and  the  favorable  opinions  expressed  by  E.vston,  Dutroulau,  Stille, 
II.  C.  Wood  and  Hkrtz.-)"  Moreover,  favorable  notices  of  the  successful  employment 
of  the  measure  on  the  West  Coast  of  Africa  may  be  found  in  the  official  volumes  con- 
taining the  statistical  returns  of  the  health  of  the  Royal  Navy  subsequent  to  those  cited 

*  S.  .S.  IlKKKlrK — Quinine  (W  u  llifi-apftilif  u(/fnt.      Tninx.  Atner.  Met}.  AsiUH-itiH'ni,  Vol,  XX,  IHfirt,  p.  (ilH. 

f.l.  Kim;  Mkkkitt — Qiniiine  ajt  it  I'}-iiphnhuiir  in  Miilariimit  m/Zoji/J.  Atiifi:  Meil.  Tiines,  Vol,  III,  IStil,  p.  .1(15.  Stephen  UinjERS — The  Protet-lii-f  ur 
prophylartit'  prffftitiri'  unit  mDiif  poiiittt  in  the  1'nritlire  hwj*  itf  Qninine,  etc.  Trunx.  3/cr/.  Htiviely^  N.  Y.  Stiite^  IHd'i,  p.  181  ;  also.  The  I'rophylitctie  iinil  the  Thent- 
peiitir  ntieninnl  itintney  (tf  Qninin  tnnt  Ui*  KtiUit.  Trtintt.  Anier.  Meil.  .4ttit<H-ittlUm,  Vol.  XX,  18fS9,  p.  187.  Both  5IEKKITT  and  RiioERS  iiiHtaiH'c  their  «?xiH-ru'iici'  on 
the  [sthniiis  of  I'aiiania  as  aiitliori/.iii<r  their  favoralilc  opinion.  S.  S.  Hekrick — cited  in  last  note.  Roberts  Barthoi.ow — .Irnu/  hijijiene.  IVneeedintjs 
t'ltitneetient  Mett.  Scrietif,  Vol.  Ill,  'M  MerieM,  IHItS-Tl,  p.  T(i ;  also.  Quinine  and  itn  mttK^  in  same  Vol.,  ]).  DO;  also,  .1  Prarlirttl  Treattue  on  Materia  Mettira  and 
Therapenties,  New  York,  1870,  p.  l;jl.  Rrnol.F  Ritter  von  Vivenot,  jcn. — Veber  die  prnphylaktinche  .inirendnmi  des  Chinin  iji'ijen  Malaria-inlnj-ilmlian.  Med. 
Jahrti.,  Weill,  18(')!t,  S.  3!t.  In  this  i»iii»er  the  writer  relies  almost  wholly  on  the  essay  of  Van  Biiren,  cited  note  J,  p.  l(jt>,  mpi-a,  and  the  English  naval 
ex|ferienee,  which  he  gleans  chiefly  from  the  work  of  C.  Frieoei. — Dit-  Krankheiten  in  der  Marine,  yeoyraphixi-h  and  Ktatij<tij<rh,  naeh  den  *^  Uepurtx  ini  the  Health 
>>/  the  lioitnl  S'arti,^^  danjentellt,  It^-rlin,  lK(Ki.  .\,  R.  vos  .IlI.EK  —  Hietrag  7.nr  PrnpliifltiJ-e  fjeijen  Marlariafieher.  Wafhenhlatt  der  k.  k.  tiexellttehaft  der  .\err.te  in  Wein, 
.\pril  -^7.  Is7l»  (No17).  S.  177.  .1.  BfTI.EU  Hamilton — IteimtrkK  mt  the  ralne  a/  Quinine  as  a  Pntphylaetic.  Indian  Med.  tiaz.^  Vol.  VI,  1871,  p.  tXi.  This  author 
relates  that  at  .Inhlinlpore,  in  18(if;.  he  gave  three  grains  of  iininine  every  second  day  to  each  of  1.3,5  men  under  his  immediate  eharj^e  ;  few  eases  of  fev<'r  and 
no  deaths  tH-eiirred  amon^  them,  the  avernj^e  numlter  in  hospital  not  exceeding;  four  jn-r  cent,  of  the  commanti.  .\t  tin-  siime  time  and  place  51  )U  men  of  the 
ii3d  R.  W.  Kusili-ers.  who  did  not  use  the  quiuia  prophylaxis,  were  attat-ked  with  si-vere  remittent  fever,  liavinj^  at  oiu^  tinn^  as  many  as  15(t  of  their  nuiiiher 
sick  in  hospital],  and  1.5U  more  convalescent  from  the  A-ver,  en<'am|M-d  on  the  hill  clos*'  hy :  "The  numlier  of  deaths  I  cannot  remendier,  hut  1  think 
they  were  about  2(». "  A.  F.  ItfTROtLAl' — Trait.-  des  Maladies  den  Knriip  'enx  dani*  lea  paijs  vhands,  2^  edit.,  Paris,  18»IH,  p.  •.i5;i.  J.  .\.  Kaston — lleneral  ohner- 
nilitnin  iHi  pidianli:,  ete.  lilimjow  Med.  ,hmr..  Vol.  VI.  1858.  p.  -^7:!.  .\j.FKEn  STll.Lt— 77«-m(ieii(/.B  ,o,.(  .If.idriii  Mediea,  ;!d  edit.,  Philadelphia,  18(;8,  Vol.  I,  p.  ^M. 
II.  C.  \\i«i\t^Treati.ie  ..„  Therapenties,  M  edit.,  Philadelphia,  l87l'.,  p.  7.i.  ilENllv  HERTZ — Malarial  diiieatUfs,  in  Zienigarn's  Olilapmlia  of  the  Prueliee  of  Med- 
icine, Vol.  II,  Auier,  tranal.,  New  Turk,  1875,  p.  657. 


MALARIAL    DL'^EASE.  173 

ill  tlie  jiaptT  iif  Van  RrRKN.  Tliese  notices  are  indeed  so  lamlatoiy  as  to  warrant  the 
anti<-i|iation  tli;it  the  statisties  wuuM  show  a  consideralde  and  permanent  reihietion  in  the 
rre(|ueni-v  of  niahirial  levers  among  llic  saiUirs  of  llii^  station  after  the  general  introihietion 
of  the  propliylaetie  use  of  quinine  under  the  auspices  of  I)i;YsoN  in  l8o4;  bui  an  examin- 
ation of  the  actual  figures  does  n(jt  show  any  such  reduction,  although  of  late  years  the 
inoi'tahty  has  been  very  materially  diminished. 

The  shore  operations  of  tlie  Ashanti  war  led  to  a  high  rate  of  prevalence  of  malarial 
fevers  among  the  men  of  the  British  Xavy  and  undermined  the  faith  of  their  medical 
otHcei-s  in  the  prophvlactic  virtues  of  quinine.  Staff  Surgeon  Thomson  exjiressed  adi>ul>t,'^' 
StaiT  Surgeon  Lucas  gave  an  unhesitating  denial, f  Surgeon  Major  GoKi-:,  on  the  stafl  ot  the 
quartej-master  general,  deelareil  that  his  unfavorable  ojiinion  was  shared  by  European  resi- 
dents in  West  Africa,!  and  Sir  AiXTHOXY  I).  HoMK,  principal  medieal  officer,  regretted  that 
he  had  been  unable  to  recognize  any  value  in  quinine  given  in  prophylactic  doses,  lor  it 
seemed  neither  to  ward  oft"  attacks  nor  to  mitigate  their  severity. § 

MoREHEAD,  from  his  observations  in  India,  entertained  the  opinion  that  the  evidence 
in  favor  of  the  power  of  quinia  to  prevent  iiitermittents  and  remittents  in  malarious  districts 
was  by  no  means  conclusive. ||  Livingston,  during  his  expedition  to  the  Zamln^si  river, 
found  that  those  of  his  men  who  took  quinine  as  a  preventive  were  attacked  with  fever  as 
frequently  as  those  who  did  not  attempt  thus  to  secure  protection. ^J  Leon  Oolin's  expe- 
rience in  Algeria  and  Italy  led  him  to  an  equally  unfavorable  opinion. '•''■'  The  methoil 
was  tried  without  success  among  the  Russian  troops  in  the  Caucasus.-|-|-  Vivknot's  essay|J 
suggested  its  use  in  the  Austrian  army  and  navy  during  the  year  1869,  when  .Jilek  obtained 

S'Siiri;-.'.!!!  .lAMKS  TllnJTsnx,  ,if  ftip  Am,thiii.l—Slnlisli<id  npoil  fnr  1874,  pp.  180  ami  1S4— writes :  "\Vh"thi'r  any  pniphvliutic-  tri'iitiii"lit  .an  li-- 
ii'iiiplilily  siiiivssful  ill  tliis  climate  is  a  pioMiMii  fcir  the  futurv.  J  confers  to  considunililu  ilisaiipointmi'iit  in  tli"  piTsi'iit  aw.  althiniL'ti  I  tliiiik  it 
pinhaWc  Unit  tin'  daily  ailiiiiriiftriiti(.n  (.f  f.nir-gi-aiii  iluscB  i.f  iiiiininc  liail  a  inoilif'yirig  iiiBuuuce.  It  is,  morciivcr,  wiirttiy  uf  remark  that  1  have  heard 
et  Mil  ease  liaviiif^  a  fata!  termiiiatieli." 

tSiireeiai  l,K.ii\ARl>  I.IcAK,  of  the  .liv/m— WiiWiin/  npoii  for  1K7:1,  p.  l(«i:  "A  questiou  arJBe.s,  iloes  (|lliliilie  Kiveu  as  a  prophylaelie  prevent  an 
altaek  i.r  remittent  fever?  I  unhesitatingly  say  no.  Take  the  ease  of  those  marines  hinded  at  Elmina  to  gnanl  tlie  jdaee.  (Quinine  was  adniiiiisteied  to 
Ilieiij  dail.v,  yet  within  a  month  all  thew!  men  returned  on  hoard  «-ith  fever.  It  is  true  Fort  St.  .lago  is  unlit  for  men  w  live  in  ;  hut  those  liillet-d  in 
the  .astle  fared  no  Letter.     It  dis's  not  follow  that  men  landed  for  a  day,  who  had  .piiiiine  hefore  U'aviiiK  their  .ship,  esiaiK'il  fever  in  eonsei|iienee,  h'eanse 

1 have  also  l.een  landed  without  any  quinine  and  have  fari'd  eijually  well.     It  remains  to  he  prov.il  whether  its  adininistnition  as  a  propliylaetie 

liiiils  t"  render  tin'  attack  of  fevir  milder  in  chaiaiter." 

;  Al.RKKT  .\.  Coke— .  I  I  ■oiilrihiilidii  I"  llir  Mi-iluiil  HMiiril  'if  thf  W'nl  Afriniii  I  •iimpmijii/',  l.ouilon,  l.sTl'i,  p.  IcH— gives  speiili,'  illustrations  ..f  the  lailiire 
of  the  iininia-prophylaxis,  as  for  instance:  "yuinine  wasserveil  out  to  the  marines  who  started  lor  KIniina  on  the  lith.lnni — live  grains  in  half  a  gill 
of  ruin  all  round,  the  same  quantity  at  daylight  in  port  wine ;  all  tli.-s.i  nieii  had  severe  attacks  of  remittent  fever,  .\fter  wet  and  d.uiip  nights  it  was 
always  given  to  the  sentries  with  no  lietter  etfect." 

SPepnty  Surgeon  tienenil  Sir  .\nthoxv  !>.  Hojik,  K.C.  B..  tn-.^MtiUnil  hMnii  •■/  Ihe  ll'.o-  lii  Ihf  <;„hl-(niial  Pruli'rhirnlr  ill  \»T.f.  Ariiiij  Mrili'iil  hi  pill  I- 
iiieiil  Hiporl/di-  Ihe  iii-iir  I87:i,  V(d.  XV,  London,  187-=>,  p.  'I'l'.' :  "  With  regret,  and  heartily  wishing  Unit  my  opinion  may  he  overthrown  hy  tho.se  of  others. 
I  have  to  say  that  I  did  not  recognize  any  value'  in  cplinine  given  prophylaitically;  it  neither  seemed  to  ward  off  attacks  nor  t.i  mitigat"  the  s.-verity  of 

malarious  feviTs  ill  those  attacked.     With  tl xi-eption   that  in  .some  nieii  a  daily  thrc-gniin  ilose  pri«lnced  transient  il 'afness.  and  in  a  f 'w  others 

nausea,  no  untoward  symptom  followed  the  use  of  tlie  medicine,  (hi  the  other  hand  I  was  nnahle  to  agi-ee  with  the  startling  ..pinion  s"ri..usly  pn.- 
|".nni|..il  t..  nil.  I.y  some  m.'n  of  the  W.'St  lii.lia  regiment  emanilNil  at  Nap..l....n,  that  the  qniuim^  they  to.>k  .laily  as  a  pnipliylacti.-  ha.l  giv.n  th-m  the 
agin'  fr.ini  which  tln-y  suffered." 

IICkari.ks  Morf.hraI) — f'rmkal  lifi^nri-hes  on  ItiseiDtrn  in  liiiliii,  2d  edit.,  I.oudon,  ISiill,  p.  I-P.I — sis-aks  of  the  alleged  su.-eess  of  two-grain  doses  ot 
.liiinine  in  jiri'venting  malarial  fevers  in  the  'I2d  Highlanders  during  its  service  in  the  jnngly  tracts  along  the  sonthern  hase  of  the  Sant|ioora  hills  during 
NovenilKT  an.l  Heiemher.  IS.">S,  hilt  shows  that  ..tlier  detachments  of  thi'  same  exiieditiou  iHdonging  t..  tin-  ISth  Royal  Iri.sli.  th.'  :!.!  |lragi...M  llnanls  an.l 
the  Bomhay  Horse  .VrtiUery  were  equally  fortunati',  altllongh  they  took  no  iininiue. 

t  I>AVin  ami  CllAni.Ks  LlvixilsTox— -Ve.™/o.    ../  mi   F.-rpiililiini  III  llif  Xniiihini,  eli:.  New  York,  LSIIC,  p.  S-.; :   ••  Wh.'th.'r  w..  t....k  it  ilaily,  ..r  ..mitt  -.1  it 

alt..gelher  for  months,  made  no  diflfen-iice ;  the  fever  was  iniiiartial,  and  seizeil  on  the  da.ys  of  ipiinin..  as  regularly  ami  sevi'ivly  as  wli.n  it  ivniai I 

iiMilisturhed  ill  the  medicine  chest,  ami  we  linally  ahandoneil  the  us.'  of  it  as  a  prophylactic  altog.'tli.'r."  In  a  ibiiht  of  earlier. lap'  hy  Davih  Livi.niwtox 
an.l  .t.iiiN  KlIlK — Iliiiiiiiks  ml  llir  Afiiiiiii  frrrr  III!  Iln'  Imnr  Xmiibci.  Miil.  Tiiiie-i  mid  (-.'.(...,  Vol.  .\IX,  X.  S.,  1S.V.I,  p.  17:1:  "Th.'  result  of  our  experiellc  has 
II.'  '11  to  .liscontinue  the  daily  us.,  of  ipiinine."' 

**Li,os  ('..MX — Tiiiiti'  lien  funri'  liilrniiilliiilii.  Paris.  IS7II,  p.  t'.;4  ;  als...  <  ■nimil,  indiim  iji'in'riilii-iiir  rediilnijii-  ili'ufi'  vn*  iiilfrniilliiili  k,  Anli.  'ieii.  ilf  Mil., 
VI"'-  B.'rie,  t.  XV,  1K7(I,  p.  ;i4.  Sec  also  his  rei«jrt  to  the  Minister  .if  Puhlic  Works,  April  4,  IHKl— Buff,  ilr  I'AiwI.  ile  Mil.,  t.  X,  IKHI,  p.  i:i;)S.  Hi-  insists 
that  .|iiinine  is  not  projierly  an  "anti-miasmatic  meilicine";  it  .uily  a.ts  against  certahi  symptoms  of  the  malarial  iiitoxi.ation,  esin'cially  tli.'  fel.ril.' 
symptoms.  Hi'  recominelids  that  it  la.  reserved  for  th.'  siik,  anil  given  to  them  in  suftieient  doses.  .-According  to  B.'.liEXoKR-FLRArn — .l/.i/.e/iVs  ilrs  Kiiin- 
pirm  an  S'lii'ijiil,  Paris,  l«7.'i,  t.  I,  p.  iU — the  Freucli  military  surgeons  in  Algeria  are  divided  iu  opinion  as  to  the  iirophylactic  virtue  of  qui-iia,  some 
being  for  aud  some  against  it. 

ffCoLix,  in  liiilt.  ih'  V  .-laiiL  de  Mtd.,  cited  in  last  note, 
\l  See  n.jte  f ,  p.  17'J.  .^npra. 


174  rKEVENTlOiS'    OF 

soiiicwiiat  rarorablo  n-.-^ults  in  h  (letacliiiient  o['  inariiips  at  Pola  on  tliP  Adriatic;""  lint  a 
siiiiilai'ex))oriiiifrit  at  the  same  time  and  [ilacc  Ky  tln' sui-gfon  in  charge  oi'  the  29th  iidaiitry 
gavcahont  the  sann'  propdrtion  of  cases  ainnng  those  who  tmik  the  (jninme  as  among  fliDse 
who  ihd  mil;  and  e<[nally  unsatisi'actory  rcsidts  wiTc  olitaincil  in  ihe  case  ol  several  small 
cavali'v  ilctaidiniciits  on  the  Danulje,  as  also,  during  the  same  year,  among  the  troops  term- 
ing the  large  gan-ison  of  K(;)m(a'n.")' 

The  evidence  bearing  on  the  virtues  ul'  ipunia  as  a  prophylactic  against  malarial 
fever  is  therefore  by  no  means  uniformly  aflirmati\c;  Imt  in  tlic  instances  of  failure  or  of 
doubtful  benefit  there  is  always  that  prolonged  exposuiv  whicli,  as  we  have  seen,  led  to  the 
disuse  of  tlie  method  in  (Uir  armies  during  the  war.  l')Ki;KNoKR-FERAr])  recognized  the 
difference  between  tempni'ary  and  pi-ohmged  exposui'es  in  this  connection,  and  even  specified 
tliat  if  the  exposure  was  to  be  continued  for  mon:  than  twenty  days,  prophylaxis  need  not 
be  attempted.!  Moreover,  some  of  the  instaiu'es  of  failure  may  perhaj)s  be  attributed  to 
the  inadequacy  of  the  quantity  given.  Quinine  as  a  prophyhu'tic  has  usually  been  adminis- 
tered in  comi>aratively  small  doses.  A  grain  and  half  to  three  gi'ains  daily  as  used  by 
JiLKK,  ami  two  grains  daily  as  at  Komorn  and  elsewhere  in  .Vustria,  might  well  be  regarded 
as  inefficient;  yet  K.i.Mii/roN,  with  three  grains  every  other  day,  reports  one  of  the  most 
brilliiint  instances  of  success. §  Most  of  thcjse  who  in  tliis  c(juntiy  have  recommended  the 
quinine  prophylaxis  have  insisted  on  a  daily  dose  of  four  or  five  or  even  more  grains. 

Heerick  advocated  the  view  tliat  the  most  efFectual  plan  is  not  to  make  daily  use  of 
quinia,  but  to  resort  to  it  in  decided  doses  on  the  first  ap[»earance  of  malarial  symptoms. || 
This  <ipinion,  whi(di  was  based  on  his  experience  of  intermittent  fever  in  his  own  person, 
corresponds  with  that  which  has  been  given  above  as  to  the  proper  mode  of  meeting  the 
dangers  attending  tiie  prolonged  exposure  of  an  army  in  malarious  districts. 

Similar  in  principle  was  the  plan  pursued  by  the  medical  officers  of  the  English  army 
during  tlie  war  of  1879  in  Zululand.  Surgeon  General  AVoolfbyes  reports  that  during  the 
sickly  season  quinine  was  administered  throe  times  a  week  to  all  the  debilitated  men.^[ 

The  o{»inion  expressed  by  Hamilton  that  (juinoidine  used  for  the  purpose  in  view  is 
more  efficacious  than  quinine,  is  not  as  yet  supported  by  adeipiate  evidence.''"'' 

Besides  the  doubts  that  have  occasionally  been  thrown  ujiou  the  power  of  quinia  to 
prevent  malai-ial  fevers,  the  serious  objection  lias  been   urged  that  those  who  take  tlie  drug 

*.lil,KK — I'ji.  fit.,  note  f,  p.  172,  mprit.  Tho  (]iiiiiia  was  jrivi'ii  in  1  '^._j  ti>  :l-;;nihi  doses  dail.v  In  nini ;  olHl  iiieti  took  it  from  .huio  1  t>»  St'i)t(Mnh('r  20, 
ISSt,  anions  wImhh  tlu're  wcr»'  '.H  caws,  wliik'  aitioiip;  'J;H1  men  wlio  did  not  taki-  it  there  were  )>H  eases.  Jii.kk  thinks,  too,  that  the  eases  antulig  those 
who  took  the  ijiiinia  were  milder  than  anHin;;  those  who  did  not. 

t  These  laetsare  rel>orted  in  an  article  F.rfithniiiijeii  iihn-  die  imiplijihiUinli,  .luirnirlilwi  rm,  r;,,,,/,,  „„  /  /,>/.  „„,  ,s  r,„i,ini  ijr.jni  Miil'iriu-liil':rikiilinwil, 
Atl'j.  Militiin:ir.tlirln'  /^'itntitj,  ISTii,  No.  10  «.  11,  S.  7l>  ft  Kfij.  Two  jiinins  were  driven  daily  in  spirits  of  u  ine.  .\t  Komorn,  hetween  .lannary  I  and  Anjinst 
2.%  IHttli,  tlMTe  wt-re  l.I4'.t  inteniiittents  in  a  mean  streiijjtii  of  .~).:tr,n  men,  or  270  jier  l.lHHt  for  the  time  named.  This  is  s])oken  of  as  less  than  the  n.snal 
pnipoition  of  eases  at  the  i)ost,  hnt  as  there  were  neither  fltHwis  nor  prolonged  heats  dnriuj;  ISliO,  it  was  considered  doubtfvil  whether  the  lessened 
Jirevalenee  was  rr-ally  dne  to  the  qninine. 

{L.  .1.  B.  IW:RK.\ciF.R-l"Eii,vri>— Oj..  '■//.,  imte**,  p.  1T;1,  .'iipr,:.  t.  I.  p.  Jill. 

^Hamilton — cited  i>.  172,  xnpni, 

II  IIerrick — I'n-  ei7.,  n(»te  *,  p.  172,  stijini,  says ;  *■  In  lsn4  the  writer  hail  occasion  to  lest  tin-  valne  of  ijninine  as  a  preventive  of  intermittent  fever 
in  his  own  iH-rson,  and  became  convinced  that  the  most  etTecttial  plan  was  not  to  Tiiake  a  liaily  tise  of  it,  Imt  to  resort  to  it  in  decideil  doses  on  the  first 
warnin;:.  It  is  <inly  nec-essary  to  exercise  constant  vij^ilaiice,  for  a  iiaroxysm  is  un-n.-i-ally  preceded  hy  nnmistakahle  si;;ns  of  malai.se  for  a  day  or  two 
prcvionsly.  and  tin-  attack  can  Ije  wanled  ofrlty  a  few  titnely  doses  of  iiniiiine."' 

«|  Snrtteon  (Jenellil  .1.  A.  Wooi.frvbs— .l/e</«-ii;  KiMnnj i,f  the  mir  ia  /itlnhni.l  l,i  ls7;i;  .1,,,,,/  M,'li,;il  Iwjiarhiifiil  ;.V;).irf,  ISTll,  London,  l.ssi,  p.  2'.l'.l  ;  The 
stretijitli  of  the  re^nlar  troops  tjf  this  conunand  was  I:i,;t:i:j  (.ifticersand  nnoi,  of  w  liom  2,1111,  or  22ii  per  1,0IK),  were  taken  on  sick  report  with  fevers  between 
.lannary  4  and  OctolM-r  ;i ;  the  proporticjii  of  malarial  fevei-s  is  not  stated. 

='*.I.  Hi:t|,KR  IIaMII-Ton — lifjxyrt  tin  ttf  la-tUiH  of  QntiiiiUIinf  unit  t'incftfniin''  ".v  n'ljnntn  their  iti^tJltntcf  mt  ^Inhtfiintn  fefttis ;  Initiau  .Ve*/.  (iVt;.,  Vol.  VI,  1S71, 
p.  nti — gave  to  each  solilier  of  a  detachment  of  KO  men  at  Allahabad,  from  August  ;J  t<>  N'oveniher  10,  187(i,  three  grains  of  quinia  daily  ;  toeach  of  adetach- 
ment  of  t>7  men  the  same  quantity  of  cinchonine,  and^o  each  of  a  thinl  detachment,  also  of  tj7  men,  the  Sitmo  quantity  of  quiuoidine.  In  the  first 
detachment  there  were  7  ca.se.s  of  ague,  or  87  i.ier  1,'K«»;  in  the  second  1:1  cases,  or  l;ll  ,ier  1,000;  lit  the  third  ')  cases,  or  77  per  1,000;  whence  he  con- 
cludes that  quimiidinr-  ninks  hlirhest  and  quinine  next  in  i)rophyIactic  virtue.  (»n  the  other  hand  (Jork — jt.  1IJ4,  op.  cU.,  inpte  J,  p.  17:J,  .tnpm — reports 
that  the  men  of  the  "West  India  regiment  who  occupied  the  camp  at  Xapoleon  during  the  Ashauti  war  took  daily  a  solution  of  quinoidine  without 
d  riving  any  iKirticulur  benefit. 


MALAKIAL    DISEASE.  175 

habitually  acquire  in  time  a  tolerance  of  it?;  action,  in  consequence  of  which  its  power  as  a 
remedy  becomes  lost.*  But,  as  during  our  war  there  frequently  occurred  casos  in  whi.'h, 
without  the  previous  administration  of  quinine  as  a  prophylactic,  this  remedy  failed  to  break 
up  the  paroxysms,  necessitatin^i^  a  recourse  to  arsenic  and  other  antiperiodics,  it  is  possible 
that  this  tolerance  to  the  habitual  use  of  the  <lrug  may  have  been  really  due  to  s(^me  preu- 
harity  in  the  individual  or  in  the  altaek.  It  has  also  been  represent^ed  that  ^^astric  and 
mtestinal  irritation,  hjss  (,f  appetite,  headache  and  ev<*n  diarrluea  result  Ironi  its  continue*! 
use;f  but  although  these  accidents  undoubtedly  occur  in  some  highly  susceptible  indi- 
viduals, it  is  not  unlikely  that,  in  most  cases  the  medicine  is  undeservedly  blamed  for  symp- 
toms referable  to  the  coincident  malarial  and  other  morbid  inHuences.  This  explanation 
uiupiestionably  applies  to  the  opinion  sometimes  expressed  by  soldiers, :j;  that  the  fevers  and 
other  serious  results  of  malarial  hitoxication  fn.m  which  tlu?y  sufl'er  are  cause*!  by  the  med- 
icine employed  to  prevent  them, — an  opinion  sustained  by  Malonk  and  RL'Danikl  in 
this  country,  and  by  the  Sicilian  physician  ToMASKnLi  and  others,  whose  error  has  been 
sufficiently  exposed  by  the  criticism  of  J^KKKNgkk-Ferauj).§ 

PKOPnyj.ACTic  Use  of  Other  Medicinal  Agents. — Several  other  medicaments  have 
been  sai<l  to  act  as  jti'ophylactics  against  intermittent  fever.  TIk;  only  one  of  these  men- 
tioned in  the  ofHcial  reports  as  having  been  tried  during  the  civil  war  was  the  bark  of  tlie 
willow.  Assistant  Surgeon  Hunter,  in  a  report  of  his  inspection,  August  31,  LS64,  of 
certain  regiments  in  camp  near  Thibodeaux,  La.,  states  that  a  spirituous  infusion  of  willow- 
bark  had  been  used  by  the  33d  111.  Vols,  with  fair  success ;||  but  the  monthly  report  of 
sick  and  wounded  of  this  regiment,  on  file  in  the  Surgeon  General's  Office,  shows  that  dur- 
ing the  month  stated  no  less  than  one-third  of  the  men  were  taken  sick  with  intermittent 
or  remittent  fever. ^ 

In  the  Confederate  armies  the  Cornus  Jlorida  or  dogwood  was  used  in  some  instances 


*  SxiLLfi  in  his  Thernpentics  and  Materia  Medira,  Pliiladelphiii,  1874,  VdI.  I,  p.  olit — refers  tu  this  ffderutiim  of  tho  nttMlk-iiic  and  its  loss  nf  ronicdial 
power  jis  (laiiKf'rs  inhoreut  in  daily  doses  continued  for  any  length  of  time,  and  (luotes  Dr.  (Iraves  {hnhliu  Qitarterhj  Jour.,  February,  184)1,  \i.  Tl)  as  jmt- 
liaps  the  lirst  to  call  attention  to  this  subject.  Dr.  Graves,  after  a  coniiHinitive  trial  <if  sevenil  iiiethinis  of  adniinisU'ring  quinine  in  u  rase  of  obstiiuito 
'liiartan  nfim;  ronelnded  that  it  was  best  to  withhold  the  n'niedy  until  prcnionitinns  of  a  fit  wenrred,  and  then  to  fiive  it  in  large  doses  ;  for  if  continued 
throuKhout  th(^  apyo'tic  interval  '"  tlie  system  becomes  accustomed  to  its  impression  and  is  less  powerfully  affected  than  when  it  is  taken  only  at  such 
times  as  the  deniiiKi'nient  which  it  is  adapted  to  remedy  is  about  to  (X-cur."  It  appt^ars  to  the  writer  that  the  tolerance  and  loss  of  power  are  by  no 
means  proved  by  Dr.  (Iraves's  experiment.  The  aMowable  concIusit>n  diM's  not  n'ach  further  than  the  greater  efficacy  of  large  as  couiiuin-d  with  small 
and  repeated  doses,  which  is  now  a  well  recognizeil  fact  in  all  malarious  districts.  See,  for  instance,  a  reference  to  Dr.  Charlks  McCormick's  cxiM-rienci', 
noti'd  on  p.  17'.',  iiifrn.  Nor  does  Dr.  Woodward  give  any  ground  for  the  ass<Ttion  as  to  tlie  loss  of  autiiK-ri^Klic  |>ower.  J.  J.  Woodward — (hifUm"  »/  the 
i  'liiff  Cuinp  It'm-iutfH^  Philadelphia,  IHlvi,  p.  171 :  "The  system  in  time  ac<piires  a  tolerance  of  the  action  of  ipiiuia,  and  wlien  acute  malarial  aft'ectioris 
su|>ervene,  as  they  fre(pu'ntly  do,  the  graud  theraiwntic  agent  on  wlii<-h  the  surgeon  relies  is  found  to  luive  lost  its  cumtive  power  to  a  great  extent." 
llARTiiitLow — Anity  h/jtiif'iif,  cited  note  f,  p.  172,  supra — says  :  "Quinine  lows  its  j»ower  by  lougctjutinued  use  ;  itsantiiK-riixIic  power  is  not  extiibited  satis- 
factorily in  cases  of  chronic  malarial  poison,  and  In-nce  its  jirophylactic  power  is  feelde  iu  the  sjime  morbid  stJite."  RotiERs — 'frnm.  Aitipr,  Med.  An^.^ 
l8K);i,  p.  tit.Ht, — expressi's  the  opinion  tliat  insusce|)tibility  to  the  thera|)eutic  effects  of  «|uiuia  is  wldom  met,  except  iu  those  who  have  used  it  coutiu" 
nously.  and  recomuH'iids.  therefore,  that  "considerable  intervals  of  abstinence  "  should  be  practiced  by  those  who  employ  it  prophylaclJcally.  Surgeon 
A.  (1.  Dk!:HJKi;k,,  of  tin*  British  navy,  who  had  charge  of  a  detHchinent  of  Koyal  iiiariues  landed  at  ('ai>e  Ciwst  Castle  during  the  Ashanti  war  of  1h7."{ — 
Sliitistirtil  iifpuri,  1S7;{.  p.  2m;, — states  that  the  officers  of  the  .\rniy  Medical  Staff  who  had  served  for  lougiierit>ds  on  the  ctMist  advised  him  to  give  (]uiui!io 
as  a  prophylactic  only  to  those,  of  his  men  who  were  esi)ecially  exposed,  as  by  its  constant  use  "  sndt  a  toleniuee  of  it  was  ireated  that  whin  attacked 
with  fever  it  would  recpiire  enormous  doses  to  jirwluce  any  effect."  Gore — p.  1*)4,  oji.  ci/.,  note  X,  p.  17;(,  mpra — states  that  it  is  a  general  idea  auuuig 
the  Kiiglish  residents  in  \Vest  Africa  "  that  when  taken  de  ilif  in  'lif>iu  it  losi's  its  power  as  a  remedy." 

t  Surh  symptoms  were  referred  to  the  quinim-  in  the  rejMirt  from  Komom,  cited  p.  174,  nupra,  althougli  only  two  grains  ilaily  were  given. 

X  As  for  example  by  the  Knglish  soldiers  in  the  Crimea,  a<^cording  to  Sir  John  Hall,  cited  in  note  f,  p.  167,  »i<pr<i,  ami  during  the  Ashanti  war, 
acconliug  to  Sir  Anthony  Home,  note  ^,  ji.  173,  supra. 

'fi^  Mai.onk  and  jMrDAMHi,  exprosserl  the  belief  that  while  (luinine  did  not  cause  malarial  lijernatnria  it  detenninod  an  attack  or  recurrence  in  tlmse 
lialile  to  the  atl'ection  frtan  continued  exposure  to  the  malarial  influence.  See  note  <»n  hiernnrrhagii:  nmiariaJ /erer,  mpra,  p.  ]2J< ;  and  also  Salvatore  Toma- 
8ELL1 — L'inlnssiru::iinie  rhinira,  ftr.,  (.'atania,  1877 — abstracted  in  the  Hull,  tie  KAratl.  »le  Mi'fl.,  2'  serie,  t.  VI,  1877,  p.  750  ;  G.  IJ.  roiiKXTi — L' iiitiumi'-'izi/me cfiinica 
e  la/ebhre  Inliom  ejnatnrica,  La  HperimniUde,  187H,  p.  614  ;  and  the  pai)er  of  Karamftzas  in  the  Bull,  of  the  Medical  Society  of  Athens,  session  of  Nov.  lS~:to, 
1878.  Bkuenuer-Fkraud — L' itUojrU-atioH  t/utni^pie  et  Vih/ectitm  palrtntre,  Arrhifen  ile  Mtd.  nanile,  t.  XXXI,  1870,  p.  3.'>.'>— has  thoroughly  exphKled  this 
charge,  an<l  shown  that  the  untoward  symptoms  attributed  to  tptinia  are  really  those  of  lifrmaturic  remittent  fever.  A  similar  explanation  of  tlie  viewa 
expressed  iu  Tomaselli's  imiimm*  was  offered  in  the  Acad,  of  Medicine,  Bull.,  vol.  cited  mipra,  p.  778,  by  Le  Roy  de  Mericourt. 

II  See  his  rf'iHirt,  p.  !■'»'»,  anprn. 

II  The  report  is  signed  by  Assist^mt  Surgeon  H.  T.  Antis,  of  the  3;5il  Hliuois  Volunteers:  Mean  strength  of  the  command  Hill  oflficcra  and  men ;  lt>7 
cases  of  intermittent  fever  and  20  of  remittent  are  reported — total  217 ;  of  the  latermittentB  5  were  congestiTt!,  and  two  of  these  died. 


176  TRKAT.Ml'.M    of 

instead  of  quinine  a.s  a  prophylactic.  (Jirciilar  No.  li:!,  is.siicd  from  tlicir  Tiirvcyor's  (  )tfice 
Auo-ust  22  1862  refers  to  an  arraii^eiiwut  In'  which  whiskev  nK'(Vicatc(l  with  (1(.l:wihm1 
and  oilier  indigL-tious  hai'ks  was  t.)  he  usc<l  by  llio  troops  tis  a  proteotiv*'  ugaiiist  inalaria/=' 
Dr.  Joseph  Jonks  I'cpoi-ts  that,  this  rompoiuul  titictm-*.:  was  issucil  l)y  tin.'  purveyors  to 
tro()[)S  serving  in  swampy  districts,  and  was  eiiiploycd  with  good  eiFcct  in  preserving  tlR'ni 
from  malarial  fevers. ■}- 


VII.— TKEATxMKNT  OF  MALARIAL  DISEASE, 

General  Considerations. — Prior  to  the  introduction  of  cinchona  bark  into  moiUcal 
practice  the  system  by  which  these  fevers  were  treated  was  palliative  and  uncertain, 
de[)ending  cliiefly  on  the  special  symptoms  manifested  l)y  the  individual  case.  The 
primary  congestions  suggested  the  propriety  of  bloodk'tting,  but  the  subsequent  deterioration 
of  the  blood,  so  marked  as  to  have  originated  the  muiw  ])ufri(l  fever,  caused  much  opposi- 
tion to  this  measure.  The  introduction  of  cinchona  as  an  element  in  the  treatment  was 
opposed  bv  those  who  considered  bloodletting  essential,  and  advocated  by  such  as  looked 
specially  to  the  putrescent  character  of  the  developed  disease.  At  first  the  bark  was 
regarded  as  an  antiseptic,  and  was  given  in  conjunction  with  camphor  and  wine;  but,  as 
early  as  1765,  Dr.  James  Lind  trusted  to  it  alone  as  a  specific  antidote  to  tlie  disease- 
poison. J     Its  value  was  also  urgetl  by  Hunter,  Clark  and  otlier8.§     But  in  1804  its  use 

♦This  rirrular  is  qiioti'il  fnpiii  Itr.  Jones's  articlo  cited  iti  tin-  next  aoto  :  ".\Uhough  iiu  onlernhave  been  issued  to  that  effect,  some  of  the  purveyors 
npiH'ar  In  he  iitidrT  the  imprcHsinii  that  tlicy  wlnmlil  make  a  iiiixturt'  of  thu  imlijifiiouH  barks  (dof^wood,  Ac.)  and  whiskey.  Tlie  arningenient  iiitcriilrd 
by  lln'  Snrj;<'(»ii  General  and  Cnniniifiwny  (icm-ral  is,  tliat  tin-  ('nininissiuy  Di-partnH'nt  sliall  Inniish  the  whiskry  to  the  trixips,  fjivitij;  cjich  man  imc  dr'iiik 
a  day.  Thr  Pnrvi'yin>;  DciMirtmciit  was  to  fnrnisli  tlie  harks  to  mix  with  (hr  whiskey,  to  make  a  spc(Mi-s  of  army  bitters,  as  a  pn-ventivo  against  mahiria, 
At.  Th*'  an-.tMt;('m(tit  is  mi-n-ly  an  issuf  of  whiskey  by  the  ('oiinnissary  Pepartmi'iit  to  the  troops,  and  the  Piirveyin};  Department  furnish  the  Iiark  t  > 
mix  with  it.  This  oftiee  lias  not  yet  been  instructed  wlietlier  tlie  mixture  is  to  lie  made  at  the  pniveyinp;  (k'pot  or  at  the  commissiry  dep.it.  Therefur- 
whiskey  will  not  be  issued  in  other  than  the  niediral  pri-|>iirations  that  have  been  or  may  be  ordered  as  ri'^ular  issues."' 

t  Ah,  for  instance,  to  the  Kutaw  (li.'tth  South  Carolinat  re;;imeiit,  whilst  it  was  encamped  upon  .binies'  Island,  in  a  notorit>usly  tualariuus  lotality. 
This  n-ninieiit  had  a  mean  streiifrth  of  ahout  ei;;ht  hundred  orticers  and  men.  Iturinj;  the  summer  and  autumn  of  b'^il2  one-third  of  tlu'  eorumand  was 
at  times  upon  the  .-iek-list  «  tth  the  various  forms  of  malarial  fever.  "The  assistant  sur;;eou  of  this  retrirueut,  J.  M'.  \\  aukkn,  of  S<iiith  I'andina,  eorn- 
municHted  to  the  author,  dnriufj;  his  iiisi»eetion  of  the  sick  n|>oii  James'  Islaiicl,  some  interesting  facts  upon  the  propliylaetic  powers  of  i-ertain  imlig- 
enoiis  n'nn'di<'s.  A  eonipouiicl  tincture,  or  medicated  whisk<'y.  pn'pared  liy  the  >Iedical  I'urvcyor  from  tlu'  (bigwoini,  cherry,  jiojdar  and  \\  iMow  barks, 
was  administered  daily,  in  the  proportion  of  oni'-half  to  one  gill  to  ea(di  man  during  two  weeks  in  the  month  of  .Sei)temt>er,  iSlVi.  I'luh-r  the  use  of  this 
tonic  mixture  the  number  of  new  cases  id'  malarial  fever  diminished  one-half,  although  as  the  autumnal  si>Hson  adv.anres  njton  James'  Island  malarial 
fevers  increase  in  nundier  and  severity.  Tlie  supply  of  this  meilicated  wliiskey  being  limited,  at  the  end  of  twi'  weeks  it  was  exhausted,  and  in  the 
course  of  eight  days  theca.ses  of  malarial  fever  had  increased  from  thirty-six  to  eighty,  A  fn-sh  supply  having  been  ttbtained  its  use  was  again  commence^i, 
and  in  the  course  of  five  days  the  nundwr  of  cases  of  malarial  fever  fell  to  the  original  iiundn'r."'  Dr.  Joseph  Jones — IinUijonuus  miifilhs  i>j  tht-  !<on(he)n 
Statfn,  A-r.,  Xn.  2,  Ihujiroo>l.—St.  Loniit  Meii.  ti'p* trier,  iKfiS,  p.  :i(tn. 

XAik  Fj*i<uii  i<H  !iise,isf'>i  i,iriil>-iihin»  Kiimin'mis  in  Il»l  CJiiuatps,  by  Jamks  Lind,  M.  P..  V.  It.  S.,  Sixth  Ed.,  London,  1808,  p.  :i2'.\  et  mj.:  "The  jirepara- 
tion  of  the  iMnly  reqnisit"  previous  to  the  ailminiwtration  of  the  hark  is  not  eonsiih'rable.  I(  is  sufticiejit  to  cleanse  the  stomach  and  alimentary  canal  by 
an  emetic  or  purge.  *  *  *  The  bark  may  be  administered  at  any  i»eriiMl  of  the  iliscase.  Vheii  the  ague  is  slight  it  need  rmt  be  given  till  a  second  Ht 
has  evinced  the  true  lutture  of  the  disease  ;  but  when  the  ague  is  severe  there  is  fri'«|Uently  an  absolute  uecessity  of  administering  it  upon  the  tirst  inter- 
mission, even  w  ith  wane  any  preparation  of  tin*  body  :  instances  have  occnired,  on  unh<'althy  spots  in  Kuglaiid,  of  agues  having  been  so  malignant 
after  hot  sunnners  that  a  nduru  of  the  tit  sometimes  proveil  fatal."  ^  *  *  After  adverting  to  the  npinion  that  an  ague  must  c(Uitinue  some 
time  iM'fnre  it  is  completely  formed,  and  that  till  siuli  time  it  is  highly  dangerous  to  apply  any  reiueily,  he  continues:  "The  advantage  of  ailministeriui: 
the  bark  as  early  as  po.<sib!e  in  the  disean-  fully  apjwared  in  the  year  ITH4  and  the  two  following  years,  durirtg  an  nnionrm<m  prevalence  of  reTuilling 
and  intermitting  fevers,  which  spread  themselves  over  the  greater  piirt  of  Kngland  and  furnished  me  with  a  numtier  of  (latients  laboring  under  all  the 
symptoms  of  these  ilis-ases.  *■  *  *  (  never  pri-wriU-d  the  bark  until  the  imtient  was  free  from  the  fever;  ami  then  without  regard  to  a  cough  or  any 
other  i-hnmical  indisposition  I  ordered  it  to  be  given  in  large  doses.  I  have  given  the  baik  In  every  circumstance  attenrling  int'-riuitting  fevers  during 
their  remission,  but  never  gavf  it  during'  the  fit." 

ifJouN  llisyr.R—Ohs>rritli';,s,n,  th''  I  ih<'is,:s  >>/  thi'  Anmj  ht  JutH'ii'u,  London,  ITss— sjM'aking  of  tlie  lure  <.f  intermittents,  s;iys,  p.  20H :  "When 
the  intermissions  were  coniph-te  the  bark  was  given  directly  without  any  previous  evacuations  in  order  to  cleans<f  tin-  stomach  and  tiowels, 
which  is  to  be  consifh-red  as  rather  re<-urriug  to  an  old  than  giving  in  to  a  new  practice.  There  was  nt>  inconvenietu:e  arose  from  omitting  the  vomiting 
and  purging,  usually  made  to  precede  the  bark  ;  on  the  contrary  it  was  so  much  time  gained."'  Huntkr  refers  to  Sydenh.am'k  use  of  bark  in  this  man- 
ner. John  Ci..\rk — fHnterratim  fn,  the  hiitfif^s  irhich  jtrfndffd  in  Unuj  royageti  to  hot  lyjiintriett,  pariifvhyrhj  <m  (hose  in  the  EitM  [iidies, — Lotidon,  1H(H): 
**A«  soon  as  the  intestinal  canal  has  been  thoroughly  ideansed  the  cure  [of  tin'  remittent  fever]  must  entindy  depend  on  giving  I'ernvian  bark  in  as 
large  doses  as  the  pittlent's  stomach  will  bear,  without  paying  any  regard  to  tlie  remissions  or  e.xacerl)ationH  of  the  fever.  If  the  remissions  bti  distinct 
the  hark,  indeed,  will  have  a  more  speedy  effect  in  subduing  the  fever;  but  even  if  it  bucome  continued,  by  a  regular  and  steady  perseverance  in  the 
Mii'dicine  it  will  be  effectually  prevented  from  growing  dangerous  ur  malignant." 


MALARIAL    DISEASK. 


177 


was  cliecked  by  the  ex})erience  of  \)i\  James  Johnson/"*'  who.  tindiiig  that  his  first  case  of 
remittent  at  Calcutta  rejected  tlie  remedy  and  died  with  an  engorged  Wvw  and  contyested 
Ijrain,  had  recourse  in  liis  succeeding  cases  to  venesection  and  evacuants.  Moreover  the 
benetlcial  effects  of  twenty-grain  doses  of  calonu'l  taken  Ity  hiniseh*  (hu'ing  an  attack  accom- 
panied by  dysenteric  symptomsf  led  him  to  urge  this  pi-actice,  which  tor  many  years 
afterward  sent  Europeans  back  from  India  with  their  constitutions  shattered  by  repeated 
salivations. 

As  the  evils  of  the  mercurial  syst(Mn  were  developed,  hh'eding  was  resorted  to  freely 
and  repeatedly  as  the  only  efficient  remedial  measure.  Altnuiwhile.  iti  IS^O,  quinine  was 
discovered  and  its  use  introduced  into  England  and  France,  but  st^veral  years  elapsed  before  it 
was  employed  by  the  Indian  practitioners  in  those  dangerous  remittents  for  which  bleeding 
to  relieve  congestions,  free  purgation  to  remove  vitiated  secretions,  and  calomel  and  opium  to 
act  on  the  secretory  and  excretory  functions,  constituted  the  standard  treatment,  altliough 
Sir  J.  Annesley  and  TwinikgJ  made  tise  of  small  doses  of  quinine,  when  full  remissions 

*  The  Influence  of  Tropical  climates  on  EtwopcKu  t'oiislitittionSy  l>y  Jamks  Johnson,  M.  I).,  St'cnml  Kd.,  London,  1818,  p.  48 — after  rt-ft^rrtufi;  to  the  instruc- 
tions for  treatment  given  in  tin;  works  of  Ttrs.  Ci.AtiK  und  I.inu,  ln'  dcscrilics  liis  first  ciis*i'  as  follows;  '"A  youn^  nmu,  of  a  ^oml  coiL-titutioii,  in  the 
juime  of  life  and  liealtli,  liad  \n-vn  assistlnf;  with  scvenil  others  to  navijiate  an  Jndianian  througli  the  Hoogly.  The  day  after  !ie  returned  he  was  seized 
with  the  usual  symptoms  of  tliis  fever.  I  did  not  see  lilni  till  the  eolil  stage  was  past ;  hut  the  reaction  was  violent ;  the  headache  intense  ;  skin  hurning 
liot ;  great  oppression  ahout  the  ]irii'conlia.  with  quick  hard  pulse  ;  thirst  and  nausea.  An  emetic  was  prescribed,  and  towards  the  close  of  its  oiH'mtiou 
discharged  a  quantity  of  ill-conditioned  bile,  lM»th  upwards  and  downwards  ;  soon  after  whicli  a  jM-rspiration  broke  out,  the  febrile  symptoms  subsided, 
and  a  remission,  alnupst  amounting  to  an  intermission,  followed.  I  now,  with  an  air  of  confidence,  began  to  "  throw  in  "  the  bark,  ijuito  sanguine  in 
my  exiM'ctations  of  soon  checking  this  formidable  disease.  But,  alas !  my  triumph  was  of  very  short  dumtion  ;  for  in  a  few  hours  the  fever  returned 
with  increased  violence,  and  attended  with  such  obstinate  vomiting  that  although  I  tried  to  pnsli  on  the  bark  through  the  paroxysms,  by  the  aid  of 
opium,  eflervesciiig  draughts,  Ac,  it  was  all  fruitless ;  i"or  every  dosi^  was  rejected  the  nujuient  it  was  swallowi^d,  and  I  was  forced  to  abandon  the  only 
means  by  which  I  had  hoped  to  curb  the  fury  of  the  disease." 

f  Oj).  ril.,  in  last  note.  p.  2^*>> :  "  I  was  bled,  and  to»ik  an  ounce  of  castor  oil  immediately;  a  few  hours  after  which  six  grains  of  calomel  and  one  of 
opium  were  taken,  and  repeated  every  tire  hours  afterwards,  with  occasional  emollient  injections.  The  day  passed  Rither  easier  than  the  preceding 
night ;  the  tormina  wei-e  somewhat  moderated  by  the  medicine  ;  but  1  had  considerable  fever,  thirst,  it^stlessuess  and  continual  <alls  to  stool ;  nothing, 
however,  coming  away  but  mucus  and  blood.  As  night  t  losed  in  the  exacerbation  was  great.  The  upium  lulled  ine  occasionally,  but  I  was  again  delir- 
ious; and  the  phantdUis  that  haunted  my  inuigination  were  worse  than  all  my  corporeal  sufferings,  which  were,  in  themselves,  iudesi-ribalily  tormenting. 
The  next  day  I  was  v<'ry  weak  ;  and  so  incessant  were  the  griping  and  tenesmus  that  I  could  liardly  leave  the  comnnxle.  The  tenesmus  was  what  I 
could  not  bear  with  any  degree  of  fortitude ;  and,  to  procure  a  momentary  ndief  from  tliis  painful  sensation,  I  was  forced  to  sit  frequently  in  warm 
water.  Tlie  calonud  and  opium  b(dua  was  now  taken  every  four  hours,  with  the  addition  of  mercurial  frictions.  .\n  occasional  lavement  was  exhibited, 
which  gave  much  pain  in  the  exhibition,  and  1  each  day  took  a  dose  of  castor  oil,  which  brtuight  ofl  a  trifiing  feculence,  with  inconsidenible  relief.  3Iy 
fever  was  higher  this  day  than  yesterday,  with  hot,  dry,  constricteil  skin.  As  night  approached  my  debility  and  appreliensiou  of  the  usual  exai-erbatiou 
Itrought  on  an  extreme  di'gree  of  mental  agitation.  The  surgeon  endeavored  to  cheer  me  with  the  hope  of  ptyalism,  which,  he  assured  ine,  would  alle- 
viate my  sufferings — I  had  then  no  local  experience  in  the  complaint  myself.  As  the  night  advanced  all  the  symptoms  became  aggravated,  and  I  was 
convinced  that  a  fatal  terminatinn  must  ensue  unless  a  s[>eedy  relief  could  be  procured.  I  had  no  other  ho[M!  hut  in  ptyalism  ;  for  my  medical  friend 
held  (ait  no  other  prospect.  I  sent  for  my  assistant  and  desired  him  to  give  me  a  Bcrujjle  of  caloinel,  which  I  instantly  swallowed,  and  found  that  it 
produced  no  adclitional  uneasiness;  on  the  eontiury  1  fancied  it  rather  lulled  the  tormina.  But  my  sufferings  were  great;  my  debility  was  in<reusing 
ni[iidly,  and  I  quite  desjiaired  of  recover}' !  Indeed  I  looked  forward  witli  irMi)atience  to  a  final  release  !  At  four  o'clock  in  the  morning  1  rejx'ated  the 
dcise  of  ealiiiuel,  and  at  eight  o'clock  (or  between  00  and  TO  hours  from  the  attack)  I  fell,  for  the  first  time,  into  a  profound  and  refreshing  sleep,  which 
lasted  till  near  midnight,  when  I  awoke.  It  was  some  minutes  before  I  could  bring  myself  to  a  jx-rfect  recollection  of  my  situation  jirior  to  this  n^pose; 
but  I  feared  it  was  still  a  dream,  for  I  felt  no  pain  whatever  I  fliy  skin  was  covered  with  a  warm  moisture,  and  I  lay  sone'  cunsidenible  time  without 
moving  a  voluntary  muscle,  doubtful  whether  my  feelings  and  senses  did  not  deceive  me.  I  now  felt  an  uneasiness  in  my  bowels  and  a  call  to  stool. 
Alas,  thought  I,  my  miseries  are  not  yet  over !  I  wrapjH'd  mystdf  up,  to  prevent  a  chill,  and  was  most  agreeably  surprised  to  find  that,  with  little  or  no 
gripingj'l  iijissi^d  a  copious,  feculent,  bilious  stool,  succeeded  by  such  agreeable  sensations — acquisition  of  strength  and  elevation  of  spirits — that  I  ejacu- 
lated aloud  the  most  sincere  and  heartfelt  tribute  of  gratitude  to  Heaven  for  my  deliveiunce  !  On  getting  into  bed  I  jwrceived  that  my  gums  were  much 
swollen  and  that  the  saliva  was  flowing  from  my  mouth.  I  took  no  more  medicine,  recovered  rapidly  and  enjoyed  the  best  state  of  healtli  for  some  time 
aftenvards.'' 

I  .James  Axnesi.EV,  of  the  Sladras  Medical  Kstabiishment — neftearrhes  info  the  (Mnse^,  \ature  ttinl  Treatment  of  the  more  pre  culent  Diseases  of  India  awl  tnirm 
rliniatcs  tft'neritlhj,  Londiui,  1828,  Vol.  II,  p.  400  H  wvy. — reconunends  in  agues  the  moderation  of  the  cold  stage,  if  severe,  by  the  hot  or  vai)or  bath,  frictions 
and  the  internal  administration  of  camjihor,  annuonia,  ether,  wine,  brandy  and  water  or  other  stimulants.  When  the  vascular  excitement  of  the  hot  stage 
is  excessive,  gener.il  or  local  bleeding  is  suggested.  esiH-cially  in  the  plethoric  and  when  accompanied  with  determination  to  the  head  and  delirium,  or 
to  the  Mverand  spleen,  w  ith  symptoms  of  inflammatory  action  in  those  viscera.  Cooling  diaplioretics,  as  the  nitnite  of  potash,  acetate  <if  ammonia,  cam- 
idior  julep,  antinionials,  etc.,  ai-e  also  reconuni'Tiiled  as  pronnitiug  the  sjieedy  suiH'rvention  of  the  sweating  stage.  When  the  paroxysm  has  ceased  an 
enietic  is  giveu,  and  its  operation  encouniged  by  the  free  use  of  tlilueuts,  after  which  a  full  dose  of  ealoniei.  fifteen  or  twenty  grains,  is  administered, 
followed  by  a  i)urging  draught,  and  if  these  fiiil  to  act  within  a  few  hours,  their  operation  is  assisted  by  a  cathartic  enema.  "  Having  thus  jiromoti'd 
discharge  of  the  morbid  secretions  and  fa'cal  accumulations,  and  removed  local  congestions  by  blotMlletting,  we  may  resort  to  the  exhibition  of  bark 
so  as  to  prevent  the  accession  of  the  paroxysm.  Tnless  purgatives  have  been  employed  previously  to  the  exhibition  of  bark,  so  as  effectually  to 
carry  off  nmrbid  accumulations,  and  unless  local  detcrminatinns  of  bloiHl  and  congestions  an^  removed  by  geneml  or  local  depletions,  we  shall  resort  to 
this  most  valuable  medicine  to  little  purpose  ;  for  it  will  either  not  h*}.  retained  on  the  stomach,  or  it  will  fail  of  priKiucing  its  fel)rifuge  effects  if  retained, 
and  occasion  obstruction  and  enlargement  of  the  liver  and  splei'U."  (Quinine,  although  in  use  in  England,  had  not  Lteen  introtluced  into  medica.1  prac- 
tice in  India  at  the  time  Annesi-ey  wrote.  Similarly  in  remittent  fever  ;  '*  lliirk  may  Ik'  resorted  to  in  the  remissions.  But  care  should  be  had  not  to 
give  this  medicine  during  active  demonstrations  to  the  head,  liver,  lungs  or  sph-en  until  such  complications  have  been  removed  by  vascular  depletion, 
either  general  or  K)cal,  and  by  the  judicious  employnnmt  <»f  whatever  means  the  particular  circumstances  of  indivithuil  cas<^s  may  require." — On  theeffecttt 
(if  IiliK>(Uetlin(j  in  the  ml'l  atiuje  <if  [,t!crmUffnt  fet'fn:  by  W.  Twinmntj,  Esq..  Trnns.  Med.  and  Phtifncal  Society  of  Calmlln,  1S;J1,  Vol.  V,  pp.  58-100.  Twining 
adopted  and  advociited  the  metlKxl  intnxtuced  by  Mackintosh  of  Edinburgh,  of  bleeding  iq  the  cold  stage  to  relieve  the  heart  and  large  vessels  from 

Med.  Hist.,  Pt.  Ill- 23 


178 


TREATMENT    OE 


were  established,  to  prevent  a  r(iturn  of  tlm  paroxysm.  Fven  as  late  as  1S61  Sir  J.  R. 
Maktin  o;a\'r  the  adniiiiisli'atioii  (.!'  qiiiniiu'  a  secondary  i»lac(.'  in  the  list  of  remedial 
agents/^'  liut  dui'inii;  this  titnc  l)i.  I1ai;k  was  iu;ii;ing  the  antidotal  powM'  of  quinine  in 
these  malarial  fevers,  lie  ohlaiiu'd  siiecessl'nl  results  I'rom  thirtv-L!;rain  dtjses,  and  from  an 
extensive  and  systematie  expcrimeuhtl  practice  of  this  method,  advocati/d  its  use  in  the 
pernicious  fevers  of  India  to  th(;  (;xchision  of  other  remedial  means  excepting  the  occasional 
use  of  small  doses  of  <'alom(d  when  there  was  gastric  irritabiht v.f  Nevertheless  the  value 
of  the  treatment  by  i|Uiinne'  may  not  be  considered  as  fully  estabiishod  in  Indian  practice, 
for  J[oKTON,  in  187W,  did  not  (Consider  th(;  i-emedy  adunssiljli-  until  portal  and  abdominal 
congestion  ami  epigastric  irritation  had  been  reheved  and  th'-  febrile  action  moderated. J 
In  France,  ^[AinnoT,  h"om  an  exj)erienee  of  many  thousand  <*ases  of  pernicious  inter- 
mittents,  urged  an  immediate  recourse  to  ([uinine  in  large  doses. §  Jiut  perhaps  to  American 
medical  men  is  due  the  credit  of  having  been  the  first  to  use  quinine  in  large  doses  and  irre- 
spective of  j>reliminary  evacuant  treatment,  as  antidotal  to  the  malarial  poison;   for  Perrine 


thoir  Htiit*'  ot"  '■nj:;or(^cinciit,  to  iinluitd  (Im  Iuiij;s  urnl  rcimivit  contfrsti'iti  of  tln'  lii"aiii  uml  ripiiiiil  murrnw  ;  Imt  as  lii'  diii  nut  iMjiLsiiliT  tliiit  vciieHcctiiiri 
BUperMi-(ii'(i  tln'  iH'ct*Hf»ity  ni'  usiiitx  othrr  ri-nu'difH,  jiccdnliiij;  as  tlit^  nature  of  tlit*  f'Xistiiij;  s_vnn)toin.s  and  the  ijoursc  nf  tlm  ilist-iisf;  might  di-inand,  liy 
occusiiinully  u.scd  (In*  sulpliatf  ul'  quiniin-  ui-  iiowdtTcd  hark  cDnihiu)-!!  with  piir;;ativrs.  Sec  ulsu  liis  It  infuses  nf  linitjitl,  <'al<-utta,  lS:i2,  p.  (127,  whi-rL-  lu; 
BttyH:  "III  every  dfMcription  nf  miuttcrit  lever  we  must  wateh  the  chaii^ew  which  take  plai-e ;  and  when  th(!  pyrexia  ahateH  admiiiistiT  Hulphato  of 
quiniiK!  f(ir  tht;  inirpnse  nf  pn-ventiiifi;  a  rf.-turn  uf  thi-  exucerhatiuii  ;  in  uiurtt  castas  where  the  cen.'ljral  syinptorus  are  nnt  urgent  and  cdiitinued  the 
effect  (if  thirt  remedy  is  uiiduuhted." 

♦Sir  J.  11.  Maktiv— 7'A.'  [nftiuua-  <'/  Tropirul  rlii,i>ilrs,  l.uutUiu,  iHtil,  i>.  4:iii:  'Mjuiniiie,  the  ^reat  fehrifu^n',  Justly  ailniinistered  acts  purely  us  a  nervo 
toni<'  to  the  cerehrusjiinal  and  viscfi-.il  symi)athetie  system.  Kxhihjted  in  extmva^ant  d(»ses  it  is  ttixieal  and  riot  thempeutic."  Anil  again,  on  page  :iGO  : 
"Subject  only  to  the  liniitatiuiirt  alrca<ly  stated,  bleeding — early  hleeding — whetln-r  geiu^rai  ur  htcal,  aufi  ahruifit  jmt'ii-^^'f  "t  Ihe  rerij  oufnet  of  the  stage  of 
rent^Um,  \a  very  generally  necessiiry  in  the  seven-r  I'nrins  of  lleiigal  reniitti-nt  fever;  then  eunie  full  doses  of  i-aloniel  and  suilorifics,  short  of  producing 
salivatinii,  with  saline  purgatives,  antiniouiiils  and  refrigerants,  and  <iuinine  in  tin-  intervals." 

f  K.  H.\RE — <hi  Old  Trratmrnt  >>f  Mnlnrimis  frrrrn.  Mr<l.  Tivu's  nnif  dazcUv,  London,  IHfU,  p.  540  :  "  In  184;J  I  was  sent  to  Segowlie,  on  tho  liordera  of 
the  Ne|ial  Terai,  the  luost  deadly  iti  India,  and  there  remained  for  four  years.  I  was  called  to  a  distaucr'  on  our-  occasion  to  see  a  medical  gentleman 
with  cholera.  He  died,  aiul  left  me  a  valualde  mi-dical  library,  in  which  I  f'mnd  tin-  now  scarce  wtprks  of  Linu  and  1U-.\tkr.  Their  practice  was  new  to 
me,  and  I  n-ad  them  with  eageriierts,  I  had  seen  enough  of  the  standard  luiutice  to  be  dissiitistied  with  it,  especially  in  somtr  recent  cases  I  tnid  treated 
of  the  Terai  fevr.  Thi-y  all  died.  No  remission  took  place ;  th(M-e  were  In-ad  symptoms,  and  I  durst  not  give  ^JuinlIU^  In  fact,  it  was  S(t  ntb'fly  for- 
bidden by  all  authorities  that  it  never  occurr-d  to  me  to  give  it.  I  tried  t<i  saliviite,  hut  the  fi-vi-r  was  so  active  that  my  patients  wer*!  dead  before  the 
mercury  had  time  to  affert  them.  It  then  struck  me  as  remarkable  that  since  the  discovery  of  <)ninin4-  no  one  had  tried  it  in  the  same  way  as  Lino  and 
HuNTKK  had  u*-d  bark,  fmm  the  dn-ac|  of  increasing  congestion  iinil  inflanuiiatitin.  and  a  case  <|uite  hopeless  under  tlie  conunon  treatment  soon  oft.-red 
its(df  to  me,  and  I  determined  to  try  ipiinini'.  *  *  *  j  tound  a  y«tuug  lad  of  about  20  lying  tpiite  insensible  on  a  native  bed.  The  natives  sjtid  that  he 
WHS  traveling  on  a  pony  in  tin*  Terai,  had  fallen  otT  insensible  in  their  village,  and  fearing  he  should  ili«'  there  and  cause  suspicion  they  had  brought  him 
to  the  nearest  doctor.  I  immediately  mixed  one  scruple  of  (piiuine  in  some  wine,  and  by  giving  him  a  ti-iispoonful  at  a  time  made  him  swallow  the  whole 
of  it.  I  reix-iited  it  every  four  hours  three  times  that  day.  Karly  in  the  morning  ho  was  sensible.  I  gave  him  another  dtisi-  and  some  arrowroiit  and 
milk.  He  titok  the  sanu-  dost-s  throughout  this  day,  with  some  Noup,  and  the  next  to  my  delight  he  was  out  of  ilangiT,  having  taken  two  and  a  half 
drachms  nf  .luinine  in  forty-eight  hours,  anil  without  nnudi  inconvenieiue.  *  *  *  In  the  fii-st  plae<-,  no  blotxl  wasdniwn  either  by  lancet  or  beeches. 
Bleeding,  therefore,  is  not  necessjiry,  ami  the  di.seas.'  not  iutlammatory.  Ni>  npium  ;  no  purgativi*  to  bring  away  bad  secretions ;  no  drug  of  any  kind  is 
required,  (-xcept  tiuinine,  for  tin-  succe.-^sful  treatment  of  malaritnis  fever.  (Juiuine  also  may  be  givi'U  in  the  largttst  doses,  whether  there  are  head  symp- 
toms, delirium,  coma  or  pain  in  the  liver.  Whether  it  be  iu  thc!  hot  stage  or  cold  ipuniiu'  is  mit  only  saft^  for  all  forms  of  malarious  fever,  but  its  certain 
cun; ;  and  iu  ca.ses  where  there  is  danger  to  life  the  earlier  and  the  larger  the  doses  of  quinimr  which  can  be  given  to  the  jiatitMit  the  lietter.  *  *  *  * 
tjuinine,  therefore,  nmy  with  n-asou  be  pn»ni>uuci'd  as  a  direct  antidote  to  the  poistm  of  malaria,  and  mit  simply  as  an  antiperitHlic  and  adapted  only  to 
stop  iK^riiKlicity,  for  it  always  cun-d  e.puilly  well  those  fevers  in  which  there  were  no  periods,  but  which  continued  without  the  slightest  remission  during 
the  twenty-four  hours." 

J  J.  A.  B.  HoKToN — The  f>i-«'asi'H  of  Tropicnl  ClimnUs  mtrl  their  Tn'tttninit,  London,  1879— spfiaking  of  quinine  as  useful  in  preventing  the  recurrence 
of  the  i)art)xysm,  says,  p.  \V.\ :  "This  valuable  remedy  requires  sonie  cautiou  in  its  administration  in  this  disease ;  in  large  doses  it  should  on  noaccount 
b-  given  when  tin'  paroxysm  of  fever  is  on  th*-  |i;itient,  and  more  especially  when  there  are  signs  i>f  gastric  or  cerebral  i[ifiammati<m  or  congestion, 
with  scanty  or  depraved  secretions,  full  and  hard  pulse,  as  it  may  lead  to  the  fixing  of  the  inflammatory  and  congestive  tendency  to  the  bmin.  Quinine 
IB  siife,  and  should  be  administered  when  there  i.*;  a  couiidete  remissicm  ;  when  there  is  no  sign  of  venous  cong(?stiou ;  when  the  pulse  is  reduced  in  fre- 
quL'uey  and  force  ;  when  the  skin  is  moist  and  the  secretions  free." 

^  TntUf'  lU'Kjiem'H  tm  irrilittiouN  n'rf'hro-sjihtttlrx  iiiterniittenteft  iViiprf-s  Iftt  obserratiotis  recueilUh  en  France,  en  Cnrae  et  en  Afriqve,  par  F.  C.  Maillot,  Paris, 
183H,  See  pp.  3(M)  ft  w[.,  where  he  s|H<aks  to  the  following  efTect :  .Many  practitioners,  still  under  the  influence  of  obsolete  ideas,  are  accustomed  to  use 
la.\atives  and  purgatives  to  pnqMtn'  the  stomatdi  for  the  reception  of  quinine.  This  custom  is  generally  followed  in  Italy  and  in  several  marshy  districts 
of  France,  Holland  and  (iermany.  Torti,  In  applying  this  meth.xl,  acb-d  consistently  with  his  principles  ;  in  a  gn.'at  number  of  cases,  however,  he  was 
forced  on  account  of  the  gravity  of  the  symptoms  to  exi»'dite  matters  aud  give  quinine  without  employing  this  hackneyed  preparation ;  wliich  fact,  it 
seems  to  me,  ought  to  have  put  him  in  the  right  luith,  or,  at  least,  shown  him  the  u.selessnes8  of  this  medication.  In  ordinary  intermittent  feveri  the 
employment  of  laxative?  sometimes  susiviids  the  attack,  but  more  often  its  only  effect  is  to  put  off  for  a  time  the  use  of  quinine— which  must  always  be 
bad  recourse  to  in  the  enii.  The  more  energetic  purgatives  and  emetics  increase  the  congestions  which  take  place  in  the  disgestive  mucous  membrane 
of  which  the  coating  of  the  tongue  is  merely  an  indication  ;  they  may  rapidly  rais**  these  irritations  to  a  higher  degree — to  intlammation.  *  *  *  In 
fact  while  laxatives  are  being  administered  i>ernic.ous  attacks  often  take  place ;  but  even  admitting  that  purgatives  and  emetics  do  not  increase  the 
gftstro-intestinal  irritation,  they  have  the  greater  inconvenience  of  fRTinitting  attacks  to  occur,  which  by  their  violence  and  continuance  always  add  to 
the  dangers  of  the  disease  and  to  the  difficulty  of  its  tn^atment.  It  is  clear  that  when  our  predecessors  used  purgatives  and  emetics  to  prepare  the  stomach 
to  receive  quinine,  they  followed  rather  their  medical  theories  than  the  teachings  of  experience.  «  *  *  Having  observed  several  thousand  cases,  I 
think  that  immediately  after  and  sometimes  liefore  bleeding,  suiphate  of  quinine  ought  to  be  usf'd  whatever  may  be  the  symptoms.  Neither  the  persist- 
ence of  th<^  arterial  excitement  nor  the  signs  of  gastro-euteritis  ought  tu  bar  its  employmeat.  All  the  morbid  phenomena  will  disappear  as  if  by  enchant- 
ment in  a  few  hours, 


MALARIAL    DISEASE. 


179 


in  1826  advocated  the  eiiiployinent  of  large  doses  at  any  period  of  the  fever,*  and  this 
practice  was  common  among  our  armv  medical  officers  during  the  Florida  war.")" 

During  the  War  of  the  Rebellion  quinine  was  the  .slue  qua  noa  of  treatment  for 
malarial  disease.  Other  drugs  and  remedial  measures  were  used  as  called  for  by  particular 
conditions  of  system;  but  other  antiperiodics  were  seldom  emjiloyed  except  in  cases  in 
which  quinine  after  a  fair  trial  failed  to  eradicate  the  disease. 

In  addition  to  the  notes  of  treatment  found  in  the  clinical  and  po-if-inorfem  records 
suljmitted  in  tins  chapter,  and  to  the  reterences  which  appear  in  the  sanitary  and  special 
reports  already  printed, J  the  following  extracts  are  presenteil  as  l)t'aring  on  this  subject:§ 

Jxs't  Siinj.  W.  W.  (iKAXGEK,  H(l  Mo.  Cm-.,  Holla,  Mo.,  (Moha-,  r><(i2. — Our  cast-s  of  interniittt'ut  fovci-,  l)otli  ([uo- 
tidian  aud  tertian  (except  two),  liave  yielded  readily  to  iiuinine  combined  with  caii.-iicuni  in  eiiual  proiiortion.s.  In 
the  two  exceptional  cases  the  system,  through  freipient  use,  had  api)arently  lost  its  susceptibility  to  the  effects  of 
((uinine,  either  alone  or  in  combination  with  stiinnhmts  or  opiates.  These  cases  finally  yielded  to  emesis,  induced 
an  hour  or  two  in  advance  of  the  expected  chill,  and  followed  as  soon  as  the  stomach  would  tolerate  it  with  one- 
fourth  of  a  grain  of  sulphate  of  morphia,  two  grains  of  capsicum  and  one-fourth  of  a  grain  of  sulphate  of  copper, 
given  every  three  hours  during  the  intermissiou.  One  of  the  cases  presented  the  unusual  idienomenon  of  imersion  of 
symptoms,  that  is,  the  precedence  of  the  hot  stage,  followed  by  the  cold.  I  think  decided  advantage  resulted  iu 
this  case  from  the  use  of  quinia  alone  in  the  intermission,  and  the  administration  of  capsicum  in  ten-grain  doses  as 
soon  as  the  sweating  stage  arrived,  continuing  every  hour  till  the  chill  had  pas.sed  off. 

There  were  sixteen  oases  of  remittent  fever,  twelve  of  which  began  with  languor  and  indisposition  to  action, 
constipation,  full  and  frequent  pulse,  dizzy  sensations,  pain  in  the  head  and,  as  the  patient  expressed  it,  in  the  bones 
and  flesh  generally.  Five  of  these  experienced  much  restlessness  during  the  later  stages.  Convalescence  was  reached 
in  from  four  to  sixteen  days  and  was  rapid  in  nearly  every  case.  Treatment  consisted  of  a  purgative  of  calomel 
and  powdered  rhubarb,  followed  in  six  or  eight  hours  by  castor  oil  and  turpentine  or  salts,  when  necessary.  After 
free  evacuation,  ([uiuine  in  full  doses  was  administered  during  the  remission;  and  during  the  accession  bathing,  cold 
or  tepid  as  proved  agreeable,  Dover's  powder,  nitrate  of  potash  and  sweet  spirit  of  nitre  were  relied  on  with  satis- 
factory results.  I  found  nothing  better  than  cold  or  tepid  sponging  as  a  sudorific,  anodyne  and  refrigerant  in 
remittent  fever;  and  when  the  fever  was  associated  with  irritation  of  the  kidney's,  a  cold  wet  cloth  over  the  luni 
bar  region  acted  satisfactorily  as  a  diuretic.  In  cases  characterized  by  much  restlessness,  sponging  was  an  efficient 
anodyne,  aud  almost  indispensable  when  cerebral  disturbance  contraindicated  the  use  of  opiates.  Under  this  course 
the  remissions  became  longer,  the  febrile  accessions  lighter;  the  circulation  resumed  its  natural  character,  the  skin 


■■-■IlK.NHV  Peruim: — Ferrr  treated  Ktlli  large  tloses  of  (^thiiue  in  Adams  couuttj,  near  Satehez,  ^[itniit^ippi.  Pliitadelpfiia  Jour.  Med.  and  Phys.  8ci.,  18'2»J,  Vol. 
l;i,  iH'.  :'.(1-41 — relates  several  cases  of  remittent  fever  treated  by  bleeding  and  quinine,  the  latter  in  eight-grain  doses,  repeated  at  intervals ;  in  one  case 
i-liiiraeterized  by  stnpor  and  insensibility  (if  grains  were  taken  in  the  twonty-finir  hours,  ami  a]>iirehunsions  of  danger  wi^e  removed,  lie  coneludes : 
"My  observations  so  tar,  exhibit  the  following  as  one  of  the  sucecssfnl  mmles  of  treating  our  autunnial  fevers,  whether  congestive  or  intlannnatory. 
lileeiling  whenever  the  symi>toms  re<iuire  it.  A  dose  of  from  fi  to  12  grains  of  sulphate  of  quinine  every  two  or  three  liours,  at  any  jieriiMl  of  the  fever, 
uiitil  its  symptoms  in  the  pulse  and  skin  are  subdued.  Then  purgatives  to  obtain  cojiious  consLstent  evacuations  from  the  bowels,  until  they  ri'gain  their 
usual  power.     Subsequent  attempts  to  form  fever  should  be  counteracted  by  a  large  dose  of  quinine." 

tThe  t^lalUtieal  Itipurt  on  the  Slehiesn  and  Mnrtalitij  in  the  Ann// of  the  Cnited  »i/c.«,  by  K.  II.  Coolidge,  Assistant  Surgeon,  U.  S.  A.,  Washington, 
M*M,  gives,  p.  (\^■^S  el  srij.,  a  special  re|iort  by  Cuables  JIcC'ormick,  dated  October  11,  1S4I,  in  which  he  lirings  to  the  notice  of  the  .Surgc'on  Ceneml's 
( Utile  his  treatment  of  intermittiMit  fever  by  large  doses,  fifteen  or  twenty  grains,  of  quinim^  administered  iiumeiliately  after  the  sweating  st;ige,  with  the 
viewof  suppressing  the  occurrence  <iffurtlier  paroxysms.  Two  years  before  the  date  mentioned  be  had  been  so  unsuecessful  in  arresting  intennittent 
pa  roxysms  witli  the  sulphate  of  <iuinine  in  two-grain  doses  every  hour,  although  as  much  as  twelve,  eighteen  and  twenty-four  grains  had  been  taken  during 
the  apyrexia,  that  he  gave  uj)  its  u.se  and  re-sorted  to  relaxants,  such  as  tartar  emetic,  ipecacnanha  anil  oiiinm.  But  soon  thereafter  lie  resumed  tlio 
use  Iff  .luinine,  giving  it  in  from  four  to  Bi.\  grains  every  hour  until  its  peculiar  effects  on  the  brain  weri'  produced,  when  he  found  himself  invariably 
suci  I'ssful  in  controlling  the  intermittent.  This  led  him  to  give  it  iu  single  doses  of  ten,  fifteen  or  twenty  grains,  according  to  the  violence  of  the  symp- 
loiiis.  He  used  it  iu  similar  iloses  with  benefit  in  remittents,  claiming  to  have  given  it  at  all  times  of  the  jsiroxysm  in  nuiny  liundreds  of  case's  without 
witnc->>iug  aTiy  alanning  or  dangerous  effects  from  its  ailministration  in  this  manner.  The  practice  of  using  quinine  in  such  large  doses,  and  during  tho 
stage  of  febrile-  exciti-ment,  having  excited  much  attention,  and  the  propriety  of  such  treatmeiLt  having  been  questioned.  Surgeon  General  L.\wsos  issued 
a  circular  to  medical  otficers  of  the  army  asking  for  their  experience  of  this  nu'thod  of  tri'ating  malarial  fevers.  Fifty-seven  rejilies  testified  to  the  value 
of  the  method.  Some  of  the  replies,  as  those  of  B.  F.  Hakney,  R.  S.  Satteui.ee,  R.  C.  Wood,  BrnroN  Raxdai.i,,  J.  J.  B.  Wkioht,  B.  M.  Bybne,  .1.  H. 
1!aii,ev,  p.  C.  DeLeox.  T.  C.  Maiiisox,  E.  F.  Simpson  and  John  Bvrne,  arc  published  in  the  Statistical  Report  above  mentioned.  See.  also,  an  article 
Ou  llie  Treatment  nf  IidenruHent  ferer,  by  Al'STlx  Fl.lXT,  in  the  .\merican  Jonr.  Med.  Sei.,  Vol.  11,  New  series,  1S41,  pp.  'iTT-i'-G.  Dr.  Fl.lXT  gives  an 
analysis  of  .'(3  cases  occurring  in  soldiers  lately  from  Fort  Gratiot,  .Michigan,  in  which  he  gradually  inc-reasnl  the  dose  of  quinine  until  twenty,  thirty 
and  in  onc'  case  forty  grains  were  administered  within  half  an  hour.  He  gives  also  a  number  of  cases  from  civil  practice  illustrating  the  efficiency  of  this 
metlnHl.  He  argues  that  the  system  requires  m»  preparatory  jiriK-ess  for  the  reception  of  the  quinine,  and  that  "  the  most  rational  policy  is  manifestly 
to  strike  at  once  at  the  /o;i»  rf  ori;/o  of  the  difficulty." 

X  See  in  the  .\ppendix  to  the  First  Part  of  this  work  the  reports  of  Haxd,  p.  2.19 ;  Hewitt,  p.  :U:) ;  Feixk,  p.  31.'i,  and  Whitehill,  p.  XZi  ;  also  in 
the  pri'sent  Vol.  those  .if  Gaoe.  ji.  12:1 ;  Peck,  p.  124;  Hcxtixuton,  p.  125;  Merkitt,  p.  142;  Gali.oi-pe,  p.  144;  Towle,  p.  IK! :  etc. 

^Few  articles  on  the  treatment  of  malarial  fevers  appeared  in  the  journals  during  the  war.  Thomas  T.  Smiley,  writing  from  Hilton  Head, 
S.  ('.,  October  l.^,  1S()2,  furnishes  the  following  iiaragraph  on  InlentiUtent  fevers  in  the  Boston  Med.  and  Sttnj.  ./our.,  Vol.  LVII,  18ii2-(>.'i.  p.  27(1 ;  "The  ca.si's 
admitted  into  the  hospital  have  not  been  numerous,  and  have  presented  no  aggravated  features.  After  a  proiH'r  attention  to  the  stomach  and  bowels, 
they  have  generally  yielded  si«H'dily  to  the  exhibition  of  quinine,  in  doses  of  from  three  to  five  grains,  repeated  more  or  less  frequently,  and  combined 
with  alcoholic  stimulants,  or  not,  accorrling  to  the  previous  habits  or  condition  of  the  jiatieut.  In  a  few  cas*>s  the  diseasi'  has  asinumed  a  congestive 
form,  when  quinine  was  administered  in  much  larger  doses.",  S.  S.  Thorn,  iu  a  letter  iiublished  iu  the  Med.  and  tiurg.  Reporter,  Vol.  VIII,  1862,  p.  280, 
refers  to  the  treatment  of  intennittents. 


180  tju-'.atmj:nt  ok 

its  iiii)isliiri'  and  I  In-  system  its  ti)iic.  AroiiKil  ic  sMl]iliiiiii-  ai-iil  \v:is  usi'd  :is  ii  iDiiic.  'I'lic  loiii'  iciiiainiiig  casfs  dirtcrril 
in  liaviii;,'  111)  cdiistiiiatioii  atthc!  licirjiniiiij;,  ami  in  ;;icalcr  mildness  tliidnnliiiMt.  >i(l(lihj;-  in  I'ldm  t'luif  ti)  six  days 
to  (jniniiic  duiini;  ic mission,  ami  live  i;iains  of  Dovei's  jidwdiT  diiiin;;  a<'ccssi(pn,  j;i\  I'li  r\iTy  live  lionrs,  and  fol- 
lowed liy  the  acid  liiliies  diirin-j;  eon  \  alesi'eiicr. 

Sunicdii  K/ltA  liK.vii,  '2\xt  lull.  I'liln.,  Cdiiiii  Di.r,  Utilliiiiorc,  Mil.,  SfjilciiilK r  '>,  ISdl. — In  the  I  ii'atmeiLt  of  inteniiit- 
tiujf  fever  I  have  relied  upon  snljihate  of  iiuinine  in  fnll  (loses,  t;ivin};  from  one  to  t  wo  srL  n|des  in  twenty-four  hours 
to  arrest  the  periodicity.  I'nriiii^  convah'scenee  I  have  continued  the  same  in  tive-urain  doses  every  nioiiiini;.  and 
have  had  no  relajises  ami  no  nni'avoralde  results  from  visceral  enlargenuMits. 

>'«;■(/'()»  .Inii.  Vi'.  Scdll,  lO/A  hiiiinds  IHIs.,  Sc/ili  uihi  r  '.'^K  IXIC — As  was  to  havi-  licen  expecled,  most  of  the  eases 
were  malarial  fevers,  ehielly  of  a  remittent  type;  a  few  assmiu'd  a  decidedly  typhoid  i  haracler,  and  in  these  was 
due  most  of  the  mortality.  I'liro  intermitt<'iits  were  of  rare  occurrence,  there  lieinj;  in  almost  every  case  more  or 
less  fehrih^  action  in  the  intervals;  but  this,  as  a  rule,  occasioned  no  delay  in  the,  administration  of  anti|)eriodii-s, 
as  the  eombimition  of  diaphoretics  with  (iiiinia  suffici'd  to  counteract  any  unduly  stimulant  elfect  of  the  latter. — and 
the  cases  yitdded  to  treatment  with  the  usual  facility.  Tlie  fe\ crs,  remittent  and  intermittent,  have  slinwu  diirini;' 
the  past  HumiiK^r  a  muidi  slij^hter  temleiicy  to  ridajise  than  usual;  and  we  hav(i  mot  with  none  ol'  those  eases  of 
enlargement  of  tlie  alidominal  \isecra  and  geiu'ial  deliilily  wliii  h  are  so  often  the  result  of  continued  attacks  of 
autumnal  levers  in  this  clinuitc.  Doubtless  this  nuirked  exi'Uiption  from  the  usual  sec|iiela'  of  ague  has  direi't  nda- 
tion  to  the  fact  that  so  few  ca.ses  of  the  disease  liave  occurred.  The  cause,  whi(di  produces  by  its  intensity  a  great 
number  of  cases  must,  by  its  persistent  .action,  occasion  relajises  in  constitutions  debilitated  by  previous  attacks. 

-S'luv/coH  D.  \V.  llKNliKltsoN,  Wtlh  Oliiii  I'lils,.  /.(iiiisrilli .  h'l/..  Xoninliir  111,  lH(i'2. — The  regiuu'Ul  left  Cam])  Hates 
[four  miles  from  ( 'ovington,  Ky.]  October  X.  IWiL',  maridiing  to  Faluuiuth,  Ky.  *  *  *  In  all  eases  of  intermittent 
fever  larger  doses  of  (luinine  ari'  re(|uil'<Ml  here  than  north  or  in  home  practice,  twenty-tive  to  thirty  grains  being 
generally  needful  to  accomplish  the  desiri'd  object. 

fliifi/eoii  D.wii)  Mehuitt,  5r)//(  I'a.  FhIk.,  HcdKl'mi,  S.  f.'.,  Mki/  10,  IStilj. — We  have  had  in  the  reginu'nt  very  many 
cases  of  iiiterinittent  fever  which  ha\e  yielded  promptly  to  the  following  mode  of  treatment  :  First.  1  give  an  emetic 
consisting  of  two  grains  of  tartar  emetic  and  twenty  of  powdered  ipecacuanha  in  conjunct  ion  with  ea)isicnm.  Then,  as 
soon  as  the  stoimieh  becomes  quiet,  1  administer  ten  giains  of  cahnnel  combined  with  twenty  of  Jala]).  After  the 
bowels  have  been  freely  opened  I  give  large  doses  of  sul[iliate  of  ijuinia,  which  generally  arrest  th(.i  paroxysms 
speedily.  In  some  eases  I  have  given  the  sedation  of  arsi'iiite  of  potassa  to  ward  olf  the  hebdomailal  <  hill  ami  its 
sequences,  but  generally  I  keep  on  with  the  sulphate  of  (luinia  in  two-grain  doses  three  times  daily,  or  it  may  be  in 
larger  doses  and  oftener,  knowing  well  that  the  mere  arrest  of  the  paroxysm  is  only  an  apparent  and  not  a  real  cure. 
1  may  also  mention  that  in  several  cases  of  intermittent  fever  I  have  cut  the  chill  short  and  prevented  a  ])aroxysni, 
both  since  V)eing  witli  this  regiment  and  wIumi  in  Iowa  (near  the  Mississippi  river  above  Diibuiiiie),  by  the  mere 
administration  of  the  emeti<'  above  mentioniMl,  with  the  exeeptioti  that  in  these  cases  more  of  the  eapsicum  was 
added  to  the  other  ingredients.  I  have  freiiuently  given  (juiniin^  in  twenty-grain  doses  since  arriving  at  this  place 
with  till' elfect  of  a  spei'dy  arrest  of  thc>  int<-nnitteiit  i>aroxysm.  and  t  hen.  liy  continuing  the  remeily  in  smaller  doses, 
have  been  mucli  gratilied  with  the  result.  With  regard  to  the  suljdiate  of  cimdiouia  I  canmit  bear  very  favorable 
testimony,  and  would  much  rather  depend  upon  the  sulphate  of  (juinia,  with  wliich.  if  it  ]ir(iiluces  gastric  distress,  I 
administer  a  few  droi)s  of  tincture  of  o])ium.  We  have  also  had  in  the  regiment  numerous  eases  of  remittent  fever, 
many  of  which  have  been  com])licated  by  ]ieriodieal  congestion  of  the  bowels,  manifested  by  mucus  and  bloody 
stools,  in  some  eases  simulating  dysentery.  The  uncomiilicated  cases  have  been  mild,  and  readily  yielded  to  treiit- 
ment.  An  emetic  was  first  given,  if  indicated,  then  a  mild  cathartic,  followed  by  blue  mass  and  Dover's  ])owder, 
neutral  mixture  or  a  solution  of  acetate  of  ammonia,  and  finally  suljihate  of  iiuinia. 

.Siuv/cod  15.  F.  H.VRlU.SOX,  ImUpentU'iit  Hatttilioii,  .V.  )'.  Vols.,  Morris  hlinid,  S.  ('.,  .fniiniirii  il,  181)1. — [This  bat- 
talion arrived  at  Hilton  Head,  S.  C,  February  1,  IXBH,  and  snl)seqiiently .  to  the  date  of  the  report  cit(^d,  served  in 
the  Department  of  the  South.] 

There  is  ])r()bably  no  point  in  which  the  medical  history  of  the  battalion  is  more  peculiar  than  in  the  small 
amount  of  (luinine  whi(di  has  lieen  used.  I  commenced  my  service  with  it  at  Yorktown.  Va.,  on  August  IH,  1S()2. 
At  that  time  intermittents  prevailed,  and  no  quinim'  was  on  hand.  I  borrowed  one  ounce,  and  before  the  lirst  of 
January,  lK(!;i,  had  obtaiin-d  thirty  ounces  from  the  medical  jiurveyor.  Since  the  commencement  of  the  year  (1863) 
to  the  16th  of  November,  I  obtained  thirty  ounces  more  from  the  purveyor,  and  of  this  we  have  now  fourteen 
ounces  on  hand,  so  that  not  more  than  forty-.six  ounces  have  been  consumed  during  fifteen  mouths,  whilst  at  the 
same  time  tliere  have  been  regiments  in  the  tield  by  the  side  of  us,  doing  no  harder  service  and  having  no  greater 
number  of  men  than  ours,  w  hich  htive  used  an  ounce  a  day  for  a  considerable  portion  of  this  period.  In  one  regi- 
ment in  particular,  which  was  in  camp  near  us  in  Virginia,  and  has  been  with  us  almost  constantly  since,  there  were, 
according  to  the  sick  rejiorts.  three  or  four  times  as  many  cases  of  intermittent  fever  during  the  month  of  October  of 
this  year  as' we  had.  This  and  many  other  circumstances  have  convinced  me  that  the  consumption  of  (ininine  in  the 
army  is  larger  than  is  usi'ful,  and  perhaps,  even  injuriously  large,  as  well  a.s  a  source  of  large  and  u.seless  expendi- 
ture. I  never  give  (juiniue  as  a  propliylactic  in  a  case  where  the  paroxysmal  character  of  the  disease  has  not  been 
distinctly  manifested.  My  practice  is,  when  the  intermittent  paroxysm  has  once  exhibited  itself,  if  the  i)atient  is 
still  in  the  cold  stage,  to  give  half  an  ounce  or  an  ounce  of  whiskey  with  some  hot  drink,  and,  if  there  are  no  vio- 
lent symptoms,  to  let  the  paroxysm  i)ass,  modifying  or  assuaging  sonii!  of  the  most  uncomfortable  manifestations  a.s 
may  seem  necessary.  About  two  hours  before  the  next  paroxysm  is  expected  I  give  eight  or  ten  grains  of  ([uinine  in 
one  dose;  and  if  the  paroxysm  is  kept  olf,  I  give  two  or  three  grains  less  two  hours  before  the  next  paroxysm  is 


MAr.ARlAI.     DISEASE.  1  ■'^l 

I'xpi'Pti^d :  Willi  if  that  floes  not  occiit'  T  a^niu  (liiiiiiiisli  the  ihisc  hy  two  or  three  iirnhis,  ami  niraiTi  repeat  two  liours 
liefiiie  Ihe  iii\l  Ma  roxvsm  is  i-x|ieeleil,  ami  iliiis  nivc  iVoiii  two  to  li\e  doses.  Iiy  wliii-li  time  the  ilisrase  has  usually 
(lisapiiea  1  rd.  I'.iit  1  am  not  always  so  t'oi  tiiiiati'  as  to  eoutrol  the  disease  in  this  |iriMiipt  and  <'asy  in.aiiiiei .  ami  soiiie- 
tiiiies  fwehc  L;iaiiLS  are  iieeessary  to  ••liicak  the  (diill:"  and  ofteutiiiies  the  system  is  out  ot  cjider  in  other  w.-iys,  the 
toiiiiiie  eoated.  the  appetite  gone,  the  dijiestion  disordered,  and  in  other  respects  tin'  i).atient  may  lie  snli'erintr  from 
conditions  which  shonlil  he  attended  to:  all  the  fiimtions  should  he  lironttlit  into  the  most  healthy  condition. 

Siir^/diii  Cl.Arnoi-UNK  .T,  W.\l  rciN.  I'l.v/  A//,  le/.s..  .Iriini  e/'  Ihr  T,  iiiii>i>in  .  Dnrmhi  r  :!1.  IMIJ. — 'I'he  intermittent  and 
remittent  fevers  ohserved  in  this  leeinieiit  have  yielded  readily  to  the  use  of  i|iiinine.  Twenty  .urains  given  at  one 
dose  usually  prexent  the  return  of  the  jiaroxysiu  in  intermittent  cases.  The  same  i|iiatitity  given  in  live-grain  do.sps 
during  tile  twenty-four  hours  (without  ri'gard  to  the  remission  i  and  continued  in  some  cases  for  two  days,  with  or 
without  mercury,  is  snilicient  to  iidieve  a  ri'inittent. 

«S'h/v/(()H  .TiiIIX  WnKilll.  ld7//(  ///.  I'o/.v  .  i:H:(iIii  Ihhiicii.  hi/.,  I  ha' iii  hi  r  '.'A .  IStiL'. —  I'lie  luti'iuiit  tent  fevers  ohserved 
ill  thi.s  regiment  have  heeti  generally  tri'atcd  w  ith  antiiieriodic  doses  of  (luininc.  |iiceeded  l>y  a  cathaitic  in  cases  of 
constiliatloii,  and  as.socialed  with  opium  in  cases  of  diarrhiea.  .Sixteen  to  twenty  giains  <•(  i|uiniiie.  giNcn  during 
the  intermission,  Kutlticed  to  prevent  a  return  of  tln^  chill.  Ueinittcnts  have  Immmi  treated  ou  the  same  plan,  the 
quinine  being  givt^ii  during  the  reniissioii.  and  with  favorable  results,  the  remission  in  a  few  days  becoming  an  inter- 
mission. ( Iccasionally  there  has  been  great  irritiihility  of  the  stoniacli:  in  siudi  cases  large  doses  i\t'  laiidaniim 
appeared  to  answer  well. 

Ill  Lntekmittents  the  suljiinitf  lit'  quiniiH'  was  usiiallv  ailiiiiiiislcr(.Ml  in  ilnsrs  of  three 
1o  th'c  grains,  repeated  every  few  hours  during  tlie  interinission.  Where  tlic  disease  was 
couuiioii  and  deaths  h'oin  sudden  enugestions  rare,  tliese  doses  were  gix'eii  ihrci'  or  four 
times  a  d;iy.  witli  tlie  intention  ot'  I'tix'ortihly  niodil'ving  and  ullunatelv  su|ijircssing  the  suc- 
ceeding paro.xysnis.  P)ut  where  the  occasional  oceurronce  oft'attd  congestions  infused  hiLo  the 
caseapossihh^  danger  to  hfe,  the  I'emedy  was  administered  witli  es[.KM-ial  inleiitto  inmiediately 
su[)press  the  morliid  manifestations.  To  this  end  tlie  dose  wtis  repeatt'd  at  .such  intervals 
that  ringing  lu  the  eai's  or  other  svinptonis  of  cinehonism  might  he  [iroduced,  or  failing 
ihis,  thai  a  sprcillod  ipiantitv  might  bo  taken,  liefore  the  time  when  the  next  paro.xysm  was 
(■ojiciqv.Ml  td  he  due.  Thus,  in  ease  55,  five  grains  were  ordered  for  administration  tit  8, 
It',  1  L*  and  2  0  clock,  to  anticipate  a  paroxysin  expected  at  B.oO  p.  M.  Tln^  quantity  need- 
lul  to  otlect  litis  oljject  varied  with  the  section  of  the  country  which  gave  rise  to  the  disease. 
I  hus.  whde  A\  KioHT  savs  that  sixteen  to  twenty  grains,  given  during  the  intermission,  were 
sufiicieiit  to  pi-event  a  reiui-n  of  the  chill,  ]Ii-;NJ)Elisox  states  that  twrnl\--[lve  to  thirty 
grains  were  generally  re(|uired  to  accomplish  this.  Ihit  the  quantity  varied  also  in  indi- 
vidual cases,  sonte  requiring  more  some  less  ;  and  thesi.'  peculiarities  hecominu'  known  in 
prinvary  attacks,  dictttted  the  (piantitios  prescribed  in  subsequent  reltipses. 

The  danger  attaching  to  the  recurrence  of  the  chill  led  to  the  very  general  adoption  of 
the  practice  of  giving  one  or  more  large  doses  as  being  nioi-e  etHcient  than  the  repetition  of  a 
smaller  dose.  The  large  dose  was  usually  adnunistered  early  in  the  intermission,  that  time 
might  be  ailorded  for  its  full  absorption  and  eflficitint  action  before  tlie  period  of  the  expected 
return.  Thus  the  medical  officer  of  the  19tli  Mass.  Vols.,  in  cases  5,  13  and  41,  gave 
iifteen  gnuns  at  once,  and  continued  the  remedy  thereafter  in  three-  or  live-grain  doses  at 
intervals.  Pt;cic  gave  fifteen  to  twenty  gi-ains  morning  and  evening;  jMerritt,  Walton 
and  others  twenty  grains.  Harrison.  Avho  comments  on  the  unuecc>ssary  expenditure 
oi  quinine  in  some  commands,  states  that  a  practice  h'ttding  to  economy  of  the  drug  in 
his  own  charge  consisted  in  the  exhibition  of  ten-grain  doses  to  ward  oil"  expected  chills; 
but  he  allows  that  he  was  not  unil'ormly  successful,  and  that  twelve  o-riuns  had  some- 
times to  be  given.  A  few  reports  referring  to  methods  of  administration  sprak  of  tlie  use 
of  evacuants  prior  to  the  exhibition  of  quinine;  but  tliat  this  was  not  usual  in  practice 
may  be  gathered  from  the  clinical  records,  where  the  remedy  is  generally  ordered  at  once 
and  unaccompanied  bv  a  cathartic.      When   called  for  by  the   condition  of  the  tongue  or 


182  TREATMENT   OP 

bowels,  l)lne  pill  mul  opium  were  combinofl  witli  tln'  quinine,  or  a  mercurial  was  given, 
followed  Ky  K;isoiii  or  llocliellc  salts,  or  the  citrate  of  magnesia;  capsicum  was  tVoquontly 
used  as  an  adjuvant,  especially  in  tlie  \V^(>sterii  armies.  Emetics  were  seldom  given;  but 
]\Ikki;[TT  and  CrRAiNuK!;  refer  to  tlieii-  successful  use  in  preventing  recurrences.  When 
gastric  irritability  interfered  with  tlu^  administration  of  quinine,  opium  was  considered  of 
value;  Hoflmann  s  anodvne,  ice  and  sinapisms  were  also  used  to  overcome  occasional 
vomiting.  b)iarrh(ea  as  a  conqdication  was  treated  with  Dover's  powder,  o].)ium  uv  aromatic 
powder  in  conjuni-tion  with  quinine  or  camphoi',  or  with  opium  combinei]  witli  acetate  of 
lead  or  nitrate  of  silver.  During  the  paroxysm  little  was  done  other  than  to  make  the 
patient  as  comfortable  as  possible  and  to  al)ridge  the  febrile  stage  by  the  use  of  hot  drinks. 

Quinine  was  used  as  freely  to  prevent  anticipated  relapses  as  to  suppress  expected 
paroxysms  after  the  relapse  had  occurred.  For  this  })urpose  siuaJl  doses  were  occasionally 
contiimed  for  several  days;  but  more  generally  tlie  patient  was  directed  to  report  at 
the  end  of  the  first,  second  and  third  weeks  for  the  administration  of  a  large  dose  in  antici- 
pation of  a  relapse  at  those  periods;  or  he  was  cautioned  to  be  on  the  outlook  for  premoni- 
.tory  symptoms  and  instructed  to  report  for  treatment  immecbately  on  their  appearance. 
An  occasional  dose  of  blue  pill,  when  the  tongue  was  furred,  was  also  given  as  a  part  of 
this  ]iro[>hylactic  system. 

Strychnia  was  sometimes  employed  in  obstinate  cases,  as  in  case  4,  in  which  it  was 
combined  with  blue  pill  and  capsicum.  But  when  quinine  failed  to  prevent  relapses, 
medical  officers  generally  had  recourse  to  Fowler's  solution,  which  was  often  found  bene- 
ficial. After  tlie  ])aroxysms  were  conti-olled  quinine  was  not  unfrequently  resumed  in 
roborant  closes  with  other  vegetable  tonics  and  the  tincture  of  iron;  or  the  citrate  ot  iron 
and  quinine  was  enqdoyed.  Surgeon  Towle  considered  the  removal  of  the  patient  from 
the  malarious  atmosphere  of  the  greatest  importance  in  treating  obstinate  fevers,  and  urged 
the  advisability  of  having  such  cases  removed  from  the  exposures  incident  to  camp  life  in 
tents,  stating  that  manv  cases  in  his  practice  which  had  proved  refractory  to  quinine 
recovered  when  the  patients  were  ti'anferred  from  a  tent  to  the  better  protection  of  a  hous(\'^' 

Remittents. — In  the  treatment  of  remittents  the  sulphate  of  quinin(>  was  generally 
used,  often  with  capsicuni  or  blue  pill  and  opium,  in  five  or  more  grains,  repeated  four  or 
five  times  in  the  twenty-four  hours.  Frequently  a  mercurial  cathartic,  followed  bv  a 
saline,  was  given;  but  the  administration  of  quinine  was  not  delayed  for  the  action  of  the 
bowels.  Tlie  specific  remedy  was  prescribed  during  the  pyrexial  periods  as  well  as  during 
the  remissions,  but  when  the  latter  were  \vell  marked,  larger  doses  were  administered  duriup; 
their  continuance,  while  acetate  of  ammonia,  spirit  of  nitre  and  neutral  mixture  were 
employed  during  tlie  exacerbations.  Local  congestions  were  not  permitted  to  interfel-e  with 
the  administration  of  quinine,  as  they  were  believed  to  originate  in  the  miasmatic  influence, 
and  were  found  to  be  relieved  when  the  latter  became  counteracted  or  modified  by  specific 
medication.  Turpentine  emulsion  was  frequently  used  in  the  diarrhoea  accompanying  these 
cases.  Dover's  powder  was  often  gi\'en  to  restrain  the  bowels,  promote  perspiration  and 
secure  rest.  In  some  instances  of  hemorrhage  from  the  intestines,  enemata  containincf 
persulphate  of  iron  were  employed.      Vomiting  was  controlled  as  in  the  intermittent  fevers. 

*  S.  K.  Towle,  Surg;poii  ;iOtli  Mass.  Vols. — Xot''n  of  Pradke  m  V.  S.  A.  deuerfd  Uos-pitnl^  ilatoii  Roiifrc,  La.,  during  tlic  yoar  18(i;],  JioHlnn  Med.  ami 
Siirg.  Jmir.  Vol.  LXX,  18(>4,  pp.  4'.t-56.  '"Whilt-  on  the  Potoiimc  I  \va»  so  well  jilcasod  with  tlie  progrci^s  of  typhoiii  cam's  in  hospital  tt'utri  that  I  th<iu;r|it 
tht'in  as  goiHl  as  himfif'S ;  hut  sino'  heing  in  thiri  department  I  have  Jjeronie  eunvinci'd  that  cases  of  malarial  disease  do  very  mucli  better  in  buililiiijrs 
tliivu  in  tents — the  canvas  iirotertinj;  the  patients  much  less  than  boards  froiu  the  two  great  excitants  to  the  action  of  miasmatic  poison,  the  heat  of  the 
euii  and  tlie  chilly  heavy  dews  of  night." 


MALARIAL    DISEASE.  183 

Sinapisms  or  blisters  were  applied  on  account  of  pain  in  tlie  Iiypocliondriac  or  ninliilical 
retfioiis;  and  calomel,  opium  and  tai'axacum  were  administei'cd  when  indications  of  jaundice 
appeared.  Active  catharsis,  as  by  calomel,  rhubarb  and  salines,  was  used  in  tlie  tVw  sthenic 
cases  wliich  occurred,  in  conjunction  with  low  diet,  cold  to  the  head,  mustard  to  the  feet, 
and  vci'v  exceptionally,  l.)loodletting.  Digitalis  was  sometimes  employed  with  the  quinine 
when  there  was  mucli  cardiac  excitement.  Aromatic  sulphuric  acid  was  used  to  restrain 
excessive  perspirations,  and  carbonate  of  ammonia  and  ali;oholic  stinmlants  when  the 
prostration  was  great. 

CoXdKSTiVK  FKVKR. — In  cougestive  cases  the  sole  reliance  was  on  (pnnine.  Dr.  (_tAL- 
LOVPF/^'  expressed  the  general  opinion  in  saying  that  in  these  cases  no  treatment  was  of  any 
avail  rxi-ciit  thai  hv  (piinine;  and  that  when  cinchomsm  was  rapidlv  produced  the  disease 
was  })romptly  and  ahnost  invariably  brokt'ii  up.  Largi'  and  I'cpeated  doses  were  given, 
irrespective  of  the  condition  of  the  patient  as  to  colhipse,  fever,  intermission,  head  symp- 
toms or  intestinal  inactivity  or  derangement.  ()tlier  nreasures  were  employed  as  adjuncts 
during  the  stage  of  collapse,  as  mustard  emetics,  capsicum,  alcoholic  or  ethereal  stimulants, 
stimulating  enemata,  hot  frictions  and  sinapisms  or  the  hot  bath.  Hewitt  recommended 
the  application  of  io(hne  to  the  sjnne,  wliich  was  assumed  to  do  good  by  relieving  passive 
congestion  of  the  coixl,  tluis  enabling  the  organ  to  generate  and  transmit  power  sufficient 
to  I'emove  local  obstructions  and  restore  integrity  of  vital  function. f 

GiiRONU'  MAL.MUAL  POisoNiNti. — Q,uinine  was  also  given  in  cases  of  chronic  malarial 
poisoning,  but  in  theso  it  was  by  no  means  so  efficacious  as  in  the  acute  manifestations  of 
the  diseasi'.  1  )'.\\-ioNON,  speaking  of  such  cases  at  New  Berne,  N.  C,  says  that  the  ordi- 
nary remedies  were  of  no  avail;  and  in  case  52,  reported  above,  iodide  of  potassium,  iron 
in  \arious  forms,  vegetable  bitters,  mineral  acids,  stimulants,  counter-irritants  and  anodynes 
were  employed  for  three  and  a  lialf  months,  during  which  tlie  patient  seemed  rather  to 
decline  tlian  improve.  Removal  to  a  non-malarious  climate  was  apparentl}*  essential  to 
recovery  from  this  condition  of  chronic  poisoning.  The  deteriorated  blood  had  to  be 
improved  hefore  the  general  h(.'alth  could  be  re-established,  and  this  could  not  be  eflPected  so 
long  as  the  individual  nMnained  exposed  to  the  influences  wliich  had  caused  his  disability. 
This  was  well  recognized  bv  our  medical  officers,  and  furlough,  discharge  from  service  or 
removal  for  treatment  to  some  northern  hospital  was  their  usual  prescription.  Iodide  of 
potassium  internallv  and  iodine  applied  to  the  region  of  the  spleen,  with  tincture  of  iron 
and  small  doses  of  quinine,  or  the  citrate  of  iron  and  quinine,  and  the  best  diet  procurable, 
constituted  the  routine  treatment  of  such  cases,  special  symptoms  receiving  attention  as 
they  became  prominent.  At  the  Satterlee  Hospital,  Philadelphia,  Fowler's  solution  suc- 
ceeded in  allaving  supraorbital  neuralgia  in  several  instances  in  which  quinine  gave  no 
beneficial  result,^  while  extract  of  belladonna  applied  locally  was  a  means  of  temporary 
relief.  At  Quincy,  111.,  this  neuralgia  was  favorably  affected  by  forty  grains  of  chlorate  of 
potash,  twelve  of  citrate  of  quinine  and  iron  and  two  of  capsicum,  given  in  four  doses 
.  during  the  day. 

Untowakd  effects  of  quinine.- — The  medical  records  of  the  war  make  no  mention 

*Sco  his  report,  atUe,  p.  144. 

f  See  luH  report  in  tlio  ApiK-ndix  to  the  first  p.irt  of  this  work,  p.  313. 

I  \n  .Assistant  Surgeon  (name  not  given) — Efectn  of  latent  Malai-Ui,  roused  into  activity  hi;  an  ej-citintj  caune.  Med.  and  Surg.  Reporter^  Yol.  X,  1863, 
p.  1(H» — ilcscribes  several  ca.ses  of  i)eri(«lic  neuralgia  in  soliliera  hntuglit  to  hospital  from  the  Army  of  the  Potomac,  in  which  arsenic  succeeded  after 
.ouinia  had  failed.  See,  also,  letter  from  Surgeou  Geokgk  It.  Willson,  3d  Mich.  "\'ol.<.,  from  Camp  Michigan,  Va.,  Feb.  25,  18G2,  Boitton  Med.  and  Sitrg. 
Juur.;  V<il.  LXVI,  1802,  p.  109, — in  which  ho  describes  some  cases  of  peri<»dic  neuralgia  relieved  by  quiuine  and  some  by  Fowler's  solution. 


184  TREATMENT    OP 

of  harmful  effects  from  tlio  use  of  large  doses  of  quinine  in  suppressing  malarial  fevers. 
Giddiness,  deafness,  ringing  in  the  ears  and  even  temporary  prostration  were  frequently 
experienced,  but  tlusc  wnv  rcgai'ded  as  desiralile  symptoms,  indicating  tliat  the  remedy 
had  been  abs(jrbcd  and  was  pervading  tlie  system  with  its  antidotal  influence.  Nausea  was 
sometimes  produced.  Imt  was  considered  as  of  little  moment  in  comparison  with  the  great 
benefit  to  be  derived  iVom  the  admiinstration.  The  absence  of  specially  dangerous  symp- 
toms or  undesirable  sequcdte  attributable  to  quinine  might  well  be  accepted,  in  view  of  its 
extensive  employment  dui'ing  the  war,  as  establishing  the  harmlessness  of  the  remedy  when 
exhibited  in  lai-ge  doses  in  malarial  fever.'-'  It  must  be  admitted,  however,  that  large  doses 
may  be  a  source  of  danger  bv  the  direct  sedative  action  of  the  drug  on  the  nervous  and 
•circulatory  systems,  especially  in  cases  having  a  tendency  to  lieart-failure  from  temporary 
enfeeblement  or  degeneration  of  tissue.  Dr.  J).  S.  Lamb  of  the  Surgeon  General's  Office, 
U.  S.  Army,  published  recently  the  case  of  a  child  of  three  years,  in  wdiich,  at  the  end  of 
the  first  week  of  a  nnld  attack  of  typhoid  fever,  death  was  caused  in  little  over  an  hour 
by  syncope  following  the  ingestion  of  forty-two  grains  of  quinine. f  Stille  cites  several 
cases  of  death  from  quinine,  in  which  the  autopsy  showed  congestion  of  the  brain  and  lungs, 
and  in  some  degree  also  of  the  stomach. J  The  toxical  effects  of  quinine  must  therefore 
be  held  in  view;  and  their  notable  absence  from  the  records  of  the  war  be  attributed  to 
that  judicious  use  of  the  remedy  which  relieved  diseased  conditions  and  even  recovered  the 
patient  from  inipending  death  without  injuring  the  system  by  an  excess. 

Other  remedial  agents. — The  sulphate  of  cinchonia  was  occasionally  used  during 
the  war,  but  no  systematic  observations  were  made  on  its  efficacy  as  compared  ^^ith  that  of 
quinia.  The  opinion  formed  was  unfavorabje  to  its  use.  Surgeon  Meeritt,  for  instance, 
states  that  he  preferred  quinine  fo  cinchonine,  but  does  not  give  the  grounds  of  his  prefer- 
ence. Certain  experiments  in  this  country,  and  recent  observations  in  India,  lead  to  tlie 
belief  that  04nchonia  is  energetic  and  in  adequate  doses  a  siu'e  remedy. §      Nevertheless,  from 


*The  medical  officers  mentioned  in  note  f  p.  ITn,  mjini,  were  rec|nested  to  ti'stify  on  tliis-  snljject.  Tlie  Vth  inijuiry  of  (Jcneral  L.vwson'.s  Circular 
was  as  follows  :  *'Since  the  practical  introduction  of  qninine  in  large  doses,  the  statistics  of  this  hurean  exhibit  a  much  higlier  ratio  of  diseases  of  the 
bowels — as,  for  instance,  diarrhu-a  and  dysentery, — and  also  a  mnch  liif;her  avenige  of  mortality  from  the  sjimo  diseases.  It  renuiins  therefore  to  he  deter- 
mined how  far  this  result  is  due  tci  this  cause,  or  to  the  operation  of  other  agents."  In  rejdy,  Snrgeon  R.  C.  Wood  stated  that— "I  have  always  been 
opposed  to  the  a<lministration  (if  quinine  in  very  large  doses,  and  have  no  douht  that  dysentery  and  diarrlnea  have  been  aggravateil  hy  the  excessive  use 
of  this  remedy."  lint  the  exjierience  of  the  others  did  not  susfciin  Dr.  Wood's  opinion.  They  attributed  tiie  increase  in  the  bowel  aflections  to  the  condi- 
tions existing  during  the  Florida  war,  and  conceived  that  ipiinine  was  efficient  as  a  reiTiedy  in  those  disea.ses.  Tiius  Surgeon  K.  S.  Sattk-klee  reported  : 
"I  have  not  the  least  hesitation  in  saying  that  the  constant  and  long  exposure  of  the  soldiers  in  Florida  to  the  influence  of  uialaria.  and  their  suffering 
from  fevers,  both  remitt.Mit  and  intermittent,  was  the  causes  of  the  great  mm-tality  as  well  as  the  gri>at  number  of  cas.-s  of  dys  -ntery  ami  diarrlnea  that 
occurred  there  and  by  no  nu!ans  the  use  of  quinine ;  cm  the  contrary,  I  have  often  seen  iutenuittent  and  chronic  dysenti.'ry,  both  in  tlie  sjinu;  case,  at 
the  same  time  checked  by  that  remedy."  .\ssistant  Surgeini  ]i.  M.  1S^  u.vK  is  the  only  officer  who  refers  to  other  evil  effects  from  the  use  of  ipiinine :  "I 
have,  however,  met  with  several  cases  of  ufrroita  affections,  which  evidently  resulted  from  the  administration  of  large  quantities  of  this  medicine.  I 
have  witnessed  four  ca.<es  in  which  {>artial  deafness  was  ex|K'rienced  for  upwards  of  three  nninths ;  one  in  which  the  deafness  wan pi'minnent ;  anil  one  in 
which  almost  total  blimlness  was  o<-casioned  for  several  days,  and  in  v\  hich  jierfect  vision  was  not  restored  for  some  months.  These  cases  were  all  clearly 
attributtible  to  the  administration  of  quinine  in  large  quantities.  I  have,  besides  these,  met  with  numerous  other  cases  of  nervous  ilerangement  of  a 
chronic  character,  such  as  slight  siKisnmdic  affections,  frecjuent  attacks  .d'  vertigo,  palpitation  of  the  heart,  cephalalgias,  nervous  tremors,  &c.,  which,  it 
appeared  to  me,  could  be  fairly  ascrilwil  to  the  .siimi'  cause.  In  nearly  all  tliesi'  ca.ses  the  ri'Uiedy  had  been  exhibited  in  doses  of  from  teji  to  thirty  grains  ; 
and  in  several  of  them,  as  high  as  two  li\inilred  grains  had  been  [olniiiusterecl  within  ten  days." 

f.Veif  York  .Ifof.  Jour.,  Vol.  XXXIX,  lss4,  p.  .">41l. 

{  Tlier<q,f Hlia  and  Miilrri.i  Mr.Urn,  by  .Vl.rr.En  .■^Tir.l.f.  M.  P.,  I'liila.b  lldiia,  I'a..  IsTI,  V,,:.  1.  p.  JiC. 

§  Ohs'-rratioit!'  nj»/ii  one  liiiwlreil  'o.ies  of  i,il,-riiiillr,il  urrr  in  I'-huh  llo'  siilplinlr  of  ( 'iwlionio  ic,r.<  /i.-. .(  ri,s  n  siihslllalf  fur  (/loiiei,  liv  .\.  l>.\|:i,  Titrxer,  M.  I)., 
Am.  Jour.  ^Te•!.  Sciences;  Ni'W.Si'ries.  Vol.  XI; V[ I.  lsi;l,  p. :','.«;.  In.  Ttuxkr,  after  referring  to  M-iokxluk.  laTTEUv.wx,  I 'i[oiiki.  and  otin  is  who,  after  slight 
inquiry  rejected  tiie  j>retensions  <.f  cim  !i..uia  a>  a  b-brifuge.  rites  M\i.r  v.  who.  in  Is--"',  ^nl■cee<lr'l  In  immediately  checking  twenty-hve  out  of  twenty-seven 
intermittents,  while  the  rel'rac  tory  .  :ims  yi.liliil  on  a  jndii  ious  pi  i-ev.  ranee  in  the  nniedy.  He  rciilis  the  favoralile  opiLLious  of  Mai!hm,  Wiitzer,  Di;f- 
RESXE,  Pi.tTiKR  and  BARnst.EV.  au'l  invites  special  attention  to  ri-ofes>or  ^^■II.LIA.M  I'ei'I'ER's  success  in  jiromptlyi  becking  eleviMi  out  of  fifteen  ca.ses,  two  of 
those  remaining  having  yieldecl  toa  second  admiuistnitiou  of  the  remedy.  (»f  his  own  ca.ses  seventy-nine  had  ih>  paroxysm  after  the  first  exhibition  of  tlie 
medicine,  fifteen  had  one  paroxysm  but  not  two,  foni-  bad  two  but  not  inon-,  mie  had  thrc'  or  mcu-e  paroxysms,  anil  in  one  the  cinchonia,  as  administered, 
was  without  effect  in  averting  the  disease.  The  niaxinnim  quantity  used  during  a  sin.gle  intermission  was  thirty  grains,  ami  the  largest  dose  given  at 
one  time  was  fifteen  grains.  It  was  usually  given  in  three-grain  doses  every  hour  during  the  intermission,  until  about  twenty  grains  had  been  taken. 
Vertigo  and  buzzing  in  the  ears  were  observed  in  nnist  of  the  cases  :  nausea  and  vomiting  occurred  in  five  and  cephalalgia  in  six.  See,  also,  lifport  of  ol 
cases  of  inierinUteiii  fever  treiUed  hy  the  sulphate  of  eittrhonio. — .1.  ( '.  Weli.s, — f'iuetioifiti  Med.  Obserrer,  ^'ol.  I,  lH-')0,  p.  lo,  and  Table  of  102  cases  of  intermittent 
fever  treiUed  with  the  mlphate  of  cinehoiiia, — G.  Marti.v,  in  Troux.  ( ■olleije  of  Pliijsiciahs,  Philadelphia,  ISSi-'.'iO,  Vol.  II,  pp.  iM-43t:.     Joseph  Bougali,  M.  D., 


MALARIAL    DISEASK. 


IBo 


the  slow  progress  made  by  tliis  remedy  into  public;  favor,  it  seems  unlikely  that  it  will 
displace  quinine  as  the  special  antidote  to  the  poison  of  malarial  fever. 

The  case-books  of  the  Pettigrew  hospital,  Raleigh,  N.  C,  fiurgeon  E.  Burke  Haywood 
in  charge,  give  the  details  of  the  treatment  of  intermittents  by  turpentine  applied  to  the 
chest  over  tlie  fourth  and  hfth  ribs.  The  application  was  made  an  hour  before  the  acces- 
sion of  the  cold  stage,  with  a  view  to  prevent  the  recurrence  of  the  paroxysm.  Mention 
lias  0(;casionally  been  made  in  the  uredical  journals  of  the  internal  use  of  turpentine  in 
intermittents;*  but  there  are  few  references  to  its  use  as  an  external  application.  Neverthe- 
less its  employment  in  this  wav  was  advocated  by  some  Southern  practitioners,  as  appears 
from  a  letter  written  in  1855  by  R.  A.  Fontaine  of  Georgia,!  in  wliich  he  reports  the 
successful  treatment  of  an  intermittent  by  anointing  the  entire  chest,  stomach  and  axillae 
with  turpentine,  as  reconnnended  by  J.  0.  Nott  of  Mobile.  Prior  to  its  use  at  the  Pettigrew 
hospital  it  had  been  employed  at  Savannah,  Ga.,  in  1862,  by  Stilks  Kennedy, J  with 
very  successful  results.  The  patient  was  directed  to  appear  at  the  steward's  tent  forty-tlve 
minutes  before  chill  time,  when  a  bandage  of  cotton  cloth  eight  inches  wide,  soaked  in 
turpentine,  was  wound  around  his  chest;  his  linen  was  buttoned  closely  down  over  the 
bandage,  after  which  he  was  wrapped  in  a  blanket  and  kept  under  medical  supervision. 
At  the  time  this  practice  was  begun  there  were  sixty-two  intermittent  cases  on  the  register. 
Of  this  number  fifty  received  immediate  relief — that  is,  the  expected  paroxysm  was  sup- 
pressed ;  nine  resulted  in  cure  on  the  second  appilication,  and  three  on  the  third ;  but  during 
these  three  days  eight  new  cases  were  reported,  all  of  wliich  were  cured  on  the  first  appli- 
cation. Fowler's  solution  was  administered  in  each  case  to  prevent  relapse.  In  his  sub- 
sequent experience  Dr.  Kennedy  found  the  turpentine  a  prompt  and  efficient  remedy  when 
used  in  this  way.  In  some  instances  failure  occurred  from  irregularity  in  the  return  of  the 
chill,  as  when,  by  anticipating  the  period  of  its  recurrence,  no  time  was  given  for  the  pre- 
ventive treatment  by  turpentine.  In  two  cases  of  failure  th(!  oil  made  no  impression  on  the 
skin,  and  in  four  or  five  cases  remittent  fever  supervened. 

It  appears  that  the  favorable  results  obtained  by  Surgeon  Kennedy,  when  reported  to 

SurgPon  Madras  Army — The  fahrifiuji' propertU^fi  of  (he  rinctmna  alkdloida — nncbonla,  tjniiii^Ua  tnitl  >-iiirliinndi't.  K4inhnrgh  Mfil.  Jonr.  VdI.  XIX,  r.irt  I,  iMTii,  pp. 
l'j;i-'^(l'.(.  Froni  (iliservatioiis  on  li)8  intcniiittcnt  csist's  Pr.  l)<n'.iAi,L  r.iiirhulrs  tluit  aftt'r  iiiiiiiiru',  iiiiiiiidiii  iw  thr  most  powerful  Jis  an  aiiti|H'ri*Hiic, 
i-iiK-liuniiiia  next  tn  it,  and  rinclionia  tlw  least  activi' ;  Init  tliat  i-vcii  cinchonia  is  oniTi^ctie,  and  in  adniuatc  doses  a  sun-  remedy.  In  the  first  trials  the 
ulkal(.ids  were  jiiveii  duriiiK  the  intermission.  "Krehiiic;  they  were  triveu  indisiriminalely  itiiriri}?  imroxysm  and  intermission.  At  leuKth  it  benime 
ujtparcnt  that  they  were  must  serviceable  wlieri  administered  during  the  paroxysm  only.""  Head  synipti'ms  were  less  ctmimmi  than  with  quinine;  but 
nausea  and  bilious  purginj^  were  frequent  cdueonutants,  the  latter  appearin<i;  to  faeilitate  th<'  i  tire.  It  docs  not  appear  from  the  history  of  lln?  eases  that 
nierc-urials  or  otlier  evacnants  were  administered.  The  doses  wen^  usually  five  jirains,  witli  an  ortasioiial  large  dose  of  twelve  grains.  See  alwo  a 
Report  o»,  (Old  Slatii<ti>'id  dcUtih  oj\  the  treiitmeiit  <>/  «(>  hundred  enseit,  of  nudanouti  fever,  iit  the  lilmpid  Jintttdiou  Iln^'pUal,  bij  cinchona  febrifuge  or  mixed  alkdloitU, 
by  F.  Ohevaise.  Induui  Medical  (iftzeUe^  1S7H,  Vol,  XIII,  p.  (>!t.  The  maximum  quantity  administered  in  twtMity-fonr  Iiours  in  any  one  case  was  twenty- 
one  grains,  which  was  usually  given  in  three  doses.  The  avemge  quantity  for  all  the  cases  from  the  conimeiicemi-nt  of  treatment  to  discharge  was  ^U.,')!) 
grains.  The  maximum  number  of  days  under  treatment  was  thirty-thre*-.  the  minimuin  one,  and  the  average  4.rM  days.  Of  the  tot;il  4t;il  were  quoti- 
dians, 111)  tertians.  ir>  quartins  and  :i  remittents;  and  the  averagi'  number  of  grains  us.m1  in  each  case  of  the  first  variety  was  'Xl.2.\\ ;  of  the  second  :i;i..')8; 
of  the  third  ;ir).:i:t,  and  of  the  last  :A.?>.\.  But  the  antiperiixlic  was  continued  on  the  averagi-  in  each  ease  l.i;'»  days  after  the  arrest  of  the  iKiroxysm,  and 
as  for  this  protective  purpose  an  average  of  14.fiS  was  used,  the  average  quantity  which  sufficed  to  arrest  the  paroxysms  amounted  only  to  21.71  gniins. 
This  quantity  of  the  uiixed  alkaloidv  was  estimated  to  contain  only  l.:i.'i  grains  of  quinine  ;  whence  it  was  assumed  that  the  combination  of  the  alkaloids 
gave  rise  to  an  increased  sp'oific  effect.  In  tertians  and  quaitaris  Fowler's  solution  was  given  on  the  days  of  intermission,  the  cinchona  febrifuge  having 
been  used  only  on  the  days  of  expected  paroxysms.  The  mixed  alkaloids  did  not  cause  nausea,  vomiting  or  head  symptoms  in  a  larger  number  of  cases 
than  tK'curs  with  quinine.  The  writer's  small  experience  of  cinehonia  is  not  so  favorable  as  that  noted  above  :  In  1808  he  supplied  a  detachment  of 
troojis  at  a  malarious  station  in  the  San  Pedro  botttmi,  Arizona  Territory,  with  sulphate  of  cinehonia,  in  the  absence  of  the  quiuia  sjilt.  The  men,  who 
were  accustomed  to  the  use  of  the  latter,  pronounced  agjiinst  the  new  medicine  as  prom-  to  cause  vomiting  and  as  Ixdng  less  efficiicious  than  quinine. 

*  M.  F.  ToLBY— /^//ecAf  of  Spiritu  of  Ttn-pentine  in  n  cme  of  iuteniutteni.  Bostrm  3fed.  .iiid  Sunj.  .hmr.,  I828,  Part  2,  Vol.  I,  p.  IVl — gave  two-thirds  of  a 
tablespoonful  of  turpentine  in  molasses  at  the  beginning  of  the  cold  stiige,  which  was  immediately  suspended  ;  vomiting  occurred,  and  the  hot  and  sweat- 
ing KtJiges  were  not  distinctly  marked.  On  subseiiuent  cH-casions  the  remedy  was  followed  by  sujipression  of  the  paroxysms  without  nausea  or  other 
unpleasant  result. 

■f-See  Atlantic  Medical  and  Surgical  Journal,  1858-011,  Vol.  IV.  p.  444. 

X  TurjietUiiie  an  a  renmiiul  agenl  by  Stiles  Kennedy,  31.  P.,  of  Ilallstown,  Del.,  in  the  Med.  and  Surg.  Reporter,  Philadelphia,  1807,  Vol.  XVI,  p.  458: 
*'A8  to  the  mode  of  action  of  the  oil  of  turpentine,  I  submit,  1st.  The  pain  yiroduced  by  it  calls  the  whole  attention  of  the  mind.  2d.  The  impression  on 
the  nervous  centres.  3d.  The  stimulant  uffect."  Slnstard  was  frequently  used  by  Dr.  Kennedy,  but  he  found  that  the  skin  became  aore,  swollen  and 
irritated  under  its  use,  while  the  turi)entine  yielded  no  such  undesirable  results. 

Med.  Hist.,  Pt.  Ill— 24 


J  35  TREATMENT   OF 

the  Surcreon  General,  C.  S.  A.,  led  to  a  series  of  experiments  on  tliis  mode  of  treatment  in 
several  sections  of  the  (Jonfederacy.  Seven  eases  were  reported  in  the  Confederate  States 
Medical  and,  Surgical  Journal ,  January  7,  1864;'^'  in  these  the  expected  accession  was  pre- 
vented, but  the  chill  recurred  on  the  seventh  or  fourteenth  day.  The  Journal,  the  official 
organ  of  the  Surgeon  (jreneral,  expressed  a  desire  for  a  larger  experience  of  this  economical 
method  of  treatment,  and  I'cquested  that  reports  of  cases  be  promptly  forwarded.  In 
response  to  this,  seventy  returns,  involving  over  400  cases,  were  received  from  different 
hospitals  and  posts,  and  the  announcement  was  made  that  with  few  exceptions  the  remedy 
was  regarded  by  the  reporters  as  one  of  great  power,  if  not  positive  efficiency,  in  prevent- 
ing a  return  of  the  paroxysm.  Nevertheless,  in  a  later  issuef  the  editor  hesitated  to  accept 
these  favorable  experiences,  considering  that  the  turpentine  had  no  special  advantage  over 
other  powerful  revulsives,  such  as  blisters,  alcoholic  stimulants,  narcotic  medicines,  sudden 
shock  as  from  a  plunge  in  cold  water,  exciting  news,  etc.,  which  sometimes  stave  off  chills, 
although  they  are  seldom  used  for  this  purpose  therapeutically.  The  results  at  the  Pettigrew 
hospital  were  not  so  satisfactory  as  those  reported  by  KKN^"EDY;  but  whether  this  was 
owing  to  the  smaller  surface  exposed  to  the  action  of  the  turpentine  or  to  a  difference  in 
the  chai'acter  of  the  cases  is  unknown;  certaiidy  in  many  instances  the  failure  was  not  due 
to  irregularities  in  the  type  of  the  disease.  A  report  from  the  Chimborazo  hospital,  Rich- 
mond, Va.,  shows  that  this  mode  of  treatment  was  employed  in  its  wards,  and  proved 
successful  in  some  cases,  although  in  many  others  it  merely  retarded  the  access. 

At  the  Pettigrew  hospital  there  was  also  tried  a  mixture  of  tincture  of  opium  J  and 
solution  of  annnonia  as  a  substitute  for  cpiinine  in  the  treatment  of  intermittent  fevers,  A 
draught  containing  thirty  drops  of  each  was  given  a  short  time  before  the  expected  onset. 
Of  thirty-three  cases  detailed  below  thirteen  were  treated  by  turpentine  applied  by  means 
of  a  roller  bandage  around  the  chest;  one  of  these  was  succes.sful  on  the  first  application: 

Cask  1. — Private  ,J.  B.  Kelly,  Co.  F,  50th  N.  C,  had  a  quotidian  chill  Nov.  7, 1864,  at  8  p.  m.  Next  day  at  7  p.  m. 
the  roller  was  applied  for  an  hour,  and  there  was  no  chill.  The  operation  was  repeated  on  the  9th  and  10th,  and 
there  was  no  recurrence  of  the  chill.  Three  ounces  of  turpentine  were  used  without  injury.  He  was  returned  to 
duty  on  the  28th. 

Three  were  successful  on  the  second  application : 

Case  2.— Private  D.  D.  Stuhbs,  Co.  F,  2l8t  S.C,  had  a  quotidian  chill  June  28,  1864,  at  3  p.m.  At  1.30  p.m. 
the  liext  day  turpentine  on  a  roller  bandage  was  applied  and  continued  for  three  hours.  The  chill  however  recurred. 
The  application  was  repeated  on  the  followinij;  day,  and  the  chill  was  suppressed.  No  strangury  or  injury  to  the 
tissues  resulted.     Three  ounces  of  turpentine  were  used. 

Case  3. — Private  M.  B.  Manners,  Co.  K,  10th  N.  C,  had  a  tertian  chill  Sept.  7,  1864,  at  7.30  a.  m.  The  applica- 
tion was  made  on  the  9th  at  5.30  a.  m.  and  continued  for  two  hours.  A  slight  chill  occurred;  but  after  a  second 
application  there  was  no  recurrence.  No  injury  to  the  tissues  or  other  bad  effect  followed.  Two  ounces  of  turpen- 
tine were  used. 

Case  4.— Private  M.  Steen,  Co.  A,  13th  Arfy  Batt.,  had  a  quotidian  chill  Sept.  19,  1864,  at  11  a.  m.  At  10  a.  m. 
next  day  the  application  was  made  and  continued  an  hour  without  success;  but  after  the  repetition  of  the  applica- 
tion on  the  21st  there  was  no  chill.     Five  ounces  of  turpentine  were  used. 

One  on  the  third  application: 

Case  5. — Private  C.  M.  Dowd,  Co.  H,  Ist  Junior  Reserves,  had  a  tertian  chill  Sept.  20,  1864,  at  3  r.  m.  On  the 
22d  at  2  P.M.  the  application  was  made  and  continued  for  one  hour;  it  was  repeated  on  the  24tli,  with  partial  suc- 
cess. The  chill  recurred  on  the  26th.  The  application  was  renewed,  and  there  was  no  chill  thereafter.  Six  ounces 
of  turpentine  were  used. 

*  Oynfedrrate  Slates  Med.  and  Surtf.  Journal,  Richmond,  1864,  Vol.  I,  p.  7; — On  the  exlemal  applicatUm  of  the  oil  of  turpentine  as  a  tmhHlitiUe  for  quinine  in 
itdermittmt  ferer,  wUh  report  of  cases. 

f  Op.  cU.,  last  note,  Editorial,  p.  110. 

JOpiiin*  has  been  frequently  used  in  ronjunction  wit!i  quinine  to  relieve  the  patient  from  the  head  symptomH  oocaaionally  prcxluoed  by  the  latter, 
to  restrain  the  bowels  when  diarrhtea  or  dy&inti-ry  acconit>anied  malarial  fever,  or,  as  we  have  already  seen,  to  allay  gastric  irritainlity  which  might 
threaten  the  rejection  of  quinine.  But  it  has  sometimes  been  used  alone,  as  for  instance  :  Eif/htcases  of  simple  intermittent  and  six  of  remiti^nt  ferer  successfully 
trettted  hy  the  exhtlniion  of  partially  denarcotized  opium. — W,  S.  SlNN  of  Ohili,  Hancock,  111. — Nashville  Med.  Jour.,  1854,  Vol.  VII,  p.  379. 


MALARIAL    DISEASE. 


187 


While  in  eight  it  was  found  advisable  to  have  recourse  to  quinine: 

Case  G.— Private  H.  L.  La\ysor.,  Co.  I,  18th  S.  C,  had  a  tertian  rhill  at  ikkhi  of  Jiino  8,  1864.  On  the  10th  at 
11  A.  M.a  roller  bandage  wet  with  turpentine  was  applied  and  oontiuui(l  lor  three  hours.  I'he  eliill,  however,  eon  tinned 
to  reeur  every  seeond  day.  The  amount  of  turi)entine  used  was  ten  ounces.  Xo  injury  to  the  tissues  or  strangury 
oceurred.     He  was  finally  treated  with  ([uinine. 

Cask  7. — Private  1).  \V  (ireenlee,  Co.  K.  50th  X.  C  had  a  (|Uotidian  chill  Xov.  8,  18()4.  at  G  A.  M.  Xext  day  at 
5  A.M.  the  roller  was  api)Iied  for  an  hour  and  no  chill  occurred.  On  the  Kith  a  chill  occurred  at  2  A.  M.  (Quinine  was 
administered  on  the  lltli  and  12th,  and  there  wa.s  no  recurrence  of  chills.  He  was  ameniic,  and  was  therefore  given 
tincture  of  iron  anil  infusion  of  quassia.     Two  ounces  of  turpentine.     Hi' was  returned  to  duty  on  the  27th. 

Cask  8.— Private  B.  J.  Pollard,  Co.  D,  oOthN.  C,  had  aciuotidian  chill  Xov.  7,  18G1,  at  !•  a.  M.  Xext  day  at  8  A.  M. 
the  roller  was  a])i)lied  for  one  hour,  and  repeated  on  the  !tth,  and  no  chill  occurred.  On  the  10th  the  roller  was  not 
applied,  and  a  chill  occurred  at  10.30  .\.  M.  He  was  then  given  (|uinine  until  the  )>aroxysni«  ceased,  and  was  continued 
on  tonic  treatment  for  debility.     Two  ounces  of  tur])entin(^  were  used.      He  was  furlouglied  on  the  1 1th  forsixty  days. 

Cask  9. — Private  T.  .J.  Turner,  Co.  F,  "lOtli  X.  ('.,  had  a  ([uotidian  chill  Xov.  7.  ISGt.at  2.l!0  i'.  M.  The  paroxysms 
were  so  irregular  that  the  roller  was  apjilied  liut  once,  on  the  !tth  at  11  a.  m.,  for  one  hour,  one  ounce  of  turpentine 
being  used.  A  chill  had  oceurred  on  the 8th  at  12.1)0  r  M.,  and  lecnned  on  th<^  !Hh  at  3  1'.  M.  Quinine  was  then  used 
and  the  paroxysms  ceased.     He  renuiined  under  treatment  for  diarrhu-a. 

Case  10.— Private  H.  W.  Canisse,  Co.  (i,  .50th  X.  C,  had  a  iniotidiaii  chill  Xov.  8, 18GI,  at  2  a.  m.  On  the  iltli  at 
1  A.M. the  roller  was  applied  for  an  hour.  At  I  i".  M.  the  chill  recitrred.  'I'lie  operation  was  repeated  at  noon  on  the 
10th,  but  ii  chill  oceurred  at  10  r.  m.  Two  ounces  of  turiientiu)^  were  used.  On  account  of  the  irregularity  of  the 
chills,  quinine  was  given,  three  grains  every  two  hours,  ami  a  cure  oll'ected.  He  was  retained  on  tonic  treatnient 
because  of  debility  following  intermittent  fever. 

Cask  11. — Private  .1.  C.  llutchiugs,  Co.  Ci,  5t)th  N.  C.,  had  a  i|Uotidian  chill  Nov.  7, 18GI,  at  11  A.M.  The  chill 
recurred  irregularly.  The  first  apjilicatiou  was  on  the  8th,  at  10  a.m.,  for  an  hour.  He  was  treated  in  the  same 
manner  as  Canisse.     Two  ounces  of  turpentine  were  used.     He  continued  in  the  hospital  taking  tonics  for  debility. 

Case  12.— Private  G.  L.  Black,  Co.  G,  50th  N.  C,  had  a  tertian  chill  Nov.  8, 1864,  at  1  i".  m.  A  ciuotidiau  char- 
acter was  afterwards  assumed.  The  roller  was  apjjlied  on  the  10th  and  11th  for  two  hours,  without  success.  Two 
ounces  of  turpentine  were  used.     Quinine  w.as  then  resorted  to.     He  remained  under  treatment  for  debility. 

Cask  1.3.— Private  .1.  C.  .Strickland,  Co.  I),  11th  S.  C,  had  a  <iuotidian  chill  Oct.  8,  18(U,  at  10  a.  m.  Next  day 
at  9.;W.A.  M.  the  r(dler  was  applied  for  half  an  hour.  A  chill,  however,  occurred.  The  applicatiim  was  repeated  on 
the  lOtli  and  no  chill  occuirred.  Next  day  he  had  fever,  which  continued  several  days.  He  was  given  (luinliu',  two 
grains  every  three  hours,  and  the  paroxysms  were  finally  checked.  On  the  18th  a  chill  occurred  at  9  r.  m.  The 
roller  was  applied  at  8.30  r.  M.  on  the  19th,  20th  and  21st,  without  success,  but  on  the  22d  the  chill  was  arrested  and 
did  not  recur.     Eight  ounces  of  turpentine  were  used  without  any  injurious  ett'ects. 

Of  the  twenty  remaining  cases  one  was  treated  successfully  by  turpentine  with  the 
subsequent  addition  of  opium  and  ammonia: 

Case  14. — Private  R.  Clarke,  Co.  D,  9th  Pa.  Reserves,  had  a  quotidian  chill  Nov.  9,  1864,  at  10  a.  m.     Next  day 

at  9  A.  M.  the  roller  was  a])plied  for  an  hour,  aiul  there  was  no  chill.  On  the  11th  laudanum  and  ammonia  were  used 
in  additi(Mi  to  the  roller.  X'o  chill  occurred.  Having  clironic  (Uarrlnea  he  was  retained  in  the  hosj)ital.  Two  ounces 
of  turpentine  were  used. 

Tiuo  were  treated  with  success  by  opium  and  ammonia  without  the  use  of  the  turpen- 
tine bandage : 

Case  15. — Private  .Jacob  W.  Cobb,  Co.  H,  Ronaud's  Georgia  battery,  had  a  chill  .Tunc  6,  1864,  at  6  p.  m.  Next 
day  at  5.30  p.  .M.  laudanum  and  solution  of  ammonia,  of  each  thirty  drops,  were  given.  The  chill  did  not  recur. 
The  dose  was  repeated  on  the  8th,  and  there  was  no  further  recurrence  of  chill.  A  tablespoonful  of  infusion  of  dog- 
wood was  given  every  three  hours  through  the  day.     He  was  returned  to  duty,  cured,  on  the  IGth. 

Case  16. — Private  G.  (i.  Davis,  Co.  H,  Houaucrs  Georgia  battery,  had  a  chill  .June  G.  18G4.  at  noon.  The  next 
day  at  11  a.  m.  thirty  drops  each  of  laudanum  and  solution  of  ammonia  were  given,  and  the  chill  did  nof  return. 
Infusion  of  dogwood  was  administered  every  three  hours. 

Six  were  treated  at  first  with  the  turpentine  bandage;  but  the  chills  persisting,  opium 
and  ammonia  were  resorted  to  with  beneficial  results: 

Cask  17.— Private  J.  B.  Woodliss,  Co.  E,  Ist  N. C.  Cav.,  had  a  quotidian  chill  Oct.  2,  1864,  at  1  p.  m.  Next  day 
at  noon  the  usual  application  was  made  and  continued  for  one  hour;  but  the  chill  recurred.  On  the  4th  the  operation 
was  repeated  ami  lau<lanuin  an<l  ammonia  in  the  usual  dose  administered-,  after  which  the  chill  did  not  recur.  There 
were  no  injurious  etfects  from  the  turpentine,  two  ounces  of  which  were  used.     He  was  returned  to  duty  on  the  15th. 

Case  18. — Private  (ieorge  W.  Thompson,  Co.  F,  2d  .Junior  Reserves,  had  a  tertian  chill  Oct.  15,  1864,  at  8  \.  m. 
On  the  17th  at  7  A.  M.  the  roller  was  applied  and  continued  for  an  hour.  On  the  19th  a  chill  occurred.  The  roller 
was  repeated  and  laudanum  and  ammonia  administered.  Xo  further  chills  occurred.  Two  ounces  of  turpentine 
were  used,  without  injurious  efliect.     He  was  returned  to  duty  on  the  24th. 

Case  19.— Private  Wm.  S.  Davis,  Co.  G,  50th  N.  C,  had  a  quotidian  chill  Nov.  10,  1864,  at  11.30  a.  m.  Next  day 
at  10.30  A.  M.  the  roller  was  applied  for  one  hour  over   the  fifth  and  sixth  ribs,  and  was  repeated  on  the   12th 


ISS 


TRKATMKNT    OF 


without  success.  On  the  13th  laudanum  ami  ammonia  wcii'  administercil.  afti'i-  which  there  was  no  recurrenci'  of 
chill.     Thii'c  ounces  of  tllI']1eutiu^^  wi-ve  used  witlioul  iiijin\ .     He  was  I'eturncd  to  duty  ou  the  SIHh. 

Case  20.— Private  (i.  W.  Wi  en.  Co.  A..'i(lth  N.C..  had  ai|Uotidiau  chill  Xo  v.  7.  ISC  I,  at  noon.  Next  day  at  11  A.  M. 
the  roller  was  applied  for  an  liour.  A  sli;:lit  iliill  occuned.  The  same  treatment  was  imrsued  on  tlie  iHh  and  lotli, 
a  chill  occurring  each  day.  On  the  lltli  hind.innm  and  ammonia  w<Te  added.  Ilieic  ui've  no  further  eliills.  Four 
ounces  of  turpentine  were  used.     He  was  treati'd  for  anaemia  with  muriate  of  iron  and  infusion  of  ([uassia. 

Cask  21.— I'rivate  J.  C.  Snead.  Co.  A.  13th  X.  C.  Arty,  had  a  quotidian  chill  Sei)t.  20,  IWU,  at  1  P.  M.  The 
roller  was  ajiplied  at  noon  and  continued  for  an  lionr.  It  was  rejieatcd  thus  for  four  consecutive  days,  hut  without 
preventing  tlu'  recurrence  of  the  chill.  On  tlie  24th  laudanum  and  amnmnia.  of  eacdi  thirty  drops,  were  given  while 
the  liandage  was  on.  A  slight  chill  occurred.  On  tlie  2."ith  tliis  treatment  was  repeated,  and  there  were  no  chills 
afterwards.  Ten  ounces  of  turpentine  were  used.  Oct.  11,  at  .">  a.  m.  he  liad  a  tertian  chill.  On  the  16th  at  4  a.m. 
the  application  was  made  and  continued  for  one  hour :  at  tlu'  sanu>  t  ime  laiidannui  and  ammonia  were  given.  No  chill 
occurred  tliereafter.     One  ounce  of  turi)entine  was  used.     He  was  returned  to  duty  on  the  liUh. 

Case  22.— Private  W.  P.  Wilson,  Co.  I,  1st  N.  C.  Reserves,  had  a  quotidian  chill  .Sept.  20,  1S64,  at  2  p.  m.  Next 
day  at  1  p.  m.  the  application  was  made  for  oni'  hour,  and  repeated  daily  till  the  2lth,  without  success.  ()n  the  latter 
date  the  usmil  dose  of  laudanum  and  anunonia  was  given,  and  the  chill  did  not  occur.  This  treatment  was  repeated 
the  next  day,  and  there  was  no  chill  afterwards.     Ten  ounces  of  turpentine  were  used. 

In  five  ca.ses  treated  by  tui'peiuiiie  externallv.  in  conjunction  witli  opium  iiiul  aminoniii, 
inteinallv,  four  were  succes.sful  on  the  first  dav  and  one  on  tlie  second  dav  : 

Cask  23.— Private  W.  H.  Roberts,  Co.  D,  2()th  Ga.  hattery,  liad  a  tertian  chill  Aug.  31,  1804,  at  10  a.  m.  At  il.30 
a.m.,  Sept.  2,  the  roller  was  api)lied  for  an  hour  over  the  fourth  and  lifth  rilis,  and  at  the  sauie  time  were  given 
laudanum  and  solution  of  ammonia,  of  each  thirty  drops.  The  chill  did  lujt  ncnr.  The  roller  and  the  laudanum 
and  anunonia  were  repeated  on  the  4tli.  No  further  chills  occurred.  There  was  no  injury  to  the  tissues  nor  other 
had  effect  from  the  turpentine.     The  amount  used  was  ten  ounces.     He  was  returned  to  duty  on  the  23d. 

Case  24. — Private  James  R.  Dean,  Co.  B,  1st  .Junior  Reserves,  had  a  quotidian  chill  Oct.  24,  1864,  at  3  p.m. 
Next  day  at  2  r.  .M.  the  roller  was  applied  for  an  hour,  with  the  laudanum  and  ammonia  internally.  The  chill  did 
not  recur.  The  same  treatment  was  repeated  on  the  26th,  and  there  were  no  chills  afterwards.  Two  ounces  of 
turpentine  were  used.     He  was  fiirloughed  on  the  2Pth. 

Case  25.— Private  J.  S.  Tribble,  Co.  15,  8th  Cieorgia,  had  a  tertian  chill  (X>t.  2,  1864,  at  0  p.  m.  On  the  4th  at 
5  P.  M.  the  roller  was  used  for  one  hour,  in  connection  with  the  laudanum  and  ammonia.  The  chill  did  not  recur- 
One  ounce  of  turpentine  was  used.     He  was  much  debilitated  from  diarrlnea. 

Case  26.— Private  J.  M.  Wilson,  Co.  H,  50th  N.  C,  had  a  <inotidian  chill  Oct.  3,  1864,  at  2  p.  m.  Next  day  at 
1.30  P.M.  the  roller  was  applied  for  half  an  hour,  and  laudanum  ami  ammonia  used.  There  was  no  chill.  The  treat- 
ment was  repeated  at  the  end  of  the  week,  and  there  was  no  recurrence  of  chill.  One  ounce  of  turi)entine  was  used. 
As  he  was  ana-mic  he  was  given  Vallet's  mass  and  ijuinine  for  a  week.     On  the  20th  he  was  returned  to  duty. 

Case  27. — Private  John  liroadbent,  Cliappell's  Train  Guard,  had  a  quotidian  chill  Oct.  2,  1864,  at  3  A..M. 
Next  day  at  2.30  a.  .m.  the  roller  was  applied  for  half  an  hour  without,  however,  preventing  a  chill.  Laudanum  and 
ammonia  were  also  used.  On  the  4th  the  treatment  was  repeated,  and  there  was  no  chill.  No  injurious  etlect  followe(' 
the  use  of  the  turpentine,  of  which  two  ounces  were  used.     He  was  returned  to  duty  on  the  18th. 

And  in  six  recourse  was  liad  to  quinine  after  a  conjoint  trial  of  the  new  methods: 

Case  28. — Private  J.  S.  Inge,  Chapman's  Guard,  had  a  quotidian  chill  Oct.  1,  1864,  at  noon.  At  11.30  a.m. 
next  day  the  roller  was  applied  for  half  an  hour,  in  connection  with  laudanum  and  ammonia  internally:  a  chill 
occurred.  Next  day  it  was  developed  an  hour  earlier.  On  the  4th  it  occtirred  at  10  a.  m.;  the  treatment  having  been 
commenced  at  !1  A.  M.  5th,  The  chill  occurred  at  10  .\.  M.;  treatment  repeated.  6th,  The  chill,  wliicli  was  less  severe, 
occurred  at  10.30  a.  M.,  the  same  treatment  having  been  pursued.  7th.  The  laudanum  and  ammonia  were  omitted. 
The  chill  began  at  11  a.  ji.  and  receded  half  an  hour  daily  until  the  10th.  On  tliat  day  lifteen  grains  of  quiniiK!  were 
given  but  without  success.  Next  day  three  grains  everj-  two  hours  were  given  until  eighteen  grains  had  been  taken, 
and  there  was  no  chill.  .Smaller  doses  of  quinine  were  used  until  the  15th;  no  chill.  Twelve  ounces  of  turpentine 
were  used  without  injury  to  the  tissues.     He  was  returned  to  duty  on  the  18th. 

Case  29. — Private  J.G.  Stephenson,  Co.  D,  50th  X.C.,  had  a  quotidian  chill  Nov.  7,  1864.  at  noon.  Next  day 
at  11  A.  M.  the  roller  was  applied  for  an  hour,  and  the  chill  did  not  recur.  On  the  itth  the  ai)i)lication  was  reiieated. 
There  was  no  chill,  but  some  fever.  A  chill  occurred  ou  the  10th.  The  application  was  repeated  at  10.30  a.  m.  of  the 
11th,  and  at  the  same  time  laudanum  and  ammonia  were  given,  but  without  success.  12th,  Two  grains  of  ((uinine 
every  two  hours  were  given.  A  chill  occurred.  13th,  The  treatment  was  repeated  and  no  chill  occurred.  Four  ounces 
of  turpentine  were  used  without  injury.  He  remained  aiia^mic^  for  some  time,  and  was  given  infusion  of  ((uassiaone 
ounce  three  times  daily;  23d,  he  was  returned  to  duty. 

Case  30.— Private  J.D.  Woodall,  Co.  C,  50th  N.  C,  had  a  quotidian  cliill  Nov.  7,  1864,  at  4  p.  m.  At  3  p.  m.  the 
next  day  the  roller  was  ai)plied  for  two  hours,  but  the  chill  occurred  at  it  P.  M.  On  the  9th  the  application  was  nnide 
at  5  P.  .M.;  there  was  slight  fever  afterwards.  On  the  lOth  the  treatment  was  repeated,  but  the  chill  occurred,  receding 
three  hours.  11th,  Laudanum  and  ammonia  were  ad<led,  but  without  effect.  12th,  Quinine  was  given,  and  there  was 
no  chill.     He  was  anaemic,  and  was  retained  in  hospital.     Five  ounces  of  turpentine  were  used. 

Case  31. — Private  S.  Laws,  Co.  I,  1st  N.  C.  battery,  had  a  quotidian  chill  Nov.  7,  186<1,  at  9  p.  m.  Next  day  at 
8  p.  M.  the  roller  was  applied  for  one  hour,  but  the  chill  occurred  at  11  P.  M.     On  the  9tb  and  10th  this  treatment  was 


MALARIAL    ItlSKARE. 


189 


rejieatt'il  wiibijiit  inevciuiu^  tln'  cliill.  lltli,  Lau(l:uuiiii  uinl  iinuiKniiM  were  iuUU'd  willuml  clVci'l.  On  the  1-th  and 
13th  (|uiiiiin>  WMS  ciiiplcjyciL  and  |](j  cliill  (ic<uiicd.  Fonr  ouncrs  <il' tnipentinc  wi'ic  nscil  witlumt  injury.  As  lio  was 
ana'raio  tincture  of  luniiati-  (if  iidii.  twenty  dio|i>  tlircc  times  daily,  was  i;ivfii. 

C.vsK  32.— Private  William  lluntiny:dcin.  (d.  1.  5(lth  X.  C,  liail  a  i|n(itiilian  eliill  Nov.  T,  IsiVl,  at  10  .v.M.  Tlio 
next  day  at  !».30  .\.  m.  tlie  roller  was  applied  for  one  hour.  The  treatment  and  results  were  as  in  tlie  ease  of  Laws. 
Four  ounees  of  tiir])cntine  were  used.     He  was  returned  to  duty  on  the  27th. 

Cask  33.— Private  A.  liritt,  t^o.  D,  ."lOth  X.  ('..  had  a  ciuotidian  chill  Nov.  7,  ISiil,  at  1  p.m.  At  noon  next  day 
the  roller  was  applied  for  an  hour  and  there  was  no  chill.  On  the  !llh  and  10th  the  ap]iIication  was  repeated,  and  a 
chill  occurred  each  day.  llth.  Laudanum  ,aiid  ammonia  were  added  to  tlie  otlier  treatment,  hut  without  avail.  On 
the  12tli  and  13th  ([uiiiine  was  used.  An  infusion  of  cjuassia.  one  ounce  three  times  daily,  was  i;iven  for  seven  days. 
Three  ounces  of  turpentine  were  used  without  injury,     lie  was  returned  to  duty  on  the  2oth. 

Ill  additiuii  to  lliese  iIk'  recui'ds  o['  tlir  l'fniL:;rt;\v  Imspital  stale  that — 

A  number  of  cases  were  treated  with  the  tiirix'titine  roller  as  an  adjuvant  to  (|uinine,  i^reatly  reducing  the 
quantity  of  the  latter  administered. 

The  following  is  tVoiii  the  case-book  of  tlie  Cliinihorazo  lios|iital,  llirlimond,  Va.;  the 
writer's  name  i.s  not  given: 

Intermittent  fever,  the  common  ague  of  this  country,  has  been  (jnite  jirevalent  this  winter,  and  (luinine, 
almost  the  only  remedy  employed  against  it  internally,  has  not  ])revented  re.la])Hes.  The  tur|ientine  stupe  has 
))roved  useful  in  some  ca.ses,  api)lied  an  hour  befoin  the  expcctccl  paicixysm,  but  in  many  others  it  has  only  retarded 
the  access  of  the  jiaroxysm.  'J'he  acetates,  citrates  and  tartrates  of  soda  or  i)otash,  so  liighly  commended  as  adju- 
vants to  the  antiperiodic  treatment  by  (Jolding  liird,  have  not  been 'employed,  nor  lias  snfticient  care  been  taken  to 
repeat  the  antiperiodic  remedy,  whether  iiuinine,  arsenic  or  other,  at  interval-s  of  seven  days.  The  individual  eases 
liave  presented  no  points  of  ])artieular  interest  except  that  of  Pitts,  who  died  of  the  congestive  or  pernicious  form. 
He  was  a  fine,  tall,  robust  fellow,  recently  from  the  Army  of  Virginia.  He  was  rational  but  taciturn  on  admission, 
and  thougli  without  tyjihoid  sym])tom.s,  gave  the  idea  of  a  profound  cerebral  impression.  Kach  evening  he  was 
seized  with  what  was  spoken  of  as  convulsive  nu)vements,  i|uite  vioh^nt,  during  which  he  struck  to  the  right  and 
left  ami  had  to  be  held  by  main  force:  it  was  siii)posed  tliat  he  sought  to  jump  out  of  the  window.  I'liis  iminiacal 
delirium  was  succeeded  by  intense  fever.  After  a  few  nights  he  became  very  cold  at  the  evening  access  and  shook 
violently.  During  the  intervals  he  remained  taciturn  and  did  not  seem  to  recognize  his  friends.  The  treatment 
emj>loyed  was  iusigniliciint.  A  few  small  doses  of  quinine,  ctipping  to  the  temples,  a  blister  to  the  nucha,  etc. 
Nothing  made  any  impression,  and  he  died  within  a  week. 

The  prevalence  of  malarial  diseases  in  the  Confederate  Armies,  togetiier  with  the 
scarcity  of  quinine  resulting  from  the  blockade  of  the  Southern  ports,  gave  origin  to  a  con- 
tinued effort  to  utilize  such  indigenous  remedies  as  were  popularly  credited  with  anti- 
periodic  powers.  In  fact,  in  the  first  year  of  the  war  Dr.  Joseph  Jones  called  attention  to 
the  advisability  of  investigating  the  properties  of  native  plants  with  a  view  to  finding  a 
substitute  for  quinine.*  Of  these  the  Pinchneya  puhens  or  Georgia  bark  and  the  Cornus 
Jiorida  or  dogwood,  had  an  extensive  trial.  Tlie  former  is  a  small  tgee  closely  allied  to 
the  cinchonas,  growing  on  the  wet  and  boggy  margins  of  the  streams  which  intersect  the 
pine  barrens  from  Xew  River,  S.  C,  to  Florida.  Dr.  Jones  reports  it  as  having  been  used 
in  conjunction  with  dogwood  and  wild  cherry  as  a  tonic  and  antiperiodic.  In  view  of  its 
reputed  virtues  the  Surgeon  General,  C.  8.  A.,  directed  his  medical  purveyor  to  have  it  col- 
lected for  experiment.     The  only  published  report  on  its  use,  that  rendered  by  Medical 

Director  A.  M.  Fauntleroy,  does  not  sustain  its  claim  for  notable  febrifuge  powers,  f 

. t — . 

*  Indu/enous  ronedies  of  the  Southern  Confederacyt  vrhich  may  he  empluyed  in  the  treatment  ofmalariai  ferer,  SovJhem  Med.  and  Surff.  Jour.,  Augusta,  (»a. 
1861,  Vtil.  XVII,  pp.  67;J  and  753.  In  this  j)aj)cr  Dr.  .Tones  insists  on  tlii^  f'X<ainiluit!tin  and  employment  of  Sonthem  remedies,  not  as  a  tcniitomry  cxih'- 
dient  in  the  absence  of  quinine,  but  as  a  permanent  advance  toward  the  establishment  of  alisoiute  independence.  He  reviews  the  various  remedies 
which  may  be  employed  in  the  treatment  of  the  most  common  and  important  of  Southern  diseases,  riting  the  evidence  on  which  the  reputati<iti 
of  each  has  been  established.  As  of  value  in  malarial  fevers,  the  following  remedial  means  and  measures  are  discussed  :  The  inner  bark  of  the  Pincknetjn 
pnheii^  or  Georpia  bark ;  the  bark  of  tlie  root,  stem  and  I»ranrhes  of  Corium  Jloridu  or  dogwood  ;  the  ttark  of  other  sjK'cies  of  dopwowl,  as  C.  rircinata,  the 
round-leaved  dopwood,  and  C.  serieen,  the  swamp  dogwooil :  the  burk  of  the  poplar  or  tulip-tree,  Liriodendron  tidipiff-ra :  tlie  l>ark  of  certain  magnolias,  as  the 
small  ma-rnolia  or  sweet  bay,  Matjnolia  tjlaitea;  the  cucumber  tree,  M.  acumintUa;  big  laurel,  M.  grandiHora,  and  umbrella  tree,  .If.  tripelala;  the  Kark 
I'f  the  persimmon,  Diospyrns  VirghiUuia ;  the  bark  of  the  ciitaljHi.  Biftnouui  calidpn;  Virginia  suake-root,  .irixtnhuhin  iterpetttaria ;  Indian  quinine  or  ague 
weed,  GenUana  iptinquefulUt ;  thoroughwurt,  boneset  or  Indian  sage,  Enp(Uorium,  petf»lmtnni  and  wild  horehound,  E.  rotundifoUum ;  willow  bark,  Salix  aUia 
and  S.  )wjra;  the  root  of  the  yellow  jessamine,  6'eJwini>iiiin  Kt'iupen-irem;  the  rotit  of  milkweed,  .\»cUpmtt  fyriuiit;  chloride  of  sodium;  hydrochlorato 
of  ammonia  ;  nitric  acid  ;  arsenious  acid  ;  ligature  of  the.  extremities  and  cold  iiffusions  and  ibmches. 

*.\.  M.  F.KCNTI.EKOY,  Medical  Director,  Wilmington,  N,  C, — Report  o/"  uddititmal  ta^tit  of  febris  iiitermiiiem  treated  icith  the  exirnet  of  Pinchneya  pnbens. 
Ontfedertttt;  State.<  Mid.  iiii-l  Sttnj.  .lour.,  Vol,  I,  p.  1:14 — concludes  thus:  ^'The  extr.ict  has  undoubted  antiiieritjdic  prop^Tties;  still  it  is  too  slow  in 
its  action  to  be  use<i  as  a  substitute  for  the  sulphate  of  qiynine.     It  has,  with  one  exception,  always  produced  diaphoresis.    Its  therapeutical  actiou 


190 


STATISTICS    OF 


The  Cornii.H  fhrrida,  a  small  tree  common  on  iiKjist  t{ravelly  soils  in  the  Northern  ami 
Middle  States  and  along  the  liorders  of  swamps  and  bottom  lands  in  the  South,  was  also 
employed  under  official  auspices.'''  Dr.  Jones  says  he  used  the  decoction  and  tincture  to  a 
considerable  extent  during  the  war,  and  fouml  the  remedy  of  valuu  in  the  treatment  of  malarial 
fever.  In  severe  cases  the  paroxysm  was  arrested  by  quinine  and  the  treatment  subse- 
quently continued  with  dogwood.  Its  use  is  incidentally  mentioned  in  some  of  the  cases 
given  above  from  the  records  of  thu  Pettigrcw  hospital.  Ikit  it  does  not  appear  that  any 
formal  reports  testifying  to  its  efficacy  were  rendered;  for  as  these  were  requested  by  the 
medical  authorities,  it  may  be  assumed  that,  had  any  such  been  returned,  they  would 
undoubtedly  have  been  published.  The  medical  journals  are  also  silent  on  the  subject. 
We  may  therefore  conclude,  with  Dr.  Kknxeuy,  that  although  the  dogwood  and  other  bitter 
infusions  furnished  by  the  Confederate  States  Army  Medical  Purveying  Department  possessed 
an  antiperiodic  power  which,  under  favorable  conditions,  would  cure  ague,  there  were  certain 
objections  to  their  use,  and  in  no  case  could  they  be  valued  as  a  substitute  for  quinine."]" 


CHAPTER  IV.— ON  THE  CONTINUED  FEVERS. 


I.— THE  STATISTICS  OF  THE  CONTINUED  FEVERS. 


I.— IN  THE  UNITED  STATES  ARMIES. 


Pkevalknce  and  Mortality. — The  uncertainties  attaching  to  the  statistics  of  the 
Camp  Fevers  from  the  abolition  of  the  term  common  continued  fever ,  and  the  institution  of 
the  new  terra  tyjyho-malarial,  have  already  been  indicated. J  The  figures  representing  the 
typhoid  cases  of  the  later  years  do  not  comprise  the  whole  of  the  cases  that  occurred  in  the 
commands  from  which  they  were  reported,  for  some  were  certainly  included  in  the  typho- 
malarial  statistics.  Indeed,  in  accordance  with  the  intent  of  the  new  term,  each  case  reported 
under  it  should  have  been  essentially  a  typhoid  case.  But  a  comparison  of  the  rates  of 
fatality  of  the  two  series  of  cases  manifests  that  in  its  acceptance  by  the  profession  the  now 
term  had  a  more  extended  signification  than  was  purposed  by  its  author.  The  percentage 
of  deaths  in  typhoid  cases  among  the  white  trooj)s  was  35.90,  among  the  colored  troops 

i.s  iirinciiially  that  of  a  tt>ni<:,  and  it  dcsorves  a  itoBition  in  tlic  front  rank  of  vegetllilo  tonicH.  From  the  tardiness  of  its  action,  and  its  effect  njion  the 
vascular  system,  together  with  its  manifest  invigoratiou  of  the  digestive  organs,  I  am  inducefl  to  think  its  energy  as  an  agent  is  displayed  through  tlie 
organic  nervous  system."  * 

*  .V  circular  from  the  Surgeon  treneral's  Office,  C.  S.  A.,  dated  Dec.  .5,  I8ti'2,  printed  ti.v  .Tones  in  liis  article  on  Jndujenmm  ItL^medwH  of  the  S<mtkern 
i^nleit — SI.  Louis  MedU'al  lieporter^  18fi.S,  Vol.  Ill,  p.  2G1  et  seq. — gives  a  formula  "for  a  conipouml  tincture  of  thi;  indigenous  barks,  to  be  issued  as  a  tonic 
and  a  febrifuge,  and  substituted,  as  far  as  practicable,  for  quinine.  *  *  *  Dried  dogworMl  bark,  :jl)  jarts ;  dried  jiojdar  bark,  ;{0  jMirts  ;  dried  willow 
bark,  40  (larts  ;  whiskey  45  degrees  strength.  Two  pounds  of  the  mixed  bark  to  one  gallon  whiskey.  Macerate  fourteen  days  and  stniin.  Dose,  one  (luid 
ounce  three  times  a  day." 

t  Dr.  StiI-ES  KenXEDY  gives  his  opinion  of  these  indigenous  remedies  incidentally  in  intntducin^  the  subject  of  turitentine  externally  applied. 
See  notf^  aupra :  "  Witile  in  Savannah.  November,  If^ti'J,  I  assumed  control  of  the  medical  dejtartment  rd'  the  47tli  (leorgia  regiment  in  iirder  that  its 
surgeon  might  visit  his  siek  wife  in  (Iriffin.  Several  companies  of  this  regiment  had  been  exiHjsed  during  the  summer  months  to  the  etlluvia  of  the  ri<^e 
fields  on  the  Savannah  river,  and  at  first  "  sick-call '  I  found  over  one  hundred  eases  of  '  chills."  Xo  quinine  was  being  issued  at  this  time  by  the  Confed- 
erate purveyor,  but  instead  of  tliis  jsttent  remedy,  infusion  of  rinckneya  jmhtns.  Spanish  willow  and  dogwisMl  were  sent  in  large  quantities  with  full 
directions  fur  their  use,  and  the  hojte  was  expressed  that  I  would  be  able  to  return  a  favorable  report  <d'  their  elTeets.  And  1  will  state  here,  that  when 
the  patient  is  in  comfortable  quarters  in  town,  away  from  exiM)Sure  and  malarial  influences,  with  sutticierd  tone  and  calibre  of  stomach  to  bear  repeated 
drenehings  of  these  nasty  infusions,  there  is  no  difficulty  in  curing  intermittent  fever.  But  my  troops  were  in  the  field  and  on  picket-duty  every  day. 
*     *    *     The  infusions  failed  during  a  severe  trial." 

X  SuprOj  p.  75  et  sei^. 


THE   CONTINUED    FEVERS. 


19] 


55.69,  wliile  in  typlio-malarial  cases  the  corresponding  rates  were  8.14  and  17.27.  Durinif 
the  fourteen  months,  July,  1862,  to  August,  186;\  inclusive,  follo\vin<f  tlio  introduction  oi" 
the  term,  and  while  yet  in  ignorance  of  the  value  intended  to  be  officially  attached  to  it, 
medical  officers  of  white  troops  reported  27,399  cases,  or  more  than  one-half  of  the  total 
number  of  cases,  49,871,  einbracL'(l  in  the  statistics;  of  these  only  1,585  died,  or  5.08  per 
'cent.  Had  enteric  fever  been  assuredly  [)resent  in  all  these  cases  a  further  deterioration  of  the 
blotnl  by  a  coincident  malai'ial  fever  must  be  regarded  as  a  desirable  complication  in  tvnhoid 
epidemics.  But,  after  tiic  public  announcement  of  the  intent  of  the  term,  tlie  suddenly 
increased  gravity  of  tlie  cases  reported  under  it  must  be  understtjod  as  meaning  that  a 
certain  propoition  of  the'  medical  officers  of  the  army  Ijccame  aware  of  thc^  value  intended 
to  bo  attached  to  ti/pho-rna/arial,  and  restricted  its  u.sc  accordingly  to  cases  which  appeared 
to  them  to  present  a  s[»eciric  typhoid  element.  The  22,472  cases  reported  subsequently  to 
August,  1863,  included  2,474  fatal  cases,  the  percentage  of  fatality  being  11. Ul.  The 
probable  proportion  of  true  typhoid  cases  embraced  by  the  typho-inalarial  statistics  will  be 
suggested  hereafter  when  the  clinical  and  pathological  features  of  the  cases  thus  reported 
have  been  submitted  and  fully  considered.*  But  although  the  whole  of  the  typho-malarial 
cases  were  not  typhoid  fevers  modified  by  coexisting  iiralarial  influences,  they  were  probably 
all  of  a  more  or  less  continued  type ;  and  while  their  statistics  have  been  presented  in  con- 
nection with  the  paroxysmal  fevei-s  in  view  of  their  malarial  element,  it  seems  proper  to 
again  submit  them  in  the  present  connection  in  view  of  their  continued,  if  not  in  all  cases 
truly  typhoid,  character. 

The  following  table  summarises  the  reported  statistical  facts : 

Table  XXXIX. 


Statement  of  the  Frequency  and  Fatality  of  the  Continued  Fevers,  givinr/  the  totals  reported  from  3fay  I, 
1S61,  to  June  SO,  18G6,  amowf  the  White  Troops,  and  from  Jidy  1, 1863,  to  June  30,  1806,  amoiuj 
the  Colored  Troops;  ivith  the  7-atio  of  cases  to  strength  and  to  cases  of  all  diseases,  and  tfie  ratio  of 
deaths  to  strength,  to  deailisfrom  all  diseases,  and  to  cases  of  the  continued  fevers. 


SPEt'lFIEl>  FKVERa, 


Among  Whitfi  Troops  from  May  1,  18B1,  to  Juno  30,  18fif> : 

Typhoid  Fever 

Common  Continued  Fever 

Typhus  Fever 

Typho-Malarial  Fever 


Total. 


Number  rc^pnrted 
(lurint;;  the  jH-riiHl 
Htateil. 


Cases. 


7.5,  ,-if)8 

U,  808 

2,  .'JOl 

40,871 


139, 638 


27,  (W! 

147 

SfKI 

4,  Ifi'J 


32,112 


IClltio[K*r  1,(HKI 

iif  strength. 


Cases.        Deaths. 


17ri 

•JA 

f, 

ll.'j 


324 


.:il 
1.82 

8.117 


68.68 


13.  IKI 

2.11) 

.46 

9.19 


26.74 


•itf.t.  11 

1.14 

6.57 

31.37 


248.19 


8 
S.  ^ 

m  ID 

a  % 

9  S 


35.  '.Kl 
1.24 

S.\.  M 
8.14 


2;!.  no 


Among  Colored  Troops  from  July  1,  1863,  to  June  30.  1800  : 

Typhoid  Fever 

Typhus  Fever 

Typho-Malarial  Fever 


Total. 


4,094 

123 

7,529 


2, 280 

108 

1,301 


67 

2 

123 


11,746 


3,689 


35.67 

1.C9 

20.35 


57.71 


6.77 

.20 

12.44 


19.41 


82.  ill 

3.93 

47.31 


134.15 


55. 69 
87.80 
17.27 


31.41 


*  See  t»/r((,  p.  375. 


192  STATISTICS   OF 

Among  the  wliite  troops  there  were  reported  139.638  cases  t)f  the  fevers  speeiiled,  and 
of  these  32,112  were  fatal  makiiiir  324.0  cases  and  68.58  deaths  per  thousand  of  strength 
present  during  the  five  and  on(>-si.\tli  years  covered  Ijy  the  statistics.  AUhougli  the  cases 
formed  only  about  one-fortieth  of  the  total  cases  of  disease,  2;"). 74  per  tliousand,  their 
fatality  was  such  that  the  deaths  constituted  one-fourth  of  the  deatlis  from  all  diseases,  or 
248.19  per  thousand.  This  was  due  to  the  relatively  large  propoi'tion  and  grave  character 
of  the  typhoid  cases.  The  percentage  of  fatal  cases  among  those  reported  as  typhus  was 
large,  33.99,  but  the  number  of  cases  being  comparatively  small,  this  fever  was  ehargeil 
with  only  6.57  of  the  248.19  deaths  from  continued  fevers  presented  by  every  thousand 
deaths  from  all  diseases.  The  cases  of  typho-malarial  fever,  on  the  other  hand,  assumed 
an  importance  from  their  number,  although  they  furnished  only  31.37  deaths  as  compared 
with  209.11  caused  by  typhoid  in  every  thousand  deaths  from  disease. 

Among  the  colored  troops  nearly  two-thirds  of  the  total  numbei',  11,746,  of  cases  of 
continued  fever  were  reported  as  typho-malarial  fever.  The  ratio  of  typho-raalarial  to 
typhoid  cases  among  the  white  troops  cannot  be  obtained  from  the  u|>per  division  ot  the 
table,  as  the  periods  during  which  the  cases  occurred  were  of  unequal  duration.     But  a 

Table  XL. 

Expressing  tJie  Frequency  and  Mortality  of  the  reported  forms  of  the  Continued  Fevers  as  percentages 

of  the  total  cases  and  deaths  canned  by  such  fevers. 

WHITE  TKOOPS. 


SPECiriED  FeVEKS. 

o 

Total  number  of  tleathe. 

Pekcentage  of — 

Ciiscs  of  Bpecifled 

fevers  in  total  of 

febrile  eases. 

Deatbw  from 

speeifieil  fevers  in 

total  (leatiis  from 

all  the  forms. 

Mayl,  1861,  to  Juno  30,  1862— 

22,  Ofi2 

841 

11,808 

6,  0G5 
2114 
147 

03. 4 

2.4 

34.2 

94.  2 
3.4 
2.4 

Typhus  Fever 

34,801 

6,016 

lOO.O 

.■•.li.  8 

1.6 

47.6 

IIKI.O 

100.0 

July  1,  1862,  to  Juno  30,  186(i— 

Typhoid  Fever                   _- _. 

l.GCO 
4!l,  871 

11)4, 8:i7 

21,:wi 
mi; 

4,05'.( 

26,  (t'tt; 

82. 0 

2.r, 

15.  .5 

10(1.  0 

Typho-malarial  Fever _ 

Total  of  specitied  forms  _ 

COLORKD  TROOPS. 

July  1,  1863,  to  June  30,  1806— 

4, 1)04 

12:; 

7,528 

2,2811 

108 

1,.101 

34.  '.I 

1.0 

64  1 

61.  8 

2.9 

35. 2 

Typhus  Fever 

Typho-malarial  Fever __      _.    ... 

Total  of  Bpe^ified  forms.          _      -  _    „ 

11,740 

3,  089 

IIXI.O 

100.0 

THK    cONTIM'KIi    I'KVKRS. 


19:>, 


IvffTcIlCi'   tn     Falili-  XT>,  nil    {][{■   n|.|.(,^itr    pilllV.   will    slluW  tliut    dui'lllL^   tllO  tlu'OC   VOfirs    ill  wllicll 

lintli  ty|ilii)-iiial;iriiil  aiiil  typlioiil  ca>fs  \vi'i\'  I'l-purtiMJ  tlif  I'linncr  (■(Jiistituti'il  L^ss  than  oiic- 
Iialf  of  tilt'  tiital.  It  will  l)e  .-^lhmi  ln'rral'tcr  that  this  o-rcafcr  inTvalciicc  dI'  tvplio-inalarial 
I'fver  auKHiu'  tin'  coloivi]  trnii].is  was  assijfiati.'d  with  a  (liiiiiiiislif(l  |nvvalence  of  tviihoiil.  the 
average  a.tiiiual  nuinljcr  ot  eases  of  eontiiiufd  fcver  aiiidug  them  having  lu'en  iiearlv  the  same 
as  among  the  white  t-ommaiids.  Ilciiee  the  deaths  fnuu  t^■[lh()-malal•ial  fevci'  eonstituted  a 
largei'  |iro|Mirti(in  ot  the  ileaths  I'luni  eoiitiniicd  fever,  and  of  th(>  deaths  from  all  causes, 
among  the  iiegi'oes  than  anumg  the  whites,  ami  the  deaths  from  tvj'hoid  fever  a.  smaller  jiro- 
jKji-tion,  although  the  pereeiitage  of  eases  that  tx-rminated  fatally  was  considerably  greater 
among  the  farmer  than  among  the  latter.  It  will  he  dhserved  aUn  that  among  the  colored 
troops  the  ileaths  ti'oin  the  eontiiiuetl  fevers  constituted  a  smaller  lu-dportion  of  the  deaths 
fi'oiii  disease,  1;)4,1.)  per  thdUsand,  than  among  the  whites,  2lS,i*l  per  thousand,  notwith- 
standing tlie  similar  rates  of  prevalence  among  both  and  the  larger  rate  of  mortality  among 
the  negroes.  This  may  be  seen,  by  Table  II.'''  to  have  ])vvn  caused  by  the  relatively  greater 
mortalit}^  from  diseases  of  the  respiratorv  organs. 

J-)uring  the  periotl  when  common  continued  fever  held  a  filace  in  the  official  nosological 
system  typhoid  cases  forme(l  (>:).l  pfr  cent,  of  the  eoiifiiiued  fevers  among  the  white  troops, 
typhus  2.4  and  common  continued  fever  i)4.2  })er  cent.,-j"  while  typhoid  was  charged  with 
94.2  per  cent,  of  the  deaths;  subsequent  to  that  jx^riod  tyjihoid  contributed  a  little  more 
and  typho-inalarial  a  little  less  than  one-half  of  the  cases,  typhus  forming  oidy  1.6  per  cent., 
while  the  deaths  attributed  to  tyjihoid  were  reduced  to  82.0  per  cent,  of  those  from  the 
continued  fevers  liy  the  substitution  of  tlie  larger  jiercentage  from  typho-malarial  fever  for 
the  smaller  percentage  formerly  referred  to  common  continued  fever. 

Among  the  colored  troops  64.1  per  cent,  of  the  febrile  cases  were  reported  typho- 

Table  XLl. 


RdiUive  Frequsney  of  Qtses  of  the  Continued  Fevers,  and  of  Deaths  occasioned  by  them,  during  the 
several  years  of  Oie  war  and  tlie  year  following  the  war,  expressed  in  anmial  rates  pet  thousand 
of  strength  present. 

WHITE  TROOPS. 


DlSE.VSES. 

180) 

CaseH. 

14.00 

2.89 

18.03 

VI. 

Dciitlia. 

2.4C 
.43 

1801-2. 

1862-3. 

1803-4. 

1804-5. 

1805-6. 

Cases. 

78.02 

2.94 

42. 13 

Deaths. 

19.  .55 
.09 
.51 

Cast's. 

52. 30 
1.55 

Deaths. 

15.89 
-.57 

Cases. 

10. 32 
..50 

Deaths. 

0.03 
.18 

Cases. 

Deaths. 

Cases. 

12.97 
.32 

Deaths. 

0. 23 
.21 

10.  90 
.57 

8.99 
.19 

Tyi>liu.s  Fever 

38.00 

1.78 

18.93 
a5.81 

1.71 

22.91 
40.44 

2.27 
11.45 

10.02 
29.91 

2.  .54 
8.98 

Total  Continued  Fevers 

35.62 

2.80 

123.69 

20.75 

91.91 

18.24 

8.52 

c 

;OLOR 

ED  TROOPS. 

Typhoid  Fever 

. 

41.07        10.35 

20.24 

..55 
37.47 

13.34 

.40 

5.51 

9.74 

.13 

34.21 

5.99 

.12 

5.49 

i 

1..50 
56.16 

1.30 
10.85 

99.39 

28-  .10 

.58.20 

19.31 

44.08 

11.60 

*  Pag«  11.  supra.  t  The  relative  fn'quency  nf  tlie  rejtDrted  iorms  ia  given  with  iinn-e  of  detail  in  Table  XLVU. 

Med.  Hist.,  Pt.  Ill— 25 


194 


TATTSTTTs    OF 


malarial,  34.9  typlioiil  ami  1.0  typhus,  wliile  iIk'  deaths  iiudfr  thi'sc  headings  wero  respec- 
tively 35.2,  Gl.S  and  2.9  per  cent.  «(  the  \vhuh.>  niuubcr  atlrlhutcd  to  these  fevers. 

Table  XLl,  presented  on  tlie  last  page,  shows  the  annual  variations  in  prevalence  and 
mortality.  The  columns  for  1860-61  may  be  overlooked,  as  their  figures  are  based  only 
on  the  reports  for  the  last  two  UKinths  of  the  tiscal  year. 

As  the  war  progressed  these  levers  became  less  fre(i[ueut  among  the  white  troops.  The 
first  year  gave  123.69  cases  per  thousand  of  strength;  the  last  year  of  the  record  gave 
only  29.91.  But  this  decline  suflered.  in  l$64-65,  a  slight  interruption,  specially  marked 
among  the  typho-malarial  cases,  and  probably  due  to  the  substitution  of  fresh  troops  for 
men  who  withdrew  to  their  homes  on  the  expiration  of  their  term  of  service.  The  death- 
rate  was  similarly  interrupted  in  its  fall  from  20.75  to  8.98  per  thousand  of  strength. 

Xo  interference  occurred  in  the  gradual  sufisidetice  of  these  fevers  amonu  the  colortM] 
troops  from  a  rate  of  99.39  per  thousand  strengtli  in  the  first  year  to  44.08  in  the  last,  nor 
in  the  fall  of  the  mortality-rate  from  28.50  to  11.60. 

But  although  the  annual  mortality  expressed  as  a  ratio  of  the  strength  present  dimin- 
ished with  the  reduction  in  the  number  of  the  cases,  the  decrease  of  the  one  was  not 
exactly  proportioned  to  the  other.  Nor  was  tiiis  disproportion  due  to  the  association  of 
lessened  virulence  with  diminished  prevalence.  On  the  contrary,  the  gravity  of  the  cases 
increased  to  the  close  of  tlie  war.  During  the  first  complete  fiscal  vear  17.4  jier  cent,  of 
the  febrile  cases  among  the  white  troops  terminated  fatally;  during  the  last  year  31.8  per 
cent.;  during  the  year  following  the  war  30.9  per  cent.  Table  XLII  illustrates  the  increas- 
ing gravity^  of  the  individual  cases  during  annual  periods  which,  according  to  Table  XLI, 
were  characterized  by  a  diminution  of  the  prevalence  of  these  fevers  and  of  the  mortality 
caused  by  them  in  the  army  as  a  whole. 

Table  XLTI. 

Showing  the  Annual  Percentages  of  Futality  of  the  Continued  Fevers. 

WHITE  TROOPS. 


Ykar  km)Ini;  June  'Mi— 


Typhoid  Fever 

T.vi.li\ls  K.v.r 

Conmioii  Cimtiiiueti  Kevt'r_ 
Typli<>-nialarial  Fever 


Total 


18U1. 
17..') 

1802. 

isra. 

ism. 

18(1.-1. 

isr,i;. 
49.4 

'i,'^t.^ 

:i2.  c 

44.2 

.TO.."; 

l.".,ll 

■1\J, 

;iii.  7 

115.  2 

:i7.8 

Ii7.8 

u.o 

l.li 

.'-,.  II 

<J.!) 

11.2 

1 
15.7 

8.1 

17.4 

■n.-.i 

2.5.9 

31.8 

30.9 

HHtes  f.ir  the 
whole  jR-ricxl. 

3fi.  !«1 
;«.  ll'.l 

«.  It 


COLORED  TROOPS. 


Typhoid  Fever 

Typhiis  Fever 

Typho-malarial  Fe 


Total- 


4(1.  :f 
8.1. 7 
19.9 


29./) 


70.3 
89.1 
LI.  7 


3fl.3 


03.2 
KHI.O 
10.  .1 

27.1 


The  rates   here   presented   cannot   l)e   accepted  as  accui'ate.      Tlu;   want  oi 
between  the  cases  and  deaths  borne  on  the  reports  has  already  been  explained. 


23.  m 


87. «" 
17.27 


31.41 


J 

relali(jn 
\\o  cases 


that  occurred  in  the  large  population  of  the  g 


rdlel'al 


ispitals  were   not   taken  up  on  the 


THE  ^o^'TI^'^KP  feverp. 


195 


reports,  Imt  all  the  deaths  were  noted.  The  iin.trtality  among  this  unknown  number  of 
cases  adds  considerably  to  the  calculated  rates  of  fatality.  The  limits  of  the  error  maybe 
fairly  defined  for  certain  diseases,  but  in  the  instance  of  tv})hoid  fever,  other  cases  thaii 
those  that  originated  in  the  hospitals  were  unrecorded.  Vast  numbers  of  ailing  men  were 
sent  to  the  general  hospitals  from  the  field,  especially  when  the  army  was  on  the  eve  of  a 
move.  Few  of  these  were  entered  as  typhoid  fever  on  the  field  reports,  although  had  they 
continued  longer  under  observation  this  diao;nosis  would  have  been  authorized;  and  in 
many  instances,  unfortunately,  opportunity  was  afforded  after  death  for  its  verification. 
The  number  of  these  unreported  cases  must  have  been  very  large,  for  the  experience  of 
medical  officers  in  charge  of  general  hospitals  near  the  base  of  operations  of  troops  on  field 
service  testifies  to  the  frequency  with  which  typhoid  fever  readied  their  wards  witliout 
appearing  on  the  antecedent  records.  Tn  view  of  these  unregistered  cases,  which  contributed 
largely  to  the  recorded  deaths,  it  is  impossible  to  ascertain  the  actual  percentage  of  fatality 
of  the  continued  fevers. 

The  ratios  of  typhoid  fever  are  modified  also  by  the  withdrawal  of  so  many  of  the 
cases  into  the  typho-malarial  group,  while  those  of  the  typho-malarial  fevers  are  valueless 
from  the  uncertainty  as  to  the  nature  of  the  fevers  thus  rejwrted  and  the  certainty  that, 
as  may  be  inferred  from  the  ratios  themselves,  not  all  of  the  cases  possessed  a  typhoid 
element.  The  comparatively  small  percentages  of  fatality  sometimes  recorded  for  typhus 
are  explained  by  the  entry  of  the  cases  in  accordance  with  tlie  diagnosis  under  the  typhus 
heading,  and  of  the  resulting  deaths,  in  view  oi  post-mortem  revelations,  under  the  heading 
typhoid — the  typhoid  rate  thereby  becoming  augmented  at  the  expense  of  tlie  other. 

But  although  of  little  value  as  indices  of  the  fatality  of  the  continued  fevers,  the  ratios 
presented  above  are  admissible  evidence  of  the  increased  gravity  of  the  cases  as  the  war 
progressed ;  for  the  statistics  from  which  they  were  calculated  were  gathered  under  similar 
conditions. 

The  average  annual  rates  per  thousand  of  strength  show,  in  Table  XLIII,  a  similarity 

Table  XLTII. 


Comparison  of  the  Frequency  of  Cases  of  the  Continued  Fevers,  and  of  the  Deaths  occasioned  by  them, 
among  the  White  and  the  Colored  Troops,  as  shown  by  the  average  numbers  annually  recorded, 
reduced  to  ratios  per  thousand  of  strength;  the  figures  for  the  White  Troops  based  on  the  statistics 
of  the  period  May  1,  1861,  to  June  SO,  186H,  and  those  for  the  Colored  Troops  oti  the  statistics  of 
the  three  years  July  1,  1863,  to  June  30,  1866. 


DISEASE. 

White 

Troops. 

Colored 

Troops. 

Cases. 

Deaths. 

Cases. 

Deaths. 

Typhoid  Fever.    .         

33.83 

1.12 

37.07 

26.15 

11.18 

.35 

.44 

1.95 

22.32 
.67 

11.89 
..56 

Typhus  Fever 

Conimoii  Continued  Fever                                   -                --         - 

Typho-malarial  Fever 

41.06 

6.79 

Total  Continued  Fevers..---      --       -     - 

62.67 

13.27 

64.05 

19.24 

• 

196 


STATIST  ITS 


in  tlie  rates  of  prevalence  among  the  white  and  the  colored  troops,  62.67  and  64.05  })er 
thousand  resp(>etively;  but  the  mortality  was  greater  among  the  colored  than  among  the 
white  men,  19.24  as  compared  with  13.27.  This  increased  mortality  was  caused  by  the 
typho-malarial  cases,  they  having  occasioned  6.79  deaths  per  thousand  of  strength  as 
against  1.95  among  the  whites.  The  mortality  from  typhoid  was  similar  in  both,  but  the 
cases  having  been  less  numerous  among  the  colored  men  their  larger  percentage  of  fatality, 
already  noted,  is  explained.  The  slight  prevalence  of  cases  reported  as  typhus,  1.12  among 
the  white  and  .67  among  the  colored  soldiers,  accounts  for  an  animal  mortality  which  was 
less  among  the  white  troops  than  that  from  common  continued  fever,  nutwithstanding  the 
high  rate  of  fatality  that  attended  the  typhus  cases. 

Prevalence  as  related  to  Season  and  Locality. — To  reduce  the  size  of  Table 
XLIV,  and  at  the  same  time  to  simplify  figures,  the  data  on  the  seasonal  and  regionic 
prevalence  of  the  fevers  reported  tvphus  have  been  consolidated  with  the  statistics  of  the 
typhoid  cases.  This  might  have  been  done  with  propriety  in  all  the  tables  of  this  section ; 
for,  as  will  be  shown  hereafter,*  the  greater  number  of  the  cases  reported  as  typhus  were 
in  reality  cases  of  typhoid  fever;  but  it  was  deemed  advisable  to  present  in  certain  of  tliese 
tables  the  rates  of  the  reported  cases  of  typhus  by  way  of  intimating  to  some  extent  the 
modification  of  the  typhoid  cases  by  crowd-poisoning,  as  the  typho-malarial  cases  similarly, 
but  perhaps  less  certainly,  indicate  their  modification  by  the  malarial  influence. 

Table  XLIV. 

Showing  the  Variations  in  the  Prevalence  of  the  Continued  Fevers  among  White  Troops  in  the  various 
Regions  during  the  years  of  the  War  and  the  year  following  the  War,  expressed  in  monthly  ratios 
per  thousand  of  mean  strength. 

YEAR  ENDING  JUNE  30,  1862. 


Disease. 

Regions. 

1861. 

1862. 

< 

■-s 

si 
u 

CQ 

S 

u 

OS 

ea 

a 
o 

iz; 

pi 

z 
< 

Bi 

< 

sa 

< 

p. 

< 

>: 
•^ 

^ 

X 

s 

H 

&     i 

1 

Typhoid  and  cases  rf'[>urtt'J  urf  Typhus 

Atlantic 

2.3 

4.6 

5,8 

7.1 

9.1 

8.3 

5.8 

4.6 

3.2 

6.0 

.5.9 

7.8 

74.0 

Central 

1.8 

2.8 

9.4 

12.1 

13.2 

9.8 

10.4 

7.1 

6.0 

6.9 

8.7 

6.3 

99.8 

Pacific 

.2 

2.5 

1.4 

1.0 

.3 

.5 

.8 

.4 

8.1 

81.6 
41.4 

In  all  the  regions 

2.0 

4.0 

6.5 

8.6 

10.2 

8.5 

7.0 

5.1 

3.9 

6.3 

7.2 

7.0 

Common  Continued  Fever 

Atlantic. 

3.4 

4.5 

4.2 

4.7 

5.3 

2.3 

2.4 

2.6 

2.4 

3.5 

3.5 

4.3 

C*;ntral 

1.0 

2.7 

4.0 

6.1 

4.3 

3.7 

2.2 

1.7 

1.7 

3.6 

4.8 

4.9 

46.2 

Pacific 

.4 
2.1 

.9 

3.8 

1.2 

5.0 

11.8 
18.2 

1.0 

"4^8 

14.4 

17.5 

.8 

2.8 

10.  6 
13.5 

.6 

!■- 

! 

1     R.2 

12.  H 

1.1 

2,4 
7.2 

8.8 

1.3 

2.2 

.7 

4.1 

3.3 

18.5 
42.1 

In  all  the  regions 

3.il 

4.2 

10.0 
13.4 

3.5 

4.1 

4.6 

All  the  Continued  Fevers 

Atlantic 

Central 

5.7 
2.8 

9.1 

5.5 

5.6 

7.7 

9.5 

10.5 

9.4 

13.5 

12.1 
11.2 

115.4 

145,  0 

Pacific 

.6 

.9 

3.8 

3.7 

2.4 

1.8 

.9 

1.6 

7.5 

2.1 

.7 

4.1 

i          '-' 

24.6 

In  all  the  regions          , 

4.1 

7.9 

10.7 

13.6 

15.0 

11.3 

9.3 

0.1 

9.8 

11.3 

1 

123.7 

*/n 

fra,  i>. 

324. 

• 

tup:  coxtixi'kp  fevers. 


Id] 


YEAR  ENDING  JUNE  30,  18ti3. 


1SC>2. 

IS 

13, 

< 

.      1 

'" 

Disease. 

RE(itcvNS. 
Atlilllli,' 

s..". 

< 

/.            ~ 
2.N         7.4 

- 
7.4 

-. 
(1.3 

y. 

4.8 

4.8 

3.11 

2.0 

2.4 

H 

(11.7 

Tyiiliiiid  iinil  cfist-s  rt'portcl  iis  Typliiis 

(Viitnil  --. 

4.T 

4.(1 

li..'-.        4.4 

4.li 

4.(1 

4.K 

4. 11 

4.8 

3.  5 

2.4 

1.8 

48.1 

I'a.'ili,'    .     _ 

•- 

2.:i 

:i.  1       2.  7 

2.  1 

.7 

,  ("l 

.  1 

.3 

.3 

i       13.(1 

In  all  thi'  n'y;inns 

11. 7 

.'..:! 

:i.l  1    .VK 

.'>.  8 

•r..4 

.">.  1 

1.8 

4.7 

3.2 

2..^ 

2.0 

5:t.  u 

Tvpho-malarittl  Fever         __. 

Aflanlie  .. 
I'enlni:     -- 

n.i 

•l.s 

4.1 

4..") 

;i.  2 

11.4 

;i.2 

.'l.s 
2.;i 

3.8 
1.!) 

4.2 

2.8 

2. '.) 
3. 11 

2.7 

3.3 

2..') 
2,(1 

2.1 

3.5 
2. 0 

1    "    "■ 

42.3 
34.8 

Pacific'  ._-. 

5.4 

2.:i 
4.:) 

1.(1 

a.  2 

2.2 

.11 
.1.(1 

3.4 
2.9 

.2 
.3.4 

.8 
3.4 

.7 

3.0 

1.3 

2.  (1 

2.3 

2.2 
2.0 

18.0 
.38.0 

III  uti  the  regions 

All  tlie  C'outluiiud  Fevers 

Atlantie— 

14.(1 

1(1.4 

(1. 1 

Ki.H 

11.2 

- 
10.1 

9.7 

7.7 

7.5 

5..1 

5.3 

5.9 

104.0 

Central 

».  fi 

'.M 

(1.7 

7.0 

G.'J 

0..'-. 

7.(i 

8.8 

8.1 

fi.l 

4.5 

3.8 

82.9 

Pacific 

2.2 

4.6 

4.7 

4.'J 

3.0 

4.1 

.8 

1.2 

1.0 

1.3 

.7 

2.5 

31.0 

In  all  tlie  regicms  .^ 



12.1 

It.  (1 

(i.:i 

....1 

8.8 

8.3  j 

%.f< 

8.2 

7.7 

5.8 

4.8 

4.6 

91.9 

YEAR  ENDING  JUNE  30, 1864. 


1»ISK,\SK. 

1 

Reikons. 
.\tlantic 

1803. 

< 

< 
1.3 

>• 

K 

,-; 

a: 

I 

ISM. 

2 

U 

a 

H 
BA 

£ 

19.6 

2.9 

.3.0 

a 
2.0 

1 

n 
E 
u 

H 

1 

X 

■< 

s 

1.0 

5 

.9 

u 

"J 

1.4 

T.vpliiiitI  anil  casets  reported  as  T.vjihus 

2.8 

1.5 

1.2 

.9 

1.0 

Central  

2.0 

2.2 

1.9 

1.3 

1.1 

.9 

1.2 

.7 

1.0 

i.ii 

1.0 

1.5 

15.7 

Pacific 

.3 
2.3 

.3 

.1 

1.0 

1.5 

2.8 
1.4 

1.3 

.3 

.4 
1.3 

.2 
.7 

.2 



.5 

.3 

4.8 

2.5 

4.2 

3.2 

2.2 

1.3 

1.0 

1.0 

1.0 

1.0 

1.2 

1.0 

1.6 

3.1 
1.5 

16.9 

24.6 
10.1 

Atlantic 

Ontral 

4.4 

2.9 

.3.(1 
1.9 

1.8 

1.2 

1.2 
.8 

1.3 

.0 

.7 
.5 

.7 

.9 

Pacific  . 

.8 
.3.4 
7.3 

2 
3.5 
7.2 

.3 
2.3 
5.8 

.1 

.4 
1.4 

.2 



1.0 

.2 
.8 

.4 
.6 

.1 
.7 

.1 

.2 

.1 

3.0 

1.9 
4.8 

.7 
1.9 

1.0 
2.1 

2.0 

18.9 

All  the  Continued  Fevers 

Atlantic 

3.3 

2.4 

2.6 

1.6 

4.5 

44.2 

Central  .-_ 

4.9 

5.4 

3.8 

2.7 

2.3 

1.7 

1.8 

1.2 

1.7 

1.7 

2.(1 

.3.0 

31.8 

Pacific 

1.1 

.5 

.4 

1.1 

1.7 

.5 

.0 

.6 

.3 

.1 

.7 

.4 

7.8 

In  all  the  regions . __.. 

6.7 

0.0 

4.5 

.3.4 

2.7 

2.0 

1 

2.1 

1.3 

1.7 

1.7 

2.0 

3.5 

35.8 

198 


STATISTICS    OF 
YEAR  ENDING  JUNE  30,  1865. 


Disease. 

Hkoions. 

18M. 

>• 

a 
< 
k 

1.6 

1.3 

.6 

1865. 

p 

e: 

< 

>• 
M 

B 

< 

r 

K 

si 

i 

O 

w 

n 
E 
u 

Q 

1.5 
1.0 
.4 

>< 

as 
< 

« 

■< 

1.0 
.7 
.4 

< 
& 

Typhoid  and  cases  reimrted  as  Typhus 

Atlantic. 

Central 

Pacific 

2.9 

2.1 

.3 

2.9 

2.  0 

.1 

1.7 

2.4 

.8 

1.9 

1.4 

.7 

1.9 

1.2 

.3 

l.fi 
.8 
.3 

1.2 

1.0 
.2 

1.3 

.7 
.5 

1.6 
.8 
.3 

20.4 
15.8 
4.8 

In  all  the  resriiius 

2.4 

2.2 

2.1 

1.6 

4.0 
1.2 
11 

1.5 

1.2 

1.4 

1.2 

1.1 

.9 

1.0 

1.2 

17.6 

Typhu-niaiarial  Foaxts 

Atlantic— 
Central  _.. 
Pacific 

V.6 
2.1 

0.0 

2.3 

.1 

4.8 
1.7 
..        ... 

2.9 
.7 

.5 

1.6 

I.l 

.2 

1.4 

.8 
.4 

1.1 

1.3 
.4 

1.5 
1.0 

1.4 

1.2 

.1 

1.7 
.8 

i.e 

1.4 

34.4 
14.9 

2.6 

22.9 

4.2 

3.8 

2.9 

6.5 
4.1 
1.2 

2.4 

5.9 
2.6 
1.8 

1.6 

1.3 

.8 

1.2 

1.2 

1.2 

1.4 

All  the  Continued  Fevers 

Atlautic___ 

Central 

Pacific 

10.5 

4.2 

.3 

9.5 

4.3 
.2 

6.0 

4.8 

1.9 

.8 

3.1 

2.1 
.6 

3.0 

2.1 
1.0 

2:5 

2.9 

1.2 

.3 

2.0 

2.7 

2.0 

.2 

2.4 

1.9 

.6 

3.0 

1.5 

3.2 

2.2 
.3 

54.8 

30.7 
7.4 

6.6 

5.0 

4.0 

3.1 

2.6 

2.3 

2.1 

2.2 

2.6 

40.4 

YEAR  ENDING  JUNE  30,  1866. 


1806. 

1806. 

< 

Disease. 

KEfllONS. 

5 

u 

1: 

p 
o 
p 

< 

U 

s 
u 

E 

o 

e 
S 

H 

> 
o 
S5 

I 

H 

>> 

< 
P 

< 
•-s 

Ed 

M 

s 

El 

ad 

Typhoid  and  cases  reported  as  Typhus 

Atlantic- 

1.7 

1.9 

1.7 

2.6 

1.5 

.8 

.5 

.6 

.7 

.4 

.4 

.4 

17.9 

Central 

1.2 

1.2 

1.2 

1.2 

.6 

.3 

.3 

.4 

.4 

.3 

.5 

.3 

11.2 

Pacific 

.4 

1.4 

.7 
1.4 

.5 
1.3 
1.6 

.8 
1.7 

1.7 

.3 

.2 
.5 

.3 

.4 

1.0 

.6 
.3 

.7 
.6 

1.3 

1.0 

.5 

7.5 

1.0 

.6 

.6 

.4 

13.3 
13  0 

Typho-malarial  Fever ._. 

Atlantic    _ 

1.4 

1.7 

.5 

2 

.1 

.2 

Central  

4.5 

1.7 

1.0 

1.1 

.9 

.3 

.1 

.1 

1.2 

22.5 

Pacific  _-_- 

.6 

.1 

.2 

.1 

.1 

.1 

.5 

1.5 

1.2 

.1 

In  all  the  regions 



3.1 
3.1 

1.6 
3.6 

1.1 

3.3 

.6 

.2 

.1 

.1 

.7 

10.6 

All  the  Continued  Fevers 

Atlantic 

4.3 

2.0 

1.0 

.5 

.9 

.7 

.4 

.5 

.6 

30.9 

Central  

5.7 

2.9 

2.2 

2.3 

1.5 

.6 

.4 

.4 

.4 

.3 

.6 

1.5 

33.7 

Pacific 

1.0 
4.5 

.8 
3.0 

.5 
2.4 

.8 

.5 

.3 

.3 

.5 

1.0 

.7 
.6 

1.4 
.6 

1.1 



.7 

1.0 
1.1 

9.0 

In  all  the  regions 

2.9 

1.6 

■^ 

.7 

29.9 

1 

The  striking  irregularities  in  the  monthly  rates  of  prevalence  of  the  continued  fevers  as 
a  class  may  be  more  readily  observed  by  means  of  the  plate  facing  page  199  than  by  the 
tabulated  figures.  There  are  six  notable  prominences  on  their  line  of  })revalence;  one, 
the  hif^hest,  culminating  in  November,  1861;  the  second,  less  acute,  spreading  over  the 
months  of   May,   June  and  July,   1862;  the  third,   still  more  obtuse,  covering  the    last 


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THK    ('(^NTTNUKD    FKVKRS.  199 

throe  moiitlis  of  lS(->2  ami  .lanuarv  ainl   Foliruary  of  l.Sfi:^;   (lie  otlier  tliri'o  j)roiniiieiicos 
are  acute  am]  culmiiiato  in  August,  1S63,  ami  in  July  of  1864  and  lS(r"). 

Evidently  something  more  than  mere  seasonal  cliauge  was  involved  in  the  production 
of  the  first  of  these  waves  of  prevalence,  for  while  in  September,  1<S61,  the  line  tends  to 
tlie  summit  of  the  first  elevation,  in  September,  1862,  it  forms  the  angle  of  the  deep  sulcus 
between  the  second  and  third,  and  whilst  it  falls  in  the  winter  months  of  1861,  the 
corresponding  montlis  of  1862  sustain  it  on  tlie  crest  of  the  tliird  e[)idemic  wave.  On 
tlie  other  hand,  the  prominences  occurring  in  luly  and  August  of  ISIilx  1864  and  1865 
suggest  l)y  their  regularity  a  seasonal  iiiHuencc  which  is  scon  by  the  green  line  to  have 
been  due  to  the  prevalence  of  typho-malarial  fever. 

The  elevations  of  tlie  line  indicating  ty})lioid  fever  show  thai  the  poison  of  this  disease 
was  the  [irincipal  cause  of  the  irregular  waves  of  fel)rile  prevalence  during  tlie  early  period 
of  the  war.  The  sudden  aggregation  of  voung  men  in  camps  where  they  were  exposed  to 
influences  favorable  to  the  spread  of  this  disease  accounts  for  its  rapid  increase  from  May 
to  November,  1861.  During  this  period  the  troops  which  furnished  the  statistics  were 
increased  from  sixteen  thousand  to  three  hundred  thousand  men,  under  President  Lincoln's 
call  of  April  15  for  75,000  men  for  three  months  and  the  closely  following  act  of  Con- 
gress, approved  July  22,  calling  for  500,000  men  for  three  years.  This  suggests  the  expla- 
nation of  the  irregularities  in  the  second  and  third  prominences  of  the  line  of  prevalence 
of  the  continued  fevers.  In  November,  1861,  tie  epidemic  among  those  who  responded  to 
these  calls  was  at  its  height,  15.03  montldy  per  tliousand  of  strength,  after  which  it  sub- 
sided rapidly  to  6.14  in  March,  18G2.  But  meanwhile  tlie  army  became  augmented  in 
response  to  a  requisition  for  300,000  three-years'  men;  and  this  second  aggregation  was 
followed  by  a  sec-ud  e])idemic  which,  as  the  volunteers  responded  less  promptly  than  on 
the  first  call,  had  a  less  prominent  but  more  prolonged  acme,  yielding  in  May  11.30,  in 
June  11.55  and  in  July  12.11  cases  in  every  thousand  men,  after  wliich  the  disease  again 
subsided  to  6.33  in  September.  About  this  time  the  call  for  300,000  nine-months'  men 
occasioned  the  third  epidemic  wave  by  the  fresh  material  thus  brought  into  the  camps; 
but  as  the  men  arrived  more  slowly  than  on  the  former  requisitions  the  monthly  rate  during 
the  acme  in  October,  9.07,  was  not  so  high  as  during  the  previous  visitations.  Nevertheless 
the  susce{)tible  men  of  the  new  levies  did  not  escape,  but  were  seized  with  fever  as  they 
arrived,  giving  monthly  rates  of  8.80,  8.29,  8.52  and  8.22  for  the  four  months  next  follow- 
ing. In  March  the  epidemic  began  to  subside,  and  as  no  large  bodies  of  new  troops  were 
added  to  the  army  after  this  date  until  the  expiration  of  the  term  of  service  of  the  three- 
years'  men,  the  only  prominences  in  the  line  of  prevalence  are  those  already  noted  as 
occurring  towards  the  end  of  summer,  and  evidently  occasioned  in  great  part  by  the  malarial 
element  of  the  fevers  reported  as  typho-malarial.  It  is  probable,  however,  that  into  the 
first  of  these,  that  culminating  in  August,  1863,  there  entered  febrile  cases  from  the  regi- 
ments that  responded  to  the  call  issued  June  15,  for  men  for  temporary  service  in  protecting 
Maryland  and  Pennsylvania  from  invasion;  and  it  is  equally  probable  that  the  high  rates 
of  July  and  August,  1864,  were  in  part  the  effect  of  the  replacement  of  discharged  veterans 
by  fresh  levies. 

It  appears,  therefore,  that  outside  of  the  influence  exercised  on  the  rates  of  prevalence 
of  the  continued  fevers  by  the  absorption  of  certain  malarial  cases  the  statistics  afford  no 
information  concerning  variations  due  to  seasonal  changes.     If  any  such  were  present  they 


200 


^^TATIsTlrS    OK 


wen:  of  SO  sliirlit,  a  dianictor  uh  to  bo  swaiiipt'd  in  those  arising  tVoiu  llio  one  groat  cause  ol 
variation — the  number  of  men  ])rcsont  susceptible  to  the  action  of  the  febrile  poison/== 

From  tliis  view  of  the  line  of  jn-ovalence  of  the  continued  fevers,  and  from  wliat  has 
been  said  of  tlm  increasing  gravity  of  the  cases  as  the  war  progressed,  it  will  bo  readily 
understood  that  the  line  of  mortality,  while  presenting  prominences  similar  to  thosi;  on  the 
line  of  prevalence,  would  not,  if  drawn,  l)e  separated  from  that  line  througliout  its  course 
by  the  same  multiple  of  its  own  height,  luit  by  a  lessei-  multiple  at  points  near  the  end 
than  at  points  near  the  beginning.  The  monthly  variations  in  the  mortality  rates  from 
typlioid  fever  have  already  been  illustrated  on  the  tinted  diagram  facing  page  20. 

The  lines  of  prevalence  and  mortality  among  the  colored  tnjops  are  traced  on  the 
plate  facing  this  page.  Typhoid  cases  formed  a  larger  proportion  of  the  strength  present 
at  the  beginning  of  the  term  of  service  than  at  subsequent  dates;  but  the  line  of  preva- 
lence is  irn.'gularly  elevated  as  fresh  regiments  were  mustered  into  service.  The  line 
expressing  the  prevalence  of  the  continued  fevers  as  a  class  presents  three  very  notable 
seasonal  prominences,  due  principally  to  the  presence  of  fevers  reported  as  typho-malarial. 

[n  treating  of  the  paroxysmal  fevers  the  seasonal  variation  was  emphasized  by  con- 
solidating the  rates  for  the  corresponding  months  of  the  several  years  into  a  line  expressing 
the  average  rate  for  each  of  the  months  or  the  average  armual  curve;  but  in  the  case  of 
the  fevers  now  under  consideration  the  prominences  due  to  the  aggregation  of  susceptible 
material  are  the  main  factors  in  determining  the  contour  and  level  of  the  line  obtained  by 
such  a  consolidation.  The  average  line  for  the  white  troops,  as  shown  on  the  diagram  on 
the  opposite  page,  exhibits  a  notable  elevation  in  July,  7.14  per  thousand  strength,  due  to 
the  malarial  clement  of  the  fevers,  and  a  smaller  elevation  stretching  over  the  months  oi 
October  and  November,  due,  so  far  as  shown  by  the  data,  to  the  incomplete  levelling  of  the 
epidemic  prominences. 

The  average  annual  curve  of  prevalence  among  the  ccdored  troops  presents  a  marked 
elevation  in  July,  August  and  September,  9.;)1,  9.45  and  .S.H4,  respectively,  per  thousand 
men  present.  This  is  evi<lently  due  maiidv,  but  net  wholly,  to  malarial  influences;  for 
while  typlio-malarial  fever  certainly  contril)uted  to  the  elevation,  typhoid  fever  was  also 
more  prevalent  then  than  at  other  seasons.  In  view  of  the  greater  prevalence  of  typhoid 
in  the  first  July  of  their  service,  as  delineated  in  the  plate  facing  this  page,  the  composi- 
tion of  the  prominence  under  consideration  may  be  appreciated. 


*  There  are  many  observations  in  the 
literature  of  typhoid  sh<iwiii^  its  in- 
ereased  prevalenee  in  the  late  autumn 
and  winter  mouths,  itsdiininislied  prev- 
alence in  tlie  spring  anil  its  presence  at 
all  seasons :  but  in  tliis  country  tliere 
have  been  few  statistics  patliered  on 
tlie  larjUfe  scale.  Tlie  National  Htiard 
of  Health  collected  and  piililished 
weekly  mortality  returns  during  the 
period  from  .January,  IHHO,  to  .May, 
188',i.  Cities  and  towns  a^pre^ating  a 
population  of  ab«tut  eip^ht  millions  were 
represented  in  these  returns.  The  ab- 
solute fijB^ures  as  reported  in  the  in- 
stance of  tj-phoid  fever  have  l>een 
ccmverted  into  monthly  rates  expressed 
as  annual  rates  per  thousand  of  popu- 
lation, and  from  them  the  accompany- 
ing diaf^in  has  been  drawn. 


Pfaoram  fhomiiff  Inj  ammal  rates  pti-  lh<>n.tn)i<f  the  Ken-tonal  rarkttlons  in  the  mortality^  and  henee  in  the  pri 
ti/phiii<l  /<  r')\  iniUDi'j  II  I'ltited  Stat<s  jiopiilntinn  iif  <tlioilt  eitjlit  inillions. 


ntleme  "f 


188  0. 

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18  8a. 

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Lines  indkating  theT^rvaUnre  and  Mortality  of'tJie  Cbntmned  Fevcm 

among  the  (blared  Iroops . 


MonOily  rates  of  tJie  Fevers  as  a  class . 
„  „      ,,    Typho  malarial-  Fex^er. 

„  „      „    Typhoid  Fever. 

„         Deaih  Rates  fronv  all  the  Fevers.] 


per  fOOO  of  average  strength. 


In  Dec.  /S6'4-  the  death  line  runs  into  that  of  typhoid  prevalenccj  the  two  in  the  re 
mainder  of  their  course    being    almost  coincident . 


Year  ending  Juiie  30.1864 . 

^ar  ending  June  3n.l8f)5  . 

Year  ending  June  30.1866. 

- 

rt-t5^^4iii4M 

tM^I  ^1^=1 41-1 

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THK    eONTI>'TKD    KK.VERS. 


201 


DiAiiHAM   showiiiii  till  iivirajir  iiniiiinl  rurvcs  nf  prirnhucr  diiil  mnrttililij  iif  cniiliiiiKd  frrrra. 

Ttit'  uppor  nnl)rokr-n  lino  s^linwr;  ttio  raTp  of  iircval'Micc  nf  itu'  fvv<Ts  jip  n  rla?!^,  tiii^  Knv.T  tlic  iloatlt-ratcs  rausnl  t>y  thoin.    Tlu-  ilntti''!  line  rcjin'tii'iitfl 
the  prfvak-nct^  of  typhu-malarial  frviT,  ami  tin'  >pai<'  lu'twi'm  it  and  tlif  line  al'ovo  it  llio  iirevah'iii-o  of  typlioiil  frvrr. 


WHITE    TItOOPS. 


C'<)I,()1!KI>   TKOori 


_L 

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10.0 

9.5 

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9.0 

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The  data  from  which  these  curves  have  been  constructed  are  submitted  in  the  two 

tables  which  follow: 

Taklk  XLV. 

Seasonal  Variations  in  the  Prevalence  and  Mortality  of  the  Continued  Fevers  among  the  White  Troops, 
expressed  in  average  monthly  rates  per  thousand  of  strength,  obtained  by  the  consolidation  of  the 
figures  for  the  corresjwnding  months  of  each  of  the  years  covered  by  the  statistics. 


Diseases. 


Cases  of — 

Typhoid  Fever  (a) 

Typhus  Fever  (a) 

f'ommon  C(>ntimu'fl  Fever  (ft), 
Typhit-nialarial  Fever  (c) 


All  the  Continued  Fevers  (fi)l 


Deatli.s  from — 

Typhoid  Fever  (rt) 

Typhus  Fever  (n) 

Common  f'outinued  Fever  (6) 

Typho-malarial  Fever{c) 


.\11  the  Continued  Fever8(rJ) ].64 


2.08 

.15 

2.1fi 

4.07 


7.14 


l.M 
.04 


.27 


2.80 

.12 

.3.92 

3.  .52 


6.47 


1.20 
.03 
.02 
.30 


1.51 


2.  (11 

.08 

4.14 

2.64 


5.47 


.89 
.02 

.04 

1 
.27    ! 


■■i.M 

.09 

.'j.02 

2.45 


6.3,5 


.91 
.02 
.03 
.18 


1.09 


3.78 

.09 

4.82 

1.98 


6.24 


l.OQ 
.03 
.«! 
.14 


.'!.  4:1 

.07 


1.16 


5.37 


.96 
.«! 
.02 
.10 


.3. 22 

.08- 

2.:t:! 

1.8.5 


2.64 
.08 

2.:w 

1.66 


5.2:j 


4.48 


.89  .85 

.(«  '       .(4 

.03  .02 

.13  I       .12 


.99 


I 

< 

May. 

1 

bi 

2.46 

2.35 

2.  .Xt 

2.40 

.10 

.09 

.08 

.10 

2.20 

3.49 

4.14 

4.  ,56 

1.65 

1..50 

1..51 
4.35 

2.04 
4.99 

4.28 

4.2.5 



.84 

.84 

.8(i 

.93 

.03 

.03 

.o:t 

.03 

.01 

.!» 

.06 

.10 

.13 

.10 

.10 

.16 

1 

1.00 

.97 

.98 

1.10 

(a)  The  rates  for  typhoid  and  typhus  art'  the  uverago  nitos  of  the  fiv<'  y*'urs  July  1,  IHCil,  to  Juno  30,  1866. 
(6)  The  common  continut'd  fever  rates  are  those  for  the  year  ending  June  :iO,  1S6'2. 
(c)The  typho-malarial  nites  are  the  averages  of  the  fo\ir  ypai"s  July!,  1S02,  to  June  30,  1866. 

{d)  The  rates  for  these  fevers  as  a  class  are  the  averages  of  the  facts  recorded  during  tlie  five  years  aforesaid  ;  they  are  of  necessity  not  the  =Tim  of  the 
rates  of  the  Mi>ecified  fevers,  as  n(dther  connnoii  continued  fever  nor  typho-inalarial  fever  was  n-ported  during  the  whole  <tf  t!io  five  years. 

Med.  Hist.,  Pt.  Ill— 26 


202 


STATISTICS    OF 


Tarlk  XLVJ. 

Seasonal  Variations  in  fhc  Prevalence  and  }[ortaUtij  of  the  Continued  Ferrrs  among  the  Colored  Troops, 
expressed  as  average  monthbj  rates  per  thousand  of  strength,  obtained  hi/  t/ir  co)isolidation  of  the 
figures  for  the  corresponding  montlis  of  each  of  the  three  years,  July  1,  1S63,  to  June  30,  1866. 


Diseases. 

>• 

•J 

i 

i 

a 

D 
H 

o 

u 

ea 

> 
o 
"A 

s 

O 
U 

< 
4 

n 

?5 

a. 
«1 

< 

'f. 

Cases  of— 

Typhciii]  IVvf  r 

2.1)4 

■J.  ■'i-T 

2.411 

2.  14 

1 .  4r. 

1.(7 

1.K2 

1.18 

1 .  45 

1.34 

l.l'i 

1.97 

.in 

.0. 
H.S7 

.14 

B.  10 

8.64 

.07 
4.44 

6.65 

.112 

1.8'.> 

.in 

1.117 

.0-1 
1.97 

3.83 

1 .  rit; 

2.79 

.  or. 
2.13 

3.64 

.  02 
1.9". 

3.31 

.09 
2.  9.'> 

4.6.5 

.08 
3. 29 

5.36 

T.vphit-uuiljirial  Kfver 

All  the  Continued  Fevers—    — .. 

9.31 

0.45 

3.37 

3.18 

Deaths  from— 

Typhoid  Fever 

1.S8 

1.23 

1.22 

1.14 

.69 

.68 

.89 

.84 

.68 

.88 

.80 

1.21 

Typhus  Fever .,_».^. 

.08 
1.02 

.07 
1.11 

.07 

.87 

.01 

.97 

.01 

.38 

.02 
.30 

.02 

.27 

.02 
.28 

.06 
.22 

.07 
.45 

.08 
.48 

.06 

.46 

Typho-raalarial  Fever 

All  the  Continued  Fevers 

2.68 

2,41 

2.16 

2.12 

1.08 

1.00 

1.18 

1.14 

.96 

1.40 

1.42 

1.73 

The  regionic  figures  in  Table  XLIV  show  that  the  lines  of  prevalence  in  the  Atlantic 
and  Central  regions  conform  in  their  general  course  to  that  already  submitted  from  the 
army  as  a  whole.  Each  presents  three  irregular  prominences  in  tlie  earlier  part  of  its 
course  not  referable  to  seasonal  or  regionic  influence,  but  to  the  aggregation  of  men  under 
the  calls  for  troops;  and  each  shows  subsequently  three  other  prominences,  apparently 
seasonal  in  their  recurrence,  and  corresponding  with  an  increase  in  the  typho-malarial  rates. 
The  line  of  prevalence  in  the  Pacific  region  is  less  regular,  but  even  in  it  the  general  con- 
tour of  the  line  of  the  army  may  be  observed.  These  have  been  traced  on  the  diagram 
which  faces  this  page. 

The  highest  rate  of  prevalence  in  the  Atlantic  region  was  14.6,  in  July  of  the  second 
epidemic  wave;  the  highest  in  the  Central  region,  18.2,  was  in  October  of  the  first  epidemic 
wave;  the  highest,  4.9,  in  the  line  of  the  Pacific  region,  was  reached  in  October  of  the  third 
wave.  Although  the  Central  region  contributed  the  highest  monthly  rate  and  the  highest 
annual  rates  during  the  first  and  last  years,  the  high  annual  rates  furnished  by  the  fevers 
of  the  Atlantic  region  during  the  three  intervening  years  gave  that  region  the  highest 
average  rate. 

The  inconsiderable  number  of  troops  in  the  Pacific  region,  10,172,  when  the  maximum 
rate  was  yielded,  is  naturally  suggested  as  a  possible  cause  of  the  small  size  of  this  maxi- 
mum and  of  the  generally  low  level  of  the  line  of  prevalence  in  that  region.  But  the 
Central  region  furnished  its  maximum  of  18.2  when  only  81,387  men  were  present,  while 
the  maximum  of  the  Atlantic  region  was  only  14.6,  although  the  strength  for  the  month 
amounted  to  227,419  men.  Again,  the  annual  rate  for  the  first  year  was  greater  in  the 
Central  region,  145  per  thousand  of  strength,  than  in  the  Atlantic  region,  115.4,  although 
in  the  latter  the  average  strength  was  176,650,  as  compared  with  105,108  in  the  former. 
The  mere  aggregation  of  troops  in  a  region  has  therefore  apparently  but  little  influence  on 
the  prevalence  of  these  fevers.     Nor  does  the  narrowing  of  the  limits  from  the  region  to 


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Oct. 

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Mar. 

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Co 


THE    OOISTTNUED    FEVERS. 


203 


the  (iopartraent  develope  in  the  statistics  of  the  latter  any  special  influence  of  locality  or 
of  aggregation  ou  the  occurrence  of  the  continued  fevers.  It  is  evident  that  for  an  exida- 
nation  of  all  the  facts  we  must  go  behind  these  aggregations  to  the  susceptibility  of  the 
material  of  which  they  were  composed. 

^rABLE    XLYII. 

Shoicing  the  relatire  Frequency  of  the  reported  forms  of  the  Continued  Fevers  among  the  White  Troops 
in  the  several  Depaiiments  ((nd  Eegions  during  the  four  years  of  war  service  from  July  1,  1801, 
to  June  30,  1865. 


Departments  and  Regions. 


Bejiartment  of  the  East 

IViiiMle  Department 

Department  of  tlie  Shcnaniloali 

Middle  Military  Division 

Department  of  Washington 

Army  of  the  Potomac 

Department  of  the  Rappahannock. 

Department  of  Virginia 

Department  of  North  Carolina 

Department  of  tlie  South 


Atlantic  Region_ 


o  2  ; 


■ii.i.a.i  A-4th 

1st,  2(1,  M  A  4th 

1st 

4th 

2d,  3d  &  4th 

Ut,  2d,  3d  A-  4tli 

1st 

1st,  2d,  3d  A  4th 

1st,  2d,  3d  A  4th 

1st,  2d,  3d  &  4th 


C   5^ 

II 


3  = 

o  ** 

noil 

3, 285 
1,114 
1,654 
10,818 
37, 053 
1,385 
7, 182 
4,713 
4,664 


72,777 


Reported  fonns  of  Fevor  hs  percentages  of  the  total  nuiu- 
ber  of  cases. 


be  *  a 
2  S  f 


71 

O'J 
35 

105 
84 
08 
69 

102 
72 


Duriiif;  tin'  yciir  I'lnliiiK-luiic 
30,  |)S62,  wlifii  CiiirUiKHi 
Cniitiinu'd  Fi'Ver  wiis  re- 
ported. 


Typhoid.    Typhu.^-3. 


62.1 
66.0 


64.0 
60. 9 
54.6 
65.8 
46.6 


62.1 


6.4 
1.6 


1.4 
7.2 
4.9 
1.5 
.5 


2.0 


31.5 
32.4 


34.6 
31.9 
40.5 
32.7 
53.9 


35.9 


Diiriii}^  tlie  three  years  from 
.Tune  30,  18112,  to  June  30. 
1865,  when  Typho-mHiariiil 
Feverwas  reported. 


Typhoid.  Typhus.  H^?-^,^ 


78.0 
73.9 


49.  .5 
56.7 
48.4 


40.9 
43.2 
31.0 


49.7 


3.8 
S.9 


2.1 

1.0 
1.0 


.6 

1.7 

.6 


1.3 


18.4 

20.2 


48.4 
42.3 
60.6 


58.6 
55.1 
68.4 


49.0 


Department  of  the  Northwest 

Northern  Department 

Department  of  West  Virginia 

Department  of  Missouri 

Department  of  the  Ohio 

Department  of  the  Cumberland 

Department  of  the  Tennessee 

Military  Division  Mississippi,  Part  I 

Military  Division  Mississippi,  Part  II_ 

Department  of  Arliansas 

Department  of  the  Gulf 


1st,  2d,  3d  &  4th 

2d,  3d  &  4th 

1st,  2d  &  3d 

1st,  2d,  3d  &  4th 

2d  k  3d 

l«t,  2d  &  3d 

1st,  2d  &  3d 

4th 

4th 

2d&3d 

Ist,  2d,  3d  &  4th 


799 

1,581 

6, 091 

5,  310 

2,968 

13,327 

15, 467 

3,928 

1,699 

1,801 

10,145 


40 
41 
9'J 
53 
56 
62 
63 
36 
18 
33 
82 


67.1 


36.7 


7.2 


70.1 
62.9 


2.3 
3.8 


27.6 
33.3 


68.9 
67.8 


2.7 

2.0 


28.4 
30.2 


31.2 


7.3 


61.5 


84.0 
64.3 
68.5 
61.1 
64.3 
61.0 
60.8 
48.3 
38.8 
39.7 
38.4 


Central  Region. 


63,016 


66 


66.0 


2.8 


31.2 


62.6 


Department  of  New  Mexico_, 
Department  of  the  Pacific 


1st,  2d,  3d  *  4th 
Ist,  2d,  3d  &  4th 


284 
352 


15.7 
42.4 


1.9 


84.3 
55.7 


40.6 
52.0 


2.0 
2.4 
1.4 
3.2 
1.4 
1.3 
1.8 
.5 
.7 
2.8 
2.9 

1.9 

1.9 
4.1 


14.0 
33.3 

30.1 
35.7 
34.3 
37.7 
47.4 
51.2 
60.5 
67.5 
68.7 


46.6 


67.5 
43.9 


Pacific  Region,  _ 


16 


31.8 


1.1 


67.1 


46.7 


3.1 


60.2 


Total  in  all  the  Regions.. 


136,429 


66 


3.6 


2.4 


34.0 


61.1 


1.6 


47.3 


On  account  of  the  greater  prevalence  of  the  continued  fevers  during  the  early  period 
of  the  war,  comparisons  in  this  connection  can  be  instituted  with  proprietv  only  on  the 
statistics  of  those  departments  that  were  kept  intact  during  the  four  years  of  active  war 


_'0  I  STATISTICS    OF 

service.  It  would  Le  inailinissiljle,  for  instance,  to  contrast  tlio  annual  rate  of  18  jier 
thousand  among  the  veteran  soldiers  of  tlie  ]\[ilitarv  Division  of  tlie  ^[ississip]u,  wlio 
inarched  from  Atlanta  to  the  coast,  with  the  72  per  tlionsand  furnished  by  the  troops  who 
operated  on  the  seaboard  of  the  department  through  wliich  the  march  was  made,  because 
the  latter  rate  includes  the  larger  figures  of  the  early  p(3riod,  while  the  former  is  unaffected 
by  them. 

Looking  only  at  those  departments  from  which  re})orts  were  furnished  during  the  whole 
period  of  active  operations,  the  rates  of  69  in  the  Department  of  Virginia,  84  in  the  Army 
of  the  Potomac  and  102  in  tlie  Department  of  North  Carolina,  all  of  which  commands 
were  contiguous  geographically,  indii'ate  that  departmental  locality  exercised  no  marked 
influence  on  the  number  of  cases. 

Again,  as  to  aggregation  in  the  departments.  The  comparatively  low  rate  in  the 
Department  of  the  Northwest,  and  the  small  number  of  ti-oops  operating  within  its  limits, 
support  the  idea  suggested  by  similar  conditions  in  the  Departments  of  the  Pacific  region, 
esf)ecially  in  view  of  the  larger  rates,  already  instanced,  in  departments  which  contained 
a  larger  number  of  men.  But  when  the  statistics  of  these  are  compared  with  each  other 
it  is  found  that  the  fever  rates  did  not  increase  in  proportion  to  the  strengtli  present.  In 
the  Army  of  the  Potomac,  with  an  average  strength  of  109,734  men,  the  average  annual 
rate  of  prevalence  was  84  per  thousand,  while  the  adjoining  territorial  command,  the 
Department  of  North  Carolina,  gave  a  rate  of  102  in  a  strength  of  only  15,541  men. 

The  consolidated  statistics  now  under  consideration  are  incompetent  to  show  precisely 
whether  concentration  in  a  locality  exercised  an  influence  on  the  prevalence  of  the  fevers. 
As  the  rate  was  greater  in  the  Department  of  North  Carolina  than  in  the  Army  of  the 
Potomac  it  would  seem  that  local  conditions  were  more  efficient  than  mere  concentration 
in  promoting  their  spread;  for  the  small  nundjer  of  troops  in  the  department  mentioned 
rendered  impossible  such  a  concentration  of  forces  as  was  found  in  the  camp  of  the  Army 
of  the  Potomac.  But  the  influence  of  susceptiljle  material  in  the  ranks  was  so  great  that 
conclusions  drawn  from  flgures  merely  arc  necessarily  of  doubtful  value.  This  influence 
has  been  seen  in  the  elevation  of  the  line  of  ])revalence  following  the  arrival  of  fresh  troops. 
It  may  also  be  observed  in  the  table  now  submitted,  by  comparing  the  rates  in  the  Depart- 
ment of  the  Shenandoah,  (.)9,  and  in  the  Department  of  the  Kappahannock,  98,  gathen;d 
during  the  flrst  year  of  the  war,  with  the  rates  in  the  ^fiddle  Military  Division,  35,  and  in 
the  Military  Divisions  of  the  Mississippi,  18  and  36,  collected  during  the  fourth  year  of 
service.  The  highest  i-ate,  105,  in  the  Department  of  Washington,  appears  exceptional, 
as  it  does  not  include  the  records  of  the  first  year.  But  this  department  was  in  a  measure 
a  camp  of  organization  and  equipment  for  new  and  undisciplined  regiments,  which  were 
subsequently  transferred,  as  the  occasion  required,  to  other  points  for  active  service.  Young 
soldiers  passed  through  it  on  their  way  to  the  front;  hence  the  high  rates  yielded  by  its 
reports.  The  rate  in  this  department  during  the  foui'th  year,  73.6,  was  higher  than  that  of 
the  Shenandoah  in  the  first  year  of  the  war.  In  the  third  year,  when  there  were  fewer 
changes  in  the  personnel,  the  rate  fell  to  63.8.  The  rate  for  the  second  year  was  151.0. 
During  the  first  year  the  reports  from  the  troops  in  Washington  and  its  vicinity  were  con- 
solidated with  the  returns  from  the  Arrav  of  the  Potomac,  which  furnished  a  rate  of  126.2 
per  thousand  of  strength. 

In  the  other   columns  of  this  table  may  be  observed  the  relative  frequency  of  the 


THE  CONTINUED  FEVERS.  205 

reported  forms  of  fever  exjn-esseJ  in  |ierceiitages  of  tlio  wliole  number  of  febrile  cases. 
Duriiiu'  llic  period  when  the  term  common  continued  fever  was  in  use  typhoid  fever  consti- 
tuted ntrtrly  two-thirds  of  the  cases  except  in  the  Pacitic  region  and  the  Department  of 
the  Gulf,  where,  on  the  contrary,  common  continued  fever  formed  this  proportion  of  the 
whole.  During  the  period  when  the  term  typho-malarial  was  in  use,  about  one-half  of  the 
febrile  cases  were  reported  as  typhoid.  A  small  percentage,  larger  generally  in  the  earlier 
than  in  the  later  years,  appeared  as  typhus.  The  unusual  percentages  of  typhus  and  com- 
mon continued  fevers  returned  from  the  Department  of  the  Northwest  during  the  first  year  oi 
the  war  originated  in  the  inconsidcrahU'  number  of  cases  entering  into  the  calculation,  only 
fourteen,  of  which  five  were  said  to  have  been  typhus  and  one  common  continued  fever. 

It  is  worthy  of  note,  as  bearing  on  the  disposition  made  of  the  continued  febrile  cases 
after  the  term  common  continued  fever  was  removed  from  the  reports,  that  those  depart- 
ments from  which  a  large  percentage  of  that  form  of  fever  was  reported  were  subsequently 
characterized  by  a  large  percentage  of  typho-malarial  cases.  Thus,  while  connnon  continued 
fever  formed  34.0  per  cent,  and  typho  malarial  47.3  per  cent,  of  the  reported  forms  in  the 
Army  as  a  whole,  the  Departments  of  the  South,  the  Gulf,  Virginia  and  New  Mexico  gave, 
in  both  instances,  percentages  lai'gely  in  excess  of  the  average.  Nevertheless,  a  high 
percentage  of  common  continued  fever  in  the  Department  of  the  Pacific  was  not  followed 
by  a  corresjDondingly  high  tvpho-malarial  figure;  and,  on  the  other  hand,  as  equally  excep- 
tional, a  high  percentage  of  typho-malarial  fever  in  the  Army  of  the  Potomac  and  in  the 
Department  of  North  Carolina  was  not  preceded  by  corresponding  figures  under  the  head- 
ing common  continued  fever. 

Lastly,  variations  in  the  percentages  of  typho-malarial  fever  may  be  noted  as  having 
been  wdiolly  unconnected  with  tht?  prevalence  of  the  continued  fevers  as  a  class.  This  may 
be  illustrated  by  taking  as  a  standard  the  figures  furnished  by  the  Army  of  the  Potomac. 
In  that  army  84  febrile  cases  occurred  annually  in  every  thousand  men,  and  of  these  50.6 
per  cent,  were  typho-malarial  cases.  But  in  the  Departments  of  West  Virginia  ana  North 
Carolina  a  greater  number  of  cases  than  84  occurred  annually,  while  the  percentage  of 
typho-malarial  cases  in  the  one  department  was  greater,  and  in  the  other  smaller,  than  in 
the  Army  of  the  Potomac;  and  on  the  other  hand,  in  the  Departments  of  Missouri  and  the 
South  a  number  of  cases  considerably  less  than  the  standard,  84,  occurred  annually,  while 
the  percentage  of  the  typho-malarial  cases,  as  in  the  other  two  departments  instanced,  was 
in  one  greater  and  in  the  other  smaller  than  in  the  Army  of  the  Potomac. 

The  statistical  relations  of  typho-malarial  fever  to  the  purely  malarial  fevers  have 
already  been  shown  in  Tables  XXXII  and  XXXIII. 

n.— IN  THE  CONFEDERATE  ARMY. 

Evidence  has  already  been  cited  in  Table  XIV  establishing  the  fact  that  i„  the  early 
period  of  the  war  the  Southern  troops  operating  in  Virginia  suffered  more  from  the  continued 
fevers  than  the  soldiers  of  the  Army  of  the  Potomac  opposed  to  them,  the  annual  rates  of 
cases  per  thousand  of  strength  having  been  respectively  275  and  125.  From  the  follow- 
ing table,  which  contrasts  the  prevalence  of  these  fevers  in  the  two  armies  during  a  period 
of  nine  months,  it  is  found  that  the  monthly  average  of  cases  in  each  was  about  the  same; 
but  as  the  United  States  Army  had  more  than  twice  the  strength  of  the  other  the  ratio  of 
cases  to  strength  was  correspondingly  smaller,  10.4  monthly  per  thousand  as  against  22.9  in 


206 


STATISTICS   OF 


the  Confederate  ranks.  It  may  be  observed  also  tliat  this  greater  ratio  in  the  rebel  army 
was  due  chiefly  to  an  epidemic  that  prevailed  during  the  months  of  August,  September, 
October  and  November,  ibllowing  the  increase  of  the  strength  present  from  21,577  to  58,918 
men,  and  that  at  the  close  of  the  record  in  March,  1862,  the  rate  of  prevalence  was  small 
and  almost  identical  in  the  two  armies.  Both  commands  during  this  period  were  composed 
of  raw  levies  unaccustomed  to  camp  life.  Both  were  similarly  rationed,  quartered  and 
disciplined,  for  the  officers  who  organized  them  had  been  comrades  in  their  military  educa- 
tion and  experiences.  It  would  seem,  therefore,  that  local  conditions  were  not  responsible 
for  the  greater  prevalence  of  fever  in  the  Confederate  camps. 

The  U.  S.  Army  of  the  Potomac  was  largely  recruited  from  the  urban  population  of 
the  New  England  and  other  Eastern  States.  In  its  ranks  there  was  certainly  a  larger  pro- 
portion of  city  men  than  in  the  Southern  Army.  This  appears  to  have  a  bearing  on  the 
greater  frequency  of  typhoid  fever  in  the  latter,  in  view  of  the  well-known  facts  that  a 
majority  of  the  enteric  cases  in  cities  occur  in  young  people  recently  from  country  districts, 
and  that  an  army  encampment  is  in  many  of  its  sanitary  relations  an  extemporized  city. 

Increased  rates  prevailed  also  in  the  Union  Army  as  its  strength  was  augmented  by 
the  arrival  of  fresh  troops,  but  the  monthly  rate  did  not  rise  above  15.9,  while  in  the  Con- 
federate camo  the  rate  in  September  was  45.2  per  thousand  of  strength. 

Table  XLVIII. 

Number  of  Cases  of  the  Continued  Fevers  in  the  Confederate  and  Federal  Armies  of  the  Potomac  from 
July  J,  1861,  to  March  31, 1862,  with  the  ratio  per  thousand  of  mean  strength  for  each  month. 


Months. 

Confederate  Teoopb. 

• 

UsiTEO  States  Troops. 

si 

«2 
a  ♦* 

U  .£9 

-1 

a  a 
SS 
P, 

21,577 
50,525 
58,360 
58, 918 
55, (m 
56,  700 
57,089 
54,810 
31,470 

Number  of  cascB  of — 

-5 
1 

H 

o 

.a 
u 

^  a 

It 

a  ** 
a  a 

Number  of  cases  of— 

i 

O 

1 

a 

1 

i 
il 

o  e 

is 

3 
"o 

■a 
>> 

H 

190 

1,716 

1,801 

947 

853 

566 

398 

283 

86 

& 

2 

4 

299 

221 

132 

77 

38 

39 

1 

Q 
o 
O 

6 

•a 
"3 
.a 
a. 
>i 
In 

a 

•a 

i 
u 

o  *^ 

O 

July,  1861 

31 

390 
546 
437 
37(J 
307 
215 
160 
88 

223 

2,1  in 

2,646 

1,  605 

1,35.5 

950 

651 

482 

175 

10.4 
41.8 
45.2 
27.2 
24.6 
10.8 
11.4 
8.8 
5.6 

17,709 
50,608 
85,408 
113,  204 
13:i,  669 

152,  759 
167,  267 

153,  308 
126, 588 

39 

311 

504 

818 

1,456 

1,361 

1,098 

772 

360 

745 

6 

1 
50 
34 
13 
32 
17 
12 

8 

101 
317 
437 
520 
663 
341 
.384 
423 
310 

146 

629 
991 
1,372 
2,132 
1,  724 
1,499 
1,207 
678 

8.2 
12.4 
11.6 
11.2 
1.5.9 
11.3 
9.0 
7.9 
5.4 

August  1861                                       

September,  1861 

October,  1861 

November,  1861 

March,  1862                     _          

MoDthly  average 

49,394 

760 

90 

283 

1, 1.33 

22.9 

111,169 

19 

388 

1,153 

10.4 

The  only  other  figures  that  reveal  the  numerical  status  of  the  continued  fevers  in  the 
Confederate  forces  are  certain  montiily  rates  calculated  and  published  by  Dr.  Jones.* 
These  are  submitted  in  juxtaposition  with  the  rates  of  the  white  troops  of  the  U.  S.  Army 
for  the  same  monthly  periods,  typho-malarial  statistics  being  included  after  June,  1862. 


'  Page  666,  Vol.  I  of  bi<  pubUshed  Memoirs. 


TTTE    COXTIXrKP    FF.VERi*. 


207 


Taiilk  XJ.IX. 

A  Comparison  of  the  Prevalence  of  the  Continued  Fevers  in  the  Union  and  Confederate  forces  during 
the  nineteen  months,  January,  186.2,  to  July,  1863,  inclusive,  expressed  in  monthly  ratios  per  thou- 
sand of  strength.  Typho-malarial  cases  are  included  in  the  statistics  of  the  Union  Armies  after 
June  30,  186S. 


MONTHS. 

Cases  of  the  Contin'Ued  Fevers  expressed 

IN  monthly  KATES  PER  1,0(K.>  OF  STRENGTH. 

MONTHS. 

Cases  of  the  Contim'Eu  Fever.s  expressed 

tN  monthly  rates   per  1,000  OF  STRENGTH. 

Confederate. 

Federal. 

Confederate. 

Federal. 

January   18G2 

1,3.8 

11.7 
11.6 
14.4 
13.7 
30.2 
27.8 
18.3 
8.5 
8.2 

9.26 
7.40 
0.14 
'.t.  77 
11.30 

ll.5r> 

12.11 
9.63 
C.  33 
9.07 

6.4 
10.7 
8.9 
0.1 
8.1 
11.0 
9.0 
6.4 
9.9 
7.9 

8.80 
8.29 
8.52 
8.22 
7.71 
6.80 
4.80 
4.61 
5.27 
11.2 

March,  1862   

April   1862         

February,  1863 

May  1862 

Marob    1803 

Juno,  1802 

April,  1.S03    - 

July,  1862         — _     

May,  186;!     

June,  1863     

September,  1862 

October,  1802  _    

JuIt,  1803            

Average  monthly  rates.. 

These  figures,  so  far  as  tliey  go,  strengtlien  the  conclusion  derived  from  the  statistics 
of  the  Confederate  Army  of  tlie  Potomac,  that  the  Southern  troops  suffered  more  from  the 
continued  fevers  than  the  Union  Army  during  the  epidemics  consequent  on  the  aggregation 
of  susceptible  material.  Their  high  rates  during  the  months  of  June,  July  and  August, 
1862,  followed  the  Conscription  Act  of  the  Confederate  Congress,  passed  April  16,  calling 
out  all  white  men  between  the  ages  of  eighteen  and  thirty-five.  Their  lower  rates  during 
the  later  months  cited  above,  and  the  lessened  prevalence  of  typhoid  in  our  own  camps 
towards  the  close  of  the  rebellion,  sustain  Dr.  Jones  in  his  assertion  that  "typhoid  fever 
progressively  diminished  during  the  progress  of  the  war,  and  disappeared  almost  entirely 
from  the  veteran  armies."* 

The  Confederate  death-rate  from  these  fevers  cannot  be  obtained  for  comparison,  but 
it  must  of  necessity  have  been  considerably  higher  than  the  Union  rate.  While  in  each 
camp  nearly  the  same  numlier  of  cases  (see  Table  XLVIII)  were  reported  as  typhoid,  the 
number  of  cases  of  common  continued  fever  was  smaller  and  of  typhus  larger  in  the  Con- 
federate tlian  in  the  Union  Army.  Thus,  in  the  former  a  hundred  cases  of  fever  consisted  of 
67  of  typhoid,  25  of  common  continued  and  8  of  typhus;  in  the  latter  the  percentages  were 
64.6  of  typhoid,  33.7  of  common  continued  and  only  1.7  of  typhus  cases.  Moreover,  it  has 
been  shown  in  Table  XIII"}'  that  up  to  December  31,  1862,  the  number  of  fatal  cases  among 
the  Confederate  forces  was  33.27  per  cent,  of  the  whole,  as  against  22.28  percent,  among 
the  Union  troops  during  the  same  period.  This,  in  connection  with  the  greater  rates  of 
prevalence  in  the  Southern  camps,  indicates  with  certainty  that  the  mortality  rates,  if 
known,  would  be  considerably  higher  than  those  calculated  from  the  Federal  statistics. 
In  fact,  if  the  rates  of  fatality  just  cited  be  applied  to  the  rates  of  prevalence  in  the  Armies 
of  the  Potomac,  the  average  mortality  rate  in  the  rebel  army  will  be  found  to  have  been 
7.62  monthly  per  thousand  of  strength,  as  compared  with  2.32  among  our  Northern  troops. 

The  number  of  cases  that  terminated  fatally  in  the  Chimborazo  hospital,  Richmond, 


*  Op.  cit.,  p.  665. 


^  Supra,  y.  31. 


208 


STATISTICS    OP 


Va.,  was  885  or  41.11  per  cent.*  of  the  total  of  2,153  febrile  cases  with  known  results, 
typhoid  fever  claiming  6<)1  (li'atlis  or  47.6  per  cent,  of  1,388  cases,  and  common  continued 
fever  224  deaths  or  29.3  i>er  cent,  of  765  cases. 

III.— AMONG  THE  UNION  SOLDIERS,  PRISONERS  OF  WAR. 

It  has  already  been  shown  that  at  Andersonville,  Ga.,  tlie  rate  of  prevalence  of  the 
continued  fevers,  77.4  annually  per  thousand  men  present,  was  higher  than  the  average 
annual  rate  among  our  white  or  colored  troops,  and  that  the  mortality  rate,  20.5,  was  nearly 
double  that  among  our  wliite  troops.  Ne\'ertheless  the  rates  among  the  prisoners  were 
very  nuich  lower  than  those  calculated  for  our  army  during  the  early  periods  of  epidemic! 
visitation. 

The  753  cases  and  199  deaths  in  Table  XVIf  consisted  of  126  cases  reported /e6r/« 
continua  eommunis,  with  10  deaths,  equalling  7.9  per  cent,  of  fatality;  155  reported /e/>7-;s 
continua  simplex,  with  4  deaths,  equalling  2.6  per  cent.,  and  472  reported /e?M'('.s  ti/phoules, 
with  185  deaths,  equalling  39.2  per  cent, — the  whole  equalling  26.4  per  cent. 

The  cases  in  Table  XV,J  281,  of  which  241  were  fatal,  were  distributed  thus: 

Ketunieil  to  Prison.         TriiiLsfemMl.         Died.         Total  Cases. 
ti  -.3  9 


Fever,  Contiuiied, 

"       Typhoid, 

Total, 


CollllMOIl, 


1 

32 

39 


18 
220 

241 


19 
253 

281 


No  case  of  typhus  fever  was  reported. 


*  See  Table  XU,  p.  30,  fupra. — Dr,  JONES,  page  064  of  lii8  Medical  and  Surgical  Memoirs,  Vol.  I — \ia&  published  some  figixres  conceniing  typhoid 

and  cMnninim  ooiitinued  fevers  vvhi<ih  are  reproduced  in  tlie  following  tabulation: 

Statlntics  of  the  Continued  Fevers  in  certain  of  the  Confederate  General  Hospitals. 


Namk  ok  HosriTAi.. 

PkRIOI)   t'OVEKEU   KV   THE  STATISTICS. 

Typhoid  and 
t-'OMMON  Con- 
tinued Fevek. 

■=&  = 

S 

V.  3 

•a  a 

s| 

11 

U  ■ 

■111 

Cases. 

Deaths. 

January,  ISlH,  to  February,  1803 

September,  1862,  to  April,  1863 

6,245 

1,61'J 

25.90 
26.31 
17.78 
23.86 
45.59 
17.57 
10.48 

5,  516 

2,705 

868 

333 

125 

46 

9,593 

293.5 

249.4 

188.2 

360.6 

279.3 

336.0' 

239.1 

269.7 

April,  180.3,  to  August,  1803 

2,863 

1,312 

204 

23(( 

105 

809 

313 

U3 

42 

11 

July,  1861,  to  Seiitember,  1863 

December,  ISIil,  to  January,  1864 

GuytoD  Hospital,  near  SavanDah,  Ga 

May,  1862,  to  January,  1864                

Total 

10,968 

2,587 

23.69 

1 

These  rates  of  fetality  have  absolutely  no  value.    They  vary  from  10.48  per  cent,  in  one  hospital  to  45.59  per  cent,  in  another;  the  experience  of 

seven  hospitals  averaging-  2^1.59  p«^r  rent,  of  fatal  cases.  It  i.s  to  be  remembered,  however,  that  the  cases  enumerated  were  not  bona  Jide  cases,  but  in 
many  instances  duplications  of  case,-*  already  recorded.  On  the  transfer  of  a  man  from  hospital  to  hospital  his  name  was  entered  us  a  new  case  on  the 
re(fig(er  of  the  hospital  to  which  he  was  transferred.  The  inHuence  <>f  this  duplication  nuiy  be  in  part  appre(;iated  when  it  is  known  that  for  every  case 
re(!orded  as  sent  from  the  field  to  the  ^■ciieni]  hospitals  there  were  more  than  four  admissions  on  the  hospital  registers.  Dr.  JONEH  in  the  Richmond  and 
LiiuisriVe  MfUrnl  Journal,  Vol.  VIM,  p.  'Ml.  acknowledg'ps  that:  "  The  larg-e  number  received  into  hosi>itaIs,  as  shown  by  these  returns,  can  only  be 
accounted  tor  in  the  repeated  transfers  of  patients  during  convalescence,  from  «)rie  liospital  to  another."'  To  calculate  rates  of  fatality  when  the  deaths 
are  unmodified  facts  and  the  cases  a  multiplication  of  fac-ts  by  an  unknown  luiniber.  is  manifestly  absurd.  These  registers  should  have  been  carefully 
revised,  excluding  all  admissions,  wliich  were  merely  tnirisfers,  from  the  list  of  cases,  as  was  done  at  this  ottice  with  the  records  of  the  Chimb<irazo  Hos- 
pital. It  is  im|>ossible  to  tell  liow  many  (jf  the  I0,*.>H8  cases  of  fever  in  the  seven  hosjiitals  were  due  to  transfers  during  convalescence;  but  were  the 
number  known  and  deducted  from  the  total  the  percentages  of  fatal  cases  would  no  doubt  be  very  different  from  those  tabulated.  The  figures  in  the  last 
column  are  of  little  value  for  purposes  of  comparison,  as  deaths  from  wounds,  uf  necessity  a  very  variable  number,  are  included  in  the  thousand  deaths 
which  fo^m  the  basis  of  the  calculation. 

t  Supra,  p.  36.  J  Supraj  p.  34, 


Tin-:  I'u.x  riMKh  i-k,vkks 


209 


IV.— AMONG  THE  CONFEDERATE  SOLDIERS,  PRISONERS  OF  WAR. 

Ill  Table  XIX'^'  the  annual  rates  o\'  prcvalfiK'c  ami  iiiortality  of  these  fevers  among 
the  rehel  prisoners  wl'Vc  stated  as  81.4  ami  !:').()  ruspectively  per  thousaml  ])r)suiu'rs.  Hut 
these  iiunibers  do  not  inchnle  the  luvcrs  reportc(l  as  tvjiho-malarial.  When  tla.'  'A7.6  eases 
ami  4.8  deaths  relumed  as  the  annual  prison  rates  of  this  fever  are  added  to  those  of 
typhoid,  tvjihus  autl  eoiinnon  eontinued  fever,  tho  I'afes  for  thoso  fevers  as  a  elass  hceoino 
69.0  and  IS. 4,  smaller  than  the  average  annual  rates  of  the  rebel  troops  on  active  serviee 
but  lar>i;er  than  tliose  of  the  Union  forecs. 

The  following  tabic  exhibits  the  statistical  relations  of  the  continued  fevers  at  certain  of 
the  prison  depots: 

T.\]5LK   L. 

Number  of  (  hses  of  the  Continued  Fevers,  with  the  result iiir/  ^fortality,  reported  from  the  jyrincipal  Frison 
Depots  us  having  occurred  amour/  (Jonfederatc  Prisoners  of  War,  with  the  annual  rates  per  1,000 
of  strength. 


f2 

_'oo 

>-i   ,- 

5,301 

-i  'M" 

1 

1,008 

as 
& 

6,030 

.3 

t  = 

It 

'a  ^ 

JS  c 

_2  * 

^X 

& 

3,870 

Elinira,  X.  Y., 
July,  1864,  to  June,  1865. 

Fort  Delaware,  Del., 
Aug.,  1863,  tu  June,  1865. 

^  c 

o  ■^ 

Is. 

Total  in  the  nine  priu- 
cipal  depots. 

2,865 

2,114 

6,591 

235 
4 

6,406 

9,610 

40,816 

2,526 
31 

o 

3,069 

CaKcs : 
'      Tvplidid            - -  -     -- 

1,114 

185 
5 

51 

1 

54 

1 

93 

115 

414 

(f,)18 

265 

,        TvnllU^                                                    -         _                  .        

2 
Ita 

Tvplio-nialarliil           , 

722 

10 

(,.)62 

606 
561 

54 

3 

2 
241 

140 

1,574 

2,006 

1.50 

35 

1,279 

912 

147 
26 

118 
53 

302 

216 
1 
1 

5,628 

1,102 

7 
389 

1,498 

31.4 
37.6 

69.0 

'  Deaths  from— 

1 

1      Tvphnid        

3S1 

67 

3 

122 

,'i2 
12 

41 

1 
98 

51 
402 

4 
30 

9 

1 

91 

192 

(<.)66 

141) 

62 

141 

247 

218 

Nnmoricrtl  ratio  per  1,000  of  strength  for  tho  cases  of — 

Typhoid  (including  Typhus  and  Common  Continued) 

1 

60.9 
8.9 

69.8 

66.5 
232.8 

6.1 
1.2 

9.2 
84.8 

21.1 
12.3 

22.7 
.6 

36.3 
.3 

35.2 
128.2 

15.1 
2.0 

Total  Continued  Fevers 

319.3 

7.3 

94.0 

33.4 

23.3 

36.6 

163.4 

17.1 

For  the  deaths  from — 

Typlmid  (including  Typhus  and  Common  Continut-d) 

Tvpho-malariul 

19.2 
2.8 

22.0 

24.5 
42.7 

6.3 
1.4 

7.0 
16.4 

5.9 
.9 

10.4 
1.8 

21.2 
.2 

12.7 
7.4 

12.3 
.1 

13.6 
4.8 

18.4 

Total  Continued  Fevers              -_ -_-    -        

67.2 

7.7 

23.4 

6.8 

12.2 

21.4 

20.1 

12.4 

i 

((()  The  number  of  eases  registered  on  admission  as  a^ue,  l)ronchitis  or  other  slight  fobrilo  ufTcction  and  (credited  to  the  continued  fevers  on  the 
occurrence  of  a  fatal  is«ue,  lias  mcire  than  nflfset  the  recoveries  anmriir  those  ailrnitfed  originiilly  as  cases  of  the  continued  fi-vcrs. 

(6)  In  these  cim^s  the  deatlis,  in  accordance  with  ii'isl'iinN-lini  n-vi-Iutions,  wi-re  chiirjred  in  typhoid,  the  diuirnosis  ou  the  record  remaining  unchanged. 

*  Sifpra,  p.  47. 

Med.  Hist.,  Ft.  111—27 


210 


CLINrCAL    KECOIIDS    OF 


Of  flio  5,628  fcljrilc  cases  uoti'd  in  this  tabk'  -11.9  |icr  cent,  woro  roportcil  tvplmiil, 
51.5  typlio-malarial  ami  only  (>.(i  typlius.  Of  the  cases  ropoftcil  as  tvpli(jiil  and  typlius 
43. o  per  cent,  wcroiatal;  of  tlioso  regai'deil  as  ty|ilio-malar)al  12.7  per  cent.;  of  the  whole 
numljer  of  febrile  cases  26.0  per  cent. 

'ryphoi<l,  notwithstanding  the  smaller  number  ex;[)ressing  the  totality  of  its  cases,  was 
the  prevailing  fever  at  two-thirds  of  the  depots.  Typho-inalarial  predominated  at  Alton, 
Camp  Morton  and  Fort  Delaware;  but  on  account  of  the  uncertainty  attaching  to  the  nature 
of  those  cases  the  large  annual  rates  at  Alton,  319.3  cases  and  ()7.2  deaths  per  thousand  of 
the  average  strength,  cannot  be  acce})ted  as  indicating  a  typhoid  epidemic  of  unusual  viru- 
lence within  the  walls  of  the  prison.  The  frequent  changes  in  the  constituents  of  the 
average  number  present  must  be  remembered,  in  connection  with  these  higli  rates,  as 
modifying  and  materially  reducing  them.*  The  deatlis,  whicli  numbered  16.9  per  cent,  of 
the  typlio-malarial  and  36.8  of  the  typhoid  cases,  imply  a  doubt  of  the  presence  of  typhoid 
in  many  of  the  cases  of  the  former  series.  Indeed,  had  this  camp  experienced  an  epidemic 
of  typhoid  or  other  continued  fever  due  to  its  insanitary  conditions,  the  fatality  of  its  febrile 
cases  would  have  been  greater  instead  of  considerably  less  than  that  of  the  continued  fevers 
in  the  prisons  generally.  The  percentage  of  fatal  cases  at  Alton  was  21.0;  in  the  nine 
prisons  tabulated  the  percentage  was,  as  already  stated,  26.6.  But  as  malarial  fevers  were 
prevalent  at  this  point,  in  the  apparent  absence  of  local  conditions  for  their  dovehjpment, 
it  is  probable  that  many  of  the  typho-malarial  cases,  which  constitute  nearly  four-hfths  of 
the  whole  numlier  on  the  record,  were  adyiuimic  remittents  imported  from  southern  lields 
of  service. 

The  comjiarative  infrequency  of  the  continued  fevers  among  the  prisoners  on  both 
sides,  notwithstanding  the  insanitary  elements'  of  their  environment,  which  included  the 
presence  of  the  typhoid  j)oison,  must  be  ascribed  to  the  same  cause  that  preserved  the  camps 
of  the  veteran  armies  from  visitation — a  want  of  susceptibility  on  the  part  of  the  individuals 
composing  the  aggregation. 


IL— CLINICAL  RECORDS  OF  THE  CONTINUED  FEVERS. 

The  clinical  records  of  the  continued  fevers  are,  as  miglit  be  expected,  contained  prin- 
cipally in  the  case- books  of  the  various  general  hospitals.  Field  reports  treated  of  such 
cases  only  in  exceptional  instances,  as  when,  during  winter  quarters,  a  medical  officer 
retained  his  tvj>hoid  cases  rather  than  expose  them  to  the  dangers  attending  trans^iortatioii 
to  a  distance.  Usually,  however,  cases  of  enteric  fever  were  sent  from  the  held  on  the  ilrst 
favorable  opportunity. 

The  recorded  cases,  as  a  rule,  arc  more  or  less  imperfect.  On  arriving  at  the  general 
hospital  the  patient  was  frequently  unable  to  give  an  account  of  the  early  history  of  his 
case.  In  some  hospitals  no  attention  was  paid  to  tlic  clinical  records.  In  others  the  case- 
books were  kept,  but  in  so  perfunctory  a  manner  that  they  show  little  to  indicate  the  nature 
of  a  particular  case  other  than  tlie  entry  of  the  disease  as  determined  by  the  examination 
on  admission  and  some  fragmentary  details  of  the  medication  prescribed.  Fortunately, 
however,  some  of  these  books  were  carefully  kept,  and  from  them  ample  materials  may  be 
gathered  for  a  representation  of  the  continued  fevers- as  they  were  seen  and  treated  by  our 

*  See  mpra,  p.  62. 


THK  co^"TIxn•:D  khvers.  211 

medical  officers  Juriiig  the  war.  iiiil  In  Dblaiii  a  clear  view  nf  the  subject  the  study  of  a 
large  luuiiber  of  cases  is  needful,  uot  cnlv  tu  su|ipli'iiiciit  the  incoiiijilcle  di'tails  of  one  case 
by  those  of  another,  but  chieHv  because  nf  the  varietv  presented  by  the  cases.  A  certain 
agiri-egation  and  sequence  of  sviuiitnins  might  l>e  selected  fur  presentation  as  ilhisti'ative  of 
a  certain  grade  and  type  of  the  febrile  luanil'estaiions,  but  such  an  arnui^-enieiit  wnuld  In- 
purely  artificial  and  arbitrary,  i^ome  medical  officers  refer  briefly  to  their  eases  on  the  med- 
ical descriptive!  lists  as  having  been  tvpical  instances  of  the  lever  as  diagUdsticateil.  This 
was  due  either  to  a  limited  experience  or  to  preconct;ived  views  of  the  general  course  of  the 
disease.  There  were  in  tact  no  typical  eases:  the  level's  presented  an  inliinte  variety.  As 
has  been  seen,  oven  the  line  separating  the  paro.xysmal  iVom  the  continued  fevers  was  not 
defined,  and  among  the  latter  every  gradation  was  found,  from  tin'  mihl  attack  in  which 
the  patient  hardly  recognized  that  he  was  sick,  and  the  abortive  case  with  its  early  con- 
valescence, to  that  in  which  a  fatal  issu(>  appeared  from  thc^  beginning  to  be  the  only 
probable  termination;  and  from  the  cases  which  progressed  with  some  regulaiity  towai'd 
their  favorable  or  unfavorable  ending,  to  those  which  were  b(;set  with  alternations  of  ho[)e- 
fuliicss  and  uncertainty,  prolonged  for  months  liy  the  continuance  of  intei'curreut  or  the 
supervention  of  sequent  disease.  Only  a  few  of  the  mild  or  abortive  cases  are  detailed  in 
the  case-books.  Huch  cases  were  treated  in  the  field,  where  clinical  records  were  not  kept. 
When  they  occurred  in  the  general  hospitals  they  seem,  owing  to  the  prevalence  of  more 
serious  cases,  to  have  reached  their  termination  without  attracting  special  attention,  and 
the  diagnosis  iyiiliokl,  entered  probably  on  a  mental  review  of  the  history,  constitutes  their 
only  record. 

L— COMMON  CONTINUED  FEVER. 

To  the  same  causes  which  possibly  account  for  the  absence  of  details  in  mild  cases  of 
typhoi<l  fever  may  be  attributed  the  absolute  want  of  clinical  records  in  cases  of  common 
continued  fever.  Although  no  less  than  11,898  febrile  cases,  147  of  which  i)roved  fatal, 
were  reported  under  this  heading  diu'ing  the  first  fourteen  months  of  tlu!  war,  no  official 
record  has  been  preserved  of  the  symptoms  and  progress  of  any  one  of  tlnun.  AVIien  details 
ot  febrile  cases  are  recorded  in  the  case-books,  the  diagnosis  is  typhoid  fever.  i>ut  among 
the  Medical  Descriptive  Lists  there  is  one  case  which  appears  as  sbnple  continued  fever. 
Remissions  are  definitely  acknowledged  as  having  occurred  in  this  case. 

Private  William  R.  Snyder,  Co.  G,  2(1  N.  C.  Battery,  was  admitted  August  8,  1863,  as  a  case  of  simple  coutinued 
fever.  He  had  beeu  left  on  the  field  at  Gettysburg  as  a  nurse  when  Lee's  army  retreated.  About  August  1  lie  was 
seized  with  severe  headache  and  loss  of  a])petite.  On  admission  he  was  very  feeble ;  pulse  120  and  weak ;  tongue 
moist  but  with  a  brown  fur  in  the  centre;  skin  liot  and  dry ;  bowels  constipated.  On  tlie  IHth  the  fever  sulisided 
by  tlie  occurrence  of  remissions;  tlie  patient's  bowels  were  alternately  loose  and  constipated.  By  September  1  lie 
was  considered  fit  to  be  sent  away,  having  been  aide  to  walk  about  the  grounds  for  the  previous  ten  days.  He  was 
treated  with  small  doses  of  q^iiinine,  spirit  of  nitre  and  blue-pill. — Axs^t  Siinj.  If.  ('.  Mmj,  Ubth  X.  V.  Vols.,  Hoxpital, 
Getiijshurg,  Pa. 

There  are  also  on  these  lists  thirty-seven  febrile  cases  which  were  reported  as  continued 
ferer'^  These  are  all  of  a  later  date  than  the  order  calling  for  the  disuse  of  the  term  com- 
mon continued  fever,  and  may  therefore  be  regarded  as  contributions  to  tlie  clinical  history 
of  that  fever  furnished  by  officers  wdio  were  unacquainted  with  the  requirements  of  existing 
orders.     Unfortunately  most  of  the  descriptive  lists  are  barren  of  information  except  as  to 


*To  tliese  may  Tto  added  tlio  caso  wliieh,  frojii  the  softening  of  tin-  mucons  nuTiibi-aiu'  nf  the  lari^u  intestine,  was  submitted  by  Dr.  Woouw.tRn  aa 
Nit.  4f.5  of  tbe  diarriitifiil  series,  \t.  103  of  tiio  Second  Part  of  tliis  woii<.  utiil  also  tlie  eases  :i4'.t,  2SX  and  ^01  of  tlie  post-in''}-t'm  reeonis  of  tlie  rontinued 
fevers  to  be  hereafter  jiri'seuted.    In  thews  the  elmracterislic  lesions  of  tvplii-id  were  observed. 


212 


CLTNTCAL    RECORPS    OF 


dates  of  admission  and  of  recovery  or  death,  with  or  without  notes  of  treatiaent.  Of  iliose 
cases  seven,  wliich  give  more  or  less  testimony  as  to  the  condition  of  the  patient,  are  here- 
with submitted: 

Case  1. — I'livato  lionjaniin  Mullor,  Co.  G,  117th  N.  Y.  Vols.;  ago  Ifi;  was  adinittpd  June  1!^,  ISO.'!,  with  a  severe 
attack  of  continued  fever  which  had  histed  two  weeks.  He  is  rejiorted  as  iiaiiroving  slowly  on  the  2(ith  :  as  uiarUedl.v 
improved  on  July  2,  and  -^s  returned  to  duty  Augusts. — Act.  A.is't  Surg.  T.  Turner,  U.  S.  Armij,  '.td  Diri.iiuii  llnspilal, 
Alexandria,  I'a. 

Came  2.— Private  J.  E.  Voshnrg,  Co.  11, 137th  N.  Y.  Vols.:  ago  18;  was  admitted  .June  17,  lS(i3,  in  the  advanced 
stage  of  an  attack  of  mild  continued  fever.  On  the  20th  the  tongiu!,  which  had  been  slightly  lirowu  and  dry,  became 
clean,  the  febrile  excitenunit  abated  and  the  appetite  returiu'd.     He  was  returned  to  duty  July  1. 

Case  3. — ^Private  Charles  Kobinson,  Co.  I,  137th  X.  Y.  ^'ols.;  age  21:  was  taken  while  in  camp,  June  7,  1863, 
with  continued  fever  of  a  mild  type.  On  adnussion  on  the  17th  he  complained  of  severe  headache,  and  his  tongue 
was  slightly  brown  in  the  centre  and  red  on  the  edges.  On  the  21st  lie  had  diarrhoea;  but  was  convalescent  on  the 
26th,  and  returned  to  duty  July  6.  He  was  treated  with  diaphoretics,  opiates  and  astringents. — Ad.  A.^8't  Surg. 
Benjamin  Wilson,   U.  S.  A.,  3d  Diviiiion  Hospital,  Alexandria,  Va. 

Case  4. — Ass't  Engineer  Jas.  Flinn,  U.  S.  Navy;  age  22;  was  admitted  July  14,  1863,  having  been  sick  for 
fourteen  daj's  with  continued  fever.  He  had  slight  delirium  at  night  and  a  diarrhoea  of  six  or  eight  light-colored 
stools  daily:  but  there  was  no  tenderness  of  the  abdomen.  The  tongue  w.as  white  furred:  appetite  deficient;  heliad 
a  slight  bronchial  cough.  He  took  a  mixture  of  dilute  phosphoric  acid  and  ipecacuanha,  and  was  sponged  over  the 
whole  surface  of  the  body  twice  daily  with  cold  sea-water.  He  was  able  to  be  uj)  on  the  18th,  and  was  returned  to 
duty  August  1. — Act.  Ass't  Surg.   T.  H.  Lichold,   U.  S.  A.,  Hospital,  Point  Lookout,  Md. 

Case  5. — Private  Sherman  Hopkins,  Co.  L,  6th  Mich.  Cav.;  age  30;  was  admitted  September  8, 1804,  with  (miu- 
tinned  fever.  On  the  12th  the  pat  ieut  is  reportetl  as  ])rcseuting  all  the  symptoms  of  typhoid  fever  and  as  being  much 
reduced.  Ho  had  muttering  delirium,  slight  diarrhoea  anol  great  tenderness  over  the  alidomen;  tongue  thickly 
coated;  teeth  covereol  with  sordes;  pulse  136.  He  seemed  to  improve  a  little  for  a  day  or  two;  but  during  the  after- 
noon of  the  14th  he  began  to  gasj)  for  breath  and  his  extremities  became  cold.  He  died  next  morning. — Act.  Ass't 
Surg.   jr.  Kempstcr,  V.  S.  A.,  Vaitcrson   Park,  Hallimore,  Md. 

Case  6. — Private  Heujamiu  Shuester,  Co.  I),  2d  Mass.  Cav.;  age  23;  a  paroleol  prisoner  from  Savannah,  Ga., 
was  admitted  December  19,  1864.  He  was  much  emaciated,  and  complained  of  headache  and  soreness  in  his  bones. 
He  liad  a  chill  on  the  25tli ;  was  restless  during  the  night,  and  next  day  his  bowels  were  loose ;  pulse  125;  eyes  red; 
face  flushed;  skin  dry;  tongue  coated  and  tremulous.  The  diarrha-a  continued  severe  until  the  end  of  the  month 
and  was  accompanied  with  much  abdominal  pain.  On  .January  2,  I860,  the  patient  became  drowsy;  on  the  .^th  a 
jietechial  eruption  was  observed  on  the  chest  and  abdomen;  there  was  much  tympanites  anol  great  tenderness  of  the 
bowels ;  pulse  120;  respirations  38.  On  the  8tli  the  tongue  was  dry  and  covered  with  sordes  and  thin  watery  i-assages 
came  from  the  bowels.  He  became  d(^Iirious  on  the  llth,  and  from  the  12th  to  the  15th,  when  he  dieol,  he  was  moan- 
ing constantly. — Act.  Ass't  Surg.  II.  A.  Maiighliii,   U.S.  .t.,  Annapolis,  Md. 

Case  7. — Private  ,J.  L.  Austin,  Co.  D,  37th  X.  C;  age  2'y;  was  admitted  from  Fort  Delaware  October  16,  1863, 
having  been  taken  sick  with  continued  fever  about  a  week  before  his  arrival.  He  suffereil  from  pains  iu  his  right 
foot  and  thigh,  probably  connected  with  an  open  sore  of  gangrenous  appearance  near  the  roots  of  the  toes;  these 
pains  occurred  in  severe  paroxysms  and  prevented  sleep.  By  the  28th  the  local  inflammation  w  as  subdued,  but  the 
fever  became  aggravated  in  the  evenings.  After  this  he  became  nuich  debilitated;  liis  tongue  was  moist  but  red  in 
color,  subsequently  Ijecoming  dry  and  brown;  and  he  had  a  diarrhoea  of  about  three  stools  iu  the  twenty -four  hours. 
By  November  16  he  was  greatly  emaciated,  and  ou  this  day  he  had  twitchings  of  the  muscles  and  involuntary  dis- 
charges.    Death  took  place  on  the  19th. — Act.  Ass't  Surg.  TT.  A.  Harney,  U.  S.  A.,  Point  Lookout,  Md. 

n.— TYPHO-MALAMAL  AND  TYPHOID  FEVERS. 

The  bedside  records  of  typho-malarial  fever  are  represented  in  the  case-books  by  but 
three  cases,  which,  moreover,  do  not  appear  characteristic  of  the  diseased  conditions  for 
which  the  name  was  suggested;  for  in  the  first  there  is,  in  view  of  our  knowledge  of  the 
symptomatology  of  malarial  fevers,  a  remittent  fever  with  nothing  to  indicate  a  specific 
typhoid,  in  the  second,  another  remittent,  but  of  a  graver  type,  and  in  the  third,  as  will  be 
seen  hereafter,  a  typhoid  fever  with  nothing  in  the  record  to  indicate  a  malarial  complication. 

Case  1.— Sergeant  Egbert  H.  Little,  Co.  A,  38tli  Wis.  Vols.;  age  20 ;  was  admitted  July  26,  1864.  About  ,luly  1 
he  contracted  diarrhoea,  which  yielded  to  treatment ;  on  the  llth  he  had  severe  headache  followed  by  a  decided  chill, 
and  afterwards  by  high  fever,  which  recurred  daily  for  a  week.  On  the  17th  he  was  aolmitted  to  the  3d  Division 
Hospital  of  the  Ninth  Army  Corps,  and  on  the  22ol  transferred  to  this  hospital,  arriving  as  above  stated.  He  was 
very  feeble,  and  had  a  tendency  to  low  fever  every  afternoon;  his  bowels  were  constipateil  and  appetite  lost.  A 
ten-grain  tlose  of  blue-mass  was  given  ou  admission,  and  three  grains  of  cpiinine  with  tincture  of  iron  were  pre- 
scribed for  administration  three  times  a  day.    On  August  7  he  coutiuued  to  have  headache  and  fever  every  afternoon. 


THE    CONTINTEP    FEVERS.  213 

and  his  liowels  were  coiistiiiiitfd  iui<l  aiipi'tito  jKior.  On  the  21st  the  (Hiiuiiio  was  omitted ;  tliree  compound  rlniliar)) 
pills  were  f,nven.  :ind  neutral  mixture  and  acetate  of  ammonia  prescribed  for  use  every  three  hours.  The  diaphoretic 
mixture  was  ouiilti'd  on  the  25th,  and  the  iron  and  (luinine  resnuu'd.  After  this  the  patient  improved  gradually 
and  was  returned  to  duty  October  18. — Satlirlec  Hoxpitdl.  riuUithljihid,  I'd. 

Cask  2. — Private  William  Smith,  Co.  K,  l.'rlth  Ind.  Vols.:  a^e  21;  was  admitted  June  21,  ISt!:"),  with  typho- 
malarial  fever,  lie  had  been  sick  for  ten  days  with  constant  nausea  and  freciuent  vomiting  of  <lark-green  bile,  head- 
ache, pain  in  the  loins  and  diarrluea:  his  tonj;ue  was  large,  tlabby  and  coated  with  a  thick  brown  fur:  pulse  !•(),  soft 
and  compressible;  skin  dry.  The  diarrbcea  continued,  coma  superveiu'd,  ami  on  the  'Mhh  convulsions  were  followed 
by  death. — Ciimhirldiid  Hospital,  Md. 

C.VSK  3. — Private  David  Markly,  Co.  A,  12t)th  Ohio  Vols.;  age  2S;  was  admitted  Sejitember  3,  l^ili:!.  He  was 
attacked  with  typho-nuilarial  fever  in  camp  at  Castle  (iarden,  ISTew  York,  on  August  31,  but  the  symptoms  were  not 
very  marked.  Quinine  and  milk  diet  were  ordered.  A  diarrliiBa  of  five  or  six  stools  daily  set  in  on  the  1th,  and 
slight  delirium  on  the  Gth.  Sudamina  apjieared  on  the  9tli,  on  which  day  there  was  Ideeding  from  the  nose.  Milk- 
punch  and  beef-tea  were  prescribed.  There  was  a  slight  pajinlar  eruption  on  the  lOth,  and  rose-colore<l  spots  on  the 
13tli.  The  diarrluea  had  meanwhile  abated  and  the  general  condition  of  the  i)atieut  improved.  Convalescence  was 
uninterrupted;  he  was  returned  to  duty  November  2I(. — Ctniral  I'luk  llospita},  N.  Y. 

In  addition  to  these  there  are  among  the  medical  descriptive  lists  thirty-seven  cases 
reported  as  typho-malarial  fever.  Twenty  of  these  are  destitute  of  value  as  they  give  no 
statement  of  the  actual  condition  of  the  patient;  the  others  are  given  below.  In  1  and  2 
the  fe\  er  had  subsided  before  admission,  as  also  in  Ciise  3,  in  which  a  diarrlui'al  sequel 
j)roved  fatal.  Cases  4-8  were  mild  febrile  attacks  which,  before  the  introduction  of  the 
new  term,  would  have  been  recorded  as  common  continued  fever:  there  is  nothing  in  the 
record  of  case  4  to  exclude  a  diagnosis  of  mild  remittent  fever,  especially  if  the  patient  had 
been  exposed  to  malarial  influences;  but  cases  5-8,  in  the  Central  Park  Hospital,  were  evi- 
dently mild  attacks  of  typhoid  fever.  The  Fairfax  Seminary  cases,  9-12,  represent  the  last 
stages  of  typhoid  fever  or  of  an  adynamic  remittent  without  the  presence  of  specific  typhoid, 
if  the  existence  of  such  a  diseased  condition  be  admitted.  Cases  13-16,  in  the  Douglas 
and  Stanton  Hospitals,  show  more  distinctly  the  presence  of  a  malarial  element.  Case  17 
was  apparently  a  pernicious  malarial  fever. 

Ca.ie  1. — Private  R.  L.  Keeth,  Co.  D,  7th  Conn.  Vols.,  was  admitted  Sept.  28,  1863,  with  typho-malarial  fever. 
When  admitted  he  was  weak,  but  the  fever  had  subsided,  the  tongue  was  cleaning  and  the  appetite  improving.  On 
October  14  he  was  placed  on  light  duty  and  recommended  for  transfer  to  the  Invalid  Corps  on  account  of  an  oblique 
inguinal  hernia. 

Case  2.— Private  B.  Earl,  Co.  TI,  142d  N.  Y.  Vols.,  was  admitted  Oct.  1,  18(53,  with  typho-malarial  fever.  The 
fever  had  subsided  but  the  patient  was  greatly  debilitated,  and  there  was  general  redema  and  effusion  into  the  peri- 
toneal and  pleural  cavities.  One  grain  of  iodide  of  iron  and  two  grains  of  powdered  squill  were  given  every  six 
hours  in  the  form  of  pill.  This  course  was  continued  until  November  1,  when  the  patient  was  reported  as  doing 
very  well — his  bowels  regular,  secretions  normal,  appetite  good  and  effusion  removed.  He  was  returned  to  duty 
November  24.  —  Charles   T.  Jieber,  Act.  Jss't   Surg.,  U.  S.  A.,  Hospital  IVo.  14,  Beaufort,  S.  C. 

Case  3. — Sergeant  Thomas  Julien,  Co.  I,  G2d  N.  Y.  Vols.;  age  27;  was  admitted  June  14,  1863,  with  typho- 
malarial  fever.  He  had  diarrhcea  and  was  somewhat  emaciated,  but  slept  well.  On  July  20  the  diarrbcea  became 
uncontrollable,  the  matters  passed  being  thin  and  slimy.  Death  occurred  August  2. — Act.  Ass't  Sury.  M.  H.  Picot, 
U.  S.  A.,  TAncoln  Hospital,  Washington,  D.  C. 

Ca.sk  4. — Private  John  Roach,  Co.  C,  26th  Pa.  Vols.;  age  16;  was  admitted  Oct.  9,  1863,  with  typho-malarial 
fever.  He  complained  of  weakness,  loss  of  appetite,  pains  in  the  back  and  limbs  and  fever  at  night;  his  pulse  w.as 
feeble,  tongue  coated  and  bowels  regular.  He  was  able  to  be  up  on  the  1,5th,  and  was  returned  to  duty  on  the  27th. 
Treatment  consisted  of  tonics,  quinine  and  milk  diet. — J.  P.  Jlossitcr,  Act.  AssH  Surg.,  XJ.  S.  A.,  2d  Viriiion  Hospital, 
Alexandria,  Va. 

Cask  5. — Private  Elam  Dye,  Co.  H,  126th  Ohio  Vols.;  ago  21;  was  admitted  Sept.  5,  1863,  with  typho-malarial 
fever,  with  which  he  had  become  affected  seven  days  before  admission.  His  fever  was  continued.  He  had  ijo  chills 
nor  eruption ;  his  tongue  was  furred  but  moist;  skin  hot  and  dry;  bowels  con.stipated.  He  had  headaclie  but  his 
mind  was  not  affected.     A  slight  bronchitis  retarded  his  convalescence.     He  was  returned  to  duty  November  29. 

Cask  6. — Private  Hector  S.  Hunt,  Co.  D,  126th  Ohio  Vols.;  age  22;  was  admitted  Sept.  5,  1863,  with  typho- 
malarial  fever.  A  week  before  this  date  he  had  been  attacked  while  in  camp  at  the  Battery,  New  York,  with  fever 
followed  by  diarrhoea.  The  fever  lasted  only  for  two  or  three  days  after  admission,  but  the  diarrha>a  continued 
until  the  10th.  After  this  he  was  placed  on  light  duty.  He  gained  strength  rapidly,  and  was  returned  to  field 
service  October  15. 

Case  7.— Private  William  Craig,  Co.  H,  126th  Ohio  Vols.;  age  21;  was  admitted  Sept.  5,  1863,  with  typho- 
malarial  fever,  having  had  continued  fever  without  diarrhcea  for  eight  days  before  his  admission.     He  had  slight 


214  CLINICAL    RKCORBS    OF 

lipadacln^  anil  iiinoli  pain  in  tlni  liaok  and  limbs:  bis  skin  was  bi)t  and  dry:  tongue  moist  and  ligbtly  fniicd:  pnlse 
8«;  bowels  rcguhir;  thcru  was  no  fiiiption.  He  bad  sonic  ilelii  iiiiii  (Inrinj,'  the  ni^'bt  on  tbe  ><tb  and  9tb,  bnt  after 
this  bis  case  progressed  favorably.  He  was  treated  with  iininint\  pills  of  rbnbarb  and  soibi,  milk-i)nncb,  and  tepid 
sponging  of  tbe  body  and  limbs.  He  was  returned  to  duty  Xovemlier 'J9. — S.  Teats,  Act.  Jsx'l  Siirtj.,  U.  IS.  J.,  Ctntral 
Park  Jlonpital,  X.  Y. 

Case  8. — Private  David  A.  Maskley,  Co.  A,  IL'Otli  Ohio  Vols.;  age  2'.i;  was  admitted  Sept.  3,  1863,  with  typlio- 
nialarial  fever.  He  had  been  sick  in  camp  at  Castle  Garden  for  seven  days  before  admission.  He  had  diarrlnea  from 
the  4th,  and  afterwards  slight  delirium.  Epistaxis  occurred  on  tlie  SHli,  on  which  day  sudamina  appeared.  A  slight 
papular  eruption,  which  faded  somewhat  under  pressure,  but  which  did  not  seem  to  be  the  specific  eruption  of 
typhoid  fever,  was  discovered  on  the  10th.  The  typhoid  eruption,  however,  was  well  marked  on  the  13th.  The 
diarrlnea  ceased  on  the  17th,  after  which  convalescence  was  progressive.  He  was  treated  with  qtiinine,  camphor 
and  opium,  and  milk-punch.  Ho  was  returned  to  his  command  November  29. — S.  Smith,  Act.  .isn't  Siiry.,  TJ.  S.  A., 
Central  Park  Hospital,  X.  V. 

Case  9. — Sergeant  William  H.  >Smith,  Co.  B,  6tli  Md.  Vols.;  age  25;  was  admitted  August  19,  1863,  as  a  case  of 
typho-malarial  fever.  He  was  much  exhausted  by  the  ftitigues  of  his  journey  to  hospital ;  ])ulse  120,  feeble  and 
vibrating ;  skin  dry;  bowels  very  loo.se,  l)ut  not  tender;  lips  and  teeth  covered  with  sordes.  Delirium  and  subsultus 
tendinnm  set  in  on  the  22d,  with  involuntary  passages  and  some  tenderness  of  the  bowels.  On  the  26th  he  appeared 
to  be  improving,  b(iing  at  times  rational,  but  the  prostrati(Ui  increased  and  death  occurred  on  the  30th.  The  treat- 
ment consisted  of  the  administration  of  neutral  mixture,  acetate  of  lead  and  opium,  small  doses  of  quinine,  turpen- 
tine ennilsion  and  milk-pnncb  ;  the  general  surface  was  sponged  repeatedly  with  diluted  alcohol,  and  mustard  was 
appli(Ml  to  the  abdomen. 

("a.se  10. — Private  (jeorge  W.  Hamilton,  ('o.  (i,  6th  Md.  Vols.;  age  22;  was  admitted  August  19,  1863,  iu  a 
dying  condition  from  ty]iho-inalarial  fever.  He  had  diarrlnea  witli  involuntary  stools,  fulness  and  tenderness  of  the 
abdiinu'n  and  sordes  on  his  li])s  and  gums.  He  liecame  delirious  on  the  21st  and  much  prostrated.  He  died  next 
d.iy.  .Neutral  mixture,  astringents,  stimulants  and  siHinging  with  warm  water  and  alcohol  were  used  in  the  treat- 
ment.—  Gcori/c  ,s'.   Hdiiiitt,  Act.   Ass't  Sin-ij.,  U.  S.   A.,  Fairfax  ScmiDary,  Va. 

Cask  11.— Private  Alfred  Cha.se,  Co.  V,  35th  N.  J.  Vols.;  age  19;  was  admitted  May  16,  1865,  with  ty])ho- 
nialarial  fever.  He  had  been  ailing  for  sonui  days  jirior  to  admission,  but  had  not  been  confined  to  bed.  In  a  few 
days,  however,  cerebral  symptoms  set  in,  acconii)anied  with  a  profuse  diarrhcea,  and  the  patient  sank  rapidly, 
dying  on  the  23d.  He  was  treated  at  first  with  acetate  of  ammonia  and  afterwards  with  moderate  doses  of  (|iiinine, 
opiates  and  stimulants. — ,T.  J).  Smith,  Act.  Ass't  Sur/f.,  V.  S.  A.,  Fairfax  Seminarij,  Alexandria,  Va. 

Case  12. — .James  MiK^ueen,  nnassigned  recruit,  was  a<lmitted  May  19, 1865,  with  typho-malarial  fever.  He  was 
received  from  the  provisional  cam]).  N'irgiiiia,  in  a  critical  condition.  Ilis  sickness  had  lasted  ten  weeks.  When 
admitted  he  was  under  the  inlliienee  of  a  chill,  which  was  followed  by  fever  and  profuse  perspiration.  He  was 
deliiioiis  most  of  tln^  time.  His  tongue  was  coated  and  very  red;  bowels  regular;  pulse  110  and  feeble,  and  be 
experienced  much  dilliciilty  iu  urinating.  Three  grains  of  (|uinine  and  Dover's  powder  were  directed  to  be  given 
every  three  hours,  and  twenty  grains  of  calomel  at  night,  followed  by  a  full  dose  of  castor  oil  and  opium  in  the 
nuirniiig.  Brandy  was  added  to  the  treatment  on  the  22d,  on  which  day  the  fever  and  perspirations  continued,  with 
dilliciilty  of  swallowing  and  much  gastric  irritability.  Hiccough  and  subsultus  teudinuiu  appeared  on  the  23d,  with 
increasing  perspiration  and  involuutary  jiassages  on  the  26th.  He  ajipeared  a  little  better  on  the  27th,  taking  some 
nourishment,  although  tbe  delirium  and  the  involuntary  passages  continued.  Death  took  place  on  the  29tli. — Fairfax 
Seminary,  Va. 

Case  13. — Private  Daniel  McCiimber,  Co.  If,  2(>th  Mich.  Vols.,  was  admitted  Novemlier  4,  1863,  with  typho- 
malarial  fever.  The  patient  was  incoherent,  constantly  endeavoring  to  get  out  of  bed.  He  had  fever  of  a  remittent 
tyjie  and  diarrlicea;  pulse  120;  re8]>iration  feeble.  He  perspired  freely  at  times,  but  the  delirium  continued,  the 
pulse  became  weaker,  and  death  took  place  on  the  13th. — I'.  1!.  ItoVy,  Act.  Ass't  Surg.,  U.  S.  A.,  Douylus  Hospital, 
Washington,  D.  C. 

Case  14. — Sergeant  Horace  Hammond,  Co.  F,  124tli  N.  Y.  V<ds.;  age  36;  was  admitted  June  14,  1863,  with 
typho-malarial  fever.  Tbe  jiatient  bad  siitfercd  with  slight  chills  and  fV^verishnes.s,  reclining  several  times  during 
the  day,  for  several  days  foUowiiig  .lune  8.  On  admission  he  had  no  intermittent  symptoms  and  the  case  was  sup- 
posed to  be  incipient  typhoid,  but  its  mixed  character  soon  became  evident.  He  was  treated  with  milk-punch  and 
beel-es.sence,  to  which,  on  August  22,  (juiuine  was  added  at  the  rate  of  sixteen  grains  daily.  At  the  end  of  three 
weeks  he  was  able  to  walk  about,  although  weak  and  having  a  slight  diarrhtral  tendency.  He  was  returned  to  duty 
August  24. — V.  C.  Lee,  Ass't  Sunj.,  TJ.   S.  A.,  Douglas  Hospital,  Washington,  I>.  C. 

Case  15.— Private  James  Wheeler,  Co.  1,  IHst  N.  Y.  Vols.;  age  29;  was  admitted  July  26,  1863,  with  typho- 
malarial  fever,  having  been  si(dv  since  the  19tli  with  fever  of  a  tj'phoid  type.  The  tongue  was  red  and  moist;  the 
pulse  fre(|iient  and  feeble;  tbe  bowels  loose  and  tender.  He  was  treated  with  opiates  au<l  aromatic  sulphuric  acid. 
(Jii  August  2  tlieri^  was  a  distinctly  marked  remission;  but  the  diarrho'a  continued  and  the  patient  became  enfeel)led. 
(jiiinine  was  given.  Peisiiirations  and  remissions  recurred,  but  delirium  set  in  on  the  7th  and  death  took  place  on 
the  10th. 

Case  16.— Corporal  N.  K.  Stille,  Co.  A,  168th  N.  Y.  Vols.;  age  19;  was  admitted  July  28,  1863,  with  typho- 
malarial  fever.  He  had  been  sick  since  the  22d  with  headache,  pain  in  the  back  and  bowels,  and  diarrluea.  His 
pulse  was  frequent  and  full  and  tongue  coated  and  dry,  but  with  red  edges.  He  had  remissions  with  profuse  per- 
spirations at  the  end  of  the  nu)uth,  having  been  taking  quinine  meanwhile  in  doses  often  to  thirty  grains  daily:  and 
during  the  first  week  of  August  he  had  some  febrile  movement  every  afternoon;  but  bis  tongue  became  moist  and 


THE    COXTrM'Kli    FFA'P'.KS. 


215 


clean  i'lul  liis  l.uwels  roiistiiiatiMl.     ()ii    Aiij;iist    L'lM   In-  was  sent   ti>  \o\v  York   lor  iiiiistci-  out. — fPion/c  .1.   .yiirxiik, 
All.  Ass'l  Shi-i/..   r.  S.  .1..  Sliiiilitii  IliixjiiUd,   iWixhiit'iloii,  I>.  C 

Cask  17. — l'ri\  atc>  Jiiliii  K.niiis.  Co.  K.  iHli  X  V.  t'av.:  ai;i'  10:  was  ailiiiittid  on  i  lie  af'trrnoon  of  May  4,  ISGI, 
wiili  t.\  plin -malarial  lever.  Siirjjeon  K.  M.  Th.^sk  of'  the  !Mh  \.  V.  l'a\.  staled  ilial  tlie  i)atieiit  had  heeii  Kick  for 
tliree  (lavs,  lie  had  deliriniii  witli  stiilior  and  snlisnltiis  teiidinuni:  his  imlsewas  rajiid  and  fnll  and  Ills  ton-iue 
eoateil  with  a  lonj;  \cllow  fur.  He  continued  in  low  delirious  eondit  ion  until  dealli  at  ;(.:>(  I  .\.  M.  of  the  (ith.  Stimu- 
lants and  lieef-tea  were  ;;i\eii.  anil  a  lly-hli.ster  wa.s  ajililied  to  the  na|ie  of  thi'  necU. — /.  .1/.  H  ullack.  Act.  Asu't  .Sm»v/., 
r.  S.  A.,  /Iii.tpitdl  .Vo.  li,  liiiiiij'ort,  S.  ('. 

(  )ulsiilc  of  these  cases,  and  a  tow  elinieal  imtes  to  Ue  [irivciiti'il  liereat'ter  in  connection 
witli  {\iv  i>osf-iui>rteiii  records,  tliere  lias  liecii  lileil  in  this  otlice  iiothin^  that  will  iiulicate 
the  proltalilo  historv  of  the  57,400  cases  (white  4:0,.S71,  coloretl  7.529)  reported  as  typlio- 
Mialarial  I'ever  duriiii;'  the  ]ieriod  extendinu;  tVoni  .lime  :'>(),  1S()2.  to  June  30,  18(^6. 

Skmixamy  llosi'ii'.VL  (WSi'is. — 'riie  cas.e-liooks  of  tli(>  Seminary  JI(>sj)ital,  Cxeorgetown, 
1).  0.,  were  kept  with  iiincli  care  dnriiig  the  autiiimi  and  winter  of  18()1,  while  the  estab- 
lisliineiit  was  under  the  supervision  of  Surgeon  .losKi'ii  II.  Smith,  U.  S.  A.  These  books 
contain  an  iidiuirable  series  of  fever  cases  received  from  the  Army  of  the  Potomac.  As  the 
term  typho-malarial  had  not  been  introduced  at  this  time,  the  cases  wt-ro  entered  on  the 
record  as  tvphoid  or  remittent,  in  accordance  with  the  views  then  held  by  the  attending 
surgeons  as  to  the  symptomatology  of  the  cani]i  fevers.  Later  in  the  war  the  relative  pro- 
])ortious  of  these  fevei's  l)ecame  clianged,  the  percentage  of  pure  tyj)hoid  cases  undergoing  a 
diminution,  partl\-  iVom  an  actual  diM'rease  in  prevalence  and  partly  from  the  comjdicatiou  of 
the  ty|i]ioid  manifestations  with  those  due  to  a  more  extensive  prevalence  of  malarial  dis- 
ease among  the  troops;  but  there  are  no  grounds  for  siipj)osing  that  the  fevers  which  occurred 
immediately  alter  June  ;^)0,  1S02,  dillered  in  ty()e  from  tlio.se  that  occurred  immediately 
before  that  date.  An  examination  of  the  records  of  the  Seminary  Hospital  will  therefore 
show,  among  the  ty])lioid  and  remittent  fevers,  those  which  at  a  later  date  would  have  been 
reported  as  typho-malarial,  in  accordance  with  the  views  of  the  late  Di-.  Wooi)W.\kd. 

The  case-books  contain  the  histories  of  one  hundred  and  twenty-three  cases  of  fever. 
The  entries  were  made  daily,  and  in  some  instances  twice  a  day,  at  the  morning  and  even- 
ing visits.  The  utmost  care  appears  to  have  been  taken  in  recording  every  thing  of  note 
in  connection  with  each  case;  but  this  very  care  renders  the  records  unpresentable  in  their 
original  form  in  a  work  of  this  kind:  the  continued  repetition  of  the  condition  of  the  skin, 
tongue,  pulse,  etc.,  and  the  persistence  of  cerebral,  pulmonary  and  intestinal  symptoms, 
day  after  day  on  the  records,  while  giving  the  cases  their  value,  render  them  unnecessarily 
tedious.  As  presented  below  they  appear  in  a  condensed  narrative  form,  care  having  been 
exercised  to  omit  no  statement  which  tends  in  any  way  to  convey  an  appreciation  of  the 
patient's  condition.     They  have  been  arranged  as  follows  : 

Fifty-one  cases  of  fever,  entered  .as  typhoid,  in  which  there  is  no  ground  for  acknowledging  the  presence  of  a 
prominent  niulariai  complication.    Ten  of  these  were  fatal. 

Sfctii  cKufs  of  fever,  entered  as  rrmittciit,  in  wliich  there  is  nothing  to  indicate  the  presence  of  the  typhoid 
poison.     Xone  of  these  terminated  fatally. 

Thirtji-Jivr  rases  of  fever,  entered  as  tiiphiiUI,  in  which  tlie  records  give  more  or  less  evidence  of  the  coexistence 
of  malarial  di.sease.     Seven  of  these  were  fatal. 

/,'.  n  II  caKiK  of  fever,  entered  as  lyplioiil,  in  which  intermittent  fever  i)receded  the  development  of  the  symptoniB 
which  authorized  the  diagnosis.     Seven  of  tliese  were  fatal. 

J'Ajilil  cases  of  fever,  entered  as  typhoid,  in  which  remittent  fever  seemed  to  precede  or  accompany  the  typhoid 
manifestations.     One  of  these  proved  fatal. 

Eight  uaaef  of  fever,  entered  as  remittent,  in  w  hich  the  rci^ords  give  more  or  I,.jj  evidence  of  the  coexistence  of 
the  typhoid  poison.     One  deatli  occurred  among  these. 

Two  cd,?!'*  of  fever,  entered  as  lyphiiid,  hut  in  which  the  malarial  diseasi'  only  is  jiromineut. 

One  case,  entered  as  typhoid,  but  w  liieh  was  probably  a  case  of  pericarditis. 


216  CLINICAL    RECOi;r)<;    OF 

This  classification  of  tlie  fever  cases  of  the  Seiiiiiiurv  Hospital  is  the  result  of  a  careful 
analysis  of  the  history  of  each.  The  syiuptoius  apparently  regarded  as  characteristic  of 
typhoid  fever  by  our  medical  officers  were  separated  from  the  aggregate,  while  holding  in 
view  the  clinical  phenomena  of  malarial  fever  as  deduced  from  the  cases  presented  in  the 
third  chapter  of  this  volume.  A  defined  periodic  character  of  the  chills,  fever  or  perspira- 
tions, epigastric  pain,  gastric  irritability,  hepatic  tenderness,  jaundice,  densely  coated  or 
large  and  flabby  tongue,  constipation  or,  concurrent  with  diarrhoea,  an  umlMlical  or  general 
abdominal  tenderness,  and  a  manifest  influence  of  quinine  on  the  febrile  condition,  were 
regarded  as  indicating  the  presence  of  the  malarial  poison  in  the  system.  Certain  symp- 
toms in  the  Seminary  Hospital  cases  appeared  common  to  both  forms  of  fever,  eitlier  as  the 
result  of  the  febrile  action  or  of  the  specific  influence  of  its  cause.  Increased  heat,  circu- 
latory excitement,  diminished  secretions,  cei'ebral  disturbance  amounting  to  delirium,  stupor 
or  coma,  hemorrhagic  extravasations  or  other  general  manifestations  of  a  depraved  condition 
of  the  blood,  were  therefore  excluded  from  consideration  as  indefinite  in  their  indications. 
There  remained  a  set  and  sequence  of  symptoms,  to  be  piirticulai'ized  hereafter,  which  our 
medii-al  oflicers  evidently  regarded  as  pathognomonic  of  tvphoid  fever. 

Of  the  one  hundred  and  twenty-two  cases  in  the  records  of  this  hospital,  excluding  the 
case  of  mistaken  diagnosis,  one  hundred  and  seven  were  regarded  as  typlioid  and  fifteen  as 
remittents  by  the  physicians  in  attendance.  But  on  arranging  them  in  accordance  with  a 
typho-malarial  symptomatology,  tlun^e  are  found  to  be  fifty-one  cases  of  typlioid  fever, 
seven  of  remittent  and  sixty-four  of  typho-malarial  fever,  fifty-six  of  the  last  having  been 
drawn  from  the  record  of  typlioid  cases  and  eight  from  that  of  the  malarial  fevers. 

The  fifty-one  typhoid  cases  furnished  ten  deaths  or  19.6  per  cent.,  and  the  sixty-four 
typho-malarial  cases  sixteen  deaths  or  25.0  per  cent.;  none  of  the  pure  remittents  died. 
These  results  diflfer  markedly  from  the  percentages  obtained  from  the  numerically  reported 
cases.  As  may  be  seen  l)y  Table  XLII,  typhoid  fever  during  the  war  gave  a  mortality  of 
35.9  in  every  hundred  cases,  while  typho-malarial  fever  was  credited  with  only  8.14  per 
cent,  of  fatal  cases. 

Although  fifty-six  of  the  sixty-four  cases  of  typho-malarial  fever  were  reported  as 
typhoid,  it  is  evident,  from  the  record  of  treatment,  that  the  medical  officers  were  not 
ignorant  of  the  presence  of  the  complication  nor  of  the  importance  of  removing  it  by  specific 
medication.  But  as  malarial  fever  gave  a  small  mortality  and  typhoid  fever  a  large  one, 
the  more  dangerous  disease  was  naturally  entered  on  the  record  as  the  diagnosis.  These 
cases  illustrate  the  true  typho-malarial  fever  of  the  autumn  of  1861,  as  well  as  those  which 
occurred  at  a  later  date;  but  it  is  manifest,  from  the  mortality  rates  to  which  reference  has 
been  made,  that  they  do  not  give  information  concerning  all  the  classes  of  cases  which 
were  afterwards  reported  as  typho-malarial. 

Fifty-one  Typhoid  C.\se.s. 

Case  1. — An  inrompleic  record. — Private  Henry  A.  Hitchcock,  Co.  1?,  3<l  Vt.  Vols.;  age  2.5;  was  admitted  Oct.  1, 
1861,  as  a  case  of  tyjihoid  fever.  On  the  2<1  he  was  dull,  stuiiid,  (U'af.  and  had  fuliie.ss  of  the  head,  tinnitus  aurinni 
and  some  (h'liriuin  and  sul>sultus:  his  slvin  was  jiot  and  dry;  tonj^ue  pale,  red  at  ti]>  but  coated  gray  in  the  centre; 
he  had  also  some  diarrhcea,  slight  tynii)aniteM  and  acute  iliac  tenderness.  C^uinine  was  given.  Next  day  the  skin 
was  moist  and  hut  one  stool  was  passed  ;  Wie  acute  tenderness  continued.     He  was  returned  to  duty  on  the  2Sth. 

Cask  2. — A  liyltt  fehrile  attack,  unmarked  by  upecijic  symptoms. — Private  Fospeld  Black,  Co.  C,  Ist  Long  Island 
Vols.,  was  admitted  SeptemLer  14,  18(il,  having  been  sick  for  twelve  days.  The  disease  l)egan  with  chills,  which 
were  followed  by  fever,  pain  in  the  head  and  bones,  buzzing  in  the  ears,  epistaxis,  anorexia  and  weakness.  On 
admission  he  slept  well  after  a  bath,  and  next  morning  liis  tongue  was  coated  yellowish-white,  skin  hot  but  moist, 
liowels  regular;  he  was  a  little  drowsy  and  had  some  cough.     l)(>vi-r"s  powder  was  given  at  night.     He  rested  well, 


TITK    r'OXTTXT'F.ri    FI-.VK?,-:.  217 

1111(1  on  tho  l(;tli  li:i(l  II  Kiiod  iipiic^litc  niiil    .|iiiri    Imui-Is.  l.ul    liis    lniiL;iir  wns  wliitc.     Cnstor  oil  ]iroillU'('(l  two  sIdoIh. 
No  riirllici-  ilii-:itioii  \\;is   i  i-i|  ii  ircd.      His    lniii;ni'   l)cc;iinc  cIcMii.      lie  w:is  icl  iinicd  to  duty  on  tile  iiOlli. 

Cask  '.i.—>^li<ihl  iiili  xliinil  KiimiiUim"  kihI  ;</.m -cii/i/ck?  sjhiIx.  hiil  y);i>(/C(  .■<«  mil  nparlid  in  (Idiiil.  —  Private  .losi-]di  Cald- 
well, Co.  K,  iMli  l>a.:  ji^'c  21:  was  adniitli'd  St-iitcnilx'r  V.K  INII.  as  a  case  ot'  typhoid  IVvit.  \lv  had  liccn  sick  I'rn' a 
week,  at  lirst  with  cliills  and  al'tcrwanls  with  jiain  in  the  head  and  bowels.  diaiilMea  and  fever,  whieli  last  was  worse 
in  the  evening  ami  on  alternate  da,\  >.  lie  had  taken  hut  little  niedleine.  On  the  day  of  ad  miss  ion  lu'  had  six  stools, 
with  tenderness  in  1  lie  riuht  iliac  region  and  rose-colored  spots  on  the  chest  and  abdomen.  disa]ipearing  on  pressure: 
the  pulse  was  71  and  slronir:  the  skin  waiiii  and  UKust:  the  toii<;m'  smooth,  lissured.  red,  dry,  ([uito  clean  anteriorly 
but  with  a  brown  fur  jiosteriorly.  On  the  20th  the  eyes  were  sutfused,  the  chetdvs  tliished,  the  pulse  80  and  full,  skin 
dry  and  warm,  the  tongu<'  dry.  lirown  and  lissured;  epistaxis.  anorexia,  tliirst.  one  tliiu  fietid  stool  and  sli>;ht  tender- 
ness of  the  abdomen  are  also  noted.  The  details  of  the  case  are  not  recorded.  'I'lie  )>atii-nl  was  n-lurned  lo  duly 
October  20. 

Ca.se  4. —  ir<(ik}ii.i.f,  |/i(/(/i/i(.s-.v.  (IfoirxiiKfiii,  }iirxj)if(ttio)i.  miihiiiihin  iind  riiac-colond  hikiIs. — Private  .lames  F.  Tomb, 
Co.  H,12th  I'a.;  age  19:  had  headache,  weakness  and  diarrluea  on  August  28,  IHIil,  and  was  admitted  .September  4 
as  a  case  of  typhoid  fever.  On  tlu^  nuirning  of  the  5tli  there  was  slight  lever,  the  |iulse  SO.  weak.tlm  skin  dry  and 
hot,  the  tongue  red,  ilabby  and  coated,  (.^uiniui'  was  onU'red  with  Dover's  powder  at  night,  lie  rested  well  during 
tlie  night,  and  next  day  ha<l  no  fever;  pulse  72,  tongue  heavily  coated,  skin,  warm  and  moist,  bowels  slightly 
relaxed;  nor  did  the  fever  recur  in  the  evening.  The  following  is  the  daily  record  of  obst^rvations  in  this  case:  titli, 
Morning:  rested  well;  ])ul8e  (12 ;  tongue  heavily  coated;  skin  warm  and  moist ;  one  stool;  no  fever.  Kvening:  ]iulae 
72;  skin  warm  and  dry;  tongue  very  red,  coated  white;  one  stool;  no  fever,  (lave  ten  grains  of  Dover's  powder. 
7th,  Morning:  rested  well :  })nlse  7<>;  drowsy;  tongue  eoutetl  brown,  red  at  tip;  skin  warm,  natural ;  bowels  ipiiet ; 
appetite  fair.  Evening:  puls((  (it);  skin  warm  and  moist;  no  fever;  tongue  slightly  coated;  bowels  ([uiet;  appetite 
good.  8th,  Morning:  rested  well;  drowsy;  juilae  .^(i,  weak:  tongue  pale,  slightly  coated  white;  skin  eool,  moist; 
no  fever;  giddiness;  bowels  (jniet;  appetite  fair;  walking  about.  Kvening:  jiulsel'iO:  tongue  coated,  jtale;  skin  coo], 
moist;  appetite  gf)od;  stronger;  bowels  (iniet ;  sleei)y.  !<th,  Kvening:  sli'cpy ;  pulse  natural ;  tongue  pale;  one  thin 
small  stool;  skin  natural.  10th,  Morning:  rested  well;  slept  much  :  pulse  102,  strong;  tongue  coated  white,  moist; 
skin  moist,  warm  :  rose-spots;  profuse  sudamiiui  :  bow(ds  natural,  (iave  wine  of  cinchona.  Kvening:  jiiilse  8.")  when 
standing;  skin  warm  and  dry;  tongue  slightly  coated;  |)rofuse  siidamina;  one  large  stool.  11th,  Morning:  rested 
well;  jinlse  88,  sitting;  tongiu'  jiale,  coated  at  base;  skin  cool;  sudamina  profuse;  three  stools;  nojiain;  ajjpetite 
good:  no  rose-spots.  Kvening:  walking  about ;  some  weakness;  profuse  siidaniiini.  Urdered  rest.  12th,  Morning: 
rested  well;  ))ulse  78,  (|nick,  compressible;  tongne  slightly  coated  gray;  skin  warm,  moist;  no  fever;  i)-ofnso 
sudamina;  lu)  tenderness  ;  one  large  stool ;  walking  annind;  weak.  Evening:  jinlseSO,  sitting;  tongue  ])ale,  slightly 
coated  grayish;  skin  natural,  covered  with  sudamina;  one  uatnral  stool;  appetite  good.  13th,  Transferred  to  hospital 
at  Haltimore,  Md. 

Case  .">,. — Tin-  mind  contiiiiiirl  tiffcctrd  after  the  other  xi/mpfomx  hud  ditappcared. — Private  Charles  Whitfield,  Co.  B, 
1st  Mich.;  ag(^  25;  admitted  starch  2,1862.  Diagnosis — typhoid  fever  and  chronic  bronchitis.  On  tlu^  4th  he  was 
(juite  deaf,  <lrowsy  and  delirious;  he  was  hoar.se  ami  had  a  frecjuent  cough  with  free  expectoration;  his  checks  were 
hot  and  Hushed,  and  he  had  much  thirst;  pulse  rapid  and  weak;  tongue  somewhat  dry,  quite  red  and  with  enlarged 
papilliB;  stools  not  frequent  hut  loose;  abdomen  tender.  Two  watery  stools  were  passed  on  the  .Otli.  The  tongne 
became  moist  on  the  6th,  the  apjietite  returned  and  the  bowels  were  quiet,  but  the  other  symptoms  remained  unchanged. 
On  the  7th  the  deafness  lessened  and  the  hoarst^ne.ss  and  cough  diminished;  pulse  !M),  good ;  skin  natural;  tongue 
moist,  fissnred,  clean;  bowels  unmoved;  but  the  mind  continued  affected  for  sonu^  time  longer.  On  thi^  l!-!th  ho 
re])lied  naturally  to  <|nestions,  but  had  curious  hallucinations  which  returm-d  occasionally  for  several  days  after 
this,  and  the  deafness  continued  for  some  days  longer.  During  this  time  the  bowels  were  regular  or  inclined  to  con- 
stipation. Milk-punch  and  tincture  of  iron  were  used.  He  was  able  to  walk  about  on  the  27th.  On  A])ril  26  he  was 
discharged  for  disability. 

Case  6. —  Deafness;  successire  crops  of  rose-reel  eruptions;  botcels  quiet  but  for  castor  oil;  skin  moist;  date  of  onset 
nndefined. — Private  Charles  Cheney,  Co.  G,  9tli  Pa.  Vols.  Admitted  Sept.  19,  1861.  Diagnosis — typhoid  fever.  No 
note  of  the  case  was  taken  until  the  2M,  when  the  patient  w-as  reported  as  quite  weak  and  without  appetite;  his 
pulse  85  and  ([uick;  face  flushed;  eyes  sutfused;  sense  of  hearing  somewhat  dulled;  skin  natural,  showing  an  eruption 
which  was  not  considered  characteristic;  tongue  brown  in  the  centre  and  moist  at  the  edges;  bowels  ([uiet.  Tinc- 
ture of  iron  was  ordered  three  times  daily,  turpentine  eiuulsion  every  three  hours,  and  Dover's  ])owder  at  night.  Ho 
slept  some  during  the  night  and  perspired  towards  morning,  when  the  eruption  of  the  i>revious  day  was  found  to  have 
disappeared  and  been  replaced  hy  an  abundance  of  rose-colored  spots;  there  was  some  borborygmus,  but  no  stool 
and  no  tenderness  or  tympanites  of  the  abdomen.  The  patient  was  thirsty  and  his  tongue  red,  dry  and  slightly 
furred,  hut  there  was  less  deafiu'ss.  In  the  evening  castor  oil  was  given, after  which  he  slept  badly  and  had  live  passages 
from  the  bowels  during  the  night  with  some  umbilical  pain;  he  perspired  towards  morning.  Next  day  the  tongue 
w  as  red,  dry  and  glossy,  and  the  eruption  fading.  On  the  evening  of  the  2.">th  acetate  of  lead  and  tannin  were  given 
with  Dovei's  j)owder.  On  the  2()th  the  ])ul.se  was  80,  the  skin  soft  and  natural,  the  erui)tion  disappeared,  the  tongue 
yellowish  and  slightly  furred,  the  appetite  improved  and  the  bowels  ([uiet.  Some  rose-spots  appeared  on  the  27th 
an<l  28th,  disappearing  on  the  30th.  The  bowels  remained  unmoved  from  the  26th  until  the  30th,  when  there  was 
one  stool;  after  this  they  continued  unmoved  until  October  3,  when  the  record  closes, — the  i)atient'8  skin  being  in 
natural  condition,  his  tongue  clean  but  a  little  dry  in  the  centre  and  his  appetite  good.  He  was  transferred  to 
Annapolis,  Md.,  on  the  10th. 

Cask  7. — Drowsiness  ;  nhdomintil  symptoms  slightly  marked;  ruse-colored  spots  on  Qlh  day;  eonralescent  on  the  Vjth. — 
Mki).  Hist,,  Pr.  HI— 28 


218  CLTNfCAL    RECORDS    OF 

Private  (i.  W.  Bcciiiiin.  Co.  A,  4tli  Mich  Vols.:  nfxr.  lil;  was  jiilMiitt(<l  Oct.  I!i>,  IStU.  Diagnosis  —  typhoid  fever. 
He  liad  cliills  on  the  L'.">tli,  followcil  by  lever  and  dial  rhiea,  lor  which  (|iiiiiiiie  had  hceii  fjiveii.  On  the  eveiiiugof 
admission  he  was  drowsy,  liis  face  sliglitly  llushcd,  [nilsc  85  and  of  good  strength,  skin  dry  and  warm,  showing  a  few 
rose-colored  s]ioIs  on  the  abdomen  and  ehest,  tongue  red.  sniootli,  dry  and  glossy,  teeth  blackened  with  sordes,  how(ds 
(iniet;  li»^  had  no  appetite,  some!  abdominal  tenderness  and  gurgling,  but  no  meteorism.  Milk-punch,  turpentint^ 
emulsion  and  beef-essence  were  prescribeil  on  November  2.  Theskin  became  covered  with  sudamina  on  tlu^  Ith  and 
the  appetite  was  imi)roved.  A  full  dose  of  castor  oil  on  this  day  pro<lnced  one  large  evacuation.  On  thi^  7th  the 
l)atient  was  looking  bright  and  lively,  and  on  the  following  day  was  \\]>  and  walking  about.  He  was  transferred  lo 
Annapolis  Md.,  ou  the  18th. 

Ca.sk  8. — Ueatlutlie  (iiul  di:zincss  ;  howth  quiet  notiritliiitandinij  piirydlirc  inKlivincn,  hut  rii/lit  ilidv  rri/hiii  tcudir;  cii.vc- 
spotH  (III  the  \itk  day,  n-iih  cdnralescenci'  Hucccfdinij. — Corjioral  H.  F.  (jale,  Co.  A, -Ith  Mich.;  age  20;  was  seized  about 
Sept.  0,  1801,  with  weakness,  pain  in  the  head  ami  back  and  fever,  and  was  admitted  as  a  case  of  tyi)hoid  fever.  In 
the  evening  his  pulse  was  found  to  be  il2,  ([tiick  and  strong,  skin  natural,  tongue  red  at  tip  but  coated  slightly  in  thi' 
middle,  bowels  (^uiet  and  appetite  poor.  Ten  grains  each  of  calomel  andjalap  were  given.  Xext  day  the  pulse  was 
74,  the  skin  natural  and  moist,  the  tongue  white  in  the  cetitre  and  red  at  the  edges,  and  the  bowels  quiet.  Quinine 
was  ordered.  In  the  evening  the  pulse  was  66  and  the  skin  and  tongue  unchanged.  One  stool  was  passed  in  the 
morning;  no  tenderness.  The  patient  had  slight  headache  and  dizziness.  The  bowels  renuiined  quiet  during  the 
following  daj-s,  but  some  tenderness  was  manifested  in  the  right  iliac  region.  The  skin  continued  warm  and  nu>ist 
and  the  tongue  unchanged,  although  the  patient  developed  some  appetite.  ■  On  the  20th  he  was  sitting  up.  On 
tlie  21st  ho  had  tinnitus  anrium  and  some  thirst,  but  the  pulse  was  l>l,  tongue  clean  and  appetite  good.  On  the 
22d  a  few  rose-colored  spots  appeared,  the  patient's  condition  otherwise  renuiining  unaltered.  He  was  improving  gen- 
erally when,  on  October  1,  he  was  transferred  to  hospital  at  Annapolis,  Md. 

Ca.se  9. — VeafneHs;  dizziness,  but  menial  faculties  clear;  diarrhita ;  rose-colored  spots  on  the  10th  and  12th  days, 
fading  on  Uth,  ichen  convalescence  followed ;  to  duty  on  21th  day. — Private  (jeorge  N.  Barber,  Co.  (i,  14tli  N.  Y.;  age  18; 
Wiis  admitted  Hept.  20,  1861,  having  been  taken  sick  a  week  before  with  weakness,  pains  in  the  head,  back  and  bowels, 
and  epistaxis.  Diagnosis — typhoid  fever.  On  adnussion  the  pulse  was  114,  the  skin  hot  and  moist,  the  face  flushed, 
the  tongue  gray  in  the  centre  and  red  at  the  tip  and  edges;  there  was  diarrluea,  with  irritability  of  the  stomacli  and 
much  tenderness  in  the  right  iliac  region;  the  patient  was  sometimes  atfected  with  dizziness,  but  his  nnnd  was  clear. 
]51ue-pill  was  given.  On  the  2l8t  he  had  five  stools  with  persisting  tenderness  and  gtirgling,  anorexia,  a  slight  cough 
epistaxis  and  deafness;  his  face  was  Hushed,  skin  hot  and  moist,  tongue  red  at  til),  whitish-gray  at  base.  On  the  22(1 
the  epistaxis  recurred;  the  tongue  was  dark-red  at  the  tip,  brown  at  the  base,  and  its  papilhe  were  prominent;  the 
skin  was  warm  and  dry  and  presented  one  or  two  rose-colored  spots;  one  stool  was  passed  and  the  tenderness  con- 
tinued; pulse  76.  Quinine  in  eight-grain  doses  was  given  three  times  daily,  with  morphia  at  night.  The  eruption 
fade<l  next  <lay,  but  appeared  again  on  the  24th.  The  tongue  began  to  clean  on  the  22d  and  the  skin  softened  on 
the  same  day,  after  which,  although  the  bowels  continued  relaxed  and  tender  for  a  few  days  and  the  throat  liecame 
slightly  sore  on  the  27th,  there  was  a  steady  improvement,  and  the  patient  was  returned  to  duty  October  9. 

Ca.sk  10. — Deafness;  muscular  twilchinys ;  ruse-colored  eruption;  aMomen  tender,  scaphoid;  improremeut  after  the 
second  week. — Private  William  Patterson,  Co.  K,  6th  Wis.;  age  28;  was  admitted  Oct.  2, 1861,  with  typhoid  fever.  The 
condition  of  the  patient  is  not  stated  until  six  days  after  admission,  when  his  pulse  was  weak  and  compressible,  110; 
countenance  haggard ;  cheeks  sunken ;  eyes  suffused ;  tongue  slightly  coated  brown  and  very  dry  and  fissured,  as  the 
mouth  was  open  much  of  the  time;  lie  was  very  deaf  and  dilhcult  to  arouse;  he  spoke  with  much  effort,  and  had 
exciuisite  tenderness  in  the  epigastric  and  right  iliac  regions  and  spasmodic  twitchings  of  the  arms.  Whiskey-punch 
was  given  every  hour.  Next  day  the  eruption  appeared  over  the  abdomen  and  the  tenderness  was  very  much  lessened  : 
sinapisms  were  applied  where  the  tenderness  had  been  acute.  The  abdomen  became  scaphoid  on  the  lOth,  the  tongue 
clean  and  very  red,  the  face  much  sunken  and  the  eyes  sutfused  and  surrounded  by  dark  areolie;  pulse  104;  the 
patient  had  much  thirst,  cough  and  hurried  respiration.  Next  day  the  countenance  was  more  natural  and  the  tongue 
moist.  On  the  12th  the  expression  was  better,  the  eyes  clearer,  and  there  was  less  epigastric  and  umbilical  jiain.  The 
sinajtisms  were  repeated  on  this  day.  After  this  the  patient  gradually  improved,  although  for  some  days  the  skin 
continued  dry  and  husky,  the  bowels  somewhat  relaxed,  about  two  thin  stools  daily,  and  the  right  iliac  region 
slightly  tender.  On  November  1,  when  he  was  transferred  to  Annapolis,  Md.,  his  pulse  was  natural,  appetite  good 
and  bowels  regular. 

Cask  11. — Bronchitis  prominent. — Private  .J.  Little,  Co.  H,  3d  Mich.  Vols.;  age  26;  was  admitted  October  19, 
1861.  Diagnosis — bronchitis.  About  October  12  he  was  taken  with  pain  in  the  head,  neck,  back  and  lind)s,  and  with 
loss  of  appetite.  Throughout  the  progress  of  this  case  there  was  cough  with  nnioli  yellowish  expectoration  and  some 
dyspnoea.  Rose-colored  spots  appeared  on  the  day  of"  admission,  and  continued  to  erupt  until  the  30th.  There  was 
headache  with  dizziness,  ringing  in  the  ears  ami  for  a  short  time  deafness;  the  tongue  was  moist,  white  in  the 
centre  and  red  at  the  tij)  and  edges:  the  pulse  was  usually  80;  the  skin  hot;  the  bowels  relaxed,  two  to  four  stools 
daily  being  passed  ;  the  abdomen  tym])anitic  and  tender,  especially  in  tlu^  right  iliac  and  umbilical  regions.  On  f  hi^ 
31st, on  the  disappearance  of  the  erniition,  the  skin  was  of  the  natural  temperature,  so  recorded  for  the  lirst  time; 
the  tongue  coated,  but  the  appetite  good;  one  stool  was  passed;  there  was  slight  headache,  and  the  cough  persisted, 
with  asthmatic  paroxysms  at  night.  He  was  transferred  to  Annapolis,  Md.,  ou  November  1,  and  discharged  on  the 
13th  on  account  of  "fever." 

Ca.sk  12. — Symptoms  yenernlly  not  strongly  marked;  free  rose-colored  eruption  from  llh  to  IStli  day  ;  dysuria  from 
20th  to  2Sth  day;  conralcscencc  rapid. — Private  J.  E.  Hollom,  Co.  11,  6th  Me.;  age  22;  of  large  frame  and  stont  habit, 
was  taken  about  Sept.  3,  1861,  with  pain  in  the  head,  back  and  shoulders,  slight  fever,  epistaxis  and  diarrhiea.     He 


THE    rOXTTNTED    FEVER?. 


219 


was  a<li]iit<e(l  on  tlio  Ofli  us  n  casr-  (if  tyiilmiil  IVvi-r,  Tlu'  |iati<-iit  was  weak  :  liis  tim{;ni>  niatcd  at  llic  base,  pale  at 
lip  and  moist  :  skin  liot  ami  ilry.  sliowiii^  a  inni'iisiDii  nl'  nisc-i-olon-il  s|iols;  liis  clu'cks  wcic  lliislu-d,  i|iiitt<  red,  and 
lie  bad  couf^b  and  hoarst'iit'ss.  but  bis  bowels  w  itc  niiift.  1  io\  el's  powib'r  was  jjivfii.  llf  ri'sli'd  well,  but  next  moni- 
iw^  tlif  li'VfV  ran  lii;;b;  pulse  104:  skin  lint  and  diy:  t'aco  niucli  llusbt-d:  touf^ue,  iini]di'  at  tbc  ti]),  coati'd,  jiab': 
biiffc  numlici's  of  iost>-spots  on  tbe  ab(Uiuu'n,  tbifjbs  anil  back,  disappcariuj;  on  ])iessui'o;  one  tliin  stool :  boiboi  yf;mns: 
anorexia.  Squill  and  tartar  euietie  were  fjiveu  to  allay  tbe  coufib.  In  tbe  eveniuj;  tbetlusbed  eonditiiui  of  the  faee 
oontinneil  and  tbe  patient  became  drowsy. — pulse  ll»<,  but  tbe  skin  lieijan  to  be  nM)ist  :  four  suuiU  tbin  stools  were 
pa.ssed ;  but  there  was  no  abdouiiual  pain,  tenderness  mir  borbory^mus.  Xext  day  tbe  skin  was  persjiiring  and 
eovered  with  rose-spots,  tbe  pulse  had  fallen  to!l2,  and  tbe  patient's  drowsiness  was  dissipated  and  biseousb  lessened; 
he  bad  e]>istaxiM.  In  the  evenin<;  he  sat  up  for  a  short  time.  ( )u  the  l'_'th  lie  bad  four  small  stools  and  some  tym- 
panites, but  no  pain  nor  tenderness.  In  the  cvi-ning  tbe  face  was  tluslu'd,  eyes  injeeted,  skin  hot  and  dry,  lull  I  be 
mind  jierfeetly  elear.  Tbe  diarrluea  abated  gradually,  and  on  tbe  ITith  be  bad  one  natural  pas:ia}j;e;  imi  whieli  day 
the  skin  was  in  luitural  condition,  the  tongue  dark-red  and  slightly  coated  and  the  mind  elear:  tlu'  patient's  t'ace 
wa.s  tinshed,  and  he  had  souu-  cough  and  hoarseness;  the  rose-spots  continued  on  the  surface  and  ilid  not  disapiiear 
Ihially  until  the  20tb.  On  the  22d  the  patient  eomj>lained  of  dysuria,  occurring  suddenly  after  beginning  to  urinate, 
and  accompanied  by  the  passage  of  a  few  drojts  of  blood  and  p.iiu  in  the  cud  of  tbe  (HMiis  ;  this  continued  nu)re  oi'  less 
until  tbe  :H)tb.     On  October  2  be  was  employed  in  light  duty  about  the  ward,  and  was  returned  to  duty  on  tbe  211th. 

Case  IS. — I)ic:hu'n>i  and  (Iniwxiiiisn;  inlt>itin<il  s>/mjittiiii«  hVujIit  ;  mi  ronc-coloml  Kpuls ;  (lifcrriwciiaalioiit  tiiil  of  xivonil 
well:;  cniifalesccnce  on  2Uh  day. — I'rivate  W.  T.  Smith,  t'o.  C,  1st  Long  Island  Vols.;  age  20;  was  admitted  Sept.  14, 
IXIil.  Diagnosi.s — typlioid  fever.  Ten  days  before  admission  be  bad  chills,  followed  by  fever,  increasing  debility,  pain 
ill  the  head  and  bones,  anorexia  and  slight  diarrlnea.  Ho  rested  well  after  a  bath  and  Dover's  i>owder,  and  on  the 
15th  the  pnlso  was  8S,  tongue  moist,  red  at  the  tip  and  sides,  brown  in  centre,  bowels  regular,  skin  dry  and  warm. 
In  the  evening  he  was  drowsy  and  had  a  sense  of  heaviness  over  the  eyes;  the  bowels  were  cpiiet.  Sulphate  of 
magnesia  was  given  with  the  eft'ect  of  moving  tbe  bowels  twice.  After  this  the  bowels  remained  quiet,  but  with 
some  tenderness  and  gurgling  in  the  right  iliac  region.  Th<'  tongue  became  somewhat  dry  on  the  18th,  hut  regained 
its  moisture  in  a  few  hours.  The  skin  bi^caiue  nuiist  on  the  20tb,  the  ajipetite  returned,  and  tin'  sense  of  heaviness 
in  the  head  was  removed.  On  the  22d  tur]ieutiiM'  emulsion  and  one  ounce  of  brandy  were  ordere<l  for  administration 
every  three  hours.  He  resteil  poorly  on  tbe  21th  and  had  some  nausea  and  less  apjietite.  Castor  oil  was  adminis- 
tered, and  repeated  on  the  2()tb  and  on  tbe  2!ltb,  after  which  one  drachm  of  extract  of  senna  was  given  daily  for 
some  days  on  account  of  headache  and  dizziness.  He  was  able  to  sit  up  on  the  27th,  and  was  transferred  to  Annap- 
olis, Md.,  on  Oct<d)or  10th.     No  rose-colored  spots  were  observed  in  the  case. 

Cask  M. — Hciidache  ;  vn  diiirrhwa  ;  nuccessivc  crops  of  eruption  ;  ei>nrale»ceiice  foUoirin;/  free  perspirations  on  the'ilth 
dojj. — Coriioral  .Joel  E.  Yaw,  Co.  H,  1st  L(uig  Island;  age  19;  had  chills,  fever  and  headache  on  Sept.  9,  IWtil,  and  was 
admitted  on  (Jctober  1st  as  a  case  of  typhoid  fever.  On  admission  his  pulse  was  95,  full  and  strong;  skin  slightly 
al)ove  the  natural  temperature  and  covered  with  elevated  rose-colored  spots  on  the  chest  and  abdouu'U ;  tongue  moist 
an<l  heavily  coated  brown  in  the  centre;  appetite  poor.  (Jniuine  was  given  on  the  2d,  tincture  of  iron  on  the  3d, 
and  turpentine  emulsion,  three  times  daily,  on  the  4th.  One  stool  was  pa.ssed  daily.  On  the  5th  he  was  jier- 
spiring  freely,  and  the  chest  and  abdomen  were  covered  with  rose-spots  and  su<lamiiia;  ou  this  and  the  following 
day  he  had  a  slight  diarrhteal  attack.     After  this  lie  gradually  improved  and  was  transferred  to  Annapolis,  Md. 

Case  15. — Menial  diihiess;  delirium;  eruption;  diarrliwal  affection  nut  prominent  as  a  si/nqytom ;  skin  moist;  date 
of  onset  not  defined. — Private  Frederick  P.  Seclor,  Co.  A,  9th  Pa.;  age  24;  liad  suffered  from  fever  and  ague  in  June, 
1801;  but  since  then  had  clone  his  duty  uninterruptedly  until  Se])tember  lit,  when  he  was  admitted  as  a  case  of 
typhoid  fever.  In  the  evening  the  patient  was  weak  and  had  headache;  the  bowels  were  (juiet,  but  there  was  some 
tenderness  in  tbe  right  iliac  region  and  intestinal  gurgling;  face  tlusbed;  eyes  bright;  breath  oft'ensive;  pulse  88: 
skin  hot  and  moist;  head  cool  and  sweating;  tongue  grayish-yellow  in  the  centre,  red  and  clean  at  the  edges.  Ten 
grains  of  calomel  and  jalap  were  given.  Next  day,  with  a  continuance  of  the  symptoms  stated,  the  patient  became 
dull  and  stupid  and  had  mnscie  and  tinnitus.  Ou  the  night  of  the  21st  there  was  delirium,  and  the  characteristic 
eruption  appeared  on  the  22d,  on  which  day  also  he  had  two  stools  with  some  tympanites  and  ten<lerness;  his  tongue 
was  black  at  the  base,  reddish-white  in  the  centre  and  red  at  the  tip.  Turpentine  emulsion  and  wine  were  given. 
Next  night  he  was  again  delirious,  and  ou  the  23d  dull,  the  skin  unaltered  save  by  the  fading  of  the  eruption  from 
the  chest  and  abdomen,  the  bowels  quiet,  slightly  tympanitic  but  free  frcm  tenderness,  and  the  tongue  cleaning. 
Dover's  powder  was  given  in  small  doses,  with  stiniulauts.  An  enema  was  administered  on  the  24th,  with  two  grains 
of  blue-pill  and  one  of  quinine  every  three  hours.  By  the  2tith  the  eruption  had  disappeared,  but  the  patient  con- 
tinued dull;  the  skin  was  moist,  the  tongue  cleaning.  The  bowels  were  moved  once  on  this  day  and  on  the  27th, 
and  some  tenderness  and  tympanites  remained;  but  after  this  the  tongue  liecanie  dean,  the  appetite  good  and  the 
bowels  natural.     The  patient  was  returned  to  duty  October  20. 

Case  16. — Date  of  onset  not  specified;  delirium;  rose-colored  spots ;  diarrluxa  persists  after  the  occurrence  of  profuse 
perspirations. — Private  Harrisim  Woods,  Co.  K,  5th  Wis.;  age  2() ;  was  admitted  October  1,  1861,  with  typhoid  fever. 
He  had  been  taken  about  September  1  with  diarrhiea  followed  by  fever.  t)n  the  day  after  admission  his  face  was 
tlusbed,  eyes  injected,  pulse  100,  skin  hot,  covered  with  perspiration,  tongue  moist,  red,  appetite  not  wholly  lost;  he 
had  some  headache  liut  no  diarrhcea  nor  cough.  Tincture  of  iron  was  ordered  three  times  daily.  On  the  3d  rose- 
colored  spots  were  noticed;  the  skin  continued  moist  but  the  tongue  was  dry,  red  and  glos.sy.  Emulsion  of  turpen- 
tine was  given.  Next  day  sudamina  appeared,  and  the  patient  was  dull  mentally,  iiuite  deaf  and  at  times  delirious. 
Kose-colored  spots  were  very  numerous  on  the  6th  and  7th.  The  bowels  were  moved  two  or  three  times  daily,  and 
there  was  more  or  less  of  right  iliac,  umbilical  and  even  general  abdominal  tenderness  and  meteorism.     The  tongue 


220  CLT^ncAL  recorps  op 

lii'oamc  iiiiiist.  on  tlic  KHIi.  tlic  fare  loss  flnslinl  anil  ilic  eyes  clfaivr.  The  deliriuiu  disappeareil  on  the  12tli,  hut  tlio 
(Icafucss  and  tinnitus  auriuni.  tofictlicr  with  I  lie  dial  rliu'ii  causing;  tliii'c  to  live  stools  daily,  continued  up  to  tlie  tinu' 
of  tlic  jiaticufs  tiansl'cr  to  Aiina))olis  on  Tv'ovcudxu-  Ist.  A  large  crop  of  rose-colored  spots  appeared  on  the  20th  and 
a  few  nioi'e  on  th(^  "ittli.     [Tliis  jiatii'ut  was  returned  to  duty  Xoveniher  il.] 

Cask  17. — IhafiicHs  itiid  iijiIkhiki  the  prominent  xiiiiipliimn ;  tlUirrhaa  ;  roac-mlored  upots  ou  the  Gth  day ;  iinpronmiiil 
on  thc2\Kl. — Private  \V.  II.  Harrington,  Co.  (4,  liL'd  Mass.;  age  19;  was  taken  sick  March  1,  1«(L',  with  heada<-lie, 
nausea,  dehility,  pains  in  the  linilis  and  diarrluea,  and  was  admitted  next  day  as  a  case  of  typhoid  fever.  No  details 
are  given  until  the  6th,  when  he  was  reported  as  weak,  dull  looking,  very  deaf  and  aphonic;  he  hadepistaxis,  cough, 
accompanied  with  eidgastrio  pain,  and  rose-colored  spots  on  the  abdomen  and  chest.  His  skin  was  hot  and  dry;  face 
congested;  eyelids  putty;  tongue  moist  and  coated:  stools  freiiuent  and  watery.  (Juiuiue  was  given.  The  symj)- 
tonis  continued,  heing  at  times  more  or  less  aggravated,  until  the  21st,  when  the  deafness  was  much  diminished,  the 
voice  iu!arly  recovered,  the  tongue  cleaning  and  the  bowels  regular.  A  discharge  issued  from  the  left  ear  on  the 
night  of  the  ItUh.  On  the  27th  the  general  health  was  improving  rapidly.  On  the  29th  the  patient  was  walking 
about.  On  April  15  he  was  discharged  from  the  service  on  account  of  a  contusion,  the  particulars  of  which  do  not 
appear  on  the  record. 

Case  18. — Cenhral  symptoms  slight ;  diarrhta  abated  after  occurrence  of  pers2>iraiions ;  rose-colored  sjjots  on  13th 
and  15th  days  and  on  11th  and  22d,  accompanied  l>y  sudamina  and  followed  hy  convalescence. — Private  Joseph  Husang,  Co. 
E,  19th  Iowa;  age  19;  had  a  chill  followed  by  fever  on  August  27,  1861,  and  was  admitted  Sept.  4  as  a  case  of  typhoid 
fever.  On  the  morning  of  tln^  5tli  he  had  slight  fever  and  anorexia;  pulse  84,  skin  dry,  tongue  coated  brown  in  the 
middle  and  dry;  the  mind  was  clear.  Quinine  was  given.  In  the  evening  there  was  modi^rate  fever,  the  pulse,  81 
and  strong,  face  flushed,  skin  dry  and  hot,  tongue  very  red,  flabby  and  coated  white,  appetite  poor,  bowels  moved 
four  times;  the  patient  was  weak  and  dizzy  and  had  headache.  Dover's  powder  was  ordered.  No  marked  change 
took  place  on  the  two  following  days;  the  face  became  flushed  towards  evening.  On  the  7th  the  skiu  was  somewhat 
moist,  and  next  day  an  eruption  of  rose-spots  was  observed.  On  this  day,  the  8th,  he  had  six  thin  painless  stools; 
he  liecamo  restless,  talking  in  his  sleep,  and  in  the  evening  drowsy.  Pills  of  acetate  of  lead  and  opium  were  admin- 
istered. On  the  9th  a  slight  cough  was  developed  with  mucous  and  sibilant  rales;  the  abdomen  became  somewhat 
tender  and  the  rose-spots  disappeared.  In  the  evening  the  pulse  was  68;  the  tongue  moist  and  heavily  coated  brown 
at  the  l)ase;  the  skin  warm  and  moist;  the  l>owels  were  moved  once  during  the  day  without  pain,  but  some  tender- 
ness was  present;  anorexia  continued  and  <'i)istaxis  was  noted.  Next  day  there  was  one  painless  stool;  a  few  rose- 
spots  appeared;  and  in  the  evening,  while  the  skin  was  perspiring  the  tongue  became  dryer  and  there  was  some 
eough,  flushing  of  the  face  and  headache.  Friction  with  alcohol  was  applied  to  the  skin.  The  perspiration  con- 
tinued on  the  11th,  during  which  there  was  one  stool  at  night  and  one  during  the  day,  and  the  patient  became  weak 
and  exhausted.  Aromatic  sulphuric  acid  was  ordered  and  the  body  sponged  with  alcohol  and  nitro-muriatie  acid. 
On  tint  12th  the  skin  became  dry  and  a  ])rofuse  characteristic  eruption  appeared.  The  lead  and  opium  was  omitt<'d. 
Next  day  night-sweats  were  reported  and  some  improvement  in  the  appetite;  but  the  tongue  continued  dry  and 
brown.  Blue-pill  three  times  daily  and  oil  of  turpentine  were  ordered.  On  the  14th  the  tongue  was  cracked,  and 
although  there  had  been  lu)  night-sweats,  the  skin  was  warm  and  moist;  the  l>owels  were  (juiet  and  the  appetite 
improved;  in  the  evening  there  was  a  slight  cough  with  diminution  of  the  appetite.  The  night-sweats  returned  o:i 
the  16th,  when  also  the  tongue  became  moist  and  less  coated,  the  bowels  remaining  quiet.  Whiskey-punch  was 
ordered.  Next  day  the  skin  and  tongue  again  become  dry;  rose-spots  and  sudamina  appeared  and  the  bowels  were 
moved  twice;  a  slight  tlushing  of  the  face  was  noted  in  the  evening,  as  also  on  the  evening  of  the  following  day. 
On  the  19th  the  tongue  assumed  a  gray,  moist  coating:  the  skin  was  warm  and  sweating;  the  liowels  moved  once: 
rose-spots  were  present  but  no  sudamina,  no  temlerness  nor  tymi)anites.  From  this  time  he  gradually  improved. 
Thus,  on  the  21th,  the  report  is  as  follows:  Kested  well;  pulse  98;  tongue  red,  moist,  sliglitly  coated;  bowels  regu- 
lar; appetite  good.     He  was  able  to  walk  about  on  October  I  and  was  transferred  to  Annapolis,  ild. 

Cask  19. — Admitted  delirious  and  in  low  condition  about  the21st  day  ;  free  perspirations  occurred  two  days  later,  after 
which  convalescence  teas  gradually  established. — Private  John  Cross,  Co.  E,  14th  N.  Y.  State  militia ;  age  23,  and  of  stout 
habit;  had  been  sick  three  weeks  when  admitted  Sept.  14,  1861,  with  typhoid  fever.  He  was  delirious  and  affected 
with  great  muscular  debility  and  twitchings;  pulse  120;  skin  hot  and  moist;  face  hot  and  dark-red;  tongue  coated 
brownish-white  and  Assured;  body  enutting  a  peculiar  odor.  Next  day  there  was  less  delirium;  but  the  subsultus 
continued  with  great  roaring  in  the  ears;  the  pulse  was  104,  tongue  brown  and  slightly  fissured,  teeth  covered 
with  sordes,  skin  hot  and  dry,  face  flushed,  on  oiu^  side  purplish-red,  and  abdomen  tender  on  pressure.  Turpentine 
emulsion  and  stimulants  were  ordered.  In  the  evening  the  tongue  was  dry  and  coated  posteriorly,  and  the  delirium 
and  subsultus  persisted.  Dover's  powder  was  administered.  On  the  16th  copious  perspiration,  with  subsidence  of 
the  delirium  aiul  subsultus  and  increase  of  appetite  was  noted;  the  patient  was  weak  and  had  great  thirst,  dryness 
of  tongue  and  some  incontinence  of  urine.  In  the  evening  the  skin  was  warm  and  pers]iiring,  the  mind  much 
clearer,  the  subsultus  absent,  the  pulse  104,  the  tongue  cleaner  and  moist  and  the  bowels  (juiet.  The  Dover's  ])owder 
was  continued.  He  rested  well,  and  on  the  I7tli  the  tongue  was  white,  iiulse  100  and  skin  moist.  Aromatic  sulphuric 
acid  was  given.  In  the  evening  the  pulse  was  100,  the  tongue  white  and  less  fissured  and  the  bowels  regular.  Next 
day  sudamina  appeared  with  free  continued  perspirations,  great  thirst  for  acid  drinks,  high-colored  urine  and 
regular  bowels.  After  this  the  daily  record  varies  but  little,  showiag  a  good  appetite,  tongue  moist,  clean  or  with 
yellow  or  brown  patches,  the  skin  natural  or  moist,  the  bowels  (luiet  except  when  sometimes  moved  after  the  admin- 
istration of  extract  of  senna,  aiuI  the  sleep  sound.  Some  deafness  and  tinnitus  were  luited  for  a  day  or  two.  The 
patient  was  transferred  to  Annapolis,  Md.,  October  1,  where  he  was  entered  as  ii  case  of  continued  fever,  ami 
whence  he  was  returned  to  duty  October  21. 


TITK    rONTINT'KO    FKVKKf?,  221 

Case  L'O. — Hicnnl  cnnimcniiiui  nhoiil  Ihinl  irrrV :  jn  rs^iirntioiis  armmpriiuiinri  !<]ih!s}(lrnrr  of  Ihr  finr. — Privntc  P.  P. 
Siiiilcy.  Co.  1'.  Ilili  I'a.  Civ.:  ii^f  111;  was  Kaiil  to  have  I'oiitiaclccl  ilianliii'a  on  !Sci>t.  !',  INtil,  and  was  adniiltcil  i>ii 
till'  ;!lltli.  Diai^rnosis — 1\  jjlioid  fcvcl'.  He  was  weak.  ha<l  a  slij^lit  coni;li,  a  dianliii'a  .vifldin};  two  stools  ilailv  and  Imt 
lit  tic,  a]ip<'titf :  pnlsc  100  anil  (|nick:  skin  natnval:  toiij^uc  moist.  l>iit  coated  in  the  ccntfc.  Next  ilay  lu' was  dull  : 
had  .some  headache  and  tendeniess  in  the  lifiht  iliac  rc<j;ion.  On  Octoher  2d  thi^  ton}i;ni'  was  di-y.  brown  and  tissni-ed 
in  the  centre.  No  chaniie  was  noted  on  the  3d,  lint  on  thi'  1th  his  j)niiils  wcic  dilati'd:  lu'  was  deliiions  and  had  a 
wild  look.  The  delirium  abated  somewhat  on  the  (ith  :  the  tonjiue  hccanic  dry,  red  and  fissnii'd  by  tln'  10th.  but  the 
appetite  improved  and  the  l)Owels  continued  unmoved  for  several  days,  the  pulse  beat  iiifx  7.")  to  ><0  ]iiv  minute,  all  honi;h 
there  was  some  abdominal  tenderness  aud  tympanites,  with  Ihished  cheeUs.  injected  eyes  and  noetniiial  diliiiiim. 
The  patient  pers])ired  durin";  the  nif^ht.  and  next  morn  in t;  the  tongue  w  as  red  ,it  I  he  tip  and  I'ds^es  and  coated  wliiti' 
in  the  centre;  there  was  less  delirium  an<l  the  appetite  was  i;ood.  On  the  ll'lh  the  tcini;ue  was  nn)isl  ami  clean  Init 
for  a  yellowish  streak  on  each  side  of  the  centre.  One  stoid  was  obtained  on  the  11th.  alter  the  administration  of 
two  com]ionnd  cathartic  ]iills.  The  tougui'  on  the  17th  was  moist  and  clean  but  for  some  w  Idle  [latches.  Tlie  pal  ii'iit 
steadily  imjiroved  and  was  returiu'd  to  duty  Xoveniber  1,". 

Case  21. — Hiiiihuhc ;  cpistaxix ;  dcUriiim  ;  xorili.s  iiiiil  i-o.si-cn/or.*/  nj»)/.s  »«  (/»■  12//(  iln>i;  i>ir>ij>'ir(iiionx  (uut  vniirn- 
IvHccnce  on  the  29//i.— Private  ,Juo.  Stoddard,  Co.  A,  l.'ith  \.  Y.  V(ds.;  ai;e  2r>;  was  adiiuttecl  \ov.  1,  ISHl,  haviuf;  lieen 
siek  for  a  week  bet'on^  admission  with  headache,  eiiisiaxis,  anoiexia,  tin  is  I  and  eolith.  On  thi'  2d  the  patient's  eyes 
were  suft'used,  face  c(>nf;<'sted.  jnilse  100,  full  and  strong,  skin  hot,  tonfjiK^  red  at  tln^  tiji  and  <'d^es  and  coated  yellow  ish 
in  the  centre;  apjietite  ))oor;  he  had  epistaxis  duriii};  the  day  and  one  passai;e  IViMii  the  bowels,  which  y:iu;;led  .-ind 
were  tender  on  pressure,  particularly  on  the  rif;lit  side;  he  had  also  soim^  eoii^li  with  yellowish  blood-streaked  sputa. 
The  epistaxis  did  not  recur,  aud  next  day  he  liad  headache,  w  hicli  was  acconi)iauie(l  by  nieiital  hebetude  on  the  Ith 
and  by  delirium  ou  the  5th.  An  eij^ht-jirain  dose  of  iiuinine,  turpentine  emulsion  threi^  times  a  tlay,  anil  six  {grains  of 
calomel  with  one  of  opium  at  night,  were  prescribed  on  the  Ith.  Kosc-eolored  sjiots  appeared  on  the  chest  at  this 
time,  as  also  dryne.ss  of  the  tongue  and  blackening  of  the  teeth  and  lips  from  Hordes.  The  delirium  lasted  only  one 
day,  but  the  dulness  of  mind  persisted.  A  diarrhiea  of  three  or  four  stools  daily  was  ])erha]is  duo  to  the  calomel, 
which  was  rejieated  on  the  5111.  Much  abdominal  tenderness  aud  tymiianites  were  also  present;  the  appetite,  how- 
ever, continued  good  and  the  thirst  was  lessened.  The  tongue  became  moist  and  covered  with  white  ]).itehes  on  the 
(ith,  swollen  and  coated  on  the  7th  and  8th  and  clean  on  the  lOth;  but  the  skin  did  not  become  moist  until  the  21st. 
Ou  the  22d  there  was  profuse  iierspiration.  Complaint  was  made  of  earache  on  tlii^  25tli.  Three  days  later  the 
patient  was  able  to  leave  his  bed.  Ou  December  3,  when  transferred  to  Baltimore,  Md.,  he  had  tinnitus  auriiim 
and  congh  and  his  bowels  were  slightly  relaxed. 

C.vsE  22. — Ddic  <if  onset  unmorded ;  cerehral, puhnonnrji  and  intcstbml  symptoms  ;  rosv-coJorvd  spots ;  connilcsciiur. — 
Farrier  Alexander  Wenrieh,  Co.  K,  2d  Pa.  Cav.  Admitted  Nov.  5,  1801.  Diagnosis — typhoid  fever.  On  the  day  after 
admission  he  was  delirious  and  slightly  deaf;  had  fre<iuent  aud  involuntary  stools,  solium  cough  and  the  res]dration 
increased  to  22;  his  eyes  were  injected;  face  congested;  pulse  100,  (|nick,  bounding  and  iiitiMiiiittent  ;  skin  hot: 
tongue  red  and  slightly  coated  yellow ish- white.  Hoffmann's  anodyne,  tincture  of  valerian,  tnriieiiline  and  astringents 
were  prescribed,  with  morjdiia  at  night.  Sordes  appeared  on  the  teeth  on  the  7tli,  on  which  day  two  stools  were 
jiassed ;  beef-essence,  punch  and  morphine  were  ordered.  lie  was  stupid  on  the  9th  ;  had  headache  and  tinnitus  on 
the  10th,  two  stools  and  slight  tynijianites  and  tenderness  in  the  right  iliac  region,  but  the  tongue  was  moist  and 
cleaning  and  the  cough  slight.  Rose-spots  appi^ared  ou  the  chest  on  the  11th.  The  <leliriuui  did  not  <|uiet  down 
until  the  Kith,  after  which  he  slept  well  aud  ha<l  a  good  ajipetite.     He  was  transferred  to  Alexandria,  Va.,  Dec.  "20111. 

Case  23. — Veafmss  and  mmtal  dulnis«;  inlcstinul  si/mptoms;  perspirations  and  rose-colurcd  s/iotson  ii^lli  dinj  :  sordis 
and  dcJiriiini  on  the  20th  and  2lst ;  conralrscena-  on  the  'AM  daij. — Private  AVilliam  O'Hiieu,  Co.  (i,  13th  N.  Y.:  age  '20:  con- 
tracted typhoid  fever  Oct.  15,  18R1,  and  was  admitted  November  1.  Next  da,y  there  was  headache  aud  di'afm'ss, 
tinnitus  and  hebetude;  the  face  was  cougested;  pulse  78;  the  tongue  was  dry,  swollen  and  coated  yellow  ;  the  ]iatient 
had  no  ajipetite,  much  thirst, relaxed  bowels  and  some  tympanites  and  abdominal  tenderness;  profuse  sweating  had 
occurred  during  the  night,  and  on  the  chest  and  abdomen  a  few  rose-colored  spots  were  discovered.  On  the  3d  sordes 
appeared  on  the  teeth,  and  ou  the  4th  delirium  supervened,  the  patient  making  fretiuent  attempts  to  leave  his  bed; 
the  tongue  became  red  at  the  tip  and  edges.  There  was  less  deafness,  and  the  mind  became  clearer  ou  the  Htli,  but 
the  delirium  did  not  entirely  subside  until  the  lltli.  On  the  Ititli  the  tongue  was  clean,  pul.se  75,  and  then!  was  no 
abdominal  tenderness.  Thecase  was  treated  from  the  3d  with  milk-]Hinch,  beef-essence  and  emulsion  of  turpentine, 
lie  was  transferred  to  Annapolis,  Md.,  on  the  18th  [and  returned  to  duty  Dec.  ItJJ. 

Case  24. — Presenting  delirium,  uneonseiousness,  Jloecitntio,  sulisnltns,  sliylit  diarrhwa,  rose-spots,  sudamina,  hed-sorcs 
and  ribices.  Improvement  manifested  about  35th  day. — Private  William  E.  Thomiison,  Co.  C,  9th  Pa.  Vols.;  age  19;  was 
taken  about  August  22,  1861,  with  pain  in  the  head  and  back,  epistaxis,  chill,  fever  and  diarrluea,  and  was  admitted 
September  12  as  a  case  of  typhoid  fever:  pulse  100,  ((iiiek;  skin  hot  and  dry;  tongue  dry  at  the  tip  and  coated  gray 
at  the  base;  the  patient  was  dull-looking  and  had  Hiibsiiltns,  relaxed  bowels,  right  iliac  tenderness  and  intestinal 
gurgling.  Dover's  powder  was  given.  On  the  13th  the  skin  was  hot  but  moist  with  perspiration:  rose-cidored  spots 
apjieared.  Next  day  the  skm  was  again  hot  and  dry,  but  covered  with  profuse  sudamina;  the  cheeks  were  tlushed, 
the  tongue  dry,  smooth,  cracked  aud  protruded  with  difficulty,  and  the  patient  stupid  but  restless.  Toward 
evening  ou  the  15th  a  few  more  rose-spots  came  out;  sordes  appeared  on  the  teeth;  the  bowels  continued  slightly 
relaxed  and  there  was  right  iliac  tenderness;  the  patient  was  haggard;  he  turned  his  head  fnmi  side  to  side, 
muttered,  and  had  subsultustendinum.  No  change  occurred  on  the  Kith,  but  on  the  17th  more  rose-spots  made  their 
appearance  and  the  patient  became  drowsy.  On  the  19th  his  iiiqiils  were  dilated  and  he  was  unable  to  articulate. 
Next  day  the  pulse  was  112,  irritable  and  full ;  the  skin  dry  and  husky ;  the  rose-spots  aud  sudamina  had  disappeared; 


222  CLINICAL    RECORDS    OF 

flic  tongue  was  rcpiij^h,  ilry  ;ni(l  liidwii :  I  lio  j^iiiiis  iiml  tcctli  cuviTtMl  witli  sdidcs:  liglit  iliac  tciidcrncss,  iiicteorism. 
gmj^liii;;  and  rdaxalioii  of  I  he  liowcls  conlinuctl.  and  tlic  jiaticnt  nmttcicd  and  ^ioanc(Ll)Ul  had  no  snli.sultns. 
11(^  was  fircatly  emaciated  and  iirostiatod.  and  tor  some  days  lay  on  his  hack  with  liis  eyes  liall-chised :  soniotinics 
partly  delirious,  iiiekini;  at  tln^  licd-elothcs,  and  at  other  times  unconscious.  JFean  while  the  pulse  became  more  rajiid, 
risini;  to  128  on  the  '2'M\,  and  the  circulation  of  the  skin  languid.  He  vouiited  on  the  eveuiuic  of  the  'J2d.  and  after 
tills  his  liowels  became  more  (|uiet.  lied-sores  appeared  over  the  sacrum.  Turpentine,  Dover's  )io\\<ler,  astrinj;cnts 
and  stimulants  had  been  used  in  the  Ireatineut.  On  the  25th  the  pulse  was  111  and  stroui;er.  the  toui;uo  eleaiiinj; 
and  the  mind  clearer,  but  the  skin  eoiitiiiued  hot  anil  dry,  and  v i bices  appoared  (profusely  on  the  cliest  ;  the 
bowels  remained  i|uiet.  The  jiatient  was  sponged  with  alcidiol  and  turpentine;  warm  bottles  were  aiiplied  to  the 
feet  and  soft  pads  to  the  saenuii  over  the  sores.  In  the  evening  tlie  eyes  became  brighter  and  the  skin  moist,  the 
pulse  having  lueaiiwliile  falb'ii  to  100.  Xext  day  the  pjitient  was  tranquil,  the  tongue  moist  and  cleaning  at  the 
edges;  the  bowels  were  moved  by  an  enema.  A  purulent  discharge  came  from  the  right  ear.  The  left  ear  lie<'ame 
similarly  affected  on  the  28tli.  The  aiipetite  leturued  on  tbe  29th,  and  afli'r  this  improvement  continued.  The  pa- 
tient was  fuiloughed  October  31. 

Ca.sk  25. — Iklirium  ;  iiivoliintarn  fttnols ;  sorden:  rtinc-colnrrd  spots:  convahsviiici'  vinncuhtil  irilh  free  pcrspiratid}!. — 
Private  W.  II.  liarnett,  Co.  D,  lltli  N.  Y.;  age  20;  was  admitted  Oct.*.  IStil,  as  a  ease  of  typhoid  fever.  On  the  (ith 
he  was  reported  a.s  weak  and  having  suffused  eyes,  quick  jmlse,  115,  hot  and  dry  skin,  moist,  brown  and  slightly 
fissured  tongue,  anorexia,  relaxed  bowels  an<l  iliac  tenderness.  Turpentine  emulsion  and  cani|dior  with  sweet  sjiirit 
of  nitre  were  ordered.  Next  day  the  patient  was  iniite  delirious  and  had  three  involuntary  sto(ds;  sordes  appeared 
on  tlie  teeth  and  six  rose-colored  spots  on  the  skin.  '  Milk-punch  and  tincture  of  oiiium  were  ordered.  On  the  8th 
the  rose-colored  spots  increased  in  nninber  and  the  delirium  was  somewhat  lessened;  the  live  stools  passed  were  not 
involuntary;  some  irritability  of  stomaeli  was  mauifested.  Sudaniina  apjieared  on  the  10th  with  a  fresh  crop  of  rose- 
colored  spots,  and  the  tongue  became  red  at  the  tip  and  edges.  On  the  lltli  ejiistaxis  occurred  and  the  iiatient  was 
stuiiiil.  Next  day  headache  accompanied  the  delirium,  the  other  symptoms  continuing  as  already  stated.  On  the 
nth  the  tongue  was  somewhat  moist  and  the  appetite  improved.  On  the  15tli  the  pulse  liad  fallen  to  80,  the  diarrho?a 
lesseiKMl,  e])istaxis  recurre<l  and  the  patient  was  more  rational.  Next  day  there  was  only  one  passage  from  the  bowels, 
but  the  right  iliac  tenderness  continued  with  some  tympanites  and  gurgling.  Rose-irolorcd  spots  ajipearecl  (ui  the 
18th  and  again  on  the  21st;  on  the  former  day  the  headache  and  delirium  were  greatly  lessened,  and  on  the  litth  tlio 
tongue  was  clean  and  the  aiijietite  good:  hut  some  general  tenderness  continued  in  the  abdomen  and  there  was  some 
cough.  A  free  perspiration  occurred  during  the  following  uight,  after  which  the  progress  of  convalescence  was 
steady.     He  was  fransferied  to  Annapolis,  Md.,  November  1  [whence  he  was  returned  to  duty  on  the  22d]. 

C.vsK  2t!. — ■Ceribntl  and  hitcsliiidl  siimploms;  rosc-colnrcd  sjwtsfrnm  the  l\1li  in  the  'iUk  day ;  hiiproirmnif  on  the  2Glh 
day,  anncidint  irith  siihsidincr  of  fchrUc  hcut  and  appvtiriiiicc  of  moistnrc.  on  surface — Private  Hugh  Murphy,  Co.  I,  3d 
Vt.;  age  22;  had  measles  in  July,  1801,  and  on  .Sept.  2.5  was  taken  with  a  heavy  cold,  chills,  headache  and  diarrhiea. 
On  admission,  Oct.  3,  his  case  was  diagnosed  one  of  typhoid  fever.  Ho  slept  well,  but  his  eyes  were  suffused  and 
he  had  some  pain  in  the  head,  anorexia  and  slightly  relaxed  bowels;  his  tongue  was  moist  and  coated  yellowish  in 
the  centre;  skin  natural;  pulse  00  and  full.  Kose-colored  spots  appeared  on  the  chest  and  abdomen  on  the  5tli  and 
were  very  profuse  on  the  7th,  when  the  skin  became  hot  and  dry,  the  lips  parched  and  the  tongue  red  and  glossy  at 
the  tip  and  edges  and  dry  at  the  base  and  centre;  live  stools  were  passed  on  this  day,  and  there  was  much  tymiian- 
ites  but  no  tenderness.  Ky  the  10th  the  eyes  had  become  injected,  the  cheeks  flushed,  the  tongue  dry  and  dark  and 
the  teeth  covered  with  sordes;  the  patient  was  stupid  ami  at  times  delirious;  meteorism  and  borborygmus  accom- 
panied the  diarrhani.  Up, to  this  time  emulsion  of  turpentine  and  Dover's  powder  had  been  used  in  the  treatment ; 
iiuinine  was  now  given  in  two-grain  doses  every  hour.  The  bowels  were  moved  nine  times  on  the  lltli  and  the 
right  iliac  region  was  markedly  tender.  Tincture  of  iron  was  given  on  the  12th.  Deafness  was  noticeable  on  the 
13th.  This  condition  of  mental  hebetude,  deafness,  occasional  delirium, flushed  face,  hot  and  dry  skin  with  eiu]i- 
tion  of  ro.se-colored  sjiots,  dry  and  dark  tongue  and  nia.iked  diarrhiea  continued  until  the  20th,  when  the  skin  lost 
its  heat,  the  tongue  its  dryness  and  the  stools  liecame  less  frequent;  the  patient  was  troubled  with  some  cough 
during  this  period.  The  skin  was  reported  moist  for  the  first  time  on  the  2ltli.  The  eruption  did  not  disappear 
until  the  28tli.  The  tongue  continued  moist  and  but  slightly  coated,  the  skin  natui'al,  the  ajipetite  good  and  the  bowels 
moved  but  once  daily  until  Nov.  1,  when  the  patient  was  transferred  to  Annapolis,  Md.  [whence  he  was  returned 
to  duty  on  Dec.  2]. 

Cask  27. — Uiarrhnu:  muttcriny  deliniim  :  coma  vigil;  sordes;  dark-red  sjyots,  persistine)  under  pressure,  on  tlie  llth 
day,  after  wltieli  imj)rovemcnt  teas  jirogressire. — Private  Andrew  Scribei',  Co.  C,  14th  N.  Y.;  age  22;  was  admitted  8ept. 
20,  1801,  having  been  taken  sick  two  weeks  before  with  chills,  pains  in  the  head  and  bones  and  great  muscular 
<lebility.  Diagnosis — tyjdioid  fever.  His  pulse  on  admission  was  118  and  soft,  face  flushed  <lark-red,  couutenanee 
anxious,  skin  hot  and  dry,  tongue  thickly  coated  gray  in  the  centre,  red  at  the  tip  and  sides,  gums  and  teeth  covered 
with  sordes:  there  was  some  diarrlnea  with  tenderness  of  the  abdiuuen  and  tympanites:  the  jiatient  lay  with  his  eyes 
and  mouth  partly  oiien.  muttering  incoherently  when  roused.  ( )n  the  21st  he  \iifis  dull,  stujiid  and  diflicult  to  arous<> ; 
pulse 90  and  (juick,  skin  hot  and  moist,  tongue  brownish-gray.  He  had  six  stools  during  the  day,  accompanied  with 
gurgling  but  no  tenderness.  Turi»eni!ne  emulsion  and  euemata  of  laudanum  were  ordered.  On  the  22d  he  was  rest- 
less; pulse  112,  small;  skin  hot  and  dry,  with  here  and  there  dark-red  spots  which  did  not  disappear  on  piessure; 
tongue  brown  and  dry  in  middle,  moist  and  red  at  edges.  The  diarrlwra  was  checked  by  the  euemata,  but  therir  was 
some  tenderness  of  the  abdomen  and  intestinal  gurgling.  lirandy  was  given.  On  the  23d  the  eruption  hail  disap- 
peared: two  stools  were  passed;  the  .sordes  persisted  about  the  lips,  but  the  tongue  was  cleaning  from  the  edges. 
The  sordes  disappeared  on  the  2oth.     Next  day  the  tongue  was  clean  ;  there  was  some  lyipetite,  and  the  patient  looked 


THE    rONTINUKP    FKVERS.  223 

and  Kaid  lie  fell  well ;  liiit  lie  was  rostless  anil  wanted  to  go  out.  lie  had  three  stoiils:  )iiilse  si.  In  the  eveninj;  the 
jiiil.se  iip.se  lo  1(10,  llie  lace  was  lliislieil,  the  skin  hot  and  dry,  and  there  was  horlHiry'iniiis  with  li^lil  iliac  leiideiness 
and  one  .stool.  On  the  iiioriiiiijj  of  the  L'Sth  the  luilse  was  Si':  the  skin  warm  and  moist  ;  tlii'  tongue  moist .  red  at  I  ho 
tip  and  slij^litly  coated.  His  apjietite  was  i;ood  on  the  2ytli.  He  had  four  stools  on  the  Hdtli,  Inil  no  tcn<leriiess;  his 
countenance  was  natural,  his  skin  warm  and  soft,  and  he  was  ;;aininn  strength.  On  October  L'O  he  was  detailed 
ou  extra  duty. 

C.\SK  2S. — I>i::i)ns8  ;  </<  »/«('.s.v  ,•  (linrrhad  :  crnpt'ion  an  ilir  Silk  lUnj,  not  disappiiiriiin  an  jin sxnr(  :  iiKiiiifisI  iiiij)r<ivi  im  nl 
ciiiiicidiiit  If  nil  rjiixtoj'ix  on  HMIi  iliiij:  hnnnrrhngi' from  hoiriJn  on  lillh  diiji,  irith  milini'iiniiit  iiitliiiiiiiiiilorii  iictioii  in  tlw  piilino- 
niiri/  mill  uriniirij  oryiuin,  and  diliriiim  histhiy  until  llii  'X'ld  dmj,  whin  imprnrinii  nl  inix  iifiiiin  niiiiiifi ulid. — I'rivale  ,)anies 
.Scoflield,  Co.  K,  6th  'Whs.:  ago  20:  liecame  suliject  alioiit  Sept.  L'."),  IHIil,  to  faiiitness  and  leeliiifis  of  weakness,  chills, 
fever,  diarrho'a,  pain  in  the  head  and  hack  and  anorexia.  He  wasadniitted  October  li  as  acase  of  typhoid  fever.  His 
face  was  Hushed  darkly;  eyes  sutl'nse<l :  exjiression  dull  and  heavy;  pulse  1(K),  strong  and  full;  skin  hot, dry,  smooth 
and  without  eruption;  tongue  slightly  moist,  red  at  tin-  tii>  and  thickly  coatiMl  grayish-white  in  the  centre:  bowels 
relaxed  but  not  tender;  ho  was  Homewhat  deaf  and  hail  a  slight  cough.  Next  day  the  iiatient  was  drowsy  and  had 
headache  with  dizziness  and  increasing  deafness:  the  skin  hot  and  slightly  moist,  showed  a  few  spots  which  did  not 
disajipear  on  ])ressnre:  the  bowels  were  moved  four  times  and  were  tender.  No  change  took  place  until  the  Tlh, 
when  tinnitus  auriuin  and  epistaxis  were  noted,  the  tongue  having  becoiiu'  clean,  dry,  red  and  lissiireil.  On  the  !Hh 
tlie  tongue  liecanie  very  rough,  red  and  grayish-white  in  the  centre;  ejiistaxis  recurred:  fonrstools  were  pa.ssed,  and 
there  was  slight  tenderness  in  the  right  iliac  region;  the  urine  was  scanty  and  very  dark-colored.  Next  day  epis- 
taxis again  occurred,  the  pulse  was  100  and  strong,  the  skin  soft  although  hot  and  dry;  the  expression  was  less 
anxious,  the  eyes  clearer,  the  hearing  improved  and  the  tongue  moist  and  elenning  in  the  centre,  but  the  patient 
complained  of  headache  and  pain  in  the  liack  and  side,  a  dry  hacking  cough  and  much  thirst  :  he  had  two  thin  stools 
with  much  tenderness  and  gurgling  and  slight  meteorism.  On  the  liith  a  profuse  lu'inorrhage  occurred  from  the 
bowels;  the  patient  became  very  pale  and  stupid,  pulse  120,  skin  hot  and  husky,  tongue  moist,  tissurcd  and  slightly 
coated;  the  abdomen  was  soft  and  tender.  Next  day  the  jnilse  was  101,  the  skin  dry  and  husky,  the  tongue  dry, 
dark,  cracked  and  rough,  the  countenance  pinched  and  somewhat  anxious,  the  teeth  and  gums  covered  with  sordes; 
the  bowels  moved  three  times  during  the  night,  about  eight  ounces  of  blood  coming  away  with  one  of  the  passages. 
No  hemorrhage  took  place  on  the  l.">th,  but  the  patient  had  subsultus  tendinum  and  .some  bronchitic  coiigli.  His 
exjiression  on  the  Kitli  was  wild;  lie  was  very  wakeful  and  conij)lained  niuch  of  jiain  in  his  heels  and  legs.  Ou  the 
ITth  ho  jiersjiired  jirofiisely  and  had  frequent  epistaxis  but  no  stool;  the  bladder  was  so  distended  as  to  re(|uire 
the  employment  of  the  catheter;  the  tongue  was  dry,  furred  and  scaly;  pulse  112,  feeble;  mind  dull;  countenance 
anxious;  resjdration  normal.  Two  stools  were  jiassed  on  the  18th;  tlie  bowels  were  tymjianitic  and  acutely 
tender;  the  skin  was  dry  but  at  times  moist  and  jiersjiiring;  the  delirium  jire.sent  was  not  of  a  violent  character. 
From  this  date  until  the  27th  the  jiatieut  was  dull,  drowsy  and  nuire  or  less  delirious,  sometimes  crying  out  loudly; 
the  skin  was  dry  and  husky  but  occasionally  moist;  the  tongue  dry,  fissured  and  scaly  and  the  teeth  black  with 
sordes;  two  or  three  stools  were  passed  daily,  and  there  was  much  right  iliac  and  hypogastric  tenderness,  with 
meteorism  and  borborygmus;  the  catheter  had  to  be  used,  and  the  urine  withdrawn  was  strongly  alkaline,  con- 
taining blood,  mucus,  pus,  ejiithelium  and  excess  of  phosphates.  Some  sibilant  niles  were  heard  in  the  njiiier  jiarts 
of  both  lungs,  and  the  respiration  at  one  time  became  increased  to  28  j)er  uiinuto.  He  was  emaciated  and  very  weak  ; 
but  on  the  27th  the  mind  became  clearer.  On  the  2Xth  the  eyes  were  bright,  the  skin  warm  and  sweating,  the  tongue 
moist  and  cleaning,  the  bowels  quiet,  the  abdominal  tenderness  much  diminisheil,  liut  still  acute  in  the  right  iliac 
and  hypogastric  regions.  On  the  29th  some  ajipetite  was  manifested.  The  teeth  and  gums  were  clean  on  November  1 . 
Micturition  was  free  and  natural  on  the  4th,  but  for  some  days  after  this  he  had  at  times  much  pain  in  the  jieiiis 
and  bladder.  On  the  9th  bed-sores  are  mentioned;  the  skin  was  hot  and  dry;  the  tongue  dry,  smooth  and  tissured; 
the  bowels  were  quiet,  but  tenderness  continued  in  botli  iliac  regions;  the  ajipetite  was  good.  No  further  record 
was  made  except  that  on  the  20th  the  patient  was  transferred  to  Annapolis,  Md.  This  case  was  treated  with  turjien- 
tiue  emulsion  on  October  7th,  Dover's  powder  on  the  9th,  acetate  of  ammonia  on  the  10th,  extract  of  buchu  on  the 
11th,  and  thereafter  with  quinine,  opium  and  stimulants. 

Case  29. — Deafness  and  headache;  abdominal  tenderness  and  tympanites,  hut  no  movement  except  by  castor  oil ;  rose- 
colored  spots  on  the  12th  to  21«<  day  ;  defervescence  by  free  perspirations  on  the  21th,  and  conralescence  on  the  3Gth  day. — 
Private  F.  Klus8man,Co.  1, 35th  Pa.  Vols.;  age23;  was  admitted  Oct.  30, 1861.  Diagnosis — typhoid  fever.  His  illness 
began  on  Oct.  20,  with  chills  and  fever,  anorexia  and  thirst.  On  the  31st  he  was  very  weak  and  did  not  sleep,  the 
eyes  dull,  cheeks  Hushed,  nulse  85,  skin  hot,  chest  and  abdomen  covered  with  a  profuse  rose-colored  erujition,  tongue 
red  at  the  tip  and  edges  but  coated  white  in  the  centre,  teeth  covered  with  sordes;  he  was  deaf  and  had  tinnitus 
aurium,  anorexia,  thirst,  extreme  tenderness  of  the  abdomen  and  tympanites  although  but  one  stool  was  passed; 
there  was  al.so  some  cough.  Quinine  and  turpentine  emulsion  were  prescribed.  Next  day  the  tongue  became  dry  in 
the  centre ;  on  the  2d  there  was  epistaxis,  and  on  the  3d  headache  and  inability  to  sleep,  the  tongue  having  meantime 
become  dry,  swollen  and  fissured  at  the  edges.  Beef-easence  and  milk-punch  were  prescribed,  and  as  there  had  been 
no  movement  of  the  bowels  for  some  day?,  castor  oil  was  given ;  the  abdomen  was  tympanitic  and  tender  and  gtirgled 
under  jiressiire.  The  tongue  became  moist  on  the  6th,  the  skin  moist  ou  the  7th,  but  free  perspiration  did  not  occur 
until  the  16th,  when  the  apjietite  returned.  The  headache  became  relieved  about  the  lOtli,  at  which  time  the  last 
crop  of  the  eruption  faded.  The  patient  was  able  to  be  up  on  the  25th.  and  was  transferred  to  Baltimore  on  Dec.  3. 
Except  on  the  day  of  admission,  no  pas.sage  was  obtained  from  the  bowels  of  this  jiatient  without  the  aid  of  castor  oil. 

Case  30. — Delirium,  diarrhoea  and  ruse-colored  spots;  inqirorement  datiny  from  the  '.iiilh  day,  when  the  tonyue  became 
moist. — Private  Andrew  Schick,  Co.  E,  Ist  Pa.  Art.,  was  taken  about  Aug.  20,  1861,  with  a  cold;  he  suflered  for  a 


224 


CLIKTiWT.    RRCORBS    OF 


Week  f'niiii  <liari-li(i'a  willi  si'Mti'  (laiii  iii  ilic  head,  anil  fever  whiili  lieeiimo  agiri'iivatnd  in  tlio  middle  of  tlu)  day. 
lie  was  adTiiittcul  Sej)!.  lit  as  a  easi'  of  ty]ilioi(l  fever.  The  patient  was  Htii]iid,  deaf  and  delirious;  the  Htools  thin; 
the  rij;ht  iliae  i-e,!;ion  so  tender  that  he  olijeeted  to  liaving'  the  iihdonieu  touelied;  the  Jiulse  128,  small  and  feeble; 
the  skin  hot  hut  soft  and  presenting  an  oeeasional  rose-eoU)red  spot  with  sndaniina  on  the  neck;  the  tongue  red 
at  the  ti])  and  gray  in  the  centre  and  at  the  liase.  A  half-ounce  of  castor  oil  w  as  given.  Next  day  three  stools  were 
passed,  tlie  skin  was  hot  and  dry,  and  there  was  much  tliirst;  otherwise  little  change  was  ]>rcsented.  Quinine  was 
given  on  the  27th.  Next  day  there  was  loss  fever:  the  pulse  fell  to  9.5  and  was  stronger:  tlie  tongue  was  moist,  hut 
the  skin  continued  dry;  the  mind  became  clearer.  The  improvomeut  progressed  on  the  2Hth.  The  pulse  on  the  liOth 
was  lull ;  the  tongue  clean;  appetite  good :  bowels  quiet  and  natural.  Whiskey-punch  was  given.  The  patient  was 
returned  to  duty  November  1. 

Ca.se  31. — Date  of  onxct  iiiinvordid ;  roKr-coIorcd  upotit ;  (lelirium  ;  cluxt  cnmplicdiioiis  interfere  with  difcrrcsaiici' 
about  end  of  itii  icvek,  und  prolong  tlic  cane  for  two  or  three  weehK. — I'rivate  Christian  15.  Krieger,  Co.  I,  4th  Mich.;  age 
22;  a<lmitted  Aug.  31,  18(>1.  Diagnosis — typhoid  fever.  He  was  weak  and  feverish,  and  had  diarrlnea,  tympanites 
and  well-marked  rose-si)Ots;  pulse  110:  t(nigu<'  dry  and  brown  but  red  at  the  tip;  teeth  covered  with  sorde.s. 
Brandy-punch,  beef-essence  and  astringents  were  given.  Next  day  he  was  slightly  incoherent,  and  on  September  4 
delirious.  The  record  does  not  again  state  his  condition  until  the  13th,  when  there  was  fever  with  much  thirst, 
delirium,  tinnitus  aurium,  muscte  volitantes,  a  moist  brown  tongue  and  dry  hot  skin.  Dover's  powder,  beef-essence 
and  brandy  were  given  at  this  time.  On  the  l.")tli,  the  patient's  general  condition  remaining  thi!  same,  his  ])nlse  rose 
to  lot),  his  tongue  became  dry.  and  in  the  evening  his  urine  was  passed  involuntarily.  On  the  Kith  the  presence  of 
bronchitis  was  reported.  Next  day  his  tongue  began  to  clean  in  i)atches,  and  on  the  IKth  was  moist,  glossy  and 
nearly  smooth,  the  appetite  improved  and  the  bowels  (|uiet;  but  the  delirium  did  not  abate  until  the  following  day, 
when  in  the  evening  it  ro(^urred,  accompanied  with  abdominal  t<!nderness  and  tympanites,  some  cough,  hurried  respi- 
ration, 30,  and  dryness  of  the  tongue,  which  was  protruded  with  difficulty.  On  the  21st  he  rested  well;  his  face  was 
pale  and  sunken  but  ))right ;  his  tongue  remained  dry,  red  and  glossy,  and  was  slightly  coated  in  patches ;  the  teeth 
were  covered  with  sordes;  the  cough  continued;  but  the  hearing  was  good,  the  bowels  quiet,  the  urine  normal  and 
the  appetite  good.  Next  day  delirium  was  again  added  to  these  symptoms,  and  on  the  23d  some  deafness  and  sul)- 
sultus  tendinum.  On  this  day  the  tongue  again  became  moist,  but  dried  on  the  24th  in  the  centre  although  remaining 
red  and  moist  at  the  edges.  Turi)entine  euniisiou  was  ordered.  This  condition  continued  until  the  26th,  when  the 
delirium  became  less(!ned,  the  face  and  lips  i)ale,  the  expression  anxious,  the  eyes  clear  and  bright,  the  pulse  9(5, 
the  skin  dry  and  husky  but  of  natural  temjierature,  and  the  tongue  clean,  soft  and  moist,  but  with  some  sordes 
remaining  on  the  teeth.  Some  perspiration  is  mentioned  on  the  27th  as  occurring  ou  the  skin  for  the  first  time  in 
the  history  of  the  case.  Delirium  recurred  ou  the  29th,  with  slight  failure  of  the  appetite  and  cough,  the  tongue 
remaining  moist  and  the  bowels  undisturbed.  After  this  the  skin  was  natural,  moist,  or  occasionally  dry,  the 
tongue  clean  or  slightly  patched  with  yellow,  the  pulse  from  72  to  96,  the  appetite  good;  but  the  bowels  became 
relaxed,  yiehling  two,  three  or  four  stools  daily.  While  in  this  condition  he  was  transferred  to  Annapolis,  Md., 
October  10.     [This  man  ultimately  recovered  and  was  returned  to  duty  with  his  regiment.] 

Cask  32. — Mnlterinij  delirium  :  sordes;  intestinal  effusion;  rose-colored  spots  on  liih  day;  petechia'  on  lUth ;  pains  in 
the  feet;  sliyhl  iniprorement  on  the  I7th,  bnt  record  incomplete. — Private  C.  D.  Emons,  Co.  D,  7th  Wis.  Vols.;  age  18;  was 
admitted  Oct.  30,  1861.  Diagnosis — typhoid  fever.  He  was  taken  sick  about  the  22d  with  diarrhoea,  chills,  weak- 
ness and  loss  of  appetite.  On  admission  his  face  was  flushed,  pulse  100  and  of  fair  strength,  skin  hot  and  dry,  tongue 
thicklj-  coated,  teeth  black  witli  sordes,  breath  very  offensive;  he  had  much  thirst,  relaxed  bowels  and  some  tender- 
ness in  tlie  right  iliac  nurion,  with  borborygmus  and  tympanites;  he  muttered  in  his  sleep.  Oil  of  turpentine,  com- 
pound catechu  powders  and  whiskey-))uneh  were  prescribed.  Delirium  became  a  prominent  symptom  for  a  few  days. 
during  which  the  ])ulse  was  strong  and  slightly  above  100,  the  face  dusky,  the  eyes  much  injected  and  the  tongue 
red  at  the  tip,  blackened  and  tissured;  but  on  Nov.  4  the  delirium  lessened,  the  pulse  fell  to  86:  he  sle])t  well  during 
the  previous  night,  the  teeth  ami  gums  were  cleaner  and  the  skin  was  soft  and  presented  a  few  rose-colored  sjjots. 
On  the  Tith  the  pulse  was  88  and  feeble;  ])etechial  spots  appeared  on  the  skin;  the  tongue  was  very  dry  and  thickly 
coated  brown.  The  patient  was  drowsj'  and  ditlicult  to  arouse;  one  stool  was  passed,  and  the  bowels  were  tender 
and  gurgled  on  pressure.  On  the  7th  the  mind  becanu!  clearer  and  the  eyes  were  less  injected,  but  otherwise  there 
was  little  change  in  the  condition;  he  comiilained  of  i>ain  in  the  feet.  The  record  gives  no  further  details.  He 
was  transferred  to  Baltimore,  ild.,  on  l)eccn\ber  3. 

Cask  33. — Mnscnlar  pains  as  a  seqnel  of  the  fever. — I'rivate  ISenjamin  F.  Reynolds,  Co.  K,  «6th  N.  Y.;  age  29; 
admitted  Feb.  18,  1862.  Diagnosis — typlioid  fever.  On  March  5  he  was  dejected  and  languid,  complaining  of  rheu- 
matic pains  in  the  lower  extremities;  his  skin  was  natural;  pulse  90  and  good;  tongue  moist  and  clean;  bowels 
unmoved.  Stiffness  and  pain  in  the  legs  increased  until  the  10th,  the  bowels  meanwhile  requiring  aperients  for  their 
regulation.     After  this  date  he  improved  and  was  transferred  to  Annapolis,  Md.,  on  the  24th. 

C.\SK  34. — Ikite  of  onset  undefined :  mental  dalness;  ei'nption ;  sordes;  perspiration  followed  by  delirium;  improve- 
ment, hut  record  unfinish<(l. — I'rivate  Henry  Klnmuur,  Co.  I.  3r)th  Pa.  Vols.;  age  20;  was  admitted  Oct.  30,  1861,  as  a 
ca.se  of  typhoid  fever,  presenting  dulness  of  miiul.  dull  and  somewhat  injected  eyes,  congestion  of  the  face,  a  full 
stiong  iml.se  beatiug  90  ]ier  niinnte,  a  hot  skin  showing  a  few  rose-spots  on  the  chest  and  abdomen,  a  dry,  tissured 
and  brown-crusted  tongue,  sordes  ou  the  lips  and  teeth,  anorexia,  thirst  and  some  tympanites.  lieef-essence,  quinine 
and  turpentine  enmlsion  were  jirescribed.  No  change  took  place  until  November  2,  when  the  skin  was  bathed  in 
perspiration  and  some  deafness  was  noted.  Delirium  set  in  on  the  3d,  on  which  day  tlie  patient  had  three  stools. 
The  tongue  .seemed  cleaning  on  the  7th  and  the  delirium  lessened,  but  the  condition  otherwise  was  as  related.  Ou 
the  9th.  after  passing  a  better  night  than  usual,  he  showed  a  return  of  appetite.     Next  day  he  was  intelligent.     On 


THK    CdXTINrKli     KKVKi;>.  ■^-'■-' 

tlif  llt]i  tin-  tiiiijiuc  was  reil  at  tlie  tip  and  imIiJi-.-..  drv  Mini  Imiw  n  in  i  hr  (  iiiiii'  aii<l  tlio  skin  wa.s  hot,  i)nt  llu'  (latii'iil 
sl»-|it  wi-ll,  lia<l  a  fidod  a|>|K-tit<',  ami  liis  liowcls  ucn-  i|iiicl.  Tlir  rcciml  i;i\ cs  no  fill  lluT  ili'lails,  llu  was  IraiisliM  rcil 
t<i  liail  liiKiie.  Md..  on  1  IimtihImt  ii. 

Casi-:  :>r».  —  fitfimj  n  r'nir  of  tin  /mlit  nt  J'lir  h  it  ilai/s  tliiriiiii  ninrnh  .st  ( itcf  J'roni  u  protfnvtul  ititiu'k  of  I'trrr  — -l'ii\ati' 
Alt'icd  {,.  r.ati-s.  ( ■(>.  A.  :id  Mich.:  a,icc  l.'l  ;  Ix-canic  atlri-li'd  w  illi  l>  idmid  l'f\  I'v  in  .liinc,  IStll,  and  was  adinillcd  Sf|d.  'Jx. 
lie  Iflt  jnidty  widl,  liiit  lie  liad  soiiif  ciiii^li  willi  cxiicitoiat  ion,  ami  ]iain  in  tlic  head,  liack  and  limlis;  liis  t'a<'i'  was 
sli.irlitly  tliislicd  and  his  evi'S  dull ;  ]nilsc  iMl.  lull  and  si  lonj;  :  skin  hot  and  soft  ;  toii-^ud  wliito  in  centre ;  aiipetite 
small:  howels  (|iiiet  but  somewhat  tender  and  tympanitie.  lli'  slept  poorly  the  lirst  ni^Jiht,  luit  very  well  after  that. 
His  toiifrne  wa.s  more  or  less  coated  while  or  yellowish  in  the  centre  and  ri'd  at  the  ti|i  and  edjjcs  ;  his  apjM'tite 
inijiroved.  His  how  els  were  not  relaxed:  small  doses  of  Iduc-pill  and  componml  I'Xtract  of  colocynth,  castor  oil 
and  sulphate  of  magnesia  had  to  he  prescrilied  to  move  them.  At  om>  time  he  had  some  ditlicnity  in  mietiiritioii. 
When  transferred  to  Annapolis,  Md.,  on  Octidier  10,  his  skin  was  olthc  normal  temperature,  tmifiiie  moist  and 
clean.  a|ipetite  jiood  and  liowcls  ([iiiet. 

('.\.SE  8(). — Diliriiim  ;  diiirrlian  :  rti><t-npotf^,  rihicix  uiid  htd-xm-ii' :  pm  nmniiic  iitiiipliciilioiix  iIiIikj  cuiinili  uniiff  iiiilil 
iiflir  llw  H)lli  (1(11/. — Private  (Jeorfje  Felter,  t'o.  IS,  lltli  I'a.  \ols.:  af;e"J'J:  was  taken  sick  alioiit  Sept.  l,lSt!l.and 
admitted  on  the  llltli  with  tyjihoid  fever.  The  notes  of  the  I'asc  on  th<^  L'Oth  are:  pulse  !>(! ;  skin  hot  and  dry;  liiflh 
fever;  tongue  coated  white  in  centre,  red  at  tip  aiidedfj;es,  slightly  moist  ;  acute  iliai^  tenderness  :  tym|ianiles;  con- 
stipation; enlargement  of  the  thyroid  glaml.  Ordered:  enema  of  soapsuds;  emulsion  of  turpentine  ;  Dover's  ](ow- 
der  at  night.  On  the  2lNt:  pulse  120,  full  and  scd't  :  skin  hot  and  moist  ;  ti)nguo  dark-red  at  the  margins,  dry  i'ikI 
lirown  in  the  <:e]itre  ;  cliaracteriHtic  nise-sp<pts:  no  sudatnina  ;  less  tympanites;  teinhirness  of  ahdoiiieii  on  pressure; 
iMirborygmns  ;  stibsiiltus;  delirium  ;  drowsiness;  deeiihitiis  dorsal  :  respinitiou  'M.  (iave  wine  whey  four  times  daily 
with  l)(<<d"-esseiiee.  On  the  2lid,  morning :  delirium;  siihsnlt  us  ;  )iulsc  IIS,  full  and  soft;  few  rose-spots:  skin  hot 
and  dry  ;  tongue  very  red  and  moist ;  respirations  hurried  ;  snhmncous  and  sihilaiit  rales  in  upper  part  of  both  lungs  ; 
decnliitus  dorsal:  acute  general  alidominal  tenderness;  tymjianitcs  less;  horhorygmus;  one  stool.  Ordefed  :  one- 
fourth  of  a  grain  of  morphia ;  cold  ajijilications  to  In^ad.  ICvening:  pulse  120;  face  Hushed;  skin  liot  and  dry; 
tongue  dry;  rose-spots;  high  fever;  d(dirinm  ;  deafness.  No  change  took  jdace  until  the  2ltli,  when  there  was  some 
diarrlnr^a.  On  the  25th  the  tongue  lieeaine  slightly  moist  and  cleaner,  the  delirium  gave  place  to  dnlness,  vihices 
ai)peared  on  the  chest,  the  nrine  and  fa'ces  were  passed  involuntarily  ami  ii  large  bed-sore  formed  over  the  saernin. 
The  tongue  became  again  dry  on  the  2()th,  and  the  lungs  were  found  consolidated  in  their  lower  ])ortions.  On  the 
27tli  the  ]iul.se  was  118  and  strong,  the  face  tinshed,  the  skin  hot  and  dry,  the  resiiirations  10,  with  submucous  and 
sibilant  rales  in  the  u])per  ])art  of  the  right  lung  and  a  short  dry  cough.  A  blister  was  applied  to  the  u)>per  ]>art  cd' 
the  chest.  The  bowels  were  (iniet  on  the  2Sth.  The  tongue  bec'ame  moist  on  the  2itth,  red  at  the  tip  and  gray  in 
the  centre;  the  skin  was  warm,  dry  and  soft;  the  bowels  were  uniet,  but  there  was  tenderness  on  both  sides,  with 
tympanites  and  borborygmns ;  the  sacral  sore  was  healing  and  the  patient  rational.  The  chest  was  again  blistered ; 
tonics  and  stimulants  were  adnnnistered.  The  stools  l>ecamo  involuntary  on  the  .'iOtli,  with  acute  right  iliac  tendt^r- 
uess  and  some  anxiety  of  expression  ;  jinlse  lOti;  surface  circulation  sluggish;  res])irations  10;  some  cough  and  much 
dyspniea.  The  patient  became  restless  on  October  1.  Vibices  appeared  <mi  the  abdomen  on  the  2d;  some  diarrluea 
occurred,  the  sto(ds  being  involuntary;  delirium  occasionally  returned  at  night.  On  the  1th  there  was  some  improve- 
ment in  the  clnrst-symptoms.  On  the  7th  the  face  was  slightly  Unshed;  the  imlsc  111,  steady;  the  skin  hot  and  dry, 
moist  in  some  ]daces;  the  tongue  moist,  red  at  tip,  coated  in  centre;  the  bed-sores  showing  points  of  granulation  ;  the 
sto(ds  involuntary  at  long  intervals,  with  borborygmns  and  some  tyni]>auites  but  no  tenderness;  niicturitiou  invol- 
untary. On  the  8th,  9th  and  10th  the  pulse  fell  respectively  to  108,  106  and  100,  one  or  twt>  stools  occurring  daily 
with  some  tenderness — the  skin  continuing  liot  and  dry,  but  the  tongue  becoming  cleaner  and  its  edges  moist.  t)n 
the  10th  the  eyes  were  bright  and  the  countenance  cheerful.  The  pnl.se  fell  to  90  on  the  11th;  the  condition  of  the 
tongue  improved  and  the  appetite  returned.  On  the  17th  the  tongue  was  clean  and  moist  but  redder  than  natural; 
the  bowels  were  regular;  the  appetite  good;  a  slight  cough  yet  remaimid.  The  re('ord,  which  is  continued  in  detail 
up  to  the  27th,  shows  the  occurrence  of  an  occasional  thin  stool  but  the  tongue  preserved  its  clean  and  red  condition, 
the  apiietite  was  good  and  the  sleep  sound  at  night;  no  further  reference  is  made  to  the  healing  of  the  bed-sores. 
This  patient  was  transferred  to  hospital  at  Alexandria,  Va.,  December  20. 

-  Case  37. — Skin  ijcncraUy  moist  and  intestinal  symptoms  not  prominent;  some  delirium  and  pulmonary  trouble;  erops  of 
rose-colored  spots  from  VMli  to  'ilsl  day;  conralcscence  on  the  3~th  day. — Private  Martin  A.  Stowell,  Co.  A,  Hd  Vt.;  age  21 ; 
was  admitted  Oct.  1, 1861,  having  been  sick  since  September  21  w  ith  pain  in  the  head,  back  and  limbs,  and  diarrluea. 
Quinine  liad  been  taken.  On  the  day  after  admission  he  was  looking  natural  although  his  face  was  somewhat  con- 
gested;  pulse  100,  full  and  strong;  skin  hot  and  moist;  t(mgue  moist,  white  at  the  edges,  dry  and  brown  iii  the 
centre;  he  had  some  headache  and  abdominal  tenderness.  Spirit  of  nitre,  camphor  and  tincture  of  iron  were  <udcrod. 
A  six-grain  dose  of  blue-pill  was  given  on  the  following  day,  and  ri'jpcated  on  the  1th,  with  two  grains  of  extract  of 
colocynth.  On  this  daj-  there  was  some  delirium ;  the  tongue  was  moist  and  yellow  coated  and  the  skin  covered  with 
pers]>iration.  This  was  followed  by  freijuent  stools  on  the  .">th,  birt  the  diarrluea  did  not  persist.  During  the  remain- 
der of  the  patient's  sickness  the  bowels  were  moved  twice  daily  for  two  weeks  and  once  daily  thereafter  to  the 
terniiuation  of  the  record.  Rose-spots  appeared  on  the  chest  on  the  fitli,  the  tongue  became  red  at  the  margins  and 
brown-coated  in  the  centre,  and  there  was  slight  tenderness  in  the  right  iliac  region.  More  rose-spots  ernpte<l  on  the 
8th;  the  tongue  became  dry,  red  and  cracked,  and  there  was  tenderness  in  the  left  iliac  and  umbilical  regions  with 
borborygiinis.  On  the  11th  a  few  rose-spots  appeared.  On  this  clay  turpentine  emulsion  was  prescribed.  Delirium 
returned  on  the  13th  and  continued  at  times  until  the  18th,  during  which  time  the  tongue,  skin  and  pulse  were  unaltered, 
although  a  slight  cough  was  developed.  But  on  the  18th  the  t(uigue  became  slightly  moist,  and  next  day  it  was 
Med.  Hist.,  Pt.  111—29 


22fi  ciJNK'Ai.  i:k('0);iis  ok 

iiioi.st  mill  cloiui,  till'  i)ii1ko  72,  icsiilar,  tlio  skin  of  ii;iliii';il  t<'iM|><Tiitiiif  iill  iMPiigli  still  shdwiii;,  Kome  rosf-colored 
s])<it.s,  llic  :l|ll)^^tite  i^oinl,  tin;  iiLdoiiiiMi  tiMwlci'  and  tyinpanil  ic  <ivcr  the  traiiMVcr.se  colon.  Sonio  rose-spots  uppoaivd 
on  the  L'llli.  On  the,  HOtli  tlii',  patient  was  dressed  and  sittinj;  uii.  Ou  November  1  he  was  transferred  to  Annapolis, 
Md.  [whence  he  was  discharged  ou  tlie  2itth  because  of  debility]. 

C\SK  'M<. — Diliriiim  iind  roxi-colorvd  xpoln  on  the  dlli  and  follDwhitj  dai/x;  inlixthml  .si/w^i/om-v  not  mrirr.  A  fiiniraUle 
thiuific  i»i  tlif  Ititli  dill)  is  i)ittrriti>lid  liy  tin'  occiii-niia'  of  piiiiuiioiiia;  iiiqiroi-ciiK  lit  on  Ihf  o2(/  diiii. — I'rivate  Hiram  Hilling- 
ton,  Co.  F,  2d  Me.;  af;e2il;  admittt^d  Oct.  7,  1861.  Diagnosis — tyi>hoi<l  fever.  lie  was  taken  with  lieadacho  on  Oct. 
1  and  w  ith  i>ain  in  the  back  on  the  .Sd,  but  had  no  chill,  diarrluea  nor  erMjil  ion.  On  the  evening  of  the  7th  he  was 
somewhat  dull,  his  face  tiushed  dark-red,  pupils  dilated,  liead  hot  and  jiainfnl  in  the  temi)oral  regions  where  the 
arteries  throbbed  strongly;  tongue  red  at  the  tip  and  coated  in  the  middle;  skin  hot  and  moist ;  he  had  ))ain  in  the 
back,  slight  cough,  abdominal  tenderness  and  slight  relaxation  of  the  l)Owels;  pulse  100.  Cold  water  was  ap])lied 
to  the  head  and  tive  grains  each  of  calomel  and  Jalap  given  at  once.  IS'ext  ilay  he  had  two  thin  stools,  his  tongue 
was  cleaning  and  his  pulse  lowered  to  StO,  but  to  the  headache,  Hushed  face  and  other  symptoms  of  the  previous  day 
sonu'  deafness  was  added.  C^uinine  was  ordered.  The  dilatation  of  the  pnjpils  continued  on  the  9th  with  increasing 
dimness  of  vision  and  nuisca-  volitantes ;  the  patient  muttered  in  his  sleeji,  and  even  when  awake  his  nund  was  at 
times  disturbed ;  he  had  a  dry  cough  and  pain  in  the  chest, but  his  respiration  was  not  accelerated;  his  l)owels  were 
moved  twice,  and  he  had  acute  tenderness  in  both  iliac  regions  but  no  borborygmus  nor  tympanites;  his  skin  was  hot 
and  moist  and  showed  a  few  rose-colored  spots  on  the  chest  and  abdomen ;  his  tongue  was  ijuite  red,  moist  and  clean, 
and  he  had  anorexia  and  great  thirst;  pulse  88;  urine  chemically  and  microscopically  uornuil.  He  was  very  drowsy  on 
the  10th  and  had  violent  delirium  in  the  afternoon.  Next  day  a  few  more  rose-spots  cauuMuit,  the  skin  became  warm 
and  dry  and  the  tongue  very  <lry,  hard  and  fissured;  two  thin  stools  were  passed  with  gurgling  but  no  tympanites. 
On  the  12t  h  the  red  spots  had  beconu;  darker  in  color  ;  there  was  less  delirium,  but  the  eyes  were  somewhat  sufliised  and 
the  expression  stupid.  'l'ur]icntine  emulsion  and  spirit  of  Mindererus  and  of  nitre  were  given.  On  the  13th  the 
mind  was  clear  and  the  countenance  natural,  but  there  was  some  dizziness  at  tinics;  pulse  80,  steady;  skin  soft  and 
warm  ;  tongne  dry  in  the  centre,  moist  at  the  edges,  (piite  pale  and  slightly  coated;  the  anorexia  continued,  but  the 
thirst  was  h'ssened;  three  stools  were  passed.  The  bowels  were  moved  but  once  on  the  14th  and  were  (|uiet  on  the 
15tli,  on  which  day  a  few  nu)re  rose-spots  appeared.  Iluring  thi^  night  he  slept  well,  and  on  the  Kith  the  skin  was 
moist  and  warm  ;  the  tongue  cleaning  fnun  ti]i  and  edges  but  still  (boated  in  the  centre;  the  bowels  continued  (jniet. 
Citrate  of  iron  aiul  (luinine  was  given.  During  the  ten  <lays  which  followed  there  was  but  little  change  in  the 
patient's  condition  ;  the  bowels  were  <|niet  or  moved  once  daily,  with  more  or  less  of  tenderness  ;  the  skin  was  warm 
and  nu)ist  in  the  day-time  and  freciuently  bathed  in  perspiration  at  night,  and  the  tongne  was  moist;  but  on  the 
25th,  after  a  sleepless  night,  the  tongue  became  dry  and  fissured,  and  complaint  was  made  of  cough  and  pain  in  the 
pra'cordia,  near  which  submucous  and  sibilant  rales  were  heard.  A  blister  was  ai)plied,  and  on  the  27th  one  drachm 
of  Epsom  salt  and  a  half  grain  of  tartar  enuitic  were  given  three  times  daily.  Next  day  there  was  mucous  expectora- 
tion withdulmiss  over  the  lower  part  of  the  left  lung,  and  the  patient  became  delirious.  Hrandy-punch  was  substi- 
tuted for  lh<^  tartar  emetic  mixture.  On  the  2nth  the  patient  was  very  drowsy,  moaned  freipiently  and  muttered  in 
his  delirium  ;  his  tongue  was  c<iated  with  scales,  dry  in  t  be  centre,  pale  and  moist  at  the  edges ;  the  teeth  and  gums 
were  thickly  covered  with  sordes;  the  skin  was  hot  and  moist;  pulse  Oti;  respiration  33,  short,  quick  and  somewhat 
labore<l ;  rales  were  heard  in  the  lower  parts  of  the  lungs,  and  to  a  less  extent  in  the  upper  parts ;  the  expectoration 
was  rust-colored;  the  bowels  were  moved  twice  and  were  tender  and  tympanitic.  Calomel  and  opium  in  repeated 
doses  were  ordered  on  the  30th.  On  the  31st  there  was  much  cough  with  rusty  sputa.  A  slight  improvement  was 
manifested  on  November  1.  He  slept  well  during  the  following  night,  and  on  the  umrning  of  the  2d  looked  bright 
although  very  weak  ;  some  thirst  continued,  but  there  was  a  slight  apiietite,  and  the  teeth,  gums  and  lips  were 
clean  :  the  tongue  was  moist,  deeply  tissureil  and  covered  with  white  patches;  the  urine  contained  a  trace  of  albu- 
men. Slight  salivation  occurred  on  the  1th,  on  which  day  the  urine  was  found  to  be  noruuil.  The  last  entry  with 
reganl  to  the  case,  dated  on  the  7th,  shows  the  patient  as  having  rested  well  during  the  preceding  night  and  as 
being  bright  and  cheerful  at  the  nu)rning  visit,  the  pulse  88  and  of  good  strength,  the  skin  soft  and  warm,  the 
tongue  soft,  moist,  fissured  and  coated;  some  cough  continued  and  the  bowels  were  moved  twice,  but  there  was  no 
tenderness.     He  was  transferred  to  hos|)ifal  at  Alexandria,  Va.,  on  December  20. 

Ca.sk  39. — I'nciiiiioniti  occitrrhig  aflir  the  appeaifiiuc  of  profuse  perxpiriilbin  and  rose-sjiotx. — Private  Warren  (i. 
Butler.  Co.  I,  2d  Me.;  age  22;  was  admitted  March  2,  18ti2.  Diagnosis — )uuMinionia.  This  man  had  measles  with 
severe  sore  throat  in  .September,  1861.  On  the  4th  he  had  headache  and  deafness;  his  cheeks  were  flushed  and  hot; 
pulse  weak  and  rapid;  skin  hot  and  moist,  showing  on  the  alidomen  some  eruj>tion,  which  disappeared  on  pressure; 
tongue  dry  and  coated;  two  watery  stools  were  passed;  cough  was  troublesome,  the  respiration  natural.  Next 
day  there  was  iirofuso  perspiration  and  great  thirst,  the  tongue  remaining  dry  and  coated;  the  bowels  were  con- 
stipated and  the  patient  suffered  from  tormina  and  freiiuent  nausea,  tinnitus  aurium  and  dizziness;  the  breathing 
became  rajiid  and  the  cough  aggravated.  Ten  grains  of  calonud  were  given  with  three  of  jalaj).  On  the  following 
day  there  was  much  tendency  to  stupor;  four  watery  stools  were  passed  during  the  night,  after  which  the  bowels 
became ((uief.  Little  change  occurred  during  the  next  two  or  three  days.  On  the  10th  profuse  perspiration  occurred; 
the  expectorated  matters  were  exceedingly  viscid.  Milk-punch,  cod-liver  oil  and  carbonate  of  annuonia  were  given. 
On  the  nth  the  skin  was  natural,  the  pulse  rapid  and  weak,  the  tongue  moist,  clean  and  tremulous,  but  the  apjietite 
remaiiu'd  poor;  three  watery  stools  were  passed  and  the  cough  continued.  During  the  next  two  days  the  quantity 
of  the  sj)uta  diminished.  On  the  13th  there  was  occasional  nausea,  and  on  the  14th  the  deafness  was  increased, 
although  otherwise  the  patient  seemed  better,  as  the  bowels  were  regular,  the  skin  natural,  the  cough  lessened  and 
the  sputa  less  viscid  and  more  frothy.     The  deafness  increased  until  the  19th,  after  which  it  lessened;  the  cough 


riiK  ctiNTi  Nri;ii   !•  kvpiiis.  'J.27 

prpventt'd  sice])  at  iiii^lit  ami  lln'  appetite  ilid  tint  icIiiiil:  tlic  toiiiiiic  was  clean  but  iiiiiLatMially  reil  ineo.di.  (in 
the  25tli,  tile  last  (lay  on  uiiifli  the  syinptcmis  weif  entered,  the  appetite  was  iinprovin;;.  The  patient  was  liii- 
loiiKhed  on  April  x. 

Cask  10. —  I'ik  lonmnd  prfcidm  Ihr  filirih  nilack.  uhUh  in  nut  chdrdclirhid  hij  ncrirc  xiimiilmiin. — Private  F.lijah 
Marsh,  Co.  D,  Ttli  Wis.  A'(ds.,  wan  admitted  Oct.  ,'>l).  IKtil.  Diaf^nosis — typhoid  lever.  (*n  Octolier  ',1  he  had  pain  in 
the  l)<)W<\ls  lint  no  <liarrhii'a,  jiaiii  in  the  chest  and  cou-ih  witli  rusty  s|inta.  On  the  27th  lie  had  a  chill  l'ollowe<l  liy 
Koiiie  fever,  lint  without  lieadache  or  cont'nsi<iii  of  mind,  c]iist.ixis  or  diarrliica.  On  admission  the  skin  was  linsky, 
tonf;ne  dry  and  smooth,  teeth  tilackeiied,  jinlse  SO;  there  was  dillicnlty  of  swallowinj^  friiin  soreness  of  the  fauces:  he 
had  two  thin  yellowish  stools  with  acute  tenderness  in  the  rif;ht  iliac  rcf^ion,  Imt  no  tympanites  nor  };urj;lin^;  he  hail 
little  appetite  and  was  very  weak;  some  cough  was  also  present.  Turiieiitim^  emulsion  and  whiskey-jiuneh  were 
prescrihed.  Next  day  he  had  soreness  in  the  bones,  occasional  dizziness  and  mental  dulnesg.  On  N<ivemlier  1  the 
tongue  lieeaine  moist,  clean  at  the  tiji  and  edges  hut  covered  with  a  grayish  fur  at  the  liase  ;  on  this  day  he  expec- 
torated some  blood.  There  was  some  lieailaclie  on  the  2d  ;  hut  the  ]iatient  slept  well  on  the  ;id,  and  next  day  there 
was  moisture  and  sndaniina  on  the  skin,  while  the  tongue  had  again  llecom(^  dry  and  brown  and  there  was  much 
abdominal  teii<lerness;  two  stools  were  obtained  on  this  day  by  means  of  castor  oil.  The  tcingiie  on  the  (itli  became 
again  moist  and  clean  at  the  tip  and  edges  and  the  skin  dry  ;  two  olVensive  stools  were  jiassed  ;  there  was  some  eongh 
and  the  respirations  at  this  time  were  increased  to  34  per  minute;  two  rose-eolored  s])ots  were  discovered  on  the 
chest.  The  record  gives  no  further  details,  closing  with  the  statement  that  the  patient  was  returned  to  duty  on 
December  1. 

Ca.sk.  41. — Iiicrciising  i1roir8incii«  :  (leofntss:  diliyium  :  rcld.rrd  hoinix :  iio  iriiplinii.  I\'ilh'(l  iiii  Ihi'  l'2lh  <Ui\j  hi/  HpritKjinr) 
from  (I  iHndoir  to  Ihf  (jroiitid. — Private  Henry  lliekman.  Co.  H,  Kid  I'a.  Vols.;  age  20;  was  admitted  March  2,  lH»i2.  Diag- 
nosis— ty)ilioid  fever.  He  became  sick  on  I'ebrnary  2;i  with  hcailache,  chilliness,  eongh  and  pains  in  the  limbs.for  w  liich 
Epsom  salt  was  given.  On  admission  he  liatl  much  )i.'iin  in  the  right  side;  he  slept  fairly  at  night,  but  was  drowsy 
during  the  day  ;  he  had  much  thirst,  slightly  Hushed  cheeks,  dejected  countenance,  full  and  rapid  pulse,  hot  and  dry 
skin,  a  moist  tongue  coated  in  the  centre  and  one  thin  scanty  stool;  liis  respiration  was  hurried.  A  blister  was 
ap|ilied  over  the  right  lung;  three-fifths  of  a  grain  of  calomel  and  one-tenth  of  Ji  grain  of  o]iiuni  were  given  every 
hour.  The  drowsiness  increased  on  the  5th  and  there  was  some  deafness.  Twenty-four  grains  of  (juinine  were 
directed  to  be  taken  during  the  day.  Ho  became  delirious  on  the  (ith,  and  at  night  rose  from  bed,  sprang  from  a 
w  indow  and  was  killed  by  the  fall. 

Cask  42. — Deafness;  delirium;  diurrhwa;  couyh  ;  vr\iption;  death  on  20tJi  dai/  from  pulmonarii  eoH<iestion. — I'rivate 
C.  A.  Hartlette,  Co.  H,  otli  Vt.  Vols.;  ago  23;  was  admitted  Nov.  I,  IHCA.  Diagnosis — typhoid  fever.  Ills  illness 
began  about  October  15  with  pain  in  the  back  and  limbs,  anorexia  and  diarrhcea.  On  November  2  he  was  wakeful, 
his  eyes  dull,  face  congested,  pulse  100,  skin  hot  and  dry,  showing  the  characteristic  eruption,  tongue  dry,  red  at  the 
tip  and  edges  and  coated  yellow  in  the  centre;  he  was  very  deaf  and  had  buzzing  in  the  ears,  much  right  iliai;  ten- 
derness and  some  cough  with  yellowish  sputa.  Next  day  he  was  stupid  and  delirious,  fre(|U<mtly  attempting  to 
leave  his  bed;  his  ]iuls«>  was  imperceptilile  and  his  breathing  laborious.  He  died  on  this  day.  Turjientine,  milk- 
piinch  and  beef-essence  were  presiribed,  w  ith  sinapisms  to  the  abclomen. 

Cask  43. — Delirium;  diiirrhiio  ;  Hide  tenderness :  no  rose-eolored  sjiols;  coma;  death  on 'I'.Hh  da ij . — I'rivate  William 
Etzel,  Co.  C,  2d  I'a.  Cav.;  age  2!t;  was  admitted  Nov. .'),  IHlil.  Diagnosis — typhoid  fever.  He  had  been  in  good  health 
until  October  22,  when  he  was  seized  with  chills  followed  by  fever,  epistaxis,  pains  in  the  back  and  limbs,  hissitude, 
anorexia  and  thirst.  On  the  6th  his  countenance  was  anxious,  eyes  dull  and  suffused,  ("aeo  congested,  ])ulse  !•,'>,  skin 
hot,  tongue  slightly  moist,  reil  at  the  tip  and  edges,  coated  white  in  the  centie,  ap]ietite  good,  thirst  considerable; 
he  was  somewhat  deaf  and  s)iokc  in  a  whisper;  one  stool  was  passed  during  the  previous  twenty-four  hours,  and 
there  was  much  iliac  tenderness  with  some  tym]ianites;  the  respirations  were  20  per  minute  and  there  was  some 
cough.  One  drachni  of  tunulsion  of  turpentine  was  jirescribed,  to  be  taken  every  four  hours.  On  the  8tli  the  tongue 
was  dry  and  yellow  in  the  centre  and  the  teeth  covered  with  sordes ;  he  slept  well  and  had  a  good  appetite. 
He  became  dull  and  stupid  on  the  10th  and  had  three  stools  with  much  tenderness  and  tympanites,  but  no  cough. 
On  the  16th  he  was  delirious  and  constantly  picking  at  the  bed-clothes.  The  diarrhcea  continued,  the  tongue  being 
moist  and  yellow-coated,  pulse  90,  skin  hot;  coma  supervened,  followed  by  death  on  the  19th. 

C.\SK  44. — Dale  of  onset  not  defined;  diarrhaa;  headache;  irakefnlness ;  mental  dnlness;  eruption;  cough;  inflam- 
mation of  parotid;  death  13  days  after  admission. — Private  .lohn  Kuenzle,  Co.  I,  3,^th  Pa.  Vols.;  age  29;  was  admitted 
Nov.  5,  1861.  Diagnosis — typhoid  fever.  He  had  been  attacked  some  time  before  with  chills  followed  by  fever,  head- 
ache, anorexia,  thirst  and  diarrhiea.  On  the  6th  he  was  wakeful,  eyes  siiftn.sed,  cheeks  slightly  injected,  pulse  1(X), 
skin  hot  and  showing  a  few  rose-sjiots  on  the  chest,  tongue  dry  and  coated  brown  in  the  centre,  teeth  black  with 
sordes;  his  appetite  was  poor  and  he  had  slight  headache  and  tenderness  in  the  parotid  region;  the  bowels  were 
relaxed  and  the  abdomen  tympanitic.  Emulsion  of  •'iir|ientine  was  given  every  four  hours;  twelve  grains  of  quinine 
and  astringents  were  ordered,  with  Dover's  jiowder  at  night  Next  day  the  tongue  was  red  at  the  tip  and  edges, 
brown  in  the  centre  and  slightly  moist  ;  the  (luinine  was  repeated.  He  continued  in  this  condition  and  under  treat- 
ment by  i|ninine  until  the  10th,  when  some  cough  was  recorded.  Next  day  he  was  dull  mentally,  and  the  cough  was 
accompanied  with  white  frothy  sputa.     No  further  details  are  given.     He  died  on  the  17th. 

C.vsE  45. — Diarrhoea;  cough;  sordes;  rose-spots  on  Sth  da i/,  succeeded  bij  others  on  the  \Uh,  14r/i  and  \lth  days; 
deafness;  delirium  ;  epistaxis;  olorrhaa  on  22rf  day,  with  relief  to  all  symptoms;  death  from  jmeumonia  ou  the  31st  day. — 
Private  Z.  McLaughliu,  Co.  A,  3d.  Pa.  Cav.;  age  18;  was  admitted  Oct.  20,  1861.  Diagnosis — typhoid  fever.  He 
had  been  healthy  until  Oct.  14,  when  he  was  seized  with  chills  followed  by  fever  and  sweating.  On  admission  he 
had  epistaxis,  diarrluea,  anorexia,  thirst  and  cough. '  Next  day  his  eyes  were  dull  and  slightly  injected ;  pulse  94  and 


228  CLINTCAL    RK.rORPS    OF 

quick;  Mkin  hot  and  dry,  iircst'iitinf;  a  iproliisioii  of  colored  siiots  on  the  chest  and  sonio  on  the  abdomen;  tongue 
sli^jhtly  inoiNt,  red  at  the  tip  and  edjjes  hut  coated  wliite  in  the  centre;  lips  hlaclc  with  sordes;  two  stools  were  passed 
durinj;  the  twenty-lour  hours;  there  was  sonic  nieteorlsni  and  also  a  slight  cough.  Tincture  of  iron  was  picserihcd. 
Next  day  eight  stools  were  jiassed,  and  there  was  sonu!  cough  with  cxjx'ctoration  of  tenacious  mucus.  Turpentine 
ennilsion,  lead,  tannin  and  opium  were  prescrihcd.  The  diarrluea,  whicli  was  attended  with  much  tympanites, 
became  checked  in  the  course  of  a  few  days  and  the  bowels  thereafter  remained  (|uiet  or  witli  not  more  than  one 
movement  daily;  the  skin  continued  hot  and  dry  throughout.  Fresh  crops  of  rose-colored  spots  ajjpeared  on  tlu) 
21th,  L'litli  and  'Mlh,  and  were  reported  on  November  2  as  fading  and  nnelevated;  hut  on  the  lid  and  5tli  the  chest  is 
noted  as  covered  with  sudamina.  Deafness  was  recorded  on  October  24;  buzzing  in  the  ears  on  the  27th;  cpistaxis 
arwl  delirium  on  the  29th,  the  former  recurring  on  the  31st  and  on  November  IJ  and  i.  On  October  30  the  patient 
was  kept  from  sleeping  liy  the  cough,  and  there  was  much  delirium,  deafness  and  tinnitus;  at  this  time  tlu^  tongue 
was  dry  and  its  papilhe  prominent.  On  November  1  the  tongue  was  swollen,  dry  and  brown.  On  the  3d  the  deaf- 
ness was  very  great,  Imt  a  discharge  occurred  from  the  ear,  and  with  this  the  tongue  became  moist  and  the  deafness 
lessened.  On  the  4th,  when  the  last  attack  of  epistaxis  occurred,  the  piilse  became  so  faint  that  it  could  scarcely  be 
counted;  but  the  appetite  improved.  On  the  5th  the  tongue  was  moist  and  yellowish,  pulse  100  and  feeble;  there 
was  no  abdominal  tenderness  and  less  cough.  On  the  8tli  the  pulse  was  105  and  the  respiration  22.  Next  day  the 
pulse  was  120.    Death  took  place  on  the  12th  with  pneumonic  symptoms. 

Case  46. — Diarrhoea;  droicsiness  and  deafness;  irouehial  and  pneumonic  accompanimenis ;  rose-colored  spots  on  lllh 
and  ribices  on  2oth  day;  otoi-rhaa ;  pains  in  the  lef/s;  death  on  the  \22d  daij. — Private  Mark  Warner,  Co.  E,  Ist  Pa.  Ait.; 
age  26;  was  taken  sick  Sept.  1,  1861,  with  pain  m  the  back  and  bones,  headache  ami  chills,  and  was  admitted  on  the 
16th.  Diagnosis— tyi)hoid  fever.  On  admission  his  pulse  w  as  ill  :  tongue  smooth  and  dry  in  the  middle,  moist  at  the 
edges;  skin  hot  and  moist;  cheeks  Hushed;  eyes  dusky;  bowels  loose  and  tender;  he  had  headache  and  was  dull 
mentally.  Catechu  was  used.  Next  day  the  characteristic  rose-colored  spots  appeared  on  the  chest  and  abdomen 
and  sibilant  and  sonorous  rales  were  heard  over  the  chest,  especially  on  the  left  side.  Whiskey-punch  and  turjientine 
emulsion  were  prescribed.  On  the  18th  the  patient  was  drowsy  and  had  acute  tenderness  in  the  abdomen  and  tym- 
panites, although  the  bowels  were  quiet.  An  enema  of  soap-suds  was  administered.  On  the  19tli  the  skin  was  moist 
and  the  mind  less  obtuse,  the  bowels  loose,  the  tympanites  reduced,  but  the  tenderness  was  not  les.sened.  The  respi- 
rations were  Increased  to  30  on  the  20th ;  bronchitic  sounds  were  heard  over  the  whole  of  the  chest,  and  a  part  of  the 
lower  lobe  of  the  right  Inng  was  consolidated.  Dover's  powder  was  given.  On  the  2l8t  the  pulse  was  108,  soft  and 
weakj  skin  hot  and  dry,  showing  a  few  fresh  rose-coloied  spots;  decubitus  dorsal  with  flexed  limbs;  tongue  smooth, 
glossy,  dry;  bowels  relaxed,  tender  and  tympanitic  in  the  iliac  regions;  the  patient  was  somewliat  deaf,  and  com- 
plained of  pains  in  the  limbs.  Vibices  appeared  on  the  skin  on  the  25th  and  29th,  sudamina  on  the  27th.  The  tongue 
became  clean  on  the  26th  audtlie  aiipetite  returned  on  the  30th,  the  chest  symptoms  meanwhile  gradually  becoming 
relieved;  the  pnlse,  however,  continued  accelerated,  100  to  112.  On  October  7  a  discharge  from  the  ear  was  treated 
with  a  solution  of  nitrate  of  silver;  hut  it  became  more  profuse  and  persisted  up  to  the  close  of  the  detailed  record. 
On  the  9th  the  patient  sufiered  much  from  pain  in  the  legs,  which  were  greatly  emaciated;  sponging  with  alcohol 
gave  temporary  relief;  this  pain  also  continued  to  the  close  of  the  record  on  October  17.  After  this  date  tlie  only 
entry  made  was  the  announcement  of  death  from  typhoid  fever  on  December  31. 

Case  47. — Severe  diarrhoea  at  the  onset ;  delirium  and  great  prostration;  improvement  on  the  12th  day  coincident  icith 
eruption  and  epistaxis;  recurrence  of  severe  symptoms  on  the  S3d  day,  and  death  on  the  36//(.— Private  F.  Taylor,  Co.  I, 
2d  Mich.  Vols.;  ago  23;  was  admitted  Aug  16,  1861,  with  rheumatism.  lie  improved  rapidly  till  Sept.  6,  when  he 
was  seized  witli  a  severe  diarrluea,  fever  and  pains  in  the  head  and  bones.  Sugar  of  lead,  tannin  and  ojiium  were 
prescribed.  On  the  11th  tinnitus  aurium,  muscie  volitantes,  slight  deafness  and  heada<die  were  among  tlitt  symp- 
toms; the  skin  was  hot  and  dry,  pulse  116  and  weak,  tongue  coated;  seven  stools  were  passed.  On  the  12tli  emulsion 
of  turpentine  was  prescribed.  On  the  13th  the  tongue  was  dry  and  brown  and  the  patient  muttered  in  his  sleep. 
Ho  complained  much  of  rheumatic  pains  in  his  bones;  liis  bowels  were  moved  five  times  during  the  night  and  nine 
times  during  the  day.  Heef-essence  and  brandy  were  given.  lie  persiiired  much  on  the  15th,  and  the  urine  passed 
involuntarily.  On  the  16th  he  was  very  weak  and  had  a  cadaverous  look  ;  his  tongue  was  dry,  brown,  glossy  and 
red  at  the  tip;  the  diarrhoea  continued.  On  the  17th  he  was  much  jnostrated,  somnolent  and  indili'erent  to  sur- 
rounding objects,  but  the  hladtWr  was  more  under  control  and  the  stools  less  fre(iuent.  He  had  cpistaxis  during  tlio 
night,  and  next  day  the  tongue  liecame  moist  and  clean  in  patches  and  some  rose-colored  spots  appeared  on  the  abdomen. 
He  was  brighter  on  the  19th,  free  fioiu  delirium,  but  with  some  headache,  dizziness  and  deafness;  the  tongue  was 
clean,  dry,  glossy  and  protruded  with  ditliculty.  On  the  20th  the  eyes  were  bright,  face  pale  and  sunken,  pulse 
90  and  weak,  skin  warm  and  moist,  tongue  dry  and  brown  but  red  at  the  tip  and  sides,  teeth  and  lips  clean ;  he  hart 
some  appetite;  one  stool  was  passed  and  the  iliac  regions  were  tender,  lie  continued  in  tliis  condition,  the  bowels 
comparatively  ([uiet, — occasional  headache,  dizziness  and  slight  deafness  being  the  only  cerebral  symptoms  until 
October  8,  when  diarrhiea  again  set  in  w  itli  delirium,  diiluess,  deafness,  great  jirostration  and  profuse  sweating, 
ending  in  death  on  the  11th.  A  copious  eruption  of  rose-S])ots  ap|ieared  on  September  24,  vibices  on  the  28th,  with 
fresh  and  numerous  outcrops  of  the  latter  on  October  4  and  8. 

Case  48. — Probable  relapse  four  months  after  primary  attack.  IHarrhica ;  abdominal  ti ndtrness;  eruptions:  snrdes; 
delirium;  death. — Private  William  Hoardman,  Co.  D,  1st  Pa.  Kifles;  age  29;  was  admitted  Oct.  10,  1861.  He  stated 
that  he  had  been  sick  since  June,  when  lie  had  an  attack  of  enteric  fever.  On  admission  he  had  headache  an<l  wiis 
anxious  looking,  his  eyes  dull,  cheeks  flushed,  pulse  90,  ijuick  and  feeble,  skill  hot  and  dry,  tongue  sliglitly  moist, 
red  at  the  tip  and  edges,  black  and  fissured  in  the  centre;  his  appetite  was  fair.  Dover's  powder  was  prescribed. 
Next  day  he  was  reported  as  having  had  four  movements  of  the  bowels;  his  tongue  had  become  white  in  the  centre 


TTTF.    COXTTNUKD    FFVT-'.ES.  •  229 

and  his  skin  covcrod  profusely  witli  an  oni]itii)n  tlic  oliaiacti'i'  of  wliicli  is  not  stati'd.  Punch  and  tincture  of  iron 
were  given.  The  eruption  is  mint  ioned  on  tlic  folloxviuj;  day  and  again  on  the  LMst.  During  the  )irogress  of  the  case 
the  howe'ls  were  rehixed,  two  stools  lieiug  passed  daily.  The  appetite  eont  inui'd  good  until  the  day  of  ileath.  There 
was  great  tt'uderness  in  the  alidonu'n,  which  was  at  first  especially  niarkeil  in  the  left  iliac  region,  hut  afterwards 
liecanie  associated  with  various  regions  as  the  epigastric,  und>ilical.  the  track  of  the  transverse  and  des<'en<ling  colon 
and  on  one  occasion  the  right  side;  the  tenderness  was  usually  accompanied  hy  nieteorisni  and  gurgling.  The  skin 
was  hot  and  dry  throughout  except  on  one  or  two  <lays,  when  it  was  rcjiorted  as  vi'ry  dry  hut  not  hot.  The  tongue 
was  dry,  red,  fissured  and  glaze<l,  the  lijis  covered  with  sordes  and  the  teeth  with  tenacious  mucus.  0\\  the  Itilli 
there  was  some  headache  with  occasional  delirium  of  a  mild  character,  which  afterwards  hecanio  more  contin- 
uous. On  the  23d  the  jiatient  is  reported  as  having  slept  well  as  usual ;  his  conntenance  was  pale,  face  pinched,  lijis 
l)arched,  skin  and  tongue  dry.  jinlse  !•.">  and  feeble,  the  abdomen  Hat.  Turpentine  emulsion,  cod-liver  oil  ami  (piinine 
were  prescribed,     lie  died  during  the  night. 

Case  49. — nelapxi:  It<in}  nipiijitiDii^  not  mnrl^ctl ;  riixr-sjxitx  from  thf  \\»t  to  the  U{)tli  iliiy ;  rilnces  on  'A)th ;  howcl 
(iffict'ion  not  ])fomiiiiiit  until  foiHtilioii  of  jxrsplfdlioitu :  rrtiiriiid  to  diilii  in  ItK)  tlai/n. — I'rivate  M.  R.  Taggart,  Co.  A,  '.'Ih 
I'a.  ^'ols.;  age  31;  was  admitted  Oct.  10,  IStil,  having  been  sick  since  Sei>t.  1  with  what  had  been  regarded  as  enteric 
fever,  for  which  <ininine  had  been  given.  On  admission  his  eyes  were  dull,  face  congested,  pulse  HO,  ([uick  and  full, 
skin  hot  and  dry,  tongue  nM)ist,  red  at  tip  and  <'dges,  coated  white  in  the  centre,  appetite  poor;  he  had  soiue  cough. 
Dover's  |>owder  was  given.  He  slept  badly  during  the  night  and  lu'xt  day  was  stupid  and  dull-eyed;  a  few  rose- 
colored  s])ots  wcrc^  fouml  on  the  chest  and  many  on  the  abdomen  ;  th<^  pulse  was  100  and  feeble;  his  bowels  had  not 
l)een  moved.  Tincture  of  iron  was  ordered  to  be  taki'U  three  tinu's  daily  and  extract  of  senna  in  the  evening.  He 
slept  well,  and  on  the  morning  of  tlu^  12th  the  jinlse  was  found  to  have  fallen  to  DO ;  the  eyes  were  bright  and  the 
tinsh  had  disapiieared  from  the  face;  the  bowels  had  not  been  moved,  but  there  was  mncli  tenderness  in  the  right 
iliac  region.  On  the  13th  the  patient  was  covered  with  a  profuse  pers])iration;  pulse  120  and  feeble;  aslightepistaxis 
had  occurred  and  one  stool  had  been  obtained.  Tincture  of  digitalis  and  sweet  spirit  of  nitre  were  ordered  to  be 
taken  four  times  during  the  day.  The  perspiration  continued  on  the  lltli,  and  the  appetite  was  found  to  be  improved. 
Five  grains  of  (piinine  were  given  every  two  hours.  On  the  15th  the  jjulse  had  fallen  to  !K)  and  was  more  regular, 
the  skin  was  hot  but  sonu'what  moist,  the  tongue  dry,  the  api)etite  poor;  the  bowels  had  been  moved  twice.  On  the 
morning  of  the  llJth  the  skin  was  dry,  but  there  had  been  a  ])rofnse  perspiration  during  the  night;  the  tongue  was  rod 
and  clean  but  <lry,  and  the  appetite  poor;  one  stool  was  passed,  and  the  patient  was  troubled  with  cough.  Profuse 
l)ers])iiation  recurred  nightly  until  the  22d.  On  the  17th  the  tongue  became  nu)ist  and  covered  with  white  patches. 
Next  day  a  few  rose-spots  appeared  on  the  abdomen ;  two  stools  were  paused,  and  there  was  slight  umbilical  teinler- 
ness.  On  the  19th  the  profuse  perspiration  continued  during  the  day;  the  pulse  rose  to  120;  tympanites  and  bor- 
borygnnis  were  present  Imt  no  stool  was  pas.sed.  Several  rose-spots  and  vihices  appeared  on  the  abdonum  on  the  20tli ; 
])ulso  86;  two  stools  wore  pa8.sed.  The  skin  was  soft  an<l  natural  on  the  21st,  and  next  day  the  tongue  was  clean  and 
moist  and  the  appetite  good.  During  the  following  week  an  occasional  nocturnal  perspiration  was  noted,  but  other- 
wise the  condition  of  the  patient  was  good.  On  the  29th  sonui  rose-spots  ai>peared  ami  three  stools  were  ]>assed. 
Four  stools  were  recorded  on  the  following  day,  and  on  the  31st  nine  stixds,  with  dry  tongue,  heat  of  skin  and  accel- 
erated pulse.  Twelve  stools  were  passed  on  November  1,  on  which  day  the  patient  was  transferred  to  Annapolis,  Md. 
[where  his  case  was  diagnosed  typhoid  fever,  and  terminated  in  a  return  to  duty  on  March  19, 1862]. 

Case  50. — IHorrhoca  ;  ro8C-r<is}i  ;  (Iclirium;  parotid  inflammation ;  coma  vigil;  return  of  consciousness  before  death  at 
end  of  third  week. — See  case  of  Private  Oscar  Snow,  Co.  H,  3d  Vt.,  No.  31  of  the  post-mortem  records. 

Cask  51. — Chiltx;  epistaxis;  diarrhoa  ;  tiimjiKnilex ;  rilii<r-i ;  deafness,  Imt  no  detirium  or  notnlde  cerebral  implication; 
temporary  improvement  foUoxeed  hi/  hed-sores,  and  death  prohahly  from  pnlmonary  engori/ement. — See  case  of  Private  Ben- 
jamin Cunningham,  Co.  D,  86th  N.  Y.,  No.  34  of  t\n'  post-mortem  records. 

Seven  Remittent  Cases. 

Case  52. — Private  .James  lirown,  Co.  B,  26th  Pa.  Vols.;  age  38;  was  attacked  Aug.  20,  1861,  with  headache, 
chill  and  pains  in  the  bones,  and  admitted  Sept.  4  as  a  ca.se  of  remittent  fever,  presenting  constipation,  anorexia 
and  epistaxis,  with  high  fever,  the  pulse  being  100,  the  skin  moist  and  the  tongue  heavily  coated  and  of  a  yellowish- 
brown  color.  A  dose  of  Epsom  salt  was  taken  at  once,  ami  (jninine  ordered  three  times  daily.  The  bowels  were 
moved  twice  during  the  night  and  once  next  morning,  after  which  the  pulse  was  found  lowered  to  60,  the  skin 
natural,  tlie  tongue  pale,  tlabby  and  coated,  ami  the  abdonuMi  sore.  Dover's  powder  was  given  at  night.  The  fever 
did  not  recur.  The  tongue  continiu'd  pale,  tlabby  and  somewhat  coated,  hut  the  appetite  returned,  and  ho  was  sent 
to  duty  on  the  lltli. 

Case  53. — Private  James  Baker,  Co.  D,  19th  la.  Vols.,  was  adndtted  Sept.  4,  1861,  having  had  a  chill  fol- 
lowed by  fever  without  diarrluea.  Diagnosis — remittent  fever.  On  the  morning  of  tlie  5th  his  pulse  was  70;  skin 
moist  and  cool;  tongue  pale,  tlabby  and  slightly  coated,  and  bowels  loose  from  the  action  of  Kpsom  salt;  he  had  a 
dry  cough  with  j)ain  in  the  chest.  (Quinine  was  given.  In  the  evening  there  was  some  heat  of  skin,  hut  otherwise 
the  condition  of  the  patient  was  nncduinged.  The  cough  was  somewhat  troublesimie  on  the  6th,  but  there  was  no 
fever.  The  tongue  continued  pale,  tlabby  and  more  or  less  coated,  but  the  ajjpetitt^  returned  and  on  the  9th  he  was 
able  to  walk  about.  His  bowels  did  not  remain  loose  after  the  purgative  action  of  the  salt  had  ceased.  Noeniption 
appeared  on  the  skin.     He  was  returned  to  duty  on  the  14th. 

Case  54. — Private  Frank  Teats,  Co.  C,  .5th  N.  Y.  Cav.;  age  22;  was  taken  sick  Sept.  19,  1861,  with  giddiness, 
chills,  epistaxis  and  pain  in  the  back,  and  adndtted  on  the  23d  as  a  case  of  remittent  fever.     His  face  was  Hushed, 


230  CLINICAL    RECORDS    OF 

eyes  suffused,  pulse  85,  ((uick  and  strong,  sLiu  liot  and  moist,  tongue  slightly  white  in  the  middle  and  red  at  the 
edges,  a)>]>etite  lost,  bowels  unmoved.  He  had  headaelie,  a  slight  eougli  and  Iniiried  lesiiiiation,  12")  i>er  minute. 
A  small  dose  (one  and  a  half  drachms)  of  sulphate  of  magnesia  with  one-eighth  of  a  grain  of  tartar  emetie  was  given, 
and  Dovers  jiowder  ordered  to  lie  taken  at  liedtime.  He  rested  well,  had  one  stool  during  the  night,  and  next  morn- 
ing his  eoiintenanee  was  natural.  In  the  evening  the  face  was  again  tliished,  the  eyes  dnil.  pulse  ill',  tongue  moist 
and  white  liut  with  the  ))aiiilla'  at  the  tip  j>roJecting:  ai>petite  small.  He  had  heailaehe.  eough  w  ith  <lilli(  ully  of 
ex])eetoratioii,  and  a  pain  in  the  oliest  and  alidomen  from  having  taken  cajisieuni  by  mistake.  Six  grains  of  (ininine 
and  three  of  Dover's  powder  were  given  every  two  hours  until  three  sueh  doses  were  taken.  On  the  2.")th  there  was 
no  fever  nor  headaelie;  the  skin  was  warm  and  moist,  the  tongue  moist  and  eoated  light  brown,  the  jiulse  itS;  the 
bowels  were  nu>ved  onee;  there  was  ejiistaxis  at  night.  Next  day  the  pulse  was  78,  and  there  was  one  stool  with 
gurgling  iu  the  right  iliac  region  and  dysuria,  but  the  cough  had  ceased  and  the  aiipetite  had  returned.  Kxtraet  of 
buclni  was  given.     He  was  returned  to  duty  on  the  30th. 

Oa.sk  .")5. — Private  Samuel  Cunningham,  Co.  H,  12th  Pa.  Vols.,  was  taken  about  Sept.  1,  181)1.  w  ith  weakness, 
headache,  nausea  and  ]iain  in  the  bones,  and  was  admitted  on  the  otli  as  a  case  of  remittent  fever.  His  tongue  was 
flabby,  white-coated  and  red  at  the  edges,  pulse  i<0,  face  flushed,  skin  nujist  and  hot,  bowels  constipated.  His  fever 
was  rejuirted  to  be  worse  in  the  morning  than  in  the  evening.  A  dose  of  Ki>som  salt  was  followed  liy  six  large  thin 
stools.  Quinine  was  given.  Next  day  he  had  two  suuill  stools,  and  on  the  7th  his  bowels  weie  quiet.  On  this  day 
the  morning  pulse  was  84,  the  evening  (i8,  full  on  both  occasions;  aiul  there  was  headache  with  flushed  face,  a  pale 
white-coated  tongue  and  anorexia.  Dover's  powder  was  given  at  night.  On  the  8th  the  morning  ])ulse  was  l!fi,  the 
tongue  coated  w  hite  in  the  middle,  the  face  slightly  tlushed  and  there  was  some  giddiness.  In  the  evening  the  ])ulse 
had  risen  to  74,  the  tongue  was  clean,  and  an  eru])tion,  stated  as  owing  to  the  poison  of  the  rhus  toxicodendron, 
ajipeared  in  confluent  patches.  After  this  he  rested  well  and  had  no  fever.  IJicarbonate  of  soda  was  applied  to  the 
eruption,  which  faded  in  four  or  five  days.  On  the  12th  the  patient's  appetite  was  good  and  he  was  walking  about. 
On  the  VMh  he  was  transferred  to  hospital  at  Paltimore,  Md. 

C.^SE  5(1. — Private  .lohn  Iloadley,  Co.  H,  12th  Pa.  Vols.,  was  taken  with  headache  and  i)ain  in  the  bones  about 
Aug.  2!t,  18til,  together  with  a  daily  recurring  chill  and  fever,  an<l  a  diarrhoea  causing  about  six  stools  daily.  He 
was  admitted  September  5  as  a  case  of  remittent  fever.  The  tongue  was  pale,  flabliy  and  coated,  the  face  flushed, 
the  skin  warm  and  moist,  the  pulse  86,  the  bowels  loose.  A  small  dose  of  tincture  of  opium  was  given.  Next  day 
ijuinine  was  ordered,  with  Dover's  powder  at  night.  He  had  no  chill  after  admission,  but  there  was  an  evening 
exacerbation  of  fever,  which  on  the  9th  and  lOtli  was  aeconi]>anied  by  drowsiness  and  stupidity.  On  the  morning  of 
the  11th  the  lemissioti  was  verj'  marked,  and  in  the  evening  the  ajipetite  became  improved.  On  the  evening  of  the 
12lh  the  tongue,  which  had  been  flabby  and  coated  hitherto,  liecame  clean.  The  bowels  were  relaxed  throughout 
the  attack,  but  there  was  no  tenderness  except  on  the  tith,  in  the  umbilical  region.  On  this  day  also  there  was  a 
slight  cough  with  a  stitch  in  the  right  side.  The  diarrhiea  abated  with  the  decline  of  the  fever  and  the  cleaning 
of  the  tongue.     The  patient  was  transferred  to  hospital  at  Baltimore,  Md.,  on  the  VMh. 

Cask  .57.  — Sergt.  Hyron  Hinman,  Co.  G,  24th  N.  Y.  V(ds.;  age  24;  was  admitted  Sept.  25,  18GI,  with  remittent 
fever  which  he  had  contracted  about  four  weeks  before.  He  had  headache  with  flushed  face,  sutliised  eyes,  a  c|uick 
pulse.  82  ]ier  minute,  and  a  warm  but  moist  skin,  a  slight  cough,  anorexia  and  moist  yellow-coated  tongue.  A  six- 
grain  dose  of  l>lne-pill  was  ordered,  with  Dover's  powder  at  night.  Next  day  there  was  some  umbilical  tenderness; 
sixteen  grains  of  (luinine  were  given  in  the  forenoon  and  a  small  dose  of  ca.stor  oil;  two  stools  were  passed.  On  the 
27tli  the  face  was  not  so  much  Hushed  and  there  was  some  return  of  appetite.  The  patient  was  dizzy  and  in  the  after- 
noon had  a  free  perspiration.  The  quinine  was  repeated  oti  the  28th,  but  the  headache,  anorexia  and  foul  tongue 
w  ere  not  removed  until  <  (ctober  1,  after  a  second  mercurial  dose  with  castor  oil.     He  was  returned  to  duty  on  the  9th. 

('.\SK  .58. — Private  H.  Hardridge,  Co.  F,  (ith  Wis.  Vols.,  was  admitted  Oct.  HO,  18til.  Diagnosis — remittent  fever. 
Since  October  23  the  jiatient  had  headache,  wi'akness,  pain  in  the  back,  some  loss  of  appetite  and  much  thirst.  On 
the  <lay  of  admission  he  had  a  slight  chill  followed  by  fever.  Quinine  was  given.  He  rested  well  but  uot  until 
after  midnight,  and  next  morning  the  skin  was  warm  and  moist  but  Jaundiced,  and  the  tongue  soft,  pale,  moist  and 
coated,  the  puLse  86  and  bowels  ijuiet.  Calomel  and  morphia  were  given  three  times  during  the  day.  Quinine  in 
six-grain  do.ses  three  times  daily  was  substituted  on  November  1  and  continued  until  the  7th.  The  patient  was 
returned  to  duty  on  the  15th. 

Thirty-i'ive  Typhoid  Fever  Cases  with  more  or  less  Evidence  of  the  Existence  of  Malarial  Affection. 

Ca.se  59. — RelapHe  manifested  hj/  diarrhua,  eruption,  wakefuhiens  and  inereaned  tempfr((ture. — Sergt.  OeorgeAL  Cook, 
Co.  G,  3d  Mich.  Vols.;  age  23;  was  admitted  Oct.  19,  18()1.  He  had  inevionsly  sutl'ered  from  rheumatism,  intermit- 
tent fever  and  enteric  fever,  and  while  convalescing  from  the  last,  about  October  14,  he  was  seized  with  a  chill 
followed  by  fever  and  perspiration,  wakefulness,  thirst,  diarrhuni  and  pain  in  the  bowels.  His  case  on  admission 
was  diagno.sed  typhoid  fever.  On  the  20th  he  was  wakeful,  his  eyes  dull,  cheeks  not  tlushed,  juilse  fiti,  full  and  strong, 
skin  .somewhat  above  the  natural  temperature,  tongue  red,  slightly  moist  and  with  a  few  yellowish  patches  in  the 
centre,  appetite  poor;  he  had  six  stools  with  .some  general  abdominal  tenderness  and  tympanites.  A  few  rose-colored 
spots  a))peaied  next  day,  but  otherwise  his  condition  was  unaltered.  On  the  22d  he  slept  well ;  the  |uilse  rose  to  74 
and  w.as  regular  and  strong;  the  .skin  was  of  the  natural  temperature;  the  tongue  tiabby  and  patched  with  a  white 
fur;  the  apiietite  ccmtinued  i>oor  and  the  diarrhu'a  active,  the  abdominal  tenderness  being  more  marked  on  the  right 
side.  .Vfter  this  the  diarrhica  gndnally  les.sened,  the  tongue  became  clean  and  the  appetite  good.  ITp  to  the  end  of 
the  month  he  was  troubled  w  ith  a  slight  cough  with  yellowish  expectoration.     He  was  returned  to  duty  Nov.  7. 


rilK    (■(iKTINrKD    KKVKRS.  2'M 

Case  (jO. — Luiht fihi-ilr  (illacl:  hilhiiviuij  inttrmittiid  J'lvn-.  Iiitl  not  uilliuiicid  spicialhj  hij  the  (iclldii  of  llii  iiKiUiritit 
poison;  (Ifhiliti/,  (Ironsiiiess  iiiiU  iliiirrhutt. —  IVaiiister  EUwanl  C.  LihUi'V,  liil  Mioli.;  ajjc  L'S;  hail  cliills  ami  tVver  with 
dianhifa  since  the  middle  of  Aufjust.  l><(il.  tint  atti'iidi-d  to  his  <liity  as  an  aiulmlaiice  driver  until  September  H, 
when  he  was  admitted  as  a  case  of  tyjilioid  fivi'i-,  presciil  inij  chills,  increased  local  and  general  heat,  anorexia,  nnis- 
cnlar  deliility  and  jiain  in  the  head  and  liones.  On  the  14th  he  was  drowsy  and  had  headache;  pnlse  78,  tongue 
moist,  red  at  the  lip  and  brown  in  the  centre,  appetite  returning.  Next  evening  tlie  headache  continued  and  he  had 
two  stools;  but  after  this  the  bowels  liecanie  regular,  the  sUin  nutist  and  warm,  the  tongue  nu)ist  and  clean,  the 
jiulse  natural,  the  sleep  sound  and  the  apiietite  and  strenglli  imi)roved.  He  was  returned  to  duty  on  the  :i(lth. 
Dover's  ))owder  and  turpentine  emulsion,  with  i|uinine  towanls  the  end,  formed  the  medication. 

Cask  61. — Dhzinrxx,  Wdkifiihuxn,  fusc-co/Drii/  :<ihiIi)  <iiii(  (lidnlida  :  iiiiiiroriiiirnl  about  mil  oj'  'JJ  wnk. — I'rivate  A. 
A.  Rich,  Co.  (i,  r>th  Vt.  Vols.;  age  17;  was  admitted  Nov.  1,  IStil.  Diagnosis — debility.  Ho  had  been  sick  about  a 
week,  first  with  chills,  afterwards  witli  fever.  On  admission  he  was  wakeful  and  had  headache,  dizziness,  buzzing 
in  the  ears,  anorexia,  thirst,  vomiting,  (liarrluea  and  cough.  Next  <lay  the  wakefulness  continued;  jiulse  KK),  quiik, 
full  and  tirni;  skin  hot  and  presenting  a  tew  rose-colored  sjiots  on  the  chest;  there  was  slight  headache  with  tinnitus 
aurium;  the  tongue  was  slightly  moist  and  furred  white,  but  red  on  the  tip,  edges  and  central  line;  the  aiipetite  was 
good,  but  there  was  considerable  thirst  ;  the  bowels  were  slightly  relaxed,  tympanitic  and  ten<ler  on  pressure  in  the 
und)ilical  and  left  iliac  regions;  there  was  also  some  cough  with  frotliy  sputa,  lie  slept  well  during  the  following 
night,  and  on  tin'  morning  of  the  Hil  the  pulse  was  reduced  to  XO,  but  otherw  ise  the  symiit<uns  continued  as  already 
stated.  Treatment  was  by  sulphate  of  (|uinine  and  astringents.  On  the  (jtli  the  diairhiea  liecame  suddenly  aggra- 
vated, five  stools  having  been  passed  in  the  t  went y -four  hours,  accompanied  with  abdominal  tenderness  and  gurgling. 
Next  day  three  stools  were  passed  and  on  the  8th  one  stool.  Improvement  was  progressive  after  this,  but  on  the 
18th,  when  the  patient  was  transferred  to  Haltimore,  Md.,  there  was  still  some  heat  of  skin,  with  slight  abdominal 
tenderness  and  some  cough,     file  was  returned  to  duty  .Ian.  27,  18(i2.  | 

Case  ((2. —  Sliyht  (liarrlura  ;  ili::iiif!<n  ;  roKi-spotx  on  Wthilaii;  imprortnunttitendof'ldn-iik. —  Private  George  W. 
Olney,  Co.  A,  4th  Mich.:  age  18 :  became  sick  about  S<'i)t.  !t.  1801,  with  weakness,  headache,  diarrluea  and  slight  fever 
without  chills,  and  was  admitted  on  the  IGth.  Diagnosis — typhoid  fever.  He  had  epistaxis;  his  pulse  was  7(1  and 
full;  skin  warm  and  moist;  tcmgue  jiale,  tlaldiy  and  slightly  coated  white:  bowels  quiet.  Ten  grains  each  of  calomel 
and  jalap  were  jirescribed.  He  had  three  passages  from  the  bowels  during  the  night,  and  next  day  the  skiu  was 
warm  and  sweating.  Kose-colored  sjjots  appeared  on  the  18th,  and  the  tongue  began  to  clean;  there  was  some 
dizziness  but  no  mental  dulness;  two  thin  large  stools  were  i)assed,  and  there  was  tenderness  in  the  right  iliac 
region.  On  tjie  llHh  the  luilse  was  '6;  tongue  tremulous,  pale  at  the  edges  and  coated  in  the  middle;  bowels  (juiet; 
skin  hot  and  moist.  Quinine  was  given.  Next  day  the  skin  was  natural ;  there  was  no  tenderness  nor  tympanites: 
the  countenance  was  pleasant  and  t  he  eyes  bright.  A  few  dark  ro.se-colored  spots  appeared  on  the  22d.  The  liowels 
remained  (|uiet  until  the  2,Sd,  when  they  were  nu>ved  seven  times,  but  there  was  no  accompanying  tenderness, 
meteorism  nor  gurgling;  the  appetite  was  good,  the  tongue  pale,  gray  in  the  centre  but  cleaning  at  the  tip.  Opiate 
enemata  controlled  the  diarrlnpa  and  the  patient  improved  on  tonics  and  atiniulants.  He  was  able  to  walk  about 
on  October  1,  when  he  was  transferreil  to  Annapolis,  Md. 

Case  63. — Mental  dnlnens ;  roHe-spot.i  on  the  9lh  dai/,  disuppearimj  on  the  H'dh ;  bowel  offection  uliijhtlii  miirked. — 
Private  .John  Dickerson,  Co.  A,  4tli  Mich.;  age  24;  was  taken  about  Sept.  9,  1861,  with  ]iain  in  the  bones,  back  and 
head,  fever  which  was  said  to  be  worst  at  noon,  and  diarrlnea.  He  was  admitted  on  the  16th.  Diagnosis — typhoid 
fever.  In  the  evening  the  fever  was  slight;  pul.se  74:  skin  warm  aiul  dry;  face  tlusheil ;  tongue  red  at  the  edges, 
coated  yellowish  at  the  base  and  in  the  miildle,  moist  and  with  ])rominent  papilhe;  a  liitti'r  taste  was  felt  in  the  nu)Uth  ; 
one  stool  was  passed  during  the  day,  and  there  was  some  umbilical  tenderness.  Two  grains  each  of  calomel  and 
Jalap  were  given.  N<*xt  day  the  pulse  was  70  and  small;  the  akin  dry;  the  tongue  dry,  heavily  coated  and  brownish  ; 
the  cheeks  flushed  ;  the  patient  was  weak  and  dull;  his  bowels  had  been  moved  once;  a  few  characteristic  rose-s])ots 
were  seen.  Quinine  was  ordered.  During  the  next  week  there  was  little  change  in  the  ])atient's  condition  ;  his  eyes 
were  injected  and  half  closed  and  he  was  dull  and  drowsy,  answering  ([uestions  in  a  low  tone;  the  face  was  flushed 
and  the  skin  hot,  dry,  husky  and  ])r(ifusely  spotted  with  the  rose-colored  eruption;  tlie  tongue,  heavily  coated  and 
brown,  became  moist  on  the  tilth;  the  bowels  quiet  and  neither  tender  nor  tympanitic;  there  was  some  headache 
with  dizziness  at  this  time.  On  the  22d  the  patient  was  dull ;  his  pulse  86  and  feeble;  face  flushed;  skin  hot,  moist 
and  spotted ;  tongue  red  at  tip  and  gray  in  centre ;  he  vomited  once  during  the  day  and  had  one  stool.  Next  day  the 
pulse  was  82  and  weak,  the  eyes  suffused,  the  skitiwarm  and  moist,  the  tongue  gray  in  the  centre  and  red  at  the  tip, 
the  bowels  quiet  and  not  tender.  On  the  24th  the  pulse  was  78,  the  skin  warm  and  soft,  the  tongue  moist  and 
slightly  coated  gray,  the  appetite  good.     Wine  was  occasionally  given.     He  was  returned  to  duty  October  24. 

Case  64. — Onxet  obscured  by  presence  of  tonsillitis  ;  headache,  deafness  and  tinnitus;  disease  marked  chiejiy  bij  abdomi- 
nal symptoms;  diarrhaa  alternating  with  perspirations. — Private  G.  W.  Conger,  Co.  1?,  19th  Ind.;  age  20;  was  admitted 
Sept.  4,  1861,  with  a  high  grade  of  inflannnatory  fever,  presenting  marked  remissions  and  accompanied  with  flushed 
face,  bloodsliot  eyes,  hot  and  moist  skin,  yellow-coated  tongue,  regular  bowels,  anorexia  and  slight  tonsillitis. 
Quinia  and  a  gargle  were  ordered.  On  the  7th  the  fever  lost  its  remittent  character  and  was  accompanied  with  head- 
ache, dry  tongue  and  frequent  stools;  pulse  80.  Turpentine  emulsion,  beef-essence  and  milk  were  substituted  for 
the  quinine.  On  the  14th  diarrhasa,  tymiiauites  and  tinnitus  aurium  were  noted;  pulse  88.  Dover's  powder  was 
given  at  night.  The  patient  rested  well  and  had  some  appetite  next  morning;  the  bowels  were  quiet,  but  the  skin 
was  hot  and  dry  and  the  pulse  108;  a  slight  eruption  had  appeared  on  the  penis  and  scrotum.  In  the  evening  the 
pulse  was  106,  the  tongue  moist  and  slightly  coated;  the  patient  had  two  stools  iind  souu^  tympanites  during  the  day. 
The  Dover's  powder  at  night  was  continued.     On  the  Kith  the  bowels  were  regular  ami  there  was  some  appetite; 


232  .  CLINICAL    KKCOKDS    OF 

pnlsi^  75  and  skin  moist.  On  the  ITtli  tlio  ti>nj;ni^  ^vas  cleaning,  tlic  api)etito  fjood,  the  inilsc  SO  and  the  hiiwels 
re;,nilin-.  Dovi'i'h  i)<)\v<h'r  was  continncd.  On  the  18th  the  rejHilt  is  varied  by  noting  ahdoniinal  tench-iness  with 
one,  stool,  and  on  tho  lilth  by  dryness  of  skin,  the  tongiu!  continuing  moist,  slight  deafness,  cough,  resjiiration 
increased  to  24  per  niinuto  and  bowels  tympanitic,  slightly  tender  in  the  right  iliac  region  and  moved  twice.  Twelve 
grains  of  ([uinine  were  given.  Coi)iou8  sweating  occurred  during  the  night  and  siidamina  ai)i>eared,  the  bowels 
again  becoming  regular  and  the  respiration  natural.  On  the  evening  of  the  li2d  pain  recurred  in  the  abdomen  with 
t\v<i  stools,  drvni'ss  of  skin,  some  headache  and  increase  of  the  pulse  to  100.  Next  day  two  stools  were  again  reported, 
but  the  skin  had  recovered  its  moisture  and  the  tonguii  was  natural.  On  the  2ltli  there  was  slight  deafness  but  no 
cough  nor  pain  ;  the  tongue  and  skin  were  in  natural  condition  and  the  appetite  good.  Again  on  the  evening  of  the 
2()tli,  with  an  acceleration  of  the  |>ulse  and  dryness  of  skin,  there  was  abdominal  pain  with  borborygnins,  followed 
by  free  perspiration  during  the  night.  From  this  (lat(f  to  Octol)er  1,  when  he  was  transferred  to  Annapolis,  Md.,  the 
jiatient  slept  well,  had  a  good  appetite,  moist  and  clean  or  yellow-patched  tongue  and  natural  skin;  but  there  was 
more  or  less  abdominal  pain  with  from  two  to  four  stools  daily. 

Cask  65. — D<itc  of  onset  oliscimd  hij  sriindo'  of  mcdslcs;  deufneiis  and  tinnitua  uiiriiitn;  dlarrkifit  and  roxf-coJored 
Dpots;  conralenrince. — Private  C.  Mills,  Co.  E,  0th  Wis.;  age  22;  had  measles  in  August,  ISIil,  and  al)out  Sej(teml)er  1 
was  taken  with  chills,  fever,  diarrluea,  cough  and  headache,  for  which  calouu^l  and  oi)iuni  had  been  administered. 
He  was  admitted  October  1.  Diagnosis — tyi>hoid  fever.  Turpentine  emulsion  and  astringents  were  ordered.  Ho 
slept  but  little,  and  next  day  was  looking  dull  and  had  slight  headache  and  congestion  of  the  face  ;  pulse  90,  (juick  ; 
skin  natural;  tongue  moist,  heavily  coated  brown;  appetite  moderate;  he  had  a  bad  cough  with  slight  expectora- 
tion ;  three  stools  were  passed  and  micturition  was  diflicult.  Cough  mixture  was  given  with  snuill  doses  of  blue-pill 
and  oi)ium  every  two  hours.  On  the  3d  the  skin  was  moist  and  covered  on  the  left  side  of  the  chest  and  abdcmieii 
with  a  |)ro  fusion  of  rose-colored  spots.  Next  day  deafness  ami  tinnitus  auriuui  were  noted.  On  the  5th  the  pulse  was 
fS5,  full,  the  skin  cool  and  moist,  the  tongue  moist  and  having  a  yellowish  patch  in  the  centre,  the  aii))etite  ]>oor; 
one  stool  was  ])assed,  and  there  was  some  tenderness  in  the  left  iliac  region;  resiiiratioii  was  natural  although  there 
was  much  cough  and  free  ex])ectoration.  Four  stools  were  passed  on  the  (ith,  six  on  the  following  day,  and  three 
daily  after  this  until  the  11th,  when  there  was  but  one;  during  this  time  the  expression  was  dull,  the  face  somewhat 
congested,  the  tongue  moist,  white  and  dabby,  and  the  appetite  poor.  On  the  lltli  the  tongue  became  clean  and  the 
ai)i)etite  good.  Tinc^ture  of  iron  was  ordered.  He  sle])t  well  during  the  night,  and  next  day  his  t^yes  wore  bright, 
cheeks  not  Hushed,  pulse  90,  regular,  skin  natural,  tongue  moist,  slightly  coated  white,  appetite  good.  On  the  14th 
lie  was  transferred  to  I'altimore,  Md. 

Cask  (!(>. — Chill  and  ri-mitlhuj  J'crcr ;  ronc-xiitilx  on  12lh  day;  drou-sinciis ;  sordes;  conyh  ;  diarrhara  and  iliac  Icndcrnrss; 
record  inijinixhcd. — Private  J.  M.  Foster,  Co.  A,  (!th  Wis.  Vols.;  age  21 ;  was  admitted  Nov.  1,  18(U,  as  a  case  of  typhoid 
fever.  Late  in  September  he  had  measles,  and  on  October  24  was  taken  with  a  chill  followed  by  fever,  weakness, 
anorexia,  pain  in  the  back  and  bones,  nausea,  vomiting  and  diarrluea,  whi<!h  continued  up  to  the  date  of  his  admis- 
sion. He  said  he  felt  better  about  noontime  daily.  On  November  2  he  was  dull,  his  eyes  slightly  sutlused,  pulse  112, 
(luick  and  of  Fair  strength,  skin  soft  and  moist,  tongU(^  soft,  coated  in  the  centre  and  at  the  tip,  teeth  coveri'd  with 
sordes;  he.  had  an(M'exia,  much  thirst  and  a.  diarrhiea,  of  four  slo(ds  daily,  with  some  alxlominal  teuderm^ss  and 
some  cough,  t^nininc  in  live-grain  <loses  was  given  three  times  daily.  Next  day  his  condition  was  unchanged  but 
on  the  4th  the  pulse  becaiius  reduced  to  100  and  lost  its  (piicikness  and  strength,  the  skin  was  hot  and  covered  with 
minute  rose-colored  spots,  tlu!  tongue  moist  and  brown,  eyes  injected  and  the  respiration  laboied.  The  patient 
continued  dull  and  drowsy  on  the  (ith,  and  the  diuirhiea  persisted,  with  some  tenderness  in  both  iliac  legions; 
but  the  tongue  apjjcared  cleaner  at  tlii^  edges  an<l  the  res]iirati<ni  was  natural.  On  the  7th  the  ]iul.se  was  108  and 
weak,  the  skin  dry,  husky  and  covered  with  rose-c<dort(l  s])ots,  tlu^  tongue  dry  and  brown,  the  gums  and  teeth 
blackened,  the  bowels  loose,  tym))anitic,  tender  and  gurgling  on  pressure.  The  record  leaves  the  ))atient  in  this  con- 
dition on  the  8th,  and  closes  with  the  remark  that  he  was  tnuisferred  to  Philadelphia,  Pa.,  Feb.  15,  18(i2. 

CaHE  67. — Headache;  epintaxis;  hchetude ;  ahdoiniinil  ni/nijitoiii.x  md  marked;  rase-xjiolH  on  Ihi'Mh  day,  n-ith  perKjii- 
ratioim  and  sndamina  ahout  the  heyinniny  of  the  '.id  ireek,  aeeonipanyiny  (liferreKcence. — Sergeant  John  F^vans,  (Jo.  H,  12th 
Pa.,  had  a  chill  on  the  nuirning  of  Aug.  .SO,  18t!l,  followed  next  day  by  fever  which  increased  towards  evening,  and 
was  associated  with  headache  and  pains  in  the  lioiws  and  small  of  the  back.  To  these  sym])toms,  on  Septeudicr  2, 
epistaxis,  lassitude  and  a  tendency  to  stnjior  were  addi'd;  but  the  bowels  remained  legular  and  urin.itiou  free.  (Jli 
the  4th  he  was  admit  tcil  to  lios|iital  as  a  case  of  typhoid  fever:  pulse  ~X,  skin  hot  and  dry,  tongue  coated  white,  bowels 
constipated  and  tender  on  pressure.  Two  grains  each  of  comjiound  cathartic  mass  and  blue-pill  were  given  at 
once,  with  sulphate  of  (|uinia,  by  which  the  bowels  were  moved  three  times.  He  rested  well  during  the  night,  and 
on  th<»  morning  of  the  5th  his  i)ulse  was  80,  skin  warm  and  moist,  but  his  tongue  was  dry^,  red,  coated  and  flabby, 
and  he  complained  of  pain  in  the  limbs.  Daring  the  day  he  had  three  small  thin  stools,  and  in  the  evening  the 
pulse  was  72,  the  tongue  red,  llabby  and  coated  white,  the  skin  dry  and  warm;  there  was  also  some  dizziness.  A  ten- 
grain  dose  of  Dover's  powder  was  given.  During  the  ])rogress  of  the  disease  there  was  but  little  variation  in  the 
]>ulse;  it  di<l  not  go  over  80,  and  on  the  11th  fell  to  (il,  coincident  with  a  warm  moist  skin  and  the  (level opnu'ut  of 
an  abuiKlant  crop  of  sudamina  on  the  abdomen  and  shoulders.  The  skin  was  warm  and  generally  dry.  but  sometimes 
it  felt  umist;  it  was  covered  with  perspiration  on  the  11th  and  14th,  after  which  latter  date  it  was  generally  either 
cool  or  natural.  The  tongue  became  l)rown-coated  and  «lry  on  the  7tli  coincident  with  the  occurrence  of  anorexia 
and  some  obtu.seness  of  the  intelligence  followed  by  drowsiness;  itbecanui  moist  again,  but  very  red  and  coated  on 
the  next  day,  when  also  the  ajipetite  showed  signs  of  return,  and  a.  few  rose-spots  were  noted  on  the  abdonuMi,  with 
slight  tenderness  anil  borborygmus  in  the  right  iliac  fossa,  but  it  was  not  until  after  the  appearance  of  the  sudamina 
(ui  the  15th  ami   li;th  that  the  nu-utal  helietude  was  removed.     The  bowels  were  not  notably  loose  at  any  time  save 


THE    rOXTINUKD    KKVKRS.  233 

iniiiifdiati'ly  iil'tiT  iiiliiiissiou,  us  ;ilrf:iil,v  iiImIimI  :  Imt  IIumv  was  a  (eiideiicy  to  laxness,  as  two  draclinis  of  castor  oil 
on  tlie  SUli  |iriMliuc(l  two  iliiii  stools: — on  tlic  otluT  liantl.  ten  };'':iins  each  of  caloiiu'l  and  jalap  on  tlir  lltli,  after 
yield  in  j^  three  thin  stools,  created  no  liirtlier  distnrl)ancc  of  the  intestinal  tract.  Dnrini;  the  nit;ht  of  the  (llh  he  had 
a  colic,  which  was  relieved  hy  the  ajiidication  of  nuistaiil.  On  the  lOtli,  as  a  slif;litly  Janndiecd  lnn'  of  the  face  was 
apparent,  small  doses,  two  jirains  each,  of  lilnc-]iill  and  i|ninia  were  <;iven  with  port  wine  three  times  daily.  Alter 
the  20tli  the  patient  did  some  lif;ht  duty  ahout  the  ward,  and  was  letiirned  to  his  cominainl  October  .">. 

Cask  (iX. — Mental  iliihienK ;  surdt'ii ;  riliicCK;  rhj!,!  ilhw  uikJ  Inpiiliv  IciiiJiriioiK,  hut  no  diiirrhiia  nor  rosc-coloral  «pol»; 
iniproreniint  ahoiit  the  enil  of  the  3d  week. — Private  \V.  I'atcheii,  Co.  F,  71th  N.  Y.  Vols.;  af;«'  1«:  was  admitted  \ov.  2, 
1861,  having  l)eeii  taken  sick  two  weeks  liefoie  w  ith  chills,  anorexia  and  pain  in  the  back.  The  case  on  admission 
was  diafTiiosed  typhoid  fever.  On  tlie  'M  the  patient  was  dnll  and  stiildd,  his  eyes  snIVnsed,  cheeks  confjested,  pnlse 
100,  skin  hot  and  dry,  tony;ne  dry  and  clean,  lijis  and  teeth  covered  with  sordes,  appetite  lost:  there  was  some 
tenderness  and  fjnrjjlinfj;  in  the  rii;ht  iliac  rej;ion :  twelve  grains  of  (|ninine  were  f;iven  at  onci',  followed  altera  time 
by  ii  hillf-onnce  dose  of  castoroil  and  by  tnrpeiitiiU' emulsion  every  threi>  honrs.  Next  day  one  stool  was  )iasse<l;  the 
patient  had  some  coiifjh  and  hejiatie  tcndeiiicss,  and  vibiecs  a])peaied  on  the  chest.  On  the  lith  he  had  tinnitus 
anrimn.  On  the  8th  he  seeme<l  better;  his  toiii^ne  was  red  :it  the  ti])  ami  edf^es  and  coated  white  in  the  centre:  his 
bowels  had  been  moved  Imt  once  since  the  day  tollow  iiij;  his  admission.  He  improvi'd  f;r;idnally  afli'r  this,  and  was 
transferred  to  Baltimore,  Md.,  IJecember  H. 

Cask  6S). — Flahhij  toni/iie;  yaairic  irritnhUitji ;  recurrbuj  ejiixtaxix ;  diiirrhiid  and  ijeneral  alidomhial  tenderuen<i ;  head- 
ache ;  deUriiim  ;  nordes  :  prostration  ;  inflammation  of  pitroliil ;  roxe-xpotx  and  vibicen  ;  dixeharijed  on  aveonni  of  ti/phoidfirer.— 
Trivate  Patrick  ])(^vine,  Co.  K,  :id  Vt.;  ajje  18;  was  admitted  Oct.  1,  18(11,  with  tyi>hoid  fever.  He  had  been  takiMi, 
September  2(>,  with  headache,  chills,  fever,  diarihoa  and  e])istaxis  (w  hi<h  last  had  b4'cn  of  fr<'(|neiit  occnrrence  (hiring 
the  previous  month),  iind  on  the  28th  with  retention  of  urine.  On  October  2  the  patient's  face  was  eotifjested;  his 
eyes  dull  aiul  heavy;  i)nlse  112,  (iiiick  and  strong;  skin  hot  and  dry;  tongue  moist  and  coated  brown;  teeth  covered 
with  sordes;  stomach  irritable  and  unable  to  retain  food  or  medicine;  he  had  headache  and  pain  in  the  back,  with 
tenderness  over  the  w  liole  of  the  abdomen  and  slight  borliorygmus.  Kei)eated  doses  of  calomel  and  opium,  with 
turpentine  emulsion,  were  given.  Quinine,  extra('t  of  bn(din  and  sweet  spirit  of  nitre  were  administered  on  the  Ith, 
and  beef-essence,  milkiinnch  and  astringentson  tln^  (ith,  as  diarrho'a  began  to  be  a  prominent  symi)tom.  On  the  7th 
the  ]iulse  was  !K)  and  strong,  the  skin  natural,  the  tongue  sliglitly  nn)ist,  red  iit  the  tiji  and  edges,  heavily  coated 
brow  11  and  lissured  in  the  center  and  jit  the  basi^;  eight  stools  were  jiassed,  and  micturition  was  ditlienlt.  Kose-coloied 
M]iots  apiieared  on  the  following  day;  there  was  some  mental  dnliiess  with  headache  and  occiisioiial  delirium  ;  cough 
was  troll blesonie,  and  the  diiiirlnea  was  accoinpa.iicd  with  general  abdominal  tenderness  which  was  esiiecially  acute 
in  the  right  iliac  region.  Kpistaxis  occurred  on  the  lltli  and  next  day  the  bowels  were  quiet.  With  the  moderation 
of  the  diarrlnea  the  tongue  became  tlabby  and  remained  dry  and  brown-coated  in  the  centre,  although  the  appetite 
improved.  Kpistaxis  recurred  on  the  1  Ith  with  some  headache  and  delirium  ;  the  tip  and  edges  of  the  tongue  became 
red,  the  lips  covered  w  ith  sordes  and  the  bowels  relaxed  to  live  stools  daily.  Nc^xt  day  the  nose  bled  again,  some 
rose-colored  s]>ots  ap]iearcd,  and  the  ]>atient  was  unable  to  protrude  his  tongue  on  ac<'<iiint  of  swelling  of  the 
parotid  gland.  Kpistaxis,  profuse  ]ierspiratiou  and  vibices  on  the  neck  and  chest,  with  headache  and  increased 
swelling  of  the  jiarotid,  but  no  delirium,  were  noted  on  the  17th  ;  the  iliarrhu-a  continued  with  general  tenderness  and 
some  nieteorisni,  especially  marked  in  the  right  iliac  region.  Vibices  were  niiinerous  on  the  abdomen  on  the  18th,  and 
fresh  rose-spots  appeareil  on  the  20tli,  22d,  2Ud,  25111  and  28th:  during  thesti  days  the  diarrlwea  moderated,  but  the 
tenderness  continued,  being  sometimes  general  and  at  others  specially  marked  in  tln^  umbilical  and  right  or  left  iliac 
regions  ;  some  headache  and  eoiigli  were  noted  but  no  delirium  ;  tln^  ap]>itit(^  was  good,  the  nkin  generally  moist,  and 
the  tongue  moist  and  but  slightly  eoati'd;  the  patient  continued  unable  to  ]irotrude  his  tongue.  Kpistaxis  recurred 
on  the  2xth  and  on  November  2d,  1th,  Oth  and  Xth,  dining  w  liicli  days  there  w  as  soni<!  heat  and  dryness  of  skin,  w  ith 
headache  and  tinnitus,  relaxation  of  the  bowels,  abiloniinal  tenderness  and  coated  tongue,  the  appetite  continuing 
good  and  the  cough  subsiding;  pulse  80  to  100.  No  change  took  place  in  his  condition  u|>  to  the  ISth,  when  he  was 
transferred  to  Annapolis,  Md.  [whence  he  was  discharged  on  the  2itth  on  account  of  typhoid  feverj. 

Cask  70. — Severe  diarrhwa  and  abdominal  pain;  free periipirations ;  mental  dulnexti;  rone-spolsfrom  lo/Zi  to  'M)th  dai/; 
tongue  flabby  and  iieUon--coated;  improremeni  in  ~>th  u'eel\ — Priv.ate  Byron  Steinbaek,  Co.  A,  1st  Pa.  Art.;  age  21 ;  became 
aftected  on  Sept.  2."),  18(11,  with  headache,  pain  in  the  ba<k  and  limbs  and  diarrlnea,  on  October  2  with  chills  and 
fever,  and  on  the  (Ith  with  epistaxis  and  some  retention  of  urine.  He  was  admitted  on  the  itth,  on  the  evening  of 
which  daj-  he  was  found  to  be  weak,  having  had  ten  stools,  with  general  abdominal  tenderness  and  some  retention  of 
urine;  a  few  rose-spots  were  scattered  on  the  chest  and  abdomen  ;  the  face  was  slightly  tluslied,  the  eyes  injected  and 
suffu.sed  and  their  lids  closed,  the  skin  of  natural  tenii>erature,  ])ul8e  80,  tongue  moist,  red  at  the  ti])  and  edges, 
coated  yellow  on  the  dorsum,  appetite  delicient;  he  had  some  cough  and  j)ain  in  the  limbs.  (')n  the  Kith  there  was 
much  thirst;  the  skin  was  hot  and  ilry ;  four  new  rose-spots  had  appeared;  the  tongue  was  moist  and  llabliy,  red  at 
the  tij)  and  etlges  and  heavily  coated  yellow"  in  the  centre;  six  stools  were  )iasscd.  Tincture  of  iron  was  given  three 
times  daily.  On  the  11th  the  skin  was  covered  w  ith  pers])iration,  the  rose-spots  had  increased  in  number,  the  bowels 
were  moved  twice  and  there  was  tenderness  at  the  nnibilicns  and  in  the  iliac  regitms,  nuirkedly  (Ui  the  right  side, 
with  some  tympanites  and  borborygnius.  Turpentine  emulsion  was  given  every  three  hours.  On  the  12th  the  patient 
was  reported  as  having  slept  well;  he  was  dull  and  stupid;  his  eyes  dull  and  injected;  cheeks  somewhat  Hushed; 
pulse  75,  regular;  skin  hot,  dry  and  profusely  covered  with  rose-colored  spots;  tongue  slightly  moist,  red  at  the  tip 
and  edges,  coated  yellow  in  the  centre;  lii)s  and  teeth  covered  with  sordes;  api>etite  poor;  his  bowels  were  moved 
five  times,  and  there  was  much  abdominal  tenderness,  notably  about  the  umbilicus.  Astringents  were  given,  l>ut  the 
diarrha'a  continued.  On  the  l.")tli.  Kith  and  17th  profuse  ]>erspi rations  were  noted,  and  rose-spots,  perceptible  to  the 
Med.  Hist.,  Pt.  HI— 30 


I'M  CTJNIOAL    "RK(.'ORI>S    OF 

touch,  continued  to  erupt.  A  lew  of  these  spots  ap))eare(l  on  the  forehead  on  the  22d  and  a  few  more  on  the  chest 
two  days  later.  On  the  22d  the  diarrhii'a  was  controIhMl:  one  stool  only  was  passed  instead  of  three,  four  or  more, 
as  ou  previous  days:  liut  the  fieueral  alidouiiiial  and  extreme  umbilical  tenderness  was  not  relieved  until  some  days 
hiter.  Meanwhile  the  toiifjne  became  clean,  the  skin  natuial  and  the  ai)petite  f^ood.  The  counh.  wlii(  li  liiid  ati'ected 
the  ))atient  more  or  less  from  his  admission,  now  assumed  i)rominence  as  a  symptom,  and  was  aii'ompauied  with 
mucous  exjiectoration.  He  was  transfeireil  Novemlicr  1  to  Annapolis,  Md.  [whence  lie  was  discluuficd  tVoiii  tlie 
service  on  the  2!lth  because  of  debility]. 

Case  71. —  IlittiUiche;  deiifiiiHn  ;  iliurrhivii  ;  cuuijh;  roxe-colorvd  siwlnfoUuu'inij  paritjjinnKil  ftvir. — Private  F.  Cameron, 
Co.  F,  74th  N.Y.;  ajje  23;  was  admitted  Nov.  2,  1861,  as  a  case  of  typhoid  fever.  He  became  sick  aliont  ( ><t()bii  1 
with  chills,  fever  ami  sweatinj;,  epistaxis,  headache,  anorexia,  thirst,  diarrho'a  and  iriitability  of  stomacli.  W  Ikui 
a<lmitti'd  his  eyes  were  dull  and  somewhat  injected,  cheeks  slightly  Hushed,  |)ulse  7r>,  regular  lint  weak;  a  few  rose- 
sjwts  on  the  chest ;  tongue  red,  ilry  and  lissured  in  the  centre;  lijis  ami  teeth  covered  with  soides;  ainietite  pool; 
he  was  a  little  deaf  and  had  l)uzzing  in  his  ears;  one  stool  was  jtassed  with  much  right  iliac  an<l  umliilical  tcnderiuiss 
and  tym])anites;  he  had  also  a  slight  cough  with  some  whitisli  expectoration.  He  slept  none  during  the  night  and 
had  hut  one  stool  on  the  lid  ;  the  tenderness  lessened  and  the  cough  ceased.  Beef-essence,  i)uuch  and  turpentine 
emnlsign  were  given.  After  this  the  bowels  continued  ([uiet,  and  on  the  7th  the  tongue  began  to  clean  and  the 
appetite  to  return.     He  was  transferred  to  Anna])olis  on  the  8th  [whence  he  was  discharged  for  disability  on  the  29th]. 

Case  72. — Cenhral  iiintiiffxltttionn  Kliyhl ;  roxr-Hpoln  oh  the  Hlh  iluy  with  siicci-nvive  crops  to  22(/  </<(// ;  dutrrhuo  ceaxinij 
nil  occurrencf  of  frci-  noclnrnol  pirxpiralioiis  on  llth  (hiij. — Private  Pinter  Martin,  Co.  H,  'M  W.  \'ols.;  age  18;  was  seized 
Sept.  28,  18til,  with  chills,  fever  and  j)ain  in  the  head,  back  and  liudjs,  for  which  he  was  admitted  October  H.  His 
pulse  was  8."i,  full  ami  strong;  skin  natural;  tongue  moist  and  furred  yellowish.  He  was  somewhat  dull  and  had 
pain  in  the  head,  anorexia  and  relaxed  meteorized  bowels.  I51ue-i(ill  was  given  with  opium  every  two  hours.  Rose- 
colored  spots  apjieared  on  the  chest  and  abdomen  on  the  utli,  and  on  the  7th  were  very  profuse.  The  tongue,  from 
being  covered  with  a  thick  yellow  fur,  became  red  at  the  tip  and  margins,  remaining  coated  on  the  dorsum.  The 
diarrh(ea<'aused  three  or  four  stools  daily,  and  was  accouiiiauied  by  tympanites  and  right  iliac,  uudiilical  and,  indeed, 
general  abdoTuinal  tcndeiuess.  Sixteen  grains  of  <|uinine  were  given  (Ui  the  forenoon  of  the  7tli.  'I'he  headaihe, 
anorexia  and  other  symptoms  as  stated  continued  until  the  1 1th,  when,  after  a  free  peispi ration  during  the  night, 
the  pulse  fell  to  6(i,  the  bowels  became  (|uii't  and  the  appetite  riiturned  ;  the  tongue,  however,  remained  coati-d  heavily 
with  a  moist  yellow  fur  at  the  base  and  ceutre.  A  small  do.se  of  blue-pill  was  given  on  the  Kith,  but  the  fur  was 
not  removed  until  the  2Hd.  Kose-ajiots  appeared  on  the  16th  and  again  on  the  19th.  Nocturnal  perspirations  were 
recorded  on  the  17th  and  lOtli.  Some  cotigli  occurred  during  the  progress  of  the  ca.se.  The  patient  was  returned  to 
duty  ou  the  28th. 

Ca.se  73. — Dhzincxx  and  xtUjht  hiudochc;  diaiThuul  tetidtiici/  not  murkvd;  roxe-colored  spots  on  the  Wlh,  I9th  and  Mill 
dai/s,  and  ril>ici'x  on  19///. — ('or)ioral  ,7.  I!.  Morgan,  Co.  K,  1st  Pa.  Hides;  age  24 ;  was  healthy  until  about  Oct.  1,  1861, 
when  he  had  chills,  fever  and  jirofuse  sweating,  with  ])ain  in  the  head,  dizziness,  epistaxis,  pain  in  back,  limlis, 
shouhler  and  chest,  some  cough,  diarrluca  and  retention  of  urine.  He  was  admitted  October  10  as  a  case  of  tjjdioid 
fever.  The  jinlse  on  admission  was  90  and  (piick;  the  skin  hot  and  dry,  exhibiting  a  profuse  eru])tion  :  the  tongue 
was  slightly  moist,  red  and  clean;  the  ap])etite  poor;  the  bowels  unmoved  but  somewhat  tender  and  tympanitic:  the 
patient  had  slight  headache,  cough  ami  ])aiu  in  micturition.  Wine  and  cinchona  bark  were  ordere<l.  The  eiTiption 
faded,  but  no  other  change  took  jdace  until  the  lIHli,  when  the  tongue  became  dry.  One  ounc<^  of  Kjisom  salt  was 
given.  Three  stools  were  jiassed  on  each  of  the  two  following  days,  and  the  tenderness  became  mori'  marked  in  the 
right  iliiie  region;  otherwise  there  was  no  change.  The,  Epsom  salt  was  rejieatcd  <ni  the  Itith.  Three  stools  were 
passed  on  the  17th  aiul  one  on  the  18tli.  \'ibices  appeared  on  the  chest  and  rose-spots  on  the  abdomen  on  the  19th. 
A  few  nu)re  rose-spots  were  dete(!ted  ou  the  .iOth.  During  this  pt^riod  the  skin  was  getierally  of  the  natural  tem- 
perature, the  tongue  moist,  red  and  clean  and  the  apjietitt^  good.  On  November  1  the  patient  was  transferred  to 
Aunapolia,  Md.,  where  his  case  was  entered  as  one  of  debility,  and  whence  he  was  returiuMl  to  duty«on  December  2. 

Cahe  74. —  Diilnexs  and  drowsiness  for  a  dai/  or  two;  diarrhiea  and  dry  slin  perxixtini/  :  rosi'-colond  xjwtx  and  ritiices; 
tongue  Jtaldii/  and  loatcd  i/illow;  nioixt  shin,  and  conralescenve  on  38</i  diii/. — Private  William  Morrison,  Co.  F,  1st  Pa. 
Ritles;  age  38;  had  a  chill  about  Oct.  1,  18)!1,  followed  by  fever  and  jierspiration,  slight  headache,  anorexia  and 
some  cough.  He  was  admitted  on  the  10th  as  a  case  of  typhoid  fever.  Next  day  he  was  dull  and  drowsy,  but 
■without  any  sign  of  congestion  about  the  face;  his  pulse  was  80  and  feeble,  skin  hot  and  dry,  tongue  slightly  moist, 
red  at  the  tip  and  edges  and  heavily  coated  with  yellowish  fur  in  the  ceutre;  he  had  intense  alxlouuual  tenderness, 
but  only  one  stool  during  the  previous  twenty-four  hours.  Emulsion  of  turpentine  and  tincture  of  iron  were  ordere<l 
in  repeated  doses.  On  the  12th  the  eruption  appeared:  the  skin  was  of  natural  temperature,  the  tongue  slightly 
nmist  but  coated  with  yellowish  fur,  and  the  a])petite  good;  two  stools  were  passed,  and  the  ))atient  had  sonu^ 
abdominal  tenderness  and  cough.  He  slept  well  ami  next  day  was  lirighter  mentally.  From  this  time  till  the 
eml  of  the  month  his  general  condition  remained  unchanged.  The  tongue  was  Hahby  and  always  more  or  less 
yellow-furred;  the  appetite  usually  good;  the  bowels  moved  from  one  to  seven  tinu's  daily,  with  general  and  occa- 
sioiuilly  umbilical  and  left  iliac  temlerness,  and  with  slight  tympanites  on  the  10th  and  29th  ;  the  skin,  usually  hot 
and  dry,  showed  some  vibices  on  the  19th  and  20th;  on  the  22d  rose-colored  spots  ajipeared  on  the  face  and  did  not 
fade  until  the  29th,  when  some  epistaxis  occurred;  there  was  more  or  less  cough  with  some  mucous  exjiecloral  ion  ; 
the  pulse  beat  generally  about  7")  per  minute.  On  the  30th  quinine  was  ordered  in  three-grain  doses  every  two 
hours.  Next  day  the  ])ulse  was  lowered  from  80  to  (>0,  and  the  diarrhiea  increased  from  one  to  seven  stools;  other- 
wise the  patient's  condition  a]ipeareil  unaltered.  Astringents  were  given,  and  in  the  course  of  four  or  live  days  the 
diarrhtta  became  lessened  to  one  or  two  stools  daily.     On  November  4  a  boil  appeared  on  the  patient's  forehead.    Ou 


THE    CONTINUEP    FKVKRS.  235 

the  7th  the  skin  is  rerordeil  lor  tlie  liist  time  as  lieiiifi  moist:  i)ulse  "5;  toii-jiie  i:h-aiiiiig:  aiil)etite  f;<>od  :  howels 
tender  aud  moved  twiee.  Cod-liver  oil  aud  wine  were  ordeaed  on  the  lUth.  The  daily  record  of  symptoms  ceases  on 
tlie  Utli.     The  jiatient  was  traiisfei'red  to  Alexandria.  \'a.,  Decemlier  liO. 

Case  75. — Siicci'ssivt'  crops  of  i-o,it-coI(>r<(J  xjiatn  fniiii  l(i//i  to  'MUh  (hnj ;  pirspirnlionii ;  (Ihirrltodl  liudoiiji  sUfilit : 
lliisti-if  inUithUitij;  conraUxii'noe  on  ;W//i  tUaj. — I'rivate  S.  U.  Frencli,  Co.  U,  lith  Wis.:  a^c  '1'^;  is  said  to  Inive  had  typhcdd 
fever  in  1X.")|I.  On  .'<e]it.L'l,  ISfil,  he  was  talien  with  chills  and  fe\  er,  headache,  pains  in  the  hack  and  limhs  ami 
diarrluea,  tor  which  (ininine  was  given.  He  was  admitted  Octolier  1.  Next  day  his  lace  was  somcwhai  congested, 
eyes  bright,  jiiilsc  lOU,  (|iiick  and  .sti'ong,  skin  luit  and  moist,  edges  of  the  tongne  diy  and  its  centre  covered  with  a 
l)rown  crust,  .■ippctite  small:  three  sto(d.s  were  i)aNsc<l.  and  there  was  some  cough  witli  vise-id  nmcons  i-xpecloration. 
rMrjientine  emulsion  and  astringents  were  given.  Kose-colored  spots  a|>pearcd  on  the  ltd  and  continued  to  crn))!  at 
intervals  until  tlie  29th.  The  skin  was  generally  moist;  hut  on  the  (itli  and  7th  free  persjiiration  occurrcil  accom- 
panied with  sudainina;  tinnitus  aurium  also  was  noted  at  this  time,  and  the  jiulse  fell  to  7.">.  The  howels  were  moved 
once  or  twice  daily,  and  there  was  more  or  less  tenderness,  ehietly  umbilical  and  left  iliac.  Five  stools  were  passed 
on  the  Kith  and  again  on  the  l.'jth,  luit  the  tendency  to  diarrluea  was  not  nuirked,  for  three  grains  of  blue-jiill  repi-ated 
twiceon  the  latterday,  and  six  grains  of  comiHiuud  cathartic  pill  rejieated  twice  on  each  of  the  two  tVdIowing  days, 
did  not  aggravate  it;  the  bowels  were  generally  nH)veil  twi<e,  but  souuitiiues  only  once  daily  to  the  end  of  llui 
record.  Profuse  nocturnal  i>erspiration  occurred  on  the  l."«tli  anil  following  days.  The  tongue  on  tlicMth  becauu- 
red  at  the  tip  and  edges  and  lirown  or  yellowish-brown  in  the  centre;  on  the  lOlh  it  becauu^  slightly  dry  in  the 
middle;  on  the  ITtli  red,  moist,  Habby  and  with  prominent  pa])ilhc,  ami  after  this  nu)re  or  less  coated  to  the  end. 
'I'he  appetite  continued  good  from  the  secoiul  <lay  after  ailmission,  but  on  the  2Gth  and  27lh  there  was  some  irritabil- 
ity of  stonuieli.  Quinine  was  given  at  this  jieriod  in  three-grain  doses  every  two  hours.  On  the  29th  the  patient 
sleiit  well;  hi.s  eyes  were  bright ;  cheeks  not  Hushed:  ]>nlse  7H,  regular;  skin  hot  and  moist,  a  few  rose-s|)ots  ap]>ear- 
ing  on  the  breast  and  abdomen  :  tongue  red  at  the  tip  and  <'dgcs,  yellow  isli  coated  ami  tissureil  in  the  centre;  appetite 
good;  one  stool  was  jiassed ;  the  stomach  continued  irritable,  and  there  was  some  ('ough  with  yellow  expectoration. 
On  the  m.st  he  was  sitting  up;  the  gastric  irritability  and  the  cough  had  ceased.  On  Novcnilier  I  he  was  transferrcad 
to  Annapolis,  Md.  [whence  he  was  discharged  im  account  of  atro])hy  of  the  leg,  March  28,  18G2|. 

C.\.sE  76. — Eivord  imperfect  cluriiKj  firnl  four  weels ;  tIeUriiiiit;  diarrhwo;  rone-npots  from  2!>//i  to  3((//i  tliii/;  coiini- 
Iraci'vce  o»  iOtli  ddij. — Private  Peter  Courtw  right,  Co.  B,  Ist  Pa.  Ritles  ;  age  27.  This  man  stated  that  he  had  suH'ered 
from  some  kidney  trouble  at  the  age  of  20,  and  afterwards  from  liotli  liver  and  kidney  disease.  About  Sept.  12, 
ISfil,  he  ha<l  chills  fcdlowed  by  fever  and  sweating,  with  epistaxis,  jiain  in  the  back  and  limbs  ami  anorexia.  He  was 
admitted  October  10,  wlu'u  he  .seemed  stupid ;  his  eyes  were  dull ;  cheeks  tluslicd  :  jmlse  !I0  ami  i|uick  ;  skin  hot  ami 
dry;  tongui^  moist,  red  at  the  tij)  and  edges,  coated  whitish  in  centre;  apiietite  poor;  the  bowids  (luiet,  but  with 
some  gurgling  and  slight  tenderness  in  the  left  iliac  aiul  umbilical  regions;  a  few  rose-s])ots  were  noted.  Dover's 
powder  was  given.  On  the  11th  and  12th  the  general  condition  remained  unaltered;  the  skin  lost  its  heat  but  con- 
tinned  dry.  Tincture  of  iron  was  ordered  to  be  taken  three  times  a  <lay.  On  the  ISth  the  eyes  were  dull,  injected 
and  sutl'used  and  the  cheeks  slightly  Hushed;  the  ])ulse  had  fallen  to  (Id;  a  few  roses])ot8  ai)i>eared  on  the  chest  and 
abdonu-n  ;  three  stools  were  ])assed,  ami  there  was  ])ain  on  nriiniting.  I'rofuse  jjerspiration  occurred  during  the  night, 
and  in  the  morning  the  patient  looked  bright  but  there  was  some  nu'utal  derangenu'nt ;  tht^  i)ulse  was  K!,  full  and 
Hrni ;  six  stools  were  j)assed.  Astringents  were  ordered.  The  condition  on  the  l.^)th  is  not  recorded,  but  on  the  fol- 
lowing day  there  were  more  rose-spots,  delirium,  tinnitus  aurium,  six  stools  and  nnddlical  tenderness;  pulse  t>«. 
Tenderness  aud  tympanites  over  the  tranverse  colon  acconij)anied  six  stools  reeordeil  on  the  17th.  'I'here  was  less 
delirium  on  the  18th;  the  face  had  become  pale  and  the  eyes  sunken;  one  stool  was  ])assed.  Three  stools  were 
reported  on  the  19th  and  six  on  the  20th,  on  which  day  also  some  rose-Ni)ots  appeared.  On  tlie  21st,  after  sleeping 
well,  the  patient's  tongue,  which  had  heretofore  been  red  at  the  tip  ami  edges  and  more  or  less  coated  in  the  centre, 
was  fouiul  to  be  clean  and  natural,  his  skin  of  normal  temperature,  jmlse  70  and  appetite  good;  two  stocds  were 
|)assed.  After  this  he  improved,  but  a  dia,rrh(ea,  causing  about  three  stools  daily,  persisted  until  November  4,  when 
the  bowels  were  reported  regular.  He  was  able  to  be  up  and  to  walk  about  October  30th,  aud  was  returned  to  duty 
November  10. 

Case  77. — Delirium,  diarrhoea  and  involuntary  stools;  eruption  of  rose-  and  dark-colored  spots;  improvement  about  end 
of  Mh  ireel-,  hut  debiliti)  irith  Jtabhi/  tongue  continuing  aftir  defei-rescence. — Private  15.  T.  Conglin,  Co.  (!,  .5th  Wis  Vols.; 
age  22;  was  taken  about  Sept.  16,  1861,  with  epistaxis,  headache,  pain  in  the  limbs  ami  back  and  diarrluea,  and  was 
admitted  October  1  as  a  case  of  typhoid  fever.  On  the  2d  his  face  was  congested  and  he  looked  dulh  his  pulse  90, 
({uick  and  strong,  skin  normal  and  tongne  moist,  brown  and  with  prominent  papilhe;  he  had  some  jiain  in  the  back 
and  anorexia,  but  no  movement  from  the  bowels;  the  abdomen  was  covered  with  dark  spots  (vibicesl')  ami  showed  a 
few  rose-spots,  which  latter  disappeared  on  pressure  ;  he  was  delirious.  Emulsion  of  turpentine  was  given  every  two 
hours,  tincture  of  iron  three  times  daily  and  beef-essence  as  required.  Five  involuntary  stools  were  passed  on  the 
3d,  and  astringents  were  administered.  The  passages  were  freciuent  but  passed  voluntarily  on  theltli;  the  abdo- 
men and  chest  were  covered  with  dark-colored  spots  imperceptible  to  the  touch  and  disappearing  on  pressure;  the 
tongue  was  dry  and  brown  and  there  was  some  hoarseness.  The  stools  became  again  involuntary  on  the  5th,  and 
the  teeth  and  lips  covered  with  sordes.  The  patient's  face  was  congested,  eyes  dull,  skin  hot  and  showing  the 
remains  of  the  dark-red  spots.  He  had  anorexia,  slight  tympanites  and  iliac  tenderness;  pulse  100.  15eef-essence 
aud  punch  were  ordered,  with  Dover's  powder  in  the  evening.  Involuntary  micturition  and  defecation,  with  ntiich 
tenderness,  were  noted  on  the  6th;  pulse  112.  The  longue  was  clean,  red  and  dry  on  the  7th;  the  appetite  improved 
and  there  was  but  one  stool.  During  the  three  or  four  days  which  followed  the  tongue  became  moist  aud  Habby, 
with  iiromineut  papilhe:  the  appetite  continued  to  improve;  the  bowels  were  quiet,  but  there  was  much  umbilical 


236 


CLTNTOAL    REOORBS    OF 


and  some  iliac  tenderness.  On  the  12tli.tlie  pulse  fell  from  UO  to  80,  the  eyes  l.eciime  bright  and  the  delirium  ceased. 
Next  day  the  toiigno  was  moist  and  clean  and  the  appetite  good ;  but  until  the  end  of  the  month  tlabbiiiesH  and 
prominent  i>apilhe  were  reported.  The  patient  was  free  from  dlarrluea,  but  the  abdomen  was  occasioually  tendei'; 
at  times  he  had  headache.  IIo  was  transferred  to  Annai>olis,  Md.,  November  1,  as  a  ease  of  debility  [and  was 
returned  to  duty  Feb.  3,  18(i2]. 

Ca.sk  78. — Iticord  impirfvH  at  liiijinnniii  ninl  end  of  case;  lufuhichv ;  <U(irrli(i'(i ;  tiliddiniiKil  tiiithriiruN:  mxi-ciiloi-iil 
Hpata. — Private  (iottfried  Serieber,  Co.  I,  (itli  Wis.;  age  30;  had  some  lung  trouble  in  July,  ISOl,  from  wliich  he  had 
not  entirely  recovered,  when  about  C»ctol)i;r  1,")  he  was  taken  with  chills  followed  by  fever  and  sweating,  with  head- 
ache, tinnitus  aurium,  pain  in  the  back,  chest  and  limbs,  lassitude,  anore.\ia,  thirst,  diarrhcra,  retention  of  urine  and 
some  cough.  He  was  admitted  November  7.  Diagnosis — debility.  On  the  8tli  rose-colored  S])ots  ai)i)cared  (Ui  the 
chest  and  abdomen,  and  there  was  much  tenderness  in  the  umbilical  and  left  iliac  regions  with  a  burning  feeling  in 
the  epigastric  region.  Hlue-pill  with  opium,  followed  by  castoroil,  was  prescribed.  The  skin  on  the  Oth  was  covered 
with  perspiration;  the  bowels  were  moved  twice.  On  the  10th  there  were  .some  rose-spots,  a  burning  feeling  in  the 
stomach,  tenderness  in  thi^  umbilical  and  left  iliac  regions,  but  no  ]>as.sag(^  from  the  bowels;  the  tongue  was  very  led 
at  the  tip  and  edges.  Eight  grains  of  <iuinine  were  given  with  turpentine  and  tincture  of  iron.  This  i)atient  was 
transferred  on  the  18th  to  Annapolis,  Md.     [Diagnosis — typhoid  fever.     Returned  to  duty  Feb.  3,  18()2.] 

Cask  79. — Cirehial  Sjimptoms  not  marked;  conntipation ;  hilioun  romitiiif/;  rone-npots  on  lith  and  ISth  dayn. — Private 
Thomas  Connell,  Co.  K,  3d  Vt.;  age  22;  caught  cold  Sept.  27,  1801,  and  had  headache,  pain  in  the  loins  and  limbs 
and  anorexia.  1  [e  was  admitted  October  3d  as  a  case  of  gastritis.  His  eyes  were  snft'used ;  pulse  95,  full  and  strong ; 
skin  moist  but  somewhat  hot;  tongue  dry,  red  and  glo.ssy  ;  constipation,  anorexia  and  great  irritability  of  the  stomach 
were  present.  Sulphate  of  magnesia  and  antimony  were  given,  and  ten  grains  of  calomel  in  the  evening.  The 
Epsom  salt  was  rejjeated  on  the  5tli.  Next  day  two  grains  of  i|uinine  were  given  every  two  hours,  and  tincture  of 
iron  on  the  7th.  One  stool  was  obtained  on  this  day;  t!ie  gastric  irritation  had  somewhat  lessened;  jiulse  70.  On 
the  9th  the  pulse  fell  to  4.5,  the  skin  was  of  natural  teniperatnr'e,  the  tongue  red,  clean  and  moist  but  rather  tlabby, 
the  ap](etite  moderate  and  the  bowels  unmoved.  Kose-colored  spots  appeared  on  the  10th;  the  appetite  was  poor; 
the  bowel.s  uniuoved  and  tender.  Two  com]iound  cathartic  pills  were  given,  with  turpentine  emulsion,  every 
three  hours,  and  two  grains  of  quinine  every  hour.  Next  day  one  stool  was  obtained,  and  there  was  marked  ten- 
derness with  gurgling  in  the  right  iliac  and  umbilical  regions.  Some  irritability  of  stomach,  cough,  ])ain  in  elie.st, 
sutlusion  of  eyes  .and  congestion  of  face  were  noted  on  this  day ;  pulse  50;  skin  natural ;  tongue  moist,  red  and  clean. 
On  the  13th,  the  bowels  luiving  continued  unmoved  and  tender  in  the  interval,  a  cathartic  enema  was  given;  this 
was  followed  on  the  Kith  by  an  onuce  and  a  half  of  castor  oil.  Three  stools  were  passed  on  the  17th,  three  on  the 
18th,  and  seven,  twelveaiid  fifteen  on  the  following  days,  after  which  two  stools  were  recorded  daily  for  several  days, 
with  some  abilominal  tenderness.  Kose-s])Ots  were  noted  on  the  14th.  The  patient  was  sent  to  Annapolis,  Md., 
November  1  [whence  he  was  returned  to  duty  December  2]. 

Ca.se  80. —  Date  of  oriijin  iinkiioini;  nnconsciousnetm;  rose-colored  spots;  moist  tongue;  diarrhoa;  rapid  conralescence. — 
Private  George  Robinson,  Co.  It,  14th  N.  Y.;  age  19;  admitted  Sept.  27,  1801,  having  been  allcctcd  with  diarrbiea  for 
two  months.  Diagnosis — typhoid  fever.  He  w.as  partly  connitose  and  diflicult  to  arouse;  pulse  80,  firm,  strong: 
face  congested  ;  eyes  suffused;  skin  hot  and  soft;  tongue  moist,  gray;  .abdonu^n  tender  and  bowels  moved  twice, 
('alonud  with  kino  was  given.  Next  day  the  abdomen  and  chest  were  coviu'ed  with  rose-colore<l  si)ots;  the  tongue 
was  moist  and  coated,  except  at  the  tip  and  edges,  with  a  rough  brown  fur;  three  stools  were  passed,  and  the  abdo- 
men w;is  tympanitic  and  tender  especially  in  the  umbilical  region ;  ther(^  was  some  jiurulent  exp(^etoration  streaked 
with  blood,  but  not  much  cough.  No  change  took  place  until  October  1,  when  sudamina  ajipcared  on  the  chest  ; 
the  stomach  became  irritable,  the  bowels  remaining  undisturbed.  Next  day  the  patient  looked  better  !uid  had  somi^ 
appetite;  his  tongue  was  white  at  the  tip  and  edges  and  brown  at  the  base  and  centre.  Turpentine  emulsion  was 
prescribed  on  the  4th.  Profuse  perspiration  occurred  on  the  5th  with  smlamina,  and  on  the  9th  rose-colored  s])ots 
appeared  in  fresh  erojis,  which  by  the  11th  were  very  profuse;  headache,  tinnitus  aurium  ami  deafness  affecting  the 
left  ear  accompanied  the  eru|)tiou,  and  the  tongue,  which  had  before  I)een  flabby  and  more  or  less  ))atched  with 
yellow,  became  red  at  the  tip  and  edges  iind  yellow-coated  in  the  centre;  he  Nle])t  well,  however,  his  a](])etit<^ 
reumining  good  and  his  bowels  undisturbed.  On  the  14th  he  was  considered  conv.alcscent,  and  on  the  21st  was 
returned  to  duty. 

Cask  81. —  Uneonsciousness ;  muscular  Iwilchintis  ;  inrolutilary  passages;  sordes;  diorrhira  during  canrahscence. — 
Private  Luther  Howard,  Co.  J},  72d  N.  Y.,  was  admitted  Sejit.  29,  1801,  having  been  sick  for  two  weeks.  Dijignosis — 
typhoid  fever.  He  was  partly  unconscious  and  unable  to  speak  except  occasionally;  the  face  was  congested,  the 
eyes  slightly  injected,  the  facial  mu.scles  di8turbe<l  and  those  r)f  the  extremities  twitching  involuntarily  in  almost 
choreic  movements;  he  had  heada<he  and  some  laryngeal  trouble;  the  skin  was  soft  and  moist;  the  pulse  88,  firm; 
the  abdomen  tender.  Camidior  and  opium  were  given.  Next  day  he  was  ]>artly  comatose,  his  face  congested, 
l>ulse  1(H),  full  and  strong,  skin  hot  and  soft;  no  stool  was  pas.sed,  but  th?  abdomen  was  tympanitic  and  tender; 
no  urine  was  voided  for  sixteen  hours;  the  muscular  twitehings  continued,  and  the  patient  was  unable  to  open 
his  month  or  speak.  Emulsion  of  tur|)entine,  sweet  spirit  of  nitre,  valerian  and  Dover's  powder  were  ordered.  On 
October  1  sordes  appeared  on  the  teeth,  the  tongue  was  coated  dark  brown  and  the  mouth  filled  with  dark  tena- 
cious muens;  the  patient  was  indifferent,  but  ate  food  when  offered  to  him;  the  bowel.s  were  unmoved.  Five  grains 
each  of  calomel  and  Jalap,  with  twelve  of  iiuinine,  were  given  him.  One  snuill  stool  was  <d)tained  next  day,  and  the 
patient  was  less  stupid;  he  was  very  deaf,  Ijut  answi-red  (juestions  correc-tly  when  ])ut  to  him  in  aloud  voice.  On 
the  3d  he  ])rotruded  his  tongue  with  less  difficulty  and  the  choreic  movements  were  lessened,  but  there  was  some 
dysphagia  and  the  stools  were  passed  involuntarily.     Ou  the  4th  he  was  rational;  the  tongue  slightly  moist ;  bowels 


THK    CO^'TINUKD    FKVKKS.  2 


37 


teniler  ami  imivcd  onci-.  Iiiit  mil  tyiii]iaiiirlc.  I'm  |i<'iil  liir  <"m'.ilsiiiii,  liiamly,  Fdulri's  siiliilion  ami  KpNoiii  salt  were 
j;ivfii.  I'ud  iiivoliiiitai  V  stools  wen>  passeil  on  llic  (illi.  lull  llie  (lyspliajlia  was  Icsscmil,  the  twililiihf^s  hail  icascii 
and  tlie  patient  was  alile  to  aitiiulate  well  anil  mastieate  his  food.  Beet-csseuee  and  astringents  weie  ordered. 
Some  lieadaclie  and  delirium  were  jiiesent  on  the  8tU;  the  tonffiie  wan  dry  and  treniiilous,  show  ing  yellow  |iateheH 
and  prominent  iiajiilla',  and  the  Imwels  were  loose.  After  this  the  skin  was  usually  hot  and  dry  or  of  the  natural 
temjierature,  althou-jh  on  the  18th  there  was  some  perspiration  at  uijjht.  The  tiiuf;iu^  was  moist,  elean  or  palilnil 
w  ith  white  or  yellow,  and  usually  llaliliy  and  with  pr<uuinent  papilhe;  hut  on  the  lUth  it  was  red  at  the  tij)  ami 
ed^es  and  coated  yellow  in  the  eentre.  The  appetite  was  flood,  and  for  several  days  was  reeordi'd  as  excessive. 
The  liowels  were  loo.se,  yieldini;  two  or  three  passafies  daily,  with  occasional  tyui]ianites  and  tendiMiiess  mostly  in 
the  ri)4:ht  iliac  ie}j;ion.  lie  slejit  well,  hut  was  occasionally  tronhled  with  a  little  eon^jh.  Kpislaxis  occurred  ou  the 
3(lth,  aiud  on  Novemher  I,  5  and  (i  ther<>  was  some  headache  with  di//.iness  and  t  w  itchiuf;s  of  the  eyetialls.  He  was 
transferred  to  Annapolis,  Md.,  on  the  I8th  [as  a  ease  of  typhoid  fever,  and  was  returned  to  duty  Decemher  21]. 

C.\SK  X2. — A<jiif;  f/uxtric  irrildlioii:  roxi-volorrd  xjiotfi;  ctnhnil  xi/iiijitoms  slifihlhi  miirki'd;  j)i'r>ij)ir<ilii>ii  ii  ii<l  ixihidic 
fpistaxht. — I'rivate  Fred.  Shaffer,  Co.  G,  7l2d  X.  Y.;  age  2S;  hecanie  alVected  in  .luly,  18(11,  with  ague  which  lasted 
for  si.x  weeks,  after  which  he  was  confined  to  lied  with  ahdominal  jiains.  He  was  admitted  Scptiiuhcr  2!l  as  a 
case  of  tyjilioid  fever.  For  souu'  days  after  admission  he  rested  well  at  night,  hut  had  from  two  to  six  stools  daily 
with,  hut  sometimes  without,  tympanites  and  alidomiual  tenderness,  chielly  uuirked  in  the  umhilical  atul  left  iliac 
regions;  he  had  some  congestion  of  the  face  aiul  lu'adache,  ami  the  jmlse  ranged  from  8.")  to  100,  heing  usually  somi'- 
what  luoro  rapid  ut  thi^  evening  visit;  his  skin,  which  was  natural  or  slightly  moist  with  the  lower  pulse  and  usually 
hot  and  dry  with  the  higher,  jiresented  a  few  r()se-s)>ot8  and  a  profuse  eruption ;  he  was  tronhled  with  anorexia  and 
great  irritahility  of  the  stomach  ;  his  tongue  was  moist  and  white  or  yellow-coated,  or  dry  and  hrown;  he  hail  some 
diflicnlty  in  micturition  and  afterwards  retcMition  of  urine.  He  was  treated  with  turpentine  eumlsiou,  Dover's  pow- 
der, astringents  and  small  doses  of  calomel  and  opium.  On  Oetoher  .'')  Im  was  restless  at  night ;  his  face  w  as  eon- 
g<'sted,  eyes  dull,  pulse  !).">  and  weak,  hut  his  skin  was  cool  aiul  covered  with  perspiration.  Next  night  he  slejit  well 
and  in  till'  nuiruing  looke<l  hctter;  jmlse  80,  regular;  skin  natural;  tonguo  moist,  clean;  appetite  good;  hut  the  stomach 
continued  irritable  and  much  green  matter  was  vomited;  four  stools  were  passed.  Tincture  of  iron  and  astringents 
were  given.  From  this  time  forward  the  record  shows  the  presence  of  occasional  headache  with  dizziness  and  tin- 
nitus aurium.  The  stouuich  continued  irritable,  but  after  the  occurrence  of  epistaxis  on  the  10th  and  free  perspira- 
tion on  the  11th,  this  symptom  became  less  prominent  and  disappeared.  The  epistaxis  recurred  on  the  IStli,  ir)th, 
17th  and  21st.  The  tongue  was  always  moist  and  generally  clean,  but  flabby  and  with  ]>rominent  papilhe.  The 
bowels  were  loo.se,  giving  two  or  three  passages  dail.v,  with  decreasing  tymiianites,  gurgling  and  general  ahdominal 
tenderness,  somotiiucs  ])articulaily  marked  in  the  umbilical  and  right  iliac  regions;  towards  tlm  end  of  tlie  month 
the  stools  became  reduced  to  oiu!  daily.  Ou  the  2.")tli  quinine  in  two-grain  doses  was  given  three  tinu!S  daily.  The 
liatieiit  was  transferred  to  Annapolis,  Md.,  November  1  [as  affected  with  tyi)hoid  fever,  on  account  of  which  he 
was  discharged  fron.  the  service  on  the  25th]. 

Cask  8!!. — ('hills;  dian-liwa;  nnibilical  pain;  free  perspirations;  nonotahlv  crrchral  sjimptoms. — .lauuis  Tohin,  attcml- 
ant;  age  20;  was  admitted  Sept.  11,  18(>1,  having  been  taken  sick  ten  days  before  with  headache,  constipation,  pains 
in  the  bones  and  a  chill  and  fever,  for  which  cjuiniue  was  administeibJ.  On  the  day  after  admission  he  was  restless  and 
had  an  anxious  expression;  he  perspired  during  sleep,  but  when  awake  his  skin  was  hot  and  dry;  pulse  71;  tongue 
pale  but  red  at  the  ti])  and  edges;  four  thin  stools  had  been  ])assed  during  the  twenty-four  hours,  and  there  was  slight 
pain,  chiefly  umbilical  anil  dtiring  micturition;  he  had  also  a  stitch  in  the  side  and  some  pain  iu  the  breast.  (Quinine 
was  given.  In  the  evening  the  i)ulse  was  78,  the  skin  hot  hut  sweating  and  the  tongue  pale,  llabhy  and  somewhat 
brown;  four  stools  were  i)assed  during  the  day.  Acetate  of  lead  and  ojiium  were  jtrescribed.  Next  morning  tho 
pulse  had  fallen  to  50  and  the  jiatient  was  sweating  profusely.  In  the  evening  theue  was  a  slight  accession  of  fever; 
only  one  stool  was  passed  during  the  twenty-four  hours.  F'or  some  dayij  after  this  the  perspiration  continued  pro- 
fuse, especially  at  night,  although  aromatic  sulphuric  acid  was  administered;  tho  bowels  remained  <|uiet  and  the 
tongue  llabby  and  coated  gray  or  brown  at  the  l)ase.  Blue-pill  was  given  throe  times  on  the  l.")th,  and  in  the  evening 
of  the  10th  ten  grains  of  calomel,  which  produced  three  painful  stools,  Imt  the  bowels  thereafter  became  again  iiuiet 
although  tender  especially  in  the  right  iliac  legion.  The  perspirations  continued.  Morphia  was  given  at  night  and 
the  patient  was  sponged  with  alcohol.  On  the  18th  some  jiustules  ap|>oared  on  the  abdomen.  Next  day  he  is 
reported  as  looking  stout  and  healthy,  with  bright  eyes  and  clear  mind,  although  there  was  some  headache  and  pain 
in  the  back  and  breast,  with  a  slight  gray  coating  on  tho  tongue.  Throe  grains  of  calomel  and  a  half  grain  of  ojiiuni 
were  given  three  times.  The  record  concludes  on  the  21st,  the  patient  still  jjcrspiring  at  night  and  having  the 
umbilical  region  tender. 

C.vsE  84. — Death,  probably  from  perforation  of  the  intestine ,  on  the  2iith  dai/. — Sergeant  David  Puckett,  Co.  E,  .%!! 
n.  S.  Cav.;  age  27;  was  admitted  Oct.  18,  1801,  having  been  sick  since  the  beginning  of  the  month  with  headache 
and  pain  in  the  limbs,  back  and  epigastrium.  A  cathartic,  to  be  followed  by  i)uinine,  was  prescrilied.  On  the  day 
after  admission  the  patient  was  wakeful,  his  eyes  dull  and  yellow-tinged,  cheeks  flushed,  pulse  110,  full  and  strong, 
skin  hot,  tonguo  slightly  moist,  red  at  the  tip  and  edges  but  heavily  coated  yellowish-white  in  the  centre;  he  had 
anorexia,  thirst,  three  passages  from  the  bowels  during  the  twenty-four  hours,  much  umhilical  tenderness  and  tympa- 
nites, a  slight  cough  and  difficult  micturition.  Sinapisms  wereai>plieil  to  the  abdomen  andenuilsion  of  turpentine  given 
every  three  hours,  with  extract  of  bueliu  as  re([uired.  On  the  20th  the  |)ulse  fell  to  IH),  but  the  condition  of  tho 
patient  was  otherwise  uuchaiiged.  A  powder  containing  three  grains  of  calomel,  one  grain  of  opium  and  one-eighth 
of  a  grain  of  tartar  emetic  was  given  every  three  hours.  Next  day  the  tongue  became  dry;  seven  stools  were  passed 
and  tho  hypogastric  and  iliac  regions  were  highly  tympanitic  and  tender.     On  the  22d  the  diarrhcea continued,  eight 


238  (ILINICAI,    RKCOKDS    OK 

stools  having  boon  passed;  <'nrcliriil  symptoms  wore  iiuiiiifested,  as  hejidaclie,  liobetnde,  dizziness  and  tinnitus ;  the 
Htomacli  became  initalile  and  tlie  t"ii^;ue  dry,  red  at  tlie  tip  and  edfjes  and  liiown  in  tlio  centie.  On  tlieL'Sd  no 
eliaiif^e  was  iccorded  except  tlic  pas«a};(i  of  urine  witlioiit  pain  for  the  first  time  in  several  days.  J>ead,  opium  and 
tannin  with  tiiielure  of  iron  were  i)rescribed.  On  tlie  2ltli  the  iiatient  was  dull,  lying  with  his  eyes  half  <'losed  in  a 
seiui-delirious  condition;  no  stool  was  passed,  hut  there  was  much  vomiting.  Two  grains  of  calomel  and  a  half 
grain  of  opium  were  ordered  for  administration  every  hour.  On  the  2(>th,  having  slept  well  at  night,  the  patient 
was  lirighter,  his  nnud  less  obtuse,  and  there  was  less  abdominal  tenderness;  but  the  tongue  was  heavily  coated 
yellow  and  the  anorexia,  thirst  and  vomiting  ])ersisted.  Next  day  five  grains  of  calomel  and  a  (juarter  of  a  grain  of 
suli)liate  of  morphia  were  given,  but  no  marked  change  was  apparent  until  the  27th,  when  the  patient  was  partly 
unconscious  and  delirious,  lying  with  his  eyes  rolled  up  and  nu)uth  o])en,  his  breathing  hurried,  pulse  125,  tongue 
dry  and  coated  brown  and  stouuich  rejecting  everything;  there  was  extreme  tenderness  of  the  abdomen  aud  mncli 
meteorism.     Stimulants  were  administered  by  enenuita.     Death  took  place  on  the  morning  of  the  28tli. 

Cask  85. — Ucmiltent  fever;  sjimptomn  of  typhoid  ferer  not  dintincHij  iiiaiiifestid;  fiitid  hij  perilonitin  on  the2i>th  ditij. — 
Private  Mason  Ilitcheoek,  Co.  A,  19th  Ind.  Vols.;  age 33;  had  a  chill  Aug.  28,  18t)l,  with  pain  in  the  bones,  back  and 
calves  of  the  legs,  relaxation  and  tenderness  of  the  l)Owels,  and  fever  which  was  wor.se  in  the  evening.  He  was 
adnntted  on  the  morning  of  Septem))er  5,  when  his  pulse  was  80,  skin  warm  and  moist,  tongue  pale  and  coated 
and  colon  tender  on  i>re88ure.  Quinine  was  given.  He  had  a  chill  at  2  P.  M.,  and  in  the  evening  the  skin  was  hot 
and  dry  and  the  tongue  very  red,  flabby  and  coated.  On  the  tith,  7th  and  8th  he  had  no  fever  at  the  morning  visit; 
but  in  the  evening  the  skin  was  hot  and  dry  aiul  the  bowels  somewhat  relaxed  and  tender;  his  complexion  was 
sallow  and  his  mind  rather  dull.  He  was  treated  with  Dover's  jiowder  and  snuill  doses  of  blue-pill.  After  the  9tli 
there  was  slight  fever  at  the  umrning  visit,  but  the  patient  was  able  to  be  up  and  walk  around  a  little  until  the  12tli ; 
the  tongue  was  dry,  brown,  j'ellow  and  white  by  turns,  but  usually  red  at  the  tip;  the  pulse  was  weak,  80  when 
lying,  100  when  standing;  the  bowels  were  moved  from  one  to  three  times  daily,  and  there  was  always  some  tender- 
ness along  the  track  of  the  colon.  (Jn  the  15th  two  bloody  stools  were  passed  and  the  patient  was  much  <lepressed, 
the  colon  tender,  the  tongue  thickly  coated  yellow,  the  skin  hot  and  sweating,  pulse  86.  A  blister  was  applied  over 
the  colon  and  opium  and  tannin  prescribed.  The  bowels  remained  (|uiet  until  the  17th,  when  an  enema  of  soap  was 
administered.  At  this  time  there  was  some  tenderness  in  the  right  iliac  region.  On  the  18th  the  stomach  was  irrita- 
ble and  the  pulse  ran  up  to  120.  Vomiting  continued  next  day  and  was  accompanied  with  acute  tenderness  in  the 
epigastrium;  the  patient  lay  on  his  back  with  his  legs  drawn  up.  On  the  21st  the  pulse  was  110,  tongue  nearly 
clean  but  very  dry,  skin  hot,  abdomen  tender.  In  the  evening  the  body  became  covered  with  a  profuse  sweat,  the 
extremities  cold,  the  features  pinched,  the  pulse  imperceptible,  the  heart's  action  irregular,  speedily  ending  in  stupor 
and  death.     No  rose-colored  spots  were  discovered  in  this  case  although  specially  looked  for. 

Ca.sk  8t>. — Defervescence  on  the  22d  daij  checked  hij  chext  complications;  return  to  dutij  deluiied  to  SOIh  dnij  hi/  diarrhoal 
sequela'. — Bugler  Henry  L.  Case,  Co.  H,  4th  Mich.;  age  22;  was  admitted  Sept.  6,  1861.  Diagnosis — typhoid  fever. 
This  patient  had  good  health  up  to  August  26,  when  he  was  taken  with  pain  in  the  head  and  bones,  (diills  aud  fever, 
somnolence,  great  thirst  and  epistaxis.  His  case  was  not  taken  u|)  in  detail  until  the  13th,  when  the  morning  record 
shows  him  to  have  rested  well  during  the  jirecediug  night  ;  he  was  very  weak  but  had  sonu'  ap|ietilr,  regular  bowels, 
a  thickly  I'oated  lirown  tongue,  a  pulse  beating  08  per  minute  and  a  slight  cough:  the  evening  record  shows  a 
white  tongue,  had  taste  in  the  mouth,  some  fever,  bowels  regular,  abdomen  tender  and  slightly  tympanitic,  cough, 
tinnitus  anrium  and  nuiscie  volitantes.  On  the  llth  anorexia  was  added  to  the  symptoms  already  stated.  Next  day 
he  became  dull,  complained  of  heaviness  over  the  eyes,  and  in  the  evening  seemed  drowsy.  On  the  evening  of  the 
16th  the  tongue  became  moist  and  white,  but  this  was  not  followed  by  any  general  improvement ;  on  the  contrary,  on 
the  evening  of  the  17th  the  fever  increased  with  slight  nausea,  the  pulse  running  up  to  106,  while  next  day  a  pain 
on  deep  inspiration  was  develoi)ed.  Hut  on  the  I'.tth  the  pulse  again  fell  to  92  and  the  skin  became  moist  and  sweat- 
ing. There  was  some  tenderness  in  the  epigastrium  on  the  20th,  in  the  hypochondriuin  on  the  22d  and  in  the  right 
iliac  region  on  the  23d,  in  addition  to  the  abdominal  tenderiu'ss  which  had  existed  from  the  time  of  admission.  On 
the  21st  the  patient  became  somewhat  deaf  in  the  left  ear,  and  next  day  his  eyes  became  dull.  The  abdominal  ten- 
derness was  relieved  on  the  24th,  when,  also,  the  tongue  began  to  clean  in  patches,  but  thirst  continued  until  the 
27th.  The  patient  slept  badly  on  the  night  of  the  24th,  the  only  night  which  furnished  such  a  record,  for  usually  he 
rested  well,  and  next  morning  his  pulse  was  96  and  he  had  a  soreness  in  the  chest.  On  the  26th  the  tongue  was  moist 
and  only  slightly  coated,  which  improvement  was  followed  next  day  by  a  brightening  of  the  eyes,  abatement  of  the 
thirst  and  a  return  of  the  appetite.  The  bowels,  which  to  this  time  had  ieimiin(Hl  i|uiet  rather  than  lax,  now 
became  loose,  giving  two,  three  or  four  stools  daily,  with  iliac  tenderness  and  a  yellow  fur  upon  the  tongue ;  but  in 
progress  of  time  this  diarrluea  abated  and  on  November  1  the  patient  was  transferred  to  Annapolis,  Md.,  whence  he 
was  returned  to  duty  on  the  13th.  He  was  tnuited  at  hrst  with  Dover's  powder  and  sweet  spirit  of  nitre,  and  after- 
wards, on  the  23d,  with  turpentine  emulsion  and  iron,  opium,  acetate  of  lead  and  tannin. 

Casf;  87. — fjeadache,  dizziness,  deafness,  delirinin  and  muscular  twitchinf)s ;  relaxation,  tenderness  and  ttimpanites  of 
the  howels;  pneumonia;  no  rose-colored  spots. — I'rivate  Sidney  I).  Way,  Co.  I,  2d  Vt.;  age  18;  was  admitted  Sept.  27, 
1861,  having  been  taken  three  weeks  before  with  intermittent  fever,  cough  and  i>ain  in  the  breast.  The  case  was 
diagnosed  typhoid  fever.  The  patient  was  weak,  his  cheeks  flushed,  countenance  anxious,  pulse  ijuick,  120,  skin 
hot  and  dry;  he  had  some  pain  in  the  head  and  chest,  with  deafness  and  muscular  twitchings;  there  was  anorexia 
with  a  moist  white  t<mgue,  and  relaxed  bowels  with  much  tympanites  and  general  abdominal  tenderness.  Small 
doses  of  blue-pill  and  opium  were  given  ou  the  28th  and  turpentine  emulsion  on  the  29th.  ■  During  the  next  four 
days  his  condition  was  but  little  altered;  the  deafness  increased,  and  delirium,  dizziness  and  aphonia  were  mani- 
fested ;  three  or  four  passages  from  the  bowels  were  recorded  every  twelve  hours  ;  the  cough  occasionally  became 


Till-:  r(iMiNUF;i)  kkvkks.  i?^'') 

troiililfSDiiir,  iiiid  was  ii(Mom]>iinitMl  with  a  iiiiKim.s  rxiMctiPiatioii  :  I  he  icspiral  ions  Vivvr  at  our  limp  as  high  as  Dli  (ici" 
111  in  lite.  I  >n  the  nioiiiiiig  of  OctolxM-  12  the  Jiaticiil,  having  sic)  it  well  dining  thr  |irr\  ions  tiiglit .  was  Ion  ml  \vit!i  the 
skin  ot'nalniiil  ti'iniK'iattiio  and  hathcd  in  |ii'rs|)iratii>n.  siKhiinina  on  tlir  light  sidr  and  over  tho  ahdomri;,  t  hi^ 
tongiii'  moist  and  slightly  Ooatt'd  yellow,  ami  the  jinlsc  !C)  lint  strong  and  (jMick  :  two  stools  had  lii-t-n  |>asscd  during 
till'  night  and  a  little  lilood  expeetorated,  after  which  the  eoiigli  liecaine  less  tionlilesonie:  resjiiiation  '2H,  with 
inneli  <  repitation  anteiiorly  on  the  left  side  and  a  little  on  th<'  right  side.  Next  day,  however,  the  pulse  was  again 
aceeleraled,  11.'!,  and  the  skill  liol  and  more  or  less  dry,  the  other  symptoms  coiitiniiiiig  as  already  deseril)e(l  until 
the  (jth.  when  with  a  freely  perspiring  skin  the  ))iil.se  fell  to  !•(•,  and  the  patient  hail  less  cough  and  some  improve- 
ment in  the  voice.  Alt<'r  this  the  juilse  again  rose  to  ID."),  the  skin  lieeoniing  hot  and  dry,  but  the  tongue  leiiiain- 
iiig  moist  and  yellow-coaied  ;  the  cough  and  ex])ectoralion  of  innciis  and  Idood  eontinni'd,  with  dnliK'ss  over  the 
lower  lolie  of  the  right  lung  posteriorly  and  mneons  ami  sulimueous  tales  aliove,  and  with  ciepitati<in  ovi'r  the 
left  lung  posteriorly;  thc^  diarrhoa  and  ahdominal  tendermss  i-oiitinned  as  already  reported.  Ity  the  llth  the  jiulse 
had  risen  to  lis,  ami  the  patient  was  (|uite  deaf  and  complained  of  headache.  On  the  llitli  thi'  tongue,  still  con- 
tinning  moist  anil  yellow-coated,  liiicaine  red  at  the  tip  and  edges;  some  sordes  formed  upon  the  lips,  and  tormina 
accompanied  the  diarrlneal  jiassages.  From  this  time  to  the  vnil  of  the  month  the  eonilition  varied  little  from  day 
to  day,  hut  a  gradual  alleviation  of  the  symptoms  of  the  lung  and  bowel  coniplaints  was  observed.  A  free  perspi- 
ration which  occurred  on  the  L'Olh  was  followed  by  a  reduction  of  the  ]iulse  on  the  "Jlst  and  the  maiiift'stalion  of 
some  ajipetite.  The  abdominal  tenderness  lieiame  lessened  and  the  jiassages  less  fie(|uent  nnlil  the  Hist,  when,  for 
the  lirst  time,  the  daily  recold  shows  that  no  stool  was  ]iassed  during  the  |iievioiis  twenty-four  hours.  On  Nii\  em- 
ber 1  the  jiiilse  was  W  and  fi'eble,  the  skin  natural,  the  toiigiu^  pale,  the  appetite  good  ;  the  cough  was  l;ss  trouble- 
some and  there  had  been  but  one  stool.  Mis  condition  had  not  changed  materially  on  the  Otli,  when  he  was 
discharged  from  the  service  on  account  of  debility:  the  cough  persisted  with  occiisional  relaxation  ol  tho  bowels 
and  abdominal  tenderness,  but  with  a  good  appetite  and  natural  skin. 

("ask  W. — Diurrhdu;  hiUnux  nimiliiiii;  jHr«phalii>)i,i;  no  ronc-colorcil  xpots ;  (J'u^invus;  jtiiliiioiiKri/  vi)iiii)lit(iti(>iis  on 
Ihi  Uilh  (luji ;  inipnircmciit  oil  '2HIIi. — I'rivate  Dwighl  Toiisely,  (^o.  K,  M  Mich.  Vids.;  age  lid;  was  admitted  Oct.  1!(, 
18t)l.  Diagnosis — tyjilioid  fever.  On  the  12th,  after  undergoing  much  fatigue,  ho  was  taken  with  headache,  v  eak- 
ness  and  slight  diarrhiea.  lie  slejit  well  after  admission,  and  on  the  luorning  of  the  20lli  his  (uninteiiiince  was  nat- 
ural, pulse  88  and  strong,  skin  perspiring,  tongue  moist,  pale-rod  at  the  tip  and  edges  and  brownish  in  the  centre; 
he  had  some  a]>petite,  slight  thirst,  two  thin  watery  stools,  some  riglit  iliac  tenderness,  borborygniusand  slight  tym- 
panites, ijnlnine  administered  in  a  full  dose  at  noon  was  vomited  along  with  much  phlegm  and  grecnish-v.atery 
li<inid.  On  the  evening  of  the  21st  ho  again  vomited  a  greenish  mass  mixoil  with  the  rejected  itigestti;  he  had  diz- 
ziness and  tinnitus  aitrinni.  The  tongue  on  the  2'M  was  coveiod  with  white  scales;  on  the  following  day  it  was 
raw,  red  in  the  centre,  pale  and  slightly  coated  at  the,  sides;  it  became  scaly  again  on  tho  li.'ith,  and  the  piilso 
lose  to  94.  On  tho  2()tli  the  pulse  was  120  and  feeble,  the  patient  delirious,  his  countenance  haggard  and  anxious, 
skin  warm,  moist  and  at  times  sweating  profusely,  tongue  moist  and  cleaning  from  the  tip  and  edges;  he  had  no 
pain,  but  there  was  much  tympanites,  which  was  relieved  by  an  oneiiia;  rales  and  creaking  sounds  were  heard  in  the 
upper  part  of  the  chest,  and  the  respirations  were  increased  to  2.").  The  ]inlse  fell  to  96  on  the  27th,  and  on  the  28tli 
the  patient  a]ipeared  somewhat  better;  his  month  and  fauces  were  covered  with  aphtha'.  He  had  a  chill  on  the 
afternoon  of  the  2!tth,  and  on  tho  30th  was  very  nervous,  although  the  tongue  was  cleaning,  apiielito  good,  bowels 
quiet  and  respiration  normal.  His  condition  did  not  inipio«re  materially  until  November  8,  the  tongue  being 
occasionally  dry  and  brown  or  moist  and  i  leaning,  the  skin  husky  and  the  pulse  accelerated.  .Vfter  that  date, 
however,  he  slept  well,  had  a  good  apjiotite,  no  thirst,  soft  skin  and  i|uiot  bowels;  some  tenderness  remained  in 
the  right  iliac  region;  he  had  sore  throat,  hut  no  cough,  and  bis  re.spiratiiii  was  normal.  Ho  was  transferred  to 
Annapolis,  Mil.,  on  tho  18th. 

Case  89. — Dale  of  oiiml  not  dr/imd;  peinistin;i  diairlKrn  and  loniitinij  of  hUionn  innltir;  nw-coloied  sjiols ;  sord,x; 
mvttering  diliriiim;  inioliiiitaiii  pasmtji'H ;  void  piinpiriilionx:  death  on  I6th  dui/  after  adni'miiuii.  --Vrivnte  Charles 
Green,  Co.  C,  1st  Long  Island;  age  18;  was  admitted  Sept.  14,  18H1,  having  been  sutfering  for  some  time  froi> 
weakness,  pain  in  the  bones,  heat  of  skin,  thirst  and  diarrhiea.  On  admission  his  stomach  was  irritable.  He 
rested  well  during  the  night,  and  next  day,  although  he  had  a  brown  and  thickly  coated  tongue  and  a  bad  taste  in 
his  month,  his  appetite  was  good,  pnlse  92  and  skin  hot  and  moist.  Dover's  powder  was  given.  The  tongue 
became  dry  and  red  at  the  tip  on  the  16th;  tho  bowels  were  moved  six  times  and  were  tender;  the  jmlse  rose  to 
108  and  there  was  some  deafness.  He  mnttered  continually  during  sleep  on  the  17th;  the  diarrho'-i  and  irrita- 
bility of  stomach  continued.  In  the  evening  rose-colored  spots  appeared  on  the  chest  and  abdomen  and  sordes 
on  the  teeth;  the  lips  were  livid,  and  a  peculiar  odor  emanated  from  the  body.  The  muttering  during  sleei> 
increased,  and  on  the  evening  of  the  18th  the  patient  was  delirious  on  awaking;  nausea  ret'irned  and  he  vomited 
twice.  During  the  night  he  vomited  five  times  a  thin  greenish-yellow  matter  of  a  highly  oll'ensive  odor.  Mild 
delirium  continued  during  the  19th,  and  the  urine  was  |)assed  involiintiirily ;  the  matter  vomited  became  of  a  liglitei 
color;  the  diarrhiea  persisted  notwithstanding  the  administratiou  of  astringents,  and  there  was  intestinal  gurgling 
with  umbilical  tenderness.  Calomel  in  one-grain  doses  was  given.  Next  day  the  gastric  irritability  was  (luieted 
and  the  diarrhiea  lessened.  In  the  evening  lie  was  restless  and  wakeful,  his  skin  hot  and  dry,  but  his  face  covered 
with  a  cold  perspiration,  pulse  120,  weak  and  trennilims;  he  had  subsnltns  tondinnm  and  jiassed  one  stool  invol- 
untarily. A  similar  stool  was  passed  on  the  21st,  during  which  tho  jirostration  increased.  The  right  ilir.c  region  is 
noted  as  having  been  tender  on  this  day.     He  died  on  the  22d. 

Case  90. — Diarrhoea;  deUrinm;  sordex;  pneumonic  complication  ;  eruption  ;  xliiihthj  marked  iinprorciiierJ  on  15</i  dai/, 
after  which  free  pvrxpirations  alternated  with  diarrnaa;  ribicex;  epigtaxis;  peritonitis;  death  on  the  3ls(  day. — Teamster 


240  CLINICAL    RKCOHDS    OF 

Jaw.  H.  Perkins,  <|iiartt'riiiaRti'r'N  depart meiit :  at;e  2'.l:  a  X'iryiniaii ;  \va»  adiiiilti'd  .Sept.  .'iO,  186L  Diagnosis — tvidioid 
fever.  lie  had  lieeii  taken  with  diaiihu-a  en  the  2.")lh  and  with  lieacLpain  and  ihonniiltisni  on  the  L'Tth.  On  admis- 
sion his  Caic,  was  tlu.shed,  eyes  hiifjhl,  jdilse  DO,  (|iiiek  and  slronj;,  tonj;ne  moist  and  slij;ht]y  eoaled  white;  his 
l>owels  hadheen  opened  thie.e  times  dniin}{  tlie  ]iicYi()Hs  twenty-four  hours,  anil  tlie  iliae  rej^ions  were  tender  and 
tynipanitie;  he  had  also  soinc^  <i)tit;li.  Calomel,  opium  and  tartar  einetie  weii^  i)rescrihed.  On  Oel((l)cr  1  the  Ixiwels 
were  (jiiiet,  lint  there  was  .some  pain  in  the  chest  when  conghinK,  wit  h  diilness  over  the  lower  lolies  of  the  lunj^. 
Small  doses  of  calomel  and  ((ninine  were  f;iven.  He  had  three  stools  on  the  '2d.  Next  day  the  ]iiilse  ran  ii|)  to  111', 
and  complaint  was  made  of  headache  and  backache.  Tincture  of  iron  and  camphor  with  o|pium  were  |(rescrilied. 
He  vomited  twice  on  the  Itli.  His  skin  became  moist  on  the  ."ith.aiiil  on  the  following;  day  was  covered  with  a 
profuse  ])er8piration;  but  there  was  some  delirium  and  much  twitchinj;  of  the  tendons.  On  the  Oth  emulsion  of 
turpentine  was  administered.  On  the  7th  the  pulse  was  10."),  ([uick  atui  stronj{,  the  skiu  uatural,  the  ton;{nc  moist 
and  heavily  coated  yidlow;  four  stools  were  ii.-issiul ;  the  transverse,  and  desccndinfj;  portions  of  the  colon  were 
tynijiauitic  and  the  umbilical  region  tender;  lie  had  some  conj^h,  w  ith  slight  jiain  in  the  right  side  below  the  nijiple, 
and  there  was  dulness  on  iK^rcussion  over  the  lower  lobes  of  both  lungs,  csjiecially  marked  on  the  right  side.  ( >n 
the  Hth  the  skiu  was  hot  and  dry  and  the  bowels  loose.  On  the  Dth  the  jiatient  was  wakeful  at  night  and  dull  and 
8tu))id  during  the  day;  the  pulse  120,  (|uick  and  strong ;  the  skin  hot  and  dry,  showing  some  eruption  (the  character 
of  which  is  not  stated);  the  tongue  red,  tissured  at  the  edges  and  coated  dark-brown  in  the  centre;  the  teeth  and  lips 
covered  with  sordes;  he  had,  moreover,  deafness,  delirium,  anorexia  and  diarrhtea.  lie  continued  iu  this  condition 
until  the  1.5th,  when  the  tongue  became  moist,  yellowish  at  the  centre  and  red  at  the  tip  and  edges,  anil  the  delirium 
and  deafness  were  somewhat  less  marked;  the  juilse  had  fallen  to  100.  The  skin  was  liathed  in  perspiration  on  the 
16th  and  17th,  and  this  condition  recurred  on  the  liHh,  21st,  2;)d  and  25tli.  Three  or  four  stools  were  pas.sed  on  the 
alternate  days  when  the  skiu  was  hot  and  dry,  but  on  the  days  when  the  skin  was  moist  the  bowels  remaine<l 
quiet  except  on  the  21st,  whi^n  they  were  moved  six  times.  On  the  19th  vibices  appeared  on  the  skin  and  on  the 
23d  became  very  numenuis.  On  the  21st  the  pulse  rose  again  to  120,  and  there  was  epistaxis  with  low  delirium 
and  increased  deafness.  Tlie  epistaxis  recurred  on  the  22d.  The  patient  became  almost  pulseless  on  the  25th ;  his 
skin  was  bathed  in  perspiration,  and  there  was  acute  pain  in  the  abdomen.     He  died  on  this  day. 

Case  itL — Ilelopue  of  typhoid;  ferer,  pcrnpiriitioti,  dcUriiim,  iVuirrhcca  and  tciidernens;  rose-runh ;  deatli  three  days 
after  the  oeeurretiee  of  what  teas  regarded  ax  a  congestire  chill. — See  case  of  Private  James  IJeckwith,  Co.  F,  2d  Me., 
No.  16  of  the  pout  mortem  records. 

Cask  92. — ChilU,  diarrhaa  and  tenderness;  nausea  and  romitiny ;  epistaxis  and  hemorrhagic  stooh;  deafness;  tempo- 
rary improremeni;  death  from  parotid  inflammation  and  gangrenous  erysipelas. — See  case  of  Private  James  M.  Forman, 
Co.  H,  ;S3d  Pa.,  No.  103  of  i\ui  post-mortem  records. 

Cask  93. — C7ii7/  and  perspiration ;  diarrhnii,  tenderness,  rose-rash  and  mental  confusion;  temporary  improvement 
followed  by  inJUunmation  of  the  larynx  and  lungs,  hemorrhagic  stools  and  death. — See  case  of  Private  D.  F.  McLacblan, 
Co.  G,  11th  N.  Y.,  No.  110  of  the  2>ost-moriem  records. 

Ei.KVEN  Typhoid  Fkvku  Cases  in  which  Acuish  PAiioxvs.MS  preceded  the  pevelopment  oi"  the  Continued 

Fe\'E1!. 

Case  94. — Intermittent  fever;  relaxation  of  the  bowels  and  abdominal  tenderness;  no  cerebral  nor  special  typhoid 
symptoms,  but  no  particulars  are  given  of  the  patient's  condition  for  some  days  preceding  death. — Private  Andrew  Landon, 
Co.  C,  74tli  N.  Y.  Vols.;  age  18;  was  admittiul  Nov.  2,  IfiOl.  Diagnoses — tyjdioid  fever.  His  health  had  been  good 
until  about  a  month  before  admission,  when  he  contracted  intermittent  fever.  On  the  3d  his  eyes  were  bright, 
cheeks  (lushed,  jiulse  100,  quick  and  small,  skin  hot  and  dry,  tongue  faintly  yellow;  he  had  some  appetite,  some 
thirst,  two  stools  and  slight  epigastric  tenderness.  On  the  5th  a  blister  was  ajiplied  on  account  of  increasing 
tenderness  with  some  tympanites  iu  the  umbilical  and  iliac  regions.  At  this  time  he  was  taking  twelve  grains  of 
quinine  daily  with  tincture  of  iron.  On  the  8tli  he  was  wakeful,  the  pulse  rose  to  120,  the  skiu  continued  hot  and 
the  tongue  coated;  the  tenderness  had  decreased,  but  the  bowels  were  slightly  relaxed  and  there  was  some  cough. 
Emulsion  of  turpentine  and  beef-essence  were  prescribed.  On  the  10th  there  was  much  tympanites  and  throe  stools 
were  passed.  Whiskey-punch  and  astringents  were  ordered.  On  the  11th  the  eyes  were  bright,  face  pale,  pulse  120 
and  quick,  skiu  hot  and  dry,  tongue  dry  and  red  but  slightly  yellow  in  the  centre,  appetite  good.  Acetate  of  lead 
and  tannin  were  jirescribed,  but  death  took  place  on  the  17th. 

Case  95. — Chills,  ferer  and ptrspirations;  eruption  on  iSth  day;  relaxation  of  bowels;  iliac  and  epigastric  tenderness; 
delirium ;  death  on  35(/i  day. — Private  John  Dietrich,  Co.  li,  35th  Pa.  Vols.;  age  19;  was  admitted  Nov.  5,  1861.  Diag- 
nosis— typhoid  fever.  He  had  been  healthy  till  Oct.  20,  when  he  was  taken  with  chills,  fever,  perspirations,  jiain 
in  the  head,  back  and  limbs,  lassitude,  anorexia,  thirst,  vomiting,  diarrlxea  and  cough  with  exiiectoratiou.  On  the 
6th  he  was  wakeful,  eyes  suffused,  cheeks  flushed,  pulse  120,  quick  and  bounding,  skin  hot,  iicrspiring  and  covered 
with  eruption  and  sudamina  on  the  chest  and  abdomen,  tongue  moist  and  white-coated,  bowels  slightly  relaxed, 
tympanitic  and  tender  in  the  iliac  and  epigastric  regions;  he  had  some  ajipetite,  much  thirst,  slight  cough  and 
Konu'what  accelerated  respiration.  Quinine  and  tincture  of  iron  were  prescribed,  with  sinapisms  to  the  abdomen. 
On  the  7th  the  tenderness  and  tympanites  were  lessened.  The  mtistard  was  repeated  and  Dover's  powder  given 
at  night.  He  had  some  headache  on  the  8th  and  became  delirious  on  the  10th.  Here  the  record  closes  abruptly  with 
the  announcement  of  death  on  the  23d.     Turpentine  emulsion  was  administered  on  the  8th. 

Case  9(). — Cerebral  symptoms  strongly  marked ;  intestinal  and  pulmonary  symptoms  obscured;  death  on  Wth  day. — 
Corporal  S.  H.  Forsyth,  Co.  A,  3d  Pa.  Cav.;  age  33;  was  taken  sick  Sept.  7,  1861,  with  chills,  nausea  and  vomiting. 


TTIF    CiJNTrNri'.T)    KK.VKKS.  241 

which  recurrert  for  tliroe  days.  lie  was  adiiiitti-il  dii  tin-  1  Itli.  IHa^nnsis — ty|)hcii(l  fever.  II<'  hail  jiaiii  In  the  liead 
aud  h(jni's.  hicri'aseil  heat  of  skin,  tinnitus  aurinni,  dnlurs^  nl'  intellect  and  occasional  eiiistaxis.  A  bath  was 
ordered  for  liim  and  Dover's  powder  at  nij^lit.  He  r<'ste<l  well,  his  Ikiwi-Is  remaining;  (piiet  althoufth  somewhat 
swollen  and  tender:  the  tonj;no  was  brown  and  dry.  rur]ientine  eninlsiun  was  jjiscn  every  two  hours.  On  tlie  llith 
the  )>iilse  was  KKi  and  stroni;,  tonjjue  brown,  buwels  rejinlar  but  tynipaiiitie,  skin  hot  and  dry,  sln>winf;  sonic  rose- 
eoloied  spots:  tltcre  was  anorexia  and  occasional  epistaxis.  He  was  lestless  diirinj;  the  ni^jht,  and  on  the  17th 
became  somewhat  deliriinis.  dnll  and  drowsy:  the  jnilse  was  lOt!  but  weaker:  the  bowids  ri';jnlar  but  distended. 
A  few  rose-colored  spots  appeared  on  the  l!StIi.  an<l  one  dark-<(ihjred  stool  was  passed.  'I'he  toiifjne  was  tremulous 
and  iirotruded  with  dilliculty  on  the  lUth,  and  the  ti'clh  were  Iduck  uith  smiles.  In  the  eveniii};  the  toiifjue  w  as 
dry,  red  at  the  tip  and  edges  and  black  in  the  centre  and  at  the  ba>c.  Hcef-esscncc  and  wliiskey-|iunch  were  pre- 
scribed. On  the  20tli  the  eyes  were  suti'iised,  jniiiils  contracted.  |inlsc  lUi,  skin  hot  and  dry  but  sott,  teeth  and 
lips  covered  with  sordes,  breathing  labored,  bowels  iiiiict  but  lyni|>anii  ic  and  f;ur;;linf;  on  pressure.  In  the  even- 
ing the  pulse  had  risen  to  l^li;  a  slight  perspiration  bedewed  the  forehead  and  arms  and  a  few  rose-colored  spots 
appeared  on  the  chest  and  abdomen:  the  ileliriuni  was  aecompanied  by  sonu'  deafness  and  muscular  Iwitchings,  but 
the  resjjiration  had  become  quiet  and  natural.  Two  days  were  passed  without  material  change,  but  on  the  '2'M  the 
respiration  became  increased  to  !i,"i :  the  skin  was  moist  and  hot,  hands  cold  and  clammy,  pulse  I'M.  small  and  trem- 
ulous, bowels  (jniet  but  largely  nioteorized,  urine  passed  involuntarily.  Tincture  of  capsicum  was  given  and  a 
blister  and  handage  ajiplied  to  the  abdoim-n.  On  the  24th  the  pulse  reached  114  and  was  very  feeble;  the  face  was 
covered  with  sweat,  the  hands  cold  and  damp,  the  feet  warm;  the  patient  was  somewhat  conscious  hut  very  deaf, 
and  he  had  some  dilliculty  in  swallowing.  A  tul)e  was  passed  to  relieve  the  tympanites.  On  the  l?.")th  he  was  uncon- 
scioUK,  muttering  in  his  delirium,  pulse  148,  features  ]>ini'hed,  foiehead  Hushed,  nose  and  lipn  blanched,  eyes  sunken 
and  injected,  cornea  dull  and  ]iartly  gla/cd,  extremities  pulseless,  heart'si  action  feeble,  skin  of  body  warm  and 
bedewed  w  ith  persiiiration,  hands  shrunken,  damp  and  cold,  tongue  dry,  brown  and  badly  fissured,  lijis  and  teeth 
covered  with  dark-brown  sordes ;  ho  was  very  deaf,  had  violent  subsultus,  dys])hagia,  involuntary  urination  aud 
excessive  tympanites,  but  no  movement  of  the  bowels;  ies])iration  was  slow  and  labored.     Ilc'died  on  this  duy. 

Case  97. — Preceded  hy  qiiotidwn  chlUn;  dale  of  oiikiI  undefined;  dinrrliuul  ((feetioii  xerere ;  delirium  ;  prostratioH ; 
death. — I'rivate  .Jacob  Benson,  (Jo.  H,  1st  I'a.  Cav.;  age  liM ;  sullered  with  i|U<>tidian  chills  during  .\ugust,  I!S<)1,  and 
on  September  7  was  admitted.  Diagnosis — typhoid  fever.  The  patient  was  weak,  dull  and  stupid;  pulse  IM,  skin 
hot  and  dry,  tongue  dry,  brown  and  heavily  coated,  bowels  relaxed  and  painful.  Whiskey  and  beef-essence  were 
administered.  Six  thin  stools  were  i>assed  during  the  next  twenty-four  hours;  the  right  iliac  region  was  tender. 
Turpentine  emulsion,  Hoffmann's  anodyne  and  morphine  were  prescribed.  On  the  9th  delirium,  epistaxis,  rosii- 
colored  sjiots  and  three  thin  dark  stools  were  noted,  and  on  the  10th  sordes,  subsultus,  dilliculty  in  protruding  the 
tongue  and  aggravation  of  the  diarrhiea.  Euemata  of  starch  and  laudanum  were  used,  but  the  diarrluea  persisted, 
giving  five  or  six  stools  daily  until  the  end.  A  profuse  eruption  of  rose-colored  spots  and  sudamina  aiipeared  ou 
the  14th.  The  stools  were  J)a8sed  inviduntarily  on  the  Ititli,  and  atterwards  the  abdomen  was  tymjianitic  and 
tender  in  the  right  iliac  region.  Carbonate  of  ammonia  was  ])rescribed  on  the  17th.  Next  day  the  stonnich  was 
irritable,  the  respiration  labored,  skin  congested,  eyes  dull,  half  opened  anil  with  contracted  ]>upils.  On  the  19th 
a  few  rose-colored  spots  appeared;  the  jiulse  was  IL'O,  soft  and  compressible,  ami  the  features  shrunken.  Death 
took  place  on  the  20th. 

Ca.se  98. — Chilh  and  ferer  uith,  siihwquently,  the  jintduitl  aee<KHion  of  jo/ih^j/di/m  of  enterie  ferer;  dinrrheral  iitiack 
on  nth  ddi/;  rose-xpoix  and  delirium  on  18/// ;  infiunnnation  of  parotid  on  'Jilh  ;  ai/t/raration  of  diainhon  on  'JHth  and  death 
on  30lh  day. — Private  .lames  Koe,  Co.  F,  1st  Mich.;  age  22;  was  admitted  Sept.  28,  18()1,  having  been  taken  sick 
about  a  week  before  with  chills  and  fever,  for  which  quinine  and  alteratives  had  been  administered.  On  admission 
he  was  weak,  had  anorexia  and  headache,  Ijut  his  skin  was  natural,  tongue  moist  and  slightly  coated,  pulse  72  and 
bowels  quiet.  Up  to  October  5  there  was  no  marked  change  in  the  patient's  condition  ;  the  coating  of  the  tongue 
became  somewhat  thickened;  the  skin  was  dry,  hot  on  the  3d,  j)erspiring  on  the  4th;  the  bowels  were  quiet  or 
moved  once  dail.v,  and  there  was  some  tenderness  in  the  right  iliac  region  ;  the  headache  continued  and  there  was 
slight  cotigh.  On  the  6th  the  patient  vomited  some  dark-colored  matters.  On  the  7th  he  was  restless  for  the  first 
time  since  admission  ;  the  bowels  were  moved  four  times  and  the  tongue  was  moist,  red  at  the  tip  and  edges  and  dark- 
brown  at  the  centre  and  base.  On  the  8th  he  was  delirious;  pulse  90  and  quick;  skin  hot  and  dry,  showing  a  few 
rose-s]>ots,  disappearing  on  pressure,  aud  mingled  with  jnofuse  eruption  (character  not  stated);  tongue  dry,  Habby, 
red  at  the  tip  and  edges,  coated  brown  in  the  centre ;  appetite  very  good  ;  he  had  one  stool,  some  tympanites  and  slight 
gtirgling  in  the  right  iliac  region.  No  change  was  manifested  save  increasing  dulne.ss  of  mind  and  prostration  until 
the  13th,  when  the  tongue  became  slightly  moist  and  the  delirium  les.sened.  During  this  period  the  teeth  were 
covered  with  sordes  and  the  mouth  tilled  with  tenacious  mucus.  On  the  14th  the  parotids  became  swollen.  Next 
day  the  pulse  was  120  and  feeble  and  the  bowels  quiet  but  tender  and  distended:  the  patient,  nevertheless,  when 
aroused  from  his  low  delirium,  expressed  himself  as  feeling  quite  well.  The  tongue  became  moist  and  its  coating 
yellowish-white  on  the  16th,  aud  on  the  following  day  the  patient  was  more  rational;  the  eruption  was  present  up 
to  this  date.  A  sharp  diarrhoea  of  seven  stools  occurred  on  the  18th  and  the  pulse  reached  140.  A  blister  was 
applied  to  the  abdomen.  On  the  19th  vibices  appeared;  the  tongue  could  not  be  protruded  on  account  of  the 
parotid  swelling;  the  bowels  were  moved  once  only,  but  they  were  generally  tender  and  much  meteorized. 
Death  took  place  on  the  20th. 

Case  99.— Typhoid  ferer  following  intermittent;  intestinal  symptomn  not  marked;  death  from  pneumonic  complications. — 
Private  A.  ^Y.  Armagust,  Co.  I,  33d  Pa.  Vols.,  was  admitted  Oct.  2,  1861.  Diagnosis — typhoid  fever.  About  Sep- 
tember 28  he  had  been  taken  with  headache  aud  chills,  which  recurred  every  night.  He  felt  well  on  the  mom- 
Med.  Hist.,  Pt.  HI— 31 


242 


I'lJNrcAr,  Ri-;roRi)S  ok 


in^  lifter  admission,  but  in  tlui  cveiiiiiij  tlic  jmlsc  liccamo  acoclcratod  anil  strong,  the,  skin  hot  and  dry  and  the 
tongue  red,  clean  at  tlie  tip  hut  coated  at  tlie  hase ;  ho  liad  three  stools  during  the  day,  with  some  soreness  of  the 
abdomen,  but  no  tyniiianites  nor  gurgling.  Quinine*  was  given.  He  is  reported  as  having  slept  well  on  the  4th 
and  as  having  had  no  chill  on  the  .5th;  on  the  (itli  liis  comlition  is  not  stated.  On  the  7th  he  had  headache  and  was 
restless;  countenance  natural;  pulse  80,  steady;  skin  hot  and  dry  but  soft;  tongue  moist,  red  and  quite  clean;  he 
had  pain  in  the  bones,  two  stools  and  abdominal  tenderness,  but  no  tympanites.  Tie  had  one  stool  on  the  8tli. 
Snuill  doses  of  caloiuel,  (juinine  and  opium  were  given.  The  headaclie  was  worse  on  the  9th;  thei'e  was  a  feeling  of 
pn^ssnni  on  the  brain  with  buzzing  in  the  eai-s  and  deafness  ;  four  stools  were  passed ;  the  tongue  was  dry,  red  at  the 
tip,  fumMl  in  the  centre  and  coated  gray  at  the  base.  Sweet  spirit  of  nitre  was  prescribed.  On  the  10th  the  bowels 
were  (jniet  and  continued  so  to  the  end  with  but  little  complaint  of  abdominal  tenderness  or  tympanites.  Emulsion 
of  turpentine  and  Mindererus'  si)irit  wi-ic  administered.  On  the  11th  the  skin  was  liot  hut  moist;  tlie  tongue 
continued  dry  and  the  ap])(^tite  did  not  icturu,  although  there  was  nnirked  improvement  in  the  cerebral  and  abdom- 
inal symptoms.  On  the  l.'jth  the  patient  was  restless,  and  there  was  some  cough  for  the  first  time  in  the  progress  of 
the  case;  the  cough  grew  worse,  and  on  the  17th  brown  mixture  was  prescribed.  Kext  day  there  was  anxiety  of 
countenance  and  much  cough,  but  neither  accelerated  respiration  nor  pain.  On  the  20th  the  patient  was  slightly 
delirious.  Whiskey-punch  and  citrate  of  iron  and  (juinine  were  given.  On  the  22d  his  face  was  jiale,  countenance 
dull,  pulse  82,  steady,  surface  ciri^ulation  good,  skin  dry  and  husky  but  not  hftt,  tongu(*  slightly  brown  and  dry  in 
the  centre,  whitish  and  moist  along  the  sides,  red  at  the  tip  and  edges,  teeth  and  gums  clean  ;  he  had  some  apjictite, 
no  thirst,  and  a  cough  with  slight  wheezing  and  gurgling  sounds  in  the  lower  parts  of  the  lungs;  at  times  also  he 
had  some  dizziness  and  tinnitus.  On  the  23d  the  respiration  became  increased  to  21);  the  pulse  to  102;  the  abdomen 
was  soft  and  natural.     He  died  on  the  29th.     No  eruption  was  noticed  in  this  case. 

Cake  100. — CltiUn;  pale,  eoated  tonijiic  and  offennirc  hrcath;  jaumUce  and  epignsiric  pain ;  howeU  quiet;  ccrehral 
Ki/inptiiinx  not  marked;  veetird  iinjininhed. — Private  (Jeorge  H.  Peters,  Co.  F,  4th  Mich.  Vols.;  age  21;  of  vvinikly  consti- 
tution, was  admitted  Nov.  1,  1801,  as  a  case  of  ty]ihoid  fever.  On  October  23  he  was  taken  with  headache  and  chills 
which  lasted  for  three  days,  and  with  anorexia,  weakness,  diarrlnea,  cold  feet;  tinnitus  aurium  and  fever,  for 
which  Epsom  salt  and  quinine  had  been  administered.  On  admission  he  was  dull  and  unable  to  collect  Ins 
thoughts  on  account  of  a  fulness  in  the  head  and  ringing  in  the  ears;  his  pulse  was  98  and  strong,  skin  warm  and 
soft,  left  cheek  flushed  darkly,  tongue  dry  and  moist  by  turns,  pale,  clean  at  the  tip  and  thickly  coated  whitish- 
gray  at  the  base;  he  had  no  appetite  but  Tunch  thirst,  acute  epigastric  and  right  iliac  tenderness,  tj-mpanites,  but 
no  diarrhiea;  resjiiration  was  normal,  but  the  breath  was  very  oft'ensive;  there  was  also  some  pain  in  urinating. 
Brandy-i)unch  and  beef-essence  were  given  with  quinine,  calomel  and  opium  tlnee  times  daily.  A  few  rose-colored 
Bjiots  appeared  next  day.  On  the  4th  the  skin  was  dry,  warm  and  somewhat  jaundiced ;  the  tongue  red  at  tlie  tii> 
and  edges,  pale  and  coated  white  iir  the  centre  and  at  the  base,  the  bowels  meanwhile  remaining  tympanitic  and 
tender  but  unmoved.  He  slept  well  during  the  night,  and  on  the  5tli  his  mind  was  clear  and  eyes  intelligent,  skin 
dry,  tongue  moist,  pale  and  slightly  coated  in  the  centre,  breath  free  from  all  oft'ensive  odor.  On  the  6th  a  few  more 
rose-colored  spots  appeared,  but  the  liowcls  remained  qniet,  and  the  slight  tenderness  ])resent  was  in  the  epigastric 
region;  the  abdomen  was  soft.  He  liad  two  stools  on  the  7th.  Turpentine  was  administered.  On  the  8th  the  skin 
was  warm  and  soft  and  presented  a  few  dark-nnl  spots  which  were  imperceptible  to  the  touch  and  disappeared  on 
pressure;  pulse  56,  small  au<l  compressible;  tongue  moist  and  thickly  coated  in  the  centre.  At  this  time  lie  did  not 
sleep  well  and  his  appetite  continued  poor.  Here  the  record  leaves  him,  concluding  with  a  statement  of  his  transfer 
to  Annapolis,  Md.,  on  the  18th. 

Case  101. — Ileeurring  chills;  ccrehral  ni/inploms  slightly  marked;  gastric  irritahility;  diarrhira  and  aldominal  tender- 
ness.— Private  Frederick  Doser,  Co.  P,  24th  N.  Y.  Vols.;  age  24  ;  had  been  troubled  with  liver  complaint  since  1856, 
and  about  Sept.  16,  1861,  was  taken  with  intermittent  fever,  which  persisted  notwithstanding  the  use  of  ([uinine 
and  opium.  He  was  admitted  on  the  30th  as  a  case  of  typhoid  fever.  His  eyes  were  dull,  jnilse  96,  skin  natural, 
tongue  moist  hut  furred  white;  he  had  pain  in  the  hones  and  anorexia,  cough  and  pain  in  the  chest,  three  stools 
daily  with  tympanites,  iliac  tenderness  and  some  gurgling.  Opium,  antimony  and  blue-mass  in  small  doses  were 
given  every  three  hours.  Next  day  tlie  pulse  was  112,  skin  somewhat  hot,  eyes  injected  and  suffused,  tongue  moist, 
furred  in  the  centre  and  red  at  the  edges,  bowels  much  meteoHzed  and  tender  at  the  umbilicus.  Quinine  was  given 
with  turpentine  emulsion  in  place  of  the  mercurial.  The  quinine  was  continued  on  the  2d  and  tincture  of  iron 
ordered  on  the  3d,  the  pulse  having  meanwhile  fallen  to  85,  the  tongue  become  cleaner  and  the  appetite  improved. 
A  diarrhft'a  of  four  stools  daily  set  in  on  the  4tli,  followed  on  the  5th  by  epigastric  pain,  intestinal  gurgling,  tender- 
ness in  the  right  iliac  region  and  in  the  course  of  the  transverse  colon,  and  on  the  6th  by  loss  of  appetite  and 
irritability  of  the  stomach.  Seven  stools  were  passed  on  the  9th  and  three  on  the  10th,  after  which  the  attack  grad- 
ually declined;  during  tliis  time  there  was  some  head-pain  with  dizziness  and  tinnitus  aurium,  and  the  tongue 
remaining  red  at  the  tip  and  edges  becaiue  covered  elsewhere  with  yellowish  patches.  Conjunctivitis,  which  appeared 
on  the  11th,  was  treated  with  a  zinc  wasli.  On  the  14th  the  pulse  was  56  and  regular,  the  skin  natural,  the  tongue 
moist  and  clean  and  the  ajipetite  good.     The  patient  was  transferred  to  Annajiolis,  Md.,  November  1. 

Cawk  102. — liecurring  chills  and  diarrhoea;  perspirations;  nothing  but  rose-spots  on  the  I'Mh  day  as  specially  char- 
acteristic of  typhoid  fever. — Private  A.  Stoughton,  Co.  C,  5th  Vt.  Vols.;  age  18;  was  admitted  Nov.  1,  1861,  as  a  case 
of  typhoid  fever.  On  October  23  tlui  patient  had  chills  which  recurred  for  several  days,  fever,  general  pains,  weak- 
ness, anorexia  and  diarrluea.  On  November  2  his  eyes  were  bright,  countenance  calm,  pulse  88  and  of  fair  strength, 
skin  warm  and  perspiring,  tongue  clean  at  tip,  moist  and  sliglitly  coated  at  the  base  and  in  the  centre,  lips  and 
teeth  clean,  aiipetite  fair,  al)d(Mueu  soft  and  res])iration  normal;  one  stool  was  passed  in  the  twenty-four  hours.  A 
full  dose  of  quinine  was  given  three  times  daily.     On  the  3d  he  was  reported  as  having  slept  well;  pulse  84,  appetite 


THK    CDXTIM'KIi     KKVKI;S. 


213 


good,  skin  natural,  tiingue  cleaning;  iwo  stools  wi-iv  (lasst-d.  dn  llic  following  (lay,  withont  any  otlici'  i-hangc  in 
the  syniiitonis,  rose-colored  spots  appeared  on  the  chest  and  alidonien:  he  had  one  stixd  on  this  day.  and  alter  this 
his  liowels  were  rejiorted  as  regular.     He  was  returned  to  duty  on  the  11th. 

C'.vsK  lOi^. — Jicvitn-'nnj  chitlx  :  didrrhn  til  tunlt  in-i/ :  imtttal  tlnhnss:  i-osi -spiit.s  <ni  \illt  (lint,  iiinitnliiiti  hf  I'ltlloirnl  hi/ 
conrdlrxcrucr, — Private  Samuel  liis.sinette.  Co.  A.  4th  Mieli.;  age  '2'J:  was  seized  alioul  Sept.  !•,  IStil,  with  daily  cliills 
aceonipanied  by  headache,  pain  in  the  hack  and  legs,  anorexia  anil  eostiveness.  He  was  adniitteil  »ii  the  Itlth. 
Diagnosis — typhoid  fever.  In  the  evening  the  patient  was  weak  and  had  no  ai)pi>tite :  the  jiiilse  was  XO;  skin  hot 
and  moist;  tougtie  coated  white,  hut  red  at  the  ti|i  and  edges:  one  stool  was  )iasscd  :  the  right  iliac  region  was  ten- 
der, and  com])laint  was  made  of  pain  in  the  hack  and  legs.  Ten  grains  of  calomel  and  .iahi)!  were  given.  Kight 
dejections  occurred  during  the  night,  and  next  morning  the  skin  and  eyi's  w  cic  Jaundiced,  t^ninine  was  given.  In 
tlie  evening  the  pulse  was  74,  the  skin  warm  and  moist,  thc^  tongue  inaled  gray  hut  red  at  the  tiji,  the  liowels  (piiet  : 
there  was  acute  right  iliac  tenderness  and  mental  dnlness  with  tinnitus  aurium.  Xcxt  day  the  howcls  remained 
quiet  and  the  tenderness  ceased;  but  pain  in  th<'  head  and  in  the  back  was  noted.  The  abd(uinnal  teinlerness 
returned  on  the  lUth,  when,  also,  the  tongue  was  nearly  clean  but  dry,  the  (dieeks  Hushed  and  th<>  i)ain  in  the  back 
so  acute  a.s  to  veiiuire  sinapisms.  The  bowels  were  i|uiet  on  the  20lh  and  without  pain  or  tympanites:  the  tongue 
coated  gray;  the  skin  moist,  iwo  stools  were  passed  on  th<'  121st:  Ihi'  tongni^  was  white,  the  skin  hot  an<l  dry,  and 
tliere  was  some  thirst  and  eongh,  Imt  the  ajipetiti'  was  good.  A  few  lose-spots  appeared  on  the  22d,  the  tongue 
being  pale  and  moist,  the  pulse  SO.  In  the  evening  of  Ibis  day  he  was  dull;  ))ulse  til.  lie  ))er8])ire(l  during  the 
niglit,  and  next  day  the  skin  was  warm  and  moist,  th<^  tongue  |>ale  anil  clean  and  there  was  no  tenderness,  tympa- 
nites nor  eruption.  A  few  dark  spots  were  found  next  day  on  the  iibdomen  and  chest.  Aftiu'  this  im|)rovenient  was 
steady.     The  ]iatient  was  walking  about  on  the  2ilth,  and  was  transferred  to  Annapolis,  Mil.,  October  1. 

Case  104. — Iiiriirrhiij  chillx  iitul  fmr:  diarrh<ni ;  nJiijht  ihlirhnii  ;  i/rciit  iirofitratioii :  rihlnn  mid  ijiniiinnc  uf  IiHh- 
tirrd  siiyfiirrs :  diiitli. — See  case  of  I'rivate  Daniel  Pliimmer,  Co.  II,  :i:id  I'a.,  No.  !IH  of  the  piiM-mnrtfin  records. 

ElOIlT   TyI'IKIIIi    1"K\  KH   ("aSE.S    I'UECEDEEl    OK    AC:COM  I'ANMEl)    HV    KEMIItK.M'    Fk.VEH. 

Case  10.">. — Hmn-d  (/inn  in  full.  'I'lir  uinliiiii  iiiiiliiriiil  iilliick  iijipniyii  lo  liiivc  ended  on  (letiiher  7,  whin  the  puhtc  had 
fullen  to  HO  (in d  the  iikin  and  tonyue  were  in  nulnral  conditimi,  leiivini/  thepdiient,  hitwerer,  icithii  diiirrhie<i,i<ni/</eKtinii  «  innijeKted 
and  perhaps  ulcerated  condition  of  the  fto«'c?.i,  and  some  pulmonari/  enijorijement.  The  typhoid  fever  in  unmarked  by  prominent 
symptoms;  its  influence,  other  than  in  the  appearance  of  the  rose-colored  spots,  seems  only  to  hare  prolonged  the  period  needful  lo 
a  return  to  health.  It  is  noticeable  that  on  October  16,  irhile  the  rose-spots  ivere  yet  fadin(j,  the  patient  was  permitted  to  he  out 
on  iiass. — Corporal  Cliristojjher  licninger,  ("o.  I),  M  Midi.;  age  2(i;  had  been  liable  to  attacks  of  intermittent  fever 
since  1S,")X.  He  was  admitted  Se))t.  '2H,  18(il,  as  a  case  of  ty])hoiil  fever.  Ho  li;id  been  taken  sick  three  days  before 
w  itii  chills,  fever  and  pain  in  the  back,  and  had  taken  quinia;  face  Hushed,  eyes  dull,  lids  dropped;  jiulse  101,  small, 
easily  conipicssed  ;  skin  moist,  slightly  above  natural  temperature;  tongue  moist,  slightly  eoateil  white;  anorexia 
and  irrital)ility  of  stomach  manifested  by  unsucceHsfnl  efforts  at  vomiting;  tenderness  over  entire  abdomen,  slight 
tympanites  in  right  iliac  region,  no  stool;  dull,  heavy  head-pain;  nervous  tvvitchiiif.'8  of  iiinscles;  no  cough  but 
respiration  hurried,  30  per  minute.  During  the  examination  a  violent  chill  came  on;  the  extremities  became  cold, 
the  pulse  small  and  at  times  imperceptible  at  the  wrist,  the  cheeks  cold,  tlie  breathing  hurried  and  inti-rrupted,  tlie 
eyes  turned  njiward;  some  stu])or  was  also  noted.  Quinia,  opium  and  calomel  were  ordered  to  be  given  every  four 
hours.  liOth,  morning:  Slept  some;  face  congested;  eyes  suffused;  pulse  120,  quick,  feeble;  some  pain  in  head  and 
limbs:  some  deafnetis  and  stupor;  skin  of  natuial  tein]Muature ;  tongue  dry,  brown,  imiist  at  edges;  anorexia; 
epigastric  and  general  abdominal  tenderness;  tympanites;  derangement  of  liver;  no  cough.  Milk-punch.  beef-essiMiee 
and  blue-mass  and  opium  were  ordered.  Mreniny:  Feeling  better ;  faceiiushed;  eyes  suffused  ;  lieaddull  and  heavy; 
pulse  120,  full  and  strong ;  skin  moist ;  tongue  moist  at  edges,  brown  tmd  dry  in  centre ;  anorexia ;  slight  tenderness 
in  abdomen,  particularly  in  right  iliac  region;  some  tympanites  and  liorborygmus;  no  stool;  no  cough.  Dover's 
powder  was  given.  30tli,  hioini'hi/;  Slept  well;  cheeks  congested  ;  eyesdiill;  head-pain;  pulse  112,  quick,  small ;  skin 
Lot  and  moist;  tongue  moist  at  edges,  dry  in  the  centre;  anorexia;  tympanites;  slight  tenderness  in  right  iliac 
region,  marked  in  left;  much  soreness  in  right  liypochoiidriac  region;  two  stools.  Ordered  three  grains  of  calomel, 
one  of  opium  and  one-sixth  of  a  grain  of  antimony  every  three  hours.  Evening:  Drowsy;  face  congested;  eyes  dull; 
head-pain;  pulse  112,  strong;  skin  above  the  natural  temperature,  covered  with  perspiration;  tongue  slightly  moist 
at  tip  and  edges,  dry  and  brownish  in  centre;  four  stools;  slight  tympanites;  tenderness  in  left  iliac  region.  Ordered 
astringents.  October  1,  morning:  Head-pain;  pulse  112,  quick,  strong;  skin  moist,  slightly  above  the  natural  tem- 
jterature;  tongue  moist  at  edges,  dry  and  white  in  centre;  appetite  small;  several  stools;  some  cough;  pain  in  right 
lung;  respiration  30.  Ordered  beef-essence  and  astringents.  Evening:  Ordered  one  grain  of  ([uinia  and  two  grains 
of  Dover's  powder  every  three  hours.  2d:  Slept  some;  face  congested ;  eyes  dull;  slight  head-pain  ;  pulse  10"),  quick 
and  strong;  skin  hot  and  moist;  tongue  moist,  coated  white  in  patches  iu  centre;  some  appetite:  sliglit  tenderness; 
no  tympanites;  paroxysms  of  coughing;  mucous  expectoration  streaked  with  blood;  respiratory  murmur  in  lower 
lobes  of  right  lung  entirely  lost.  Veratrum  viride  and  sweet  spirit  of  nitre  were  ordered  to  be  taken  every  hour. 
3d:  Slept  some;  head-pain  and  slight  delirium;  pulse  112,  quick,  strong;  skin  somewhat  hot;  tongue  moist,  clean 
but  for  a  few  yellowish  patches  in  centre;  some  appetite;  two  stools;  much  cough;  viscid  mucous  expectoration 
streaked  with  blood;  respiration  35;  resi)iratory  murmur  absent  over  lower  part  of  right  side;  some  dnlness  on  per- 
cussion on  both  sides.  4th:  Slept  but  little  ;  some  head-pain  ;  pulse  108,  strong;  skin  hot;  tongue  moist,  covered  with 
yellowish  patches  in  centre;  vomiting;  anorexia;  three  stooLs;  some  cough;  mucous  expectoration  streaked  witk 
blood;  respiration  30  l)ut  deeper ;  dnlness  decreased  in  left  lung,  increased  in  right.  Fifteen  drops  of  veratrum  viride 
were  given  during  the  day.     5th:  Slept  well;  pnlseHf),  full;  skin  soft  but  rather  warm  ;  tongue  moist,  slightly  coated  in 


2M  CLTXri'AT,    RFCORPS    OF 

centre  wit  li  yellowisli  prttclios;  sonio  nppotitc :  tlirco  stools:  Imt  little  oxppntoratioii ;  respiration  21).  Milk-punch 
and  Dover's  powder  were  f^iven.  (ith:  iSleptwell;  lieiid-|iiiin ;  pulse  IK),  lull;  skin  of  niitnrul  temperature,  covered 
Nliglitly  with  )>ers]iirati(iu ;  tcuiiiue  moist,  coated  white  in  centre:  appetite  K<"><1 1  some  tymiiauites;  right  iliac  ten- 
derness: two  stoids:  sli^;ht  cough  and  expectoration;  respiration  25.  7th:  .Sle)it  well;  looking  better:  pulse  8(1, 
natural;  skin  and  tongiu;  natural :  two  stools;  slight  cough  ;  rcsi)iration  2."i:  rcsjiiratory  murmur  absent  on  b-ft  side 
below  third  rib.  Sth:  Not  so  well;  countenance  and  skin  natural;  pulse  MO,  (|iiick:  tongni'  moist  and  clean;  apjietite 
good;  three  stools;  some  cough:  slight  expectoration  of  mucus  slightly  tinged  with  Idood;  I'espiratiou  35;  some 
cre.jiitation  and  absence  of  respiratory  murmur  on  left  side,  lower  portion  ;  mucous  rah>s  in  middle  lobe  of  right  lung, 
vesicular  murmur  in  upiier  portion,  tlth:  Slept  well:  pulse  XO,  weak;  skin  natural;  ajipetite  improving;  two  stools; 
respiration  '26.  10th:  Restless;  eyes  nu)re  natural,  checks  less  congested;  i)ulse  W,  quick;  skiu  natural;  tongue 
moist,  clean;  appetite  moderate:  cougii  slight:  two  stools.  Tincture  of  iron  ordered  three  times  daily.  11th: 
Stronger;  slept  some;  eyes  bright :  face  sliglitly  tlushed:  pulse  85,  (|uick:  skin  natural  ;  tongue  moist,  clean;  ai)i)etite 
good;  three  stools:  cougli  slight.  12th:  Slei)t  well :  looking  better;  cheeks  congested  ;  pulse  90,  strong,  wiry ;  skin 
of  natural  temperature,  au  occasional  rose-s])ot  appearing;  tongue  moist,  clean;  slight  tenderness  in  right  iliac 
region;  two  sto'ils;  no  cough.  i:itli:  Slept  well:  looking  bright;  pulse  90,  quick;  skin  a  little  above  the  natural 
temperature;  slight  jiain  in  right  lung;  tongue  moist  and  clean;  appetite  good;  six  stools:  no  cough,  lltb;  Slept 
well;  looking  bright;  pulse  110,  iiuick,  corded:  skiu  of  natural  temperature,  an  occasional  rose-spot  appearing; 
tongue  slightly  coated  yellowish  in  centre;  appetite  moderate;  three  stools;  moderate  tenderness  in  right  umbilical 
and  left  iliac  regions.  15th:  Slept  some;  ])nlse  80,  regular,  corded;  skin  of  natural  temperature,  showing  a  few  rose- 
spots,  disappearing  on  i)ressure;  tongue  moist,  coated  yellowish-white  in  centre:  appetite  good;  three  stools;  some 
umbilical  tenderness;  some  pain  in  middle  of  right  side  on  deep  inspiration.  16th:  Out  on  pass.  17th:  Slept  wfell; 
pul.se  85,  quick;  skin  of  natural  temperatui'e:  tongue  moist,  coated  slightly  white  in  centre  ;  appetite  moderate;  two 
stools.  18th:  Wakeful;  pulse  80,  somewhat  irregular;  skiu  covered  witli  perspiration;  slight  headache;  tongue 
moist,  clean;  appetite  poor;  two  stools;  some  epigastric  pain  and  tenderness.  19th:  Slept  well;  pulse  02,  regular; 
skin  natural;  tongue  moist,  clean;  ajipetite  moderate;  three  stools;  pain  on  deep  inspiration.  20th:  Slept  well; 
pulse  86,  regular:  skin  and  tongue  natural  ;  ajipetite  good;  two  stools.  2lst;  Slept  well;  pulse  90,  quick;  skiu  and 
tongue  natural;  buzzing  in  cars;  a])petite  good;  two  stools.  22d:  Slept  well:  bright;  pulse  90,  somewhat  (juick; 
tongue  clean;  appetite  good;  two  stools;  some  abdominal  tenderness.  2iid:  Sleptwell;  pulse  90,  natural ;  still  some 
pain  in  right  side  of  cliest.  24th:  Wakeful;  pulse  90,  (juick;  skin  moist;  tongue  white;  appetite  moderate;  two 
stools;  less  tenderness.  25th:  Sleptwell;  pulse  90,  quick;  skiu  natural;  tongue  clean  ;  appetite  good;  two  stools; 
some  general  tenderness.     26th:  Keturned  to  duty. 

Case  106. — Hemiltent  fever  not  nmenahle  to  treatment  iy  quinine;  record  deficient,  hut  typhoid  fever  suggested  hy 
diarrhoea,  tenderness  in  the  right  iliac  region,  lirown  tongue  and  suhsequent  discharge  for  delnlily. — Private  James  Ellison, 
Co.  F,  19th  Ind.;  age  24.  This  num  contracted  tertian  ague  about  Aug.  20,  1861.  The  chills  were  liroken  up  by 
quiuia.  He  was  admitted  September  4  as  a  case  of  typhoid  fever.  On  the  morning  of  the  5tb  the  fever  was  slight,  the 
pulse  72,  skin  natural,  tongue  flabby  and  coated  yellowish-brown,  appetite  good,  bowels  somewhat  relaxed  and 
tender  on  pressure.  (Quiuia  was  ordered.  In  the  evening  there  was  a  moderate  fever  with  tiushed  face,  hurried 
respiration,  liot  and  dry  .skin  and  a  burning  iu  the  mouth  and  throat;  the  bowels  were  moved  twice  during  the  day. 
Dover's  powder  was  given.  He  rested  well  during  the  night,  and  next  morning  was  sweating  and  without  fever; 
but  iu  the  evening  the  skin  became  hot  and  dry,  the  tongue  pale,  drj-  and  slightly  coated,  and  seven  loose  stools 
had  been  passed  accompanied  with  umbilical  i)ain.  A  similar  remission  and  exacerbation  occurred  on  the'  7th,  the 
dejections  on  this  day  being  thin,  small  and  lumpy.  The  remission  on  the  morning  of  the  8th  wa8  not  so  well  nuirked, 
although  the  bowels  had  not  been  distuilicd  during  the  night;  the  min<i  was  clear.  On  the  9th,  in  the  nu)rning,  the 
face  was  Hushed,  the  pulse  6H,  the  tongue  pale,  tlabliy  and  coated  in  the  centre  and  at  the  back,  the  skin  warm  and 
drj';  one  thin  stool  had  been  passed  without  pain  but  with  borborygmi.  In  the  evening  the  pulse  was  86,  the  skin 
warm  and  dry,  the  tongue  pale  and  coated  brown  in  the  middle;  there  were  no  rose-spots;  three  thin  small  stools  had 
been  passed  without  pain;  the  apiietite  was  improving.  Dover's  powder  with  small  doses  of  blue-pill  and  citrate 
of  iron  and  (luinine  were  ordered.  The  10th  gave  a  similar  record,  but  in  the  evening  the  tongue  was  dry  and  coated 
brownish,  and  in  connection  with  four  thin  small  stools  passed  during  the  day,  it  is  stated  that  there  was  some  light 
iliac  tenderness.  The  blue-pill  and  iron  were  omitted  and  the  Dover's  powder  and  (|uinine  continued.  On  the 
11th  an  acetate  of  lead  and  opium  pill  was  given  three  times,  but  the  diarrluea  continued  with  slight  fever  in  the 
evening,  and  a  moist  tongue,  coated  brown  in  the  centre,  up  to  the  13th,  when  he  was  transferred  to  hospital  at 
Baltimore,  Md.     [He  was  discharged  October  15  on  account  of  general  debility.] 

Case  107. — Recurring  chills;  diarrhaa;  rose-colored  spots;  gastric  irritability;  improvement  about  end  of  ith  week. — 
Private  R.  M.  Robinson,  Co.  C,  9th  Pa.  Vols.;  age  19;  was  admitted  Sept.  19,  1861,  with  typhoid  fever.  About  three 
weeks  before  his  admission  he  bad  been  taken  with  chills  and  pain  in  the  head  and  bones;  the  former  recurred  at 
intervals  of  several  days  with  fever  at  night  and  continued  diarrluea.  On  the  evening  of  the  19th  the  patient  was 
weak  but  looked  well:  pulse  78,  eyes  bright  and  clear,  skin  warm  l>nt  dry  and  covered  on  the  abdomen  and  (diest 
with  characteristic  ro.se-sp<its,  tongue  dry,  smooth,  glossy  and  nearly  clean:  liut  he  had  pains  in  the  head,  l)ack  and 
limbs  and  in  the  hypogastric  and  right  iliac  regions,  with  distended  bladder  and  dysuria.  Castor  oil,  acetate  of 
potash  and  sweet  spirit  of  nitre  were  given.  He  slept  badly  and  had  epistaxis  at  night.  Next  day  the  pain  in  the 
back  and  limbs  was  severe;  the  skin  was  dry  and  warm,  the  tongue  dry,  cracked  and  yellowish-brown  in  color,  the 
stomach  slightly  irritable,  the  bowels  tender;  one  stool  was  passed.  On  the  23d  a  second  crop  of  rose-colored  spots 
appeared  on  the  surface;  the  bowels  were  quiet  aiul  the  tenderness  much  relieved.  The  tongue  became  clean  on 
the  25th,  On  the  30th  the  i)atieiit  was  considered  convalescent.  He  was  transferred  to  Annapolis,  Md.,  November  1 
[and  was  returned  to  duty  December  12]. 


TIIK   coNriNTKli    KK\'i:i;s.  _  I'') 

Cask  lOS. — MHd  iijlihiiid  ijruflid  mi  i-nnilli  nl  /,  n  r.—  Vv'w.iU-  It.  1>.  La.ssi-y.  ('(j.  A,  llli  Mii-li.;  ;i;;i-  L'S:  was  scizctl 
with  lieadaclic,  weakness  anil  nausea  aliout  Sept.  li.  1M>1.  and  (in  tin-  lUlh  was  ailiiiilled  as  a  rase  nf  Ivplioiil  I'ever. 
In  the  eveiiinj;  tlie  patient's  t'aee  was  lliished  and  lie  had  nausea  and  loss  cif  ajipetite.  pnlsi'  III',  skin  wanii  anil 
moist,  tongue  moist,  yellowish  ami  heavily  coatecl,  howels  i|iiiet .  Ten  iriains  eaidi  (<(  eahnmd  and  .jalap  were  jjiv  en ; 
two  dejections  followed,  ami  next  morninj;  the  tonnne  was  eleanei  at  the  tip  an<l  ed^cs.  (Quinine  was  ordered. 
In  the  eveniiij;  there  was  no  fever,  the  skin  was  eool,  nndst  iiml  jieispiriiii;  :  one  stoid  was  jiassi'd  diniu!;  the  ilay, 
and  there  was  tenderness  in  the  rij;ht  iliae  region.  On  the  inornin;;  id'  the  ISth  there  was  no  fever,  the  skin  l>ein>; 
eool  and  moist,  and  the  ahdomimil  tendenu'ss  relieved:  Iml  in  tin-  eveniiif;  the  ])atient  had  one  thin,  lar^e  stool, 
and  the  rijjlit  iliae  region  lieeame  aentely  tender.  Domm's  powder  was  preserilied.  On  the  liHli  there  was  tympa- 
nites and  the  iliac  re<;ion  eontinned  tender,  lint  the  skin  remained  cool  and  moist  and  thi'  luiwids  ipiiid.  1  lie  con- 
dition of  the  )iafieiit  was  chaii<;ed  on  the  L'Olh  only  liy  the  diininntion  of  the  tympanites;  one  stool  was  |iassed 
during  the  day.  <  >n  the  L'lst  there  was  deafness  with  anxiety  «(  expression:  theic  was  also  some  thirst,  hut  the 
ai)petite  was  good  and  skin  iiiittiral.  The  tongue  wtis  clean  on  the  L'L'il,  the  jmlse  (iS,  small  and  soft ,  the  skin  natural, 
the  bowels  (|uiet  and  neither  tender  nor  tymjianitic,  hut  the  face  wtis  somewhat  llushed.  In  the  evening  rose-spots 
made  their  a])iiearauce,  and  a  second  crop  on  the  iMtli.  Wiin-  and  bark  were  ordereil,  lie  was  reporte<l  as  walking 
about  on  the  liOtli,  and  was  transferred  to  Annaiuilis,  M<1.,  October  1. 

Case  Kli). — Mild  liijilioiil  iii-Kftid  on  rimitlcnl  f<i-<r. — I'rivate  I'.li  Snlgrave,  Co.  1),  lilth  Ind.:  age  1«:  had  a 
chill  about  Aug.  25,  1861,  ami  was  admitted  Sei)tember  1.  Diagnosis — typhoid  fiver,  lie  had  hi'adaehe,  pain  in 
the  bones  and  back,  and  slight  diarrhu'a  with  fever,  which  was  aggravated  daily  about  noon.  On  the  nuirning  of 
the  5tli  there  was  tinnitus  tiuriniu  but  no  fever;  the  jiul.si'  was  7S,  skin  <-old  and  moist,  tongue  coate<l.  jiale  and 
liabby,  iip])etite  good,  bowids  regular.  Quinine  was  ordered.  In  the  evening  thi^  (inlse  was  72  and  strong,  tongue 
pale,  flabby,  red  at  the  (r<lges  ami  white  at  the  base  and  ceuti'e.  During  the  ilay  he  had  one  thin  stool  and  was 
weak  aiul  giddy.  Dover's  ])owder  was  given  at  night.  I'litil  tlu!  lllh  the  patient  eontinueil  without  change,  ii 
slight  febrile  action  occurring  every  evening,  manifesting  itself  in  Hushing  of  the  face,  but  the  pulse  in  no  instance 
rose  higher  than  80;  there  was  one  stool  daily,  with,  on  one  occasion,  pain  in  the  left  iliac  fossa,  lie  usually 
rested  well  and  had  a  fair  tipjietite,  although  his  tongue  continued  pale,  lliibby  and  coated.  On  the  11th  a  few 
rose-spots  appeared,  which  faded  next  day.  but  weic  rc|ilaeed  by  others  and  an  eruption  of  sudiimimi;  the  pulse  was 
()8,  the  skin  eool,  bowels  (|niet  and  not  tender,  tongue  coated  brownish  but  red  tit  the  tiji.  On  the  Kith  he  was 
sent  to  hospital  at  Haltimore,  Md.  [He  was  afterward  transferred  to  the  2()th  Ind.  and  served  until  the  close  of 
the  war.] 

Case  WO.—MUd  tiipluiid  (jroflid  on  nmiltnil  J't'vcr. — I'livate  K.  S.  Klmer,  Co.  K,  11th  N.  Y.;  age  22;  was  admitted 
Sept.  24,  1861,  having  been  ttikeii  sick  three  weeks  before  with  diarrhira  foUowtMl  by  bilious  remittent  fever.  On 
admission  he  had  severe  headache  with  Hushed  face,  injected  eyes  and  accelerate<l  jmlse.  Hi-  slcjit  little  during  the 
following  night ;  in  the  imi ruing  he  was  covered  with  sweat,  |)ulse  108,  full  but  w(^ak,  tongue  slightly  yellow,  bowids 
moved  once,  respiration  natural:  his  ap])etite  was  good,  htit  he  had  much  thirst  and  was  somewhat  iliz/y.  Two 
grains  of  blue-mass  ami  a  half  grain  of  (]uiiiino  were  ordered  to  be  given  every  two  hours.  On  the  2()th  he  was 
not  so  well;  his  face  was  Hushed,  eyes  much  suffused  and  countenance  anxious;  the  dizziness  was  increased 
and  there  was  delirium:  the  tongue  was  heavily  coated  yellow  and  the  appetite  lost;  there  was  also  retention  of 
nrine,  but  the  skin  was  moist  and  profusely  covered  with  sudainina:  there  had  been  but  one  stool,  ami  the  iiatient 
had  no  pain  nor  tenderness.  Ciistor  oil  and  extract  of  buchn  were  ordered.  In  the  evening  the  skin  was  hot  but 
bathed  in  perspiration,  the  pulse  it(3,  strong,  the  tongue  coat(^d  tind  nudst,  the  bowels  tender  ami  slightly  tympa- 
nitic. On  the  27tli  the  face  was  not  Hushed;  the  skin  was  soft  and  mitiiral,  the  rcs|iir;ition  m)rmal,  the  tongue 
moist,  yellow  in  the  centre,  and  the  apjietite  good ;  two  stools  were  passed  and  there  w  as  some  right  iliac  temlerness  ; 
ii  few  rose-colored  spots  appeared  on  the  jilidomen.  One  draidim  of  turiientim^  emulsion  was  given  every  three 
hours,  with  twelve  grains  of  (|uiiiine  in  the  forenoon.  In  the  (evening  the  cheeks  were  flushed,  the  eyes  suffused, 
the  pulse  96,  the  skin  dry  and  hot,  the  tongue  moist  and  heavily  coated  gray,  the  appetite  good;  two  stools  were 
passed  and  tympanites,  borboryginus  and  tendernes.s  were  i)resent.  Sweet  si)irit  of  nitre  and  Dover's  powder  were 
given.  No  stool  was  pasised  on  the  28th:  the  skin  was  natural,  jiulse  02,  strong,  the  tongue  moist  and  yellow,  the 
appetite  moderate;  there  was  some  difficulty  in  micturition  but  m)  abdominal  pain  nor  tenderness.  In  the  evening 
four  or  five  rose-colored  spots  ai)peared  on  the  abdomen  and  chest.  Next  day  the  skin  was  soft  but  rather  al)Ove 
the  natural  tein]ierature,  the  tongue  moist  and  yellow -coated  but  red  at  the  lip  ami  edges:  there  were  twelve  dull 
red  8])ot8  on  the  abdomen,  which  was  slightly  tym]ianitic  but  not  tender.  He  vomited  during  the  following  night 
and  had  three  stools  with  some  tympanites  and  left  iliae  tenderness.  Lead,  opium  and  tannin  were  given.  Slight 
relaxation  of  the  bowels  continued  up  to  October  10,  when  the  patient  was  sent  to  hospital  at  Annapolis,  Md. 

Case  111. — Chill;  rnnittitKj  fever ;  slight  didrrhna  :  moixt  Hkiii :  Jlohhi/ loiu/iir ;  roM-xpntx  on  I'lth  diKj ;  drousiness; 
perspiraliovn ;  nordes :  reeord  imperfect;  death. — I'rivate  Henry  Martindale,  Co.  F,  lilth  Ind.  Vols.;  age  24;  was  taken 
Aug.  28,  1861,  with  headache,  i>ain8  in  the  bones,  languor  and  chill.  He  took  ([uinia  and  had  no  recurrence  of  the 
chill :  but  the  fever  which  followed  was  generally  worse  in  the  morning.  He  was  admitted  September  4.  Diagnoses — 
typhoid  fever.  On  the  .5th:  Pul,se76;  skin  warm  and  moist ;  tongue  heavily  coated,  ]iale  and  flabby:  slight  diarrluea; 
pain  in  the  back.  Quinine  was  given.  Ereniny:  Skin  warm,  dry;  tongue  flabby  and  coated  white  ;  four  thin  small 
stools,  but  no  pain  or  tenderness  in  the  bowels;  appetite  fair.  Dover's  powder  at  night.  On  the  6th  and  7th  the 
symptoms  were  unchanged.  On  the  8th  the  mind  was  somewhat  dull ;  the  patient  continued  to  be  up  and  to  walk 
about  occasionally.  Sugar  of  lead  and  opium  were  given.  No  nniterial  change  took  place  until  the  11th,  when 
the  warm  and  moist  skin  showed  sudamina  and  some  ro.se-colored  spots  on  the  abdomen,  the  tongue  at  this  time 
being  pale,  flabby  and  coated  gray,  the  bowels  but  slightly  relaxed  and  the  appetite  good.     Whiskey-punch  was 


246 


CLINlCAi.    Kl'X/OJUXS    OF 


prescribed.  The  patient  was  drowsy  on  tlm  12tli,  and  on  the  followinjj  day  the  tongue  became  1)rown  and  cracked 
but  reinain(Hl  paUs  at  tlie  tip,  tlie  skin  hot  and  dry,  tlie  breathing  liurricd,  and  tlie  bowels  moved  eiglit  times  Init 
free  from  pain  and  distention.  On  tlie  Mth  the  tongue  was  dry  and  the  coiiiitenanee  haggard.  Two  grains  of 
ijninine  and  one  of  cahimel  were  incscribed  for  administration  three  times  daily,  rrofuse  )iers]>iratious  occurred  on 
the  l.^th,  but  the  diarrlio'a  continued  and  sordes  api>eared  on  the  teeth.  TMipenline  emulsion  was  given.  On  the 
evening  of  the  16th  there  was  some  ten(U'rness  of  the  al)domen  and  the  patient  kept  tossing  his  head  from  side  to 
side.  On  the  18th  the  pulse  was  XU.  weak  and  small,  tongue  lu'avily  coated,  br.)wn  in  tlii'  middle  and  red  at  tip  aud 
edges,  skin  hot  and  moist,  bowels  not  tencb'r  liut  ([uitci  loose,  especially  at  night.  On  the  liHh  there  was  some 
tenderness  in  the  riglit  iliac  region.  Ten  stools  were  jiassed  on  the  '22d,  and  on  thi;  following  day  the  abdomen  was 
tympanitic.     The  record  closes  abruptly  with  the  announcement  of  death  on  the^Sth. 

C'.vsK  112. — ('oi)icidfiicc  (</  reniitleiit  fevtr  aiid  li/phaid. — .Vrminius  Tyler,  attendant;  age  21;  was  admitted  Sept. 
9,  1861,  having  been  sick  sin<'e  the  1st  with  headache,  i)ain  in  the  Ijack  and  fever,  aggravated  at  night,  but  not  jire- 
ceded  l)y  a  chill.  On  admission  his  face  was  tlushed,  jiulse  Tit,  tongue  white  and  coated,  skin  warm  and  sweating; 
he  had  e))i8ta.\i8  and  a  few  ro.se-colored  spots  on  the  abdomen.  Next  day  the  tongue  was  luoist,  brown-coatcMl  in 
the  centre  and  red  at  the  tip  and  edges;  the  bowels  were  ((uiet  but  tender  on  iiressure.  (,)uinine  was  taken  during 
the  day  and  Dover's  powder  at  night.  On  the  11th  tlu'  patient  was  dull  and  jnostrated,  pulses  (iS  aud  feeble;  but  iu 
the  evening  there  was  much  restlessness  with  high  fever,  pulse  i(0  and  strong.  Next  morning  a  remission  occurred, 
followed  by  an  exacerbation  in  the  evening;  the  tongue  was  jiale,  tlabby  and  coated  brown,  and  the  bowels  con- 
tinued (|uiot.  On  the  13th  the  evening  exacerbation  was  not  so  marked,  but  the  tongue  was  heavily  coated  gray 
and  the  skin  and  conjunctiva'  were  jauiuliced.  Hlue-mass  was  given  in  addition  to  the  <|uinine.  On  the  l.lth  two 
large  stools  were  passed,  and  in  the  evening  three  free,  thin  and  jiainless  stools.  Aromatic  sul|diuric  acul  was 
l)rescribed.  On  the  Ititli  the  pulse  was  (i2,  the  tongue  jiale  and  heavily  coated  gray,  the  bowels  quiet,  the  .jaun- 
dice disappearing;  there  were  rose-colored  spots  and  a  profusion  of  sudamina  on  the  skin,  which  perspirinl  fi'e(dy. 
Kose-C(dored  spots  appeared  again  on  the  18th;  the  bowels  continued  quiet  and  the  evening  accession  beeanus  less 
nianifest;  night-sweats  were  profuse.     On  t)ctober  1  the  patient  had  so  far  recovered  as  lo  be  placed  ou  light  duty. 

Eight  Kemittknt  Fevku  ('a.sks  wnit  .mohk  ok  lk.ss  kvidkxce  ok  iiik  i o-KxisiKxtK  oi-  Tvi'Ikud  Fkx  ku. 

Case  113. — Dvir/nniiix — re  mi  I  tin  I.  DiTtriimi,  uliipor,  (Icufiirxx  ;  diiirrhfrii ;  rosc-co/orci^  kjkiIx  mid  hi'd-idna. — Private 
Bennett  I'epper,  Co.  II,  G2d  N.  Y.;  age  19;  was  taken  sick  early  in  February,  18(i2,  with  headache,  nausea,  vomit- 
ing and  i)ains  in  the  back  and  limbs,  and  was  admitted  on  the  27th  as  a  case  of  remittt^nt  fever.  On  March  5  he 
was  delirious,  drow.sy  and  inclined  to  stupor;  he  had  tinnitus  aurium  and  twitching  of  the  mouth,  puffy  eyelids. 
Hushed  cheeks,  rapid  and  weak  jmlse,  hot  aud  dry  skin,  moist  but  much  coated  tongue,  sordes  ou  the  teeth,  sonio 
appetite,  much  thirst,  a  diarrho'a  of  four  watery  stools  daily,  whicli  were  sonuttimes  passed  involuntarily;  respira- 
tion was  hurried  and  there  was  some  cough.  Beef-essencM^,  turpentine  emulsion  and  tincture  of  oiiium  were  pre- 
scribed. On  the  t)th  there  was  profuse  iierspiration  with  sudamina.  Next  day  the  didirinm  abated  and  the  patient 
replied  rationally  but  with  <litiicnlty ;  the  tongue  was  coated  but  moist,  and  was  permitted  to  remain  protruded 
indefinitely;  the  bowels  wi^re  regular  but  meteoiized  aud  tender  and  tln^  abdonu'U  showed  some  rose-eolorcMl  spots; 
the  breath  was  very  oll'ensive  from  o/iena.  There  was  mnch  tendency  to  stupor  on  the  ittli,  with  occasional  delirium. 
Free  perspiration  with  sudamina  occurred  again  on  the  10th,  and  the  urint^  was  excessive  in  (|uantity;  cough  per- 
sisted and  there  was  some  dulness  on  percussion  a  little  beh)W  tlie  clavicle  on  the  right  side.  The  skin  became 
hot  and  dry  on  the  12th  and  the  watery  stools  retiirni'd  ;  resjiiration  was  hurried  and  the  breath  very  offensive. 
The  mind  liecanie  clear  on  the  lltli.  and  on  the  following  day  thi'  skin  was  natural,  the  tongue  clean,  the  ])ulse 
good,  but  the  bowels  continued  loose.  The  diarrlnea,  however,  sul)si<led  on  the  Itith,  on  the  occurrence  of  copious 
sweating  with  sudamina,  and  the  cough  was  much  relie\ed;  earache,  developed  on  this  day,  was  noted  also  on  the 
17th,  when  the  skin  again  became  hot  and  dry  and  the  tongue  .somewhat  (;oated.  Some  sore  spots  on  the  back 
and  hips  were  ob.served  on  the  18th,  and  next  day  the  ]iatient  was  ida<'ed  on  a  watiu-bed.  lie  became  deaf  at  this 
time,  but  his  general  condition  improved,  and  on  the  28th  he  was  able  to  walk  about.  He  was  discharged  April  26 
because  of  general  debility. 

Cake  114. — Dianiionin — remittent  fever.  Diarrheen  and  ohdomitial  jxiin  ;  deiifness,  delirium  and  proHiriiHon  ;  reeord 
incomplete. — Private  Kdwin  White,  Co.  H,  86th  N.  Y.  Vols.;  age  18;  was  admitted  March  2,  18t)2,  with  remitting 
fever,  headache,  giddiness,  nausea  and  constipation.  The  record  is  silent  as  to  his  condition  until  the  IStli,  when 
he  was  dull  and  dejected  and  talked  much  in  his  sleep,  having  a  hot  and  dry  skin,  a  dry  tongue,  rough  and  coated 
but  clean  and  moist  at  the  edges,  some  pain  in  swallowing,  diarrhoea,  abdominal  pain  and  slight  iliac  tenderness, 
with  headache  and  tlushed  cheeks,  rapid  pulse  and  occasional  epistaxis.  The  fever  increased  towards  evening  and 
was  followed  by  a  chill.  From  the  14th  to  the  18th  he  had  delirium  at  night  but  was  rational  during  the  day;  his 
bowels  were  slightly  relaxed,  the  stools  thin  and  watery,  and  there  was  much  abdominal  tenderness.  Quinine  was 
ordered  on  the  14th,  tincture  of  iron  and  turpentine  ennilsion  on  the  l.">th;  epistaxis  was  noted  on  the  Hith  and 
deafness  on  the  17th.  On  the  18th  delirium  gave  place  to  dulness  and  stupidity,  which  increased  until  on  tlie  21st 
the  patient  was  unable  to  protrude  his  tongue  well  and  swallowed  with  ditiiculty;  there  was  epistaxis;  cough 
became  troublesome  and  the  expectoration  was  tinged  with  blood,  which  was  conceived  to  be  owing  to  the  epis- 
taxis. From  this  time  to  the  3()th,  when  the  daily  record  ends,  there  was  little  change  in  the  symptoms.  The 
patient  was  discharged  for  debility  May  10. 

Case  115. — Symptoms  of  typhoid  in  a  case  entered  as  remittent;  discharged  on  account  of  rheumatism. — Private  L. 
Pettit,  Co.  D,  3d  Mich.  Vols.;  age  22;  of  delicate  constitution  aud  liable  to  pulmonary  troubles,  was  admitted 
Oct.  19,  1861,  as  a  case  of  remittent  fever.     Next  day  his  eyes  were  bright,  cheeks  slightly  flushed,  jiulse  74  and 


THK    CoNTINrKli     FKVKIIS.  -i/ 

regular,  skin  .sdinowhat  abov<'  the  natiual  tcinpiMatuic.  toiijiuc  nmist,  fissuifil  ami  I'aiiuly  cdatnl  vi'Uow,  a]iiM'tit<- 
good;  he  had  a  slight  cough,  pain  in  the  liark  and  linil>s,  iclaxcd  liowcls,  t\  iii|iaMilcs  and  general  alidoiiiinal  tender- 
ness, marked  iu  the  right  iliac  region.  Two  rose-colored  spots  were  discovered  on  the  21st.  the  8Yni])tonis  otherwise 
remaining  as  stated.  Twelve  grains  of  (Hiinine  and  iv.n  of  opium  were  given  daily  in  divided  doses,  with  Dover's 
powder  at  night.  On  the  24th  the  skin  became  nmist.  Next  day  he  w  as  wakef'nl,  his  eyes  dull  and  cheeks  congested. 
Two  drachms  of  sulphate  of  magnesia  ■nith  one-twelfth  of  a  grain  of  tartar  emetic  wi're  gi\en  in  thi'  morning  and 
two  compound  cathartic  ]>ills  at  night.  After  this  he  seemed  to  ini|n'ove.  his  pulse.  ton;;ne  and  skin  lieconiing  natural 
and  appetite  good.  He  Nle])t  well,  and  on  the  2ittli  was  out  of  lied  and  dressed;  hiit  <in  this  day  his  eyes  wore 
bright,  cheeks  somewhat  Hushed,  pulse  80,  and  he  had  pain  in  the  hiji.  knee  and  ankle-joints,  which  continued  until 
his  transfer,  November  1,  to  Annajjolis,  Md.     [Diagnosi.s — rheumatism  :  iiatient  discharged  from  service  on  the  2;ith.] 

Case  llfi. — Didt/iidiiin — rfinUtint.  ll'uirrhim  tnuj  nixi-cdhircil  njiats;  ui>  c(  rihnil  siimiitumx. — Private  OscarH.  Field, 
Co.  C,  21th  X.  Y.  Vols.:  age  30:  was  taken  Sept.  23,  1801,  with  intermittent  ft^ver,  and  admitted  on  the  30th  as  a 
case  of  remittent  fever,  presenting  a  (juiek  strong  ])ulse,  100,  continuous  headache,  a  red  and  slightly  coated  tongue 
and  capricious  appetite.  Dover's  j)Owder  was  given.  The  patient  vomited  during  the  night:  next  day  the  tongue 
was  dry,  red  at  the  edges  and  brown  in  the  centre,  and  the  teeth  covered  with  sordes.  Turpentine  emulsion  was 
given  every  two  hours,  with  small  doses  of  opium,  ipecaciianha  and  nitre.  On  Oc^tober  2  wine  and  cinchona  were 
ordered  in  repeated  doses;  at  night  the  patient  perspired  a  little.  On  the  3d  the  skin  was  of  natural  temperature 
and  presented  some  rose-colored  sjtots,  w  liicli  were  jierceptible  to  the  touch  and  disa))peare<l  on  pressure:  the  bowels, 
which  had  been  quiet  since  admission,  were  on  this  day  nu)vcd  four  times.  lie  rested  well  at  night,  and  on  the  1th 
had  a  natural  skin,  moist  and  slightly  brown  tongue  ami  feeble  jiulse,  00  ytrr  minute;  three  stools  were  passed. 
During  the  following  week  tlie  patient  continued  without  much  change.  On  the  oth  there  was  some  ringing  in  tlie 
left  ear,  with  slight  headache  on  the  following  day;  on  the  lOtli  marked  deafness  witli  tinnitus  aurium.  The  bowels 
were  somewhat  relaxed  at  this  time,  the  pulse  from  80  to  100,  the  skin  natural  and  the  tongue  brownish  and  inclined 
to  be  dry  or,  occasionally,  moist  and  yellow-coated  except  at  the  edges,  which  w  ere  red.  On  tlio  11th  fifteen  grains  of 
quinine,  with  si.x  of  blue-pill  and  two  of  opium,  were  given  in  two  doses  at  an  interval  of  two  hours,  with  four 
grains  of  (luinine  every  two  hours  thereafter.  During  the  night  i)rofnse  sweating  occurred,  and  next  day  there 
was  no  stool.     On  the  14th  the  jtatient  was  transferred  to  Baltimore,  Md. 

Case  117. — Diagnosia — rcmittciil.  Jloncls  Ioohc  and  iympuuitiv;  no  chnracterktk  si/mplomH  of  typhoid. — I'rivate  O. 
Gunderson,  Co.  B,  6th  Wis.  Vols.;  age  19;  was  admitted  Nov.  8,  1861,  having  been  attacked  about  the  1st  with 
chills  and  fever,  headache,  pain  in  the  back  and  limbs  ami  am)rexia.  On  admission  he  was  wakeful  and  suffering 
from  headache,  his  countenance  anxious,  eyes  dull,  cheeks  (lushed,  pulse  100  ami  thread-like,  skin  about  the  natural 
temperature,  tongue  red  and  moist  at  the  tip  and  edges,  dry  an<l  coated  yellow  in  the  centre,  ap|)elite  lost  and 
bowels  loose  and  tj'mpanitic;  ho  had  some  cough  with  whitish  ex))Cctoration.  One  drachm  of  swet't  spirit  of  nitre 
was  given  every  hour.  Small  doses  of  blue-])ill  an<l  opium  were  ]prescribed  on  tlu^  0th  and  rejieated  on  the  10th  and 
11th,  with  twelve  grains  of  (|uiniue  each  day,  and  with  eight  grains  on  the  12th,  on  which  day  heef-essence  and 
emulsion  of  turpentine  were  also  administered.  The  tongue,  however,  renniined  coated  yellowish-white  ami  tlui 
appetite  ])oor  up  to  the  19tli,  when  the  last  notes  were  entered  on  the  record.  The  jiatient  was  transferred  to  Balti- 
more, Md.,  December  3, 

Cask  118. — Bimittent  fifir  followed  hy  typlioid.^Vrixntts  A.  \Vhi])i)le,  Co.  A,  Ith  Mich.  Vols.:  age  lit;  was 
admitted  Oct.  30,  1861,  as  a  case  of  remittent  fever.  On  October  8  he  had  chills  and  fever  w  liicli  continued  a  week, 
Avitli  weakness,  anorexia,  nausea  and  vomiting,  and  during  this  period  lie  felt  better  in  the  morning  tlnm  in  the 
evening.  He  was  treated  with  quinine,  rhubarb  and  capsicum.  On  admission  his  clfceks  were  slightly  Hushed, 
countenance  calm,  eyes  bright,  conjunctiva'  yellow,  inilse  09,  full  and  strong,  skin  yellow,  warm,  dry,  soft  ami  without 
eruption  or  sudamina,  tongue  moist,  red  at  the  ti]i  and  coated  grayish  in  the  centre,  a|)i>etite  deficient:  the  bowels 
were  moved  five  times,  and  there  was  abdominal  tenderness  with  slight  gurgling  but  ni>  nu'teorisni.  Calomel  and 
full  doses  of  (luinine  were  prescribed.  During  the  night  the  patient  was  delirious  at  times,  and  on  the  following 
daj-  he  had  some  deafness  and  tinnitus  aurium.  The  ([uinine  was  continued  and  the  calomel  omitted.  ( )n  November 
1  the  tongue  was  moist,  pale  and  coated  somewhat  in  the  centre  and  at  the  base.  Next  day  two  ro.se-colored  spots 
were  noticed  and  sordes  appeared  on  the  teeth.  Milk-punch,  beef-essence  and  turpentine  emulsion  were  ]>re8cribed. 
On  the  4th  the  patient's  condition  was  unchanged;  he  was  very  delirious,  his  face  much  flushed,  pulse  98  and 
strong,  skin  very  hot  and  showing  some  rose-colored  spots,  tongue  dry  in  the  centre  but  nu)iBt  at  the  edges;  he  liad 
no  cough,  but  nnicous  and  sibilant  rales  were  heard  in  some  parts  of  the  chest;  the  bowels  were  moved  by  an 
enema  of  castor  oil  and  turpentine  and  the  tympanites  which  had  been  ])reseut  was  thereby  reduced.  He  was  dull 
and  stupid  on  the  ath  and  had  subsultns  tendinnm.  Next  day  ,s(uue  petechial  spots  a]>pearcd.  No  further  details 
are  given.     The  patient  was  transferred  to  Annapolis,  Md.,  on  the  18th. 

Case  119. — Typhoid  fever  following  remittent  fever;  prognonis  farortible  unlil  the  advent  of  peritonitin. — Private 
Abraham  Haner,  Co.  D,  14th  N.  Y.  Vols.;  age  21;  was  admitted  Sept.  23,  1861,  as  a  case  of  remittent  fever.-  He  had 
been  epileptic  from  infancy  to  the  age  of  19,  when  the  fits  ceased.  He  was  taken  two  weeks  before  admission  with 
a  convulsion,  t^uinine  was  given  but  the  convulsions  recurred.  On  admission  his  face  was  flushed,  eyes  injected, 
bowels  loose  and  abdomen  painful.  A  slight  fever  was  present  on  the  25th;  ajipetite  deficient,  thirst  considerable, 
pulse  88,  full  and  strong,  skin  warm  and  moist  (he  had  perspired  profusely  at  night),  tongue  light-brown  and 
fissured;  he  had  a  little  headache  and  dizziness.  Acetate  of  ammonia  was  prescribed  with  five  drops  of  Fowler's 
solution  four  times  daily.  He  did  not  sleep  well  at  night,  and  on  the  26th  was  restless,  his  cheeks  flushed,  eyes 
suffused,  pulse  96,  skin  hot  and  moist,  tongue  brown  and  dry  in  the  centre,  fissured  and  moist  at  the  edges;  he  had 
headache  and  slight  delirium,  pain  in  the  stomach,  pain  and  groat  tenderness  in  the  iliac  region,  some  cough  and 


248  CLINICAL    RKCORDS    OF 

difficulty  in  retaining  urino.  Tlip  acetate  of  ainiiionia  was  continued  and  tiir]ientine  emulsion  was  ordered  for 
administration  every  two  hours.  In  the  eveninf;  tlie  skin  was  moist .  the  jiulse  102,  the  tongue  yellowish.  HoH- 
niann's  anodyne  was  ])rescribed  in  drachm  diiscs  cNcry  four  hours.  He  slept  liul  little  during  the  night,  and  on 
tlie  27th  tlu'  j)ulse  was  90,  skin  hot  and  dry,  tongue  dry  in  the  centre,  moist  at  the  edges;  he  had  headache,  anorexia, 
tympanites  on  the  right  side,  tenderness  in  the  right  iliac  region  an<l  liis  bowels  had  been  moved  six  times.  Tur- 
pentine emulsion  and  Fowler's  solution  were  renewed  and  iiills  of  opium,  lead  and  tannin  prescribed.  In  the  evening 
the  pulse  was  101,  the  skin  hot  and  moist  but  witli  no  erupti'U]  nor  siidamina,  the  tongue  rather  yellow  in  the  centre 
but  less  fissured ;  the  headache  was  lessened  and  the  diarrhwa  reduced  to  one  stool,  but  the  tenderness  and  tympanites 
continued.  Sweet  spirit  of  nitre  and  wine  of  antimony  were  administered  during  the  night.  He  slept  well  and 
perspired  early  in  the  morning;  no  stool  was  i>assed.  On  the  28th  the  skin  was  hot  and  moist,  tongue  brown,  dry 
and  fissured  in  the  centre,  its  edges  moist  and  white;  the  anorexia,  headache  and  cough  persisted,  and  there  was 
partial  retention  of  urine,  with  pain  in  the  hypogastriuni.  I'.xtract  of  buchu  was  given.  In  the  evening  the  face 
was  flushed,  eyes  bright,  pulse  strong  and  regular,  skin  soft  but  somewhat  hot,  tongue  moist,  white  and  fissured; 
bowels  moved  once,  tender  and  tymiianitic;  the  cough  had  subsided  aiul  the  appetite  was  returning.  Dover's  powder 
was  ordered.  He  slept  well  during  the  night,  and  on  the  2i(th  the  face  was  somewhat  flushed,  eyes  injected,  pulse  88 
and  strong,  skin  hot  and  moist,  tongue  brown  and  dry  in  the  centre,  moist  at  the  edges,  the  bowels  (luiet  but  a  little 
tender  and  tympanitic.  In  the  evening  there  was  slight  headache;  the  bowels  were  moved  once,  but  the  tenderness 
and  distention  continued;  the  appetite  was  good.  Tincture  of  opium  and  essence  of  peppermint  were  administered. 
On  the  30tli  the  skin  was  soft  and  its  temperature  decreased  :  tlu^  tongue  moist  at  the  edges,  brown  and  dry  in  the 
centre,  the  appetite  moderate;  three  stools  were  passed  and  there  was  much  tymi)anite8  with  nuirked  tenderness  in 
the  right  iliac  region  and  some  in  the  left  side.  On  October  1  the  skin  was  natural,  the  tongue  slightly  coated  in  the 
centre  and  fissured,  the  appetite  good  and  the  bowels  ([uiet.  He  improved  after  this,  so  that  from  the  3d  to  the  (ith 
no  note  of  his  condition  was  recorded.  On  the  Tth  the  pulse  was  85j  skin  natural,  tongue  moist  but  red  at  the  tip 
and  edgee,  yellow  and  fissured  in  the  centre;  bowels  moved  three  times.  No  marked  change  occurred  until  the  10th, 
when  the  skin  became  hot  and  dry,  followed  on  the  11th  by  a  profuse  eru]>tion  of  rose-colored  spots ;  on  this  day  the 
tongue  was  slightly  moist,  yellow  in  the  centre,  the  appetite  good  and  the  bowels  quiet,  but  the  abdomen  was  tender 
and  tympanitic,  especially  in  the  umbilical  and  right  iliac  regions.  Tincture  of  iron  was  prescribed.  Fresh  crops  of 
rose-colored  spots  appeared  at  intervals  until  the  28th,  when  they  faded.  The  heat  of  skin  gradually  lessened  until 
on  the  16th  it  became  normal;  two  days  later  the  skin  was  moist.  The  bowels  were  moved  once  or  seldom  twice 
daily,  but  a  good  deal  of  ten<lerness  and  distention  was  noted  in  the  umbilical  and  right  iliac  regions.  On  the  20th 
extract  of  senna  was  administered  and  two  passages  followed  its  exhibition.  The  patient  usually  slept  well  and  his 
appetite  was  good;  the  tongue  was  nmist  and  clean,  faintly  furred  or  yellow-coated  in  the  centre.  He  appeared  to 
be  doing  well  when,  on  the  20th,  he  was  seized  with  extreme  tenderness  of  the  abdomen.  After  a  wakeful  night  his 
eyes  on  the  30th  were  dull,  cheeks  flushed,  jiulse  100,  skin  hot,  tongue  moist,  brown  and  fissured,  lips  and  teeth 
covered  with  sordes;  he  had  some  deafness  and  mental  dulness,  anorexia  and  thirst;  there  was  no  diarrhoea,  but 
much  general  abdominal  tenderness  and  some  tympanites.  A  blister  was  applied  to  the  abdomen  and  calomel  aiul 
opium  prescribed  for  administration  every  th.ee  hours.  On  the  31s>t  the  pulse  was  140  and  irregular  and  the  skin 
bathed  in  perspiration,  but  the  abdomen  was  less  tender.     Death  took  place  on  this  day. 

Case  120. —  Remittent  fever  and  a  recurrence  of  remittent  oeerlappini/  the  typhoid  case. —  Private  Fi.  .1.  Tice,  Co.  G, 
14th  N.  Y.  "Vols.;  age  23;  had  chills,  perspirations,  pain  in  the  head  and  umbilical  tenderness  on  Sept.  28,  1861,  and 
was  admitted  October  2  as  a  case  of  remittent  fever.  Oi  the  evening  of  admi8si(ui  the  patient's  jdilse  was  not  accel- 
erated, but  his  face  was  flushed,  eyes  injected  and  skin  hot;  his  tongue  was  moist  and  coated  white,  appetite 
deficient,  bowels  tender  and  moved  once  during  the  day.  Blue-pill  and  ojjium  were  given.  Next  morning  the 
tongue  was  coated  yellow  and  bowels  moved;  pulse  80,  strong-  skin  perspiring.  Quinine  was  ordered  to  be  taken 
at  the  rate  of  sixteen  grains  a  day,  with  Dover's  powder  in  the  evening.  This  condition  of  slight  fever  with  yellow- 
coated  tongue,  anorexia  and  .some  headache  continued  for  several  days-  but  in  the  meantime  the  bowels  became  quite 
loose,  meteorized  and  tender,  especially  in  the  right  iliac  region.  On  the  8tli  the  tongue  was  red  at  the  tip  and 
edges  and  yellowish-white  in  the  centre,  the  appetite  improved  and  the  pulse  lowered  to  60.  Tincture  of  iron  was 
ordered.  During  the  following  week  the  bowels  were  less  affected,  only  one  or  two  stools  being  passed  daily;  the 
skin  was  of  the  natural  temperature  and  somi^times  perspirin^j.  Hie  appetite  good,  but  a  slight  headache  persisted.  A 
chill  occurred  suddenly  on  the  16tli,  and  next  day  the  pulse  was  100,  full  and  strong,  the  skin  hot  and  dry,  the 
tongue  slightly  moist,  white  at  the  sides,  yellow  in  the  centre,  the  appetite  poor,  the  bowels  moved  once,  the  abdomen 
tender,  especially  in  the  right  iliac  region.  151ue-pill  an<l  opium  were  given  in  repeated  doses.  On  the  18th  the  pulse 
fell  to  70  and  several  rose-colored  spots  appeare<l  on  the  skin;  but  the  tongue  continued  coated  until  the  28th, 
Fowler's  solution  having  been  given  in  t!ie  meantime,  and  the  headache,  relaxed  bowels  and  abdominal  tenderness 
lasted  for  ten  days  longer.  The  patient  was  transferred,  November  18,  to  Annapolis,  Md.  [as  a  case  of  typhoid  fever; 
he  was  returned  to  duty  with  his  regiment  December  2]. 

Two  Cases  entered  as  Tvpiioid,  iu't  in  which  only  tiif  Malahiaf,  Element  was  t'uominent. 

Case  121. — Miilarial  symplomit  prominent;  tlte  presence  of  enteric  fever  not  clearly  estahlixhed. — Private  Matthew 
Baird,  Co.  C,  3d  Mich.  Vols.;  age  23;  was  admitted  Oct.  19,  1861,  as  a  case  of  typhoid  fever.  AI)out  October  5  ho 
had  been  seized  with  pain  in  the  head  and  bones,  fever  and  chills;  he  had  some  nausea  and  vomiting  at  first,  and  a 
diarrhoea  which  continued  for  two  days;  the  headache  lasted  four  days;  during  the  second  week  his  urine  had  to  be 
removed  by  catheter.  On  admission  his  pulse  was  62  and  of  fair  strength,  skin  soft  aud  warm,  tongue  pale,  moist  and 
slightly  coated  brownish  in  the  centre,  apjietite  good;  he  had  tinnitus  aurium  and  giddiness,  but  no  pain,  eruption 


THK    r()XTIXUKli    KKVKK-:.  249 

nor  sudaiuiua:  duo  thin  watt'iy  .stocil  wn^  pa>sr(l.  but  tlunf  was  no  ti-iiili-riicss.  iMirlidiyjxiiuis  nor  tyiii])aiutes.  and  the 
abdomen  was  sot't :  there  was  no  eont;li  and  the  mine  was  noiiiial.  l,ininine  was  ]iresiTibed  in  full  doses  three  times 
daily.  Next  <lay  the  faee  was  calm  and  natnial,  the  pulse  ill,  steady  and  of  fail  stri'iiirth,  the  skin  soft  and  warm, 
the  tonune  slij;litly  jialo  and  llald)y  but  moisi  and  <lean,  the  ajiiietite  t;ood:  one  thin  fetid  stool  was  jiassed.  On 
the  'S2d  the  (ininine  was  reduced  to  twi>  grains  three  times  daily,  and  ilnrinj;  the  night  the  patRMit  had  a  rhill,  but 
next  day  its  etloets  disap]>eared.  On  the  L'^'th  he  reste<l  badly  and  had  some  diarrlnea.  but  there  was  no  tenderness 
nor  tympanites  :  the  tongue  was  jiale  and  moist  and  the  aii))etite  fair.  The  skin  and  e(uijumtiva>  beeami'  jaundiced 
on  the  31st.  .Small  doses  of  cah)mel  and  oiiiuni  were  given.  Xnxcmber  1  he  sle]it  well:  his  mind  was  clear,  counte- 
nance calm,  bowels  regular  and  a]ipetite  good.      He  was  transferred  to  .\nnai)idis.  Md..  (Ui  the  \><\\[. 

C.\si-;  122. — fh-itih  ill  riijlit  tlfiifs.  I  >i<ifitinsis — lifjihitid,  hill  ■•^iiinptoin.i  ami  tnatiitt  iif  Ihosr  nf  n  niilh  til  t'trtr. — IMivate 
Edwin  (haves,  Co.  D.  J^lith  X.  ^^  \ols.:  age  2l):  was  admitted  .March  17.  1MIJ2.  He  was  taken  sick  about  the  12th 
with  pain  in  the  chest,  headache,  miusea.  a  feeling  of  general  swelling  and  mn(di  debility,  succeeded  by  a  chill, 
fever  and  profuse  persiuration.  which  symjitoms  recurred  daily  about  U  A.  .M.;  he  had  also  mncli  annoyance  from  a 
numb  feeling  in  his  fingers.  On  admission  the  pulse  was  rajiid  and  weak,  the  skin  hot  .and  moist,  the  tongue  moist, 
red  and  slightly  coated;  the  ]iatient's  api>etite  was  |K>or  ami  he  ha<l  some  diarrli(ea  and  pyrosis:  he  stated  that  the 
chill  and  fever  occurred  at  the  same  tiiue  in  rapid  alternations  in  different  |iarts  of  the  body,  thi'  paroxysms  lasting 
two  or  thiee  liours.  Twenty-four  giains  of  (|uiniiie  were  dirccti'd  to  be  taken  <luring  the  day.  He  was  delirious 
during  tlu^  18th  ;  his  pulse  raiiiil  and  weak,  skin  natural,  tongue  moist  ami  coaled  white.  l'un<h  and  beef-essence 
were  given  every  two  hours.     He  die<l  delirious  on  the  nnirning  ot  the  l!Uh. 

The  last  case  of  this  series  appears  to  liave  b('(>ii  one  of  inistaki'ii  diau'iiosis: 

Case  123.— rrivat(^  Win.  H.  Conrtney,  Co.  H,  2ltli  N.  V.  Vols.;  age  21;  was  tak<>n  Sept.  I,  IHtU,  with  pain  in 
the  shoulders  and  left  side  and  also  on  breathing;  he  had  chills  and  fever  and  had  been  Mistered.  He  was  admitted 
on  the  18th.  ]>iaguosis — typhoid  fever.  The  ]>ulse  was  Hi,  skin  cool  and  moist,  lelt  side  tender  and  dull,  respira- 
tion short,  deculiitus  on  the  sound  side,  tongue  smooth,  nearly  di y,  bowels  constiiiated  ami  tender  in  both  iliao 
regions.  Two  grains  of  calomel  and  one-fourth  grain  of  morphia  were  ))re.scribed.  Next  day  the  pain  was  less 
sharp,  the  pracordia  seemed  elevated  and  the  sounds  of  the  heart  were  obscured.  In  the  evening  the  patient  was 
drowsy,  jiulse  50  and  irregular,  skin  natural,  tongue  slightly  coated  gray  posteriorly,  red  at  the  lip.  Calonud  in 
two-grain  doses  with  o])inm  was  given  every  two  hours.  On  the  2l)th  there  was  acute  tenderness  in  both  iliac 
regions  but  the  bowels  continued  constipated.  On  the  21st  the  breath  bceauui  fetid,  and  on  the  following  day  the 
glims  were  swollen  and  tender.  The  mercurial  was  omitted.  On  the  2-lth  <dilorate  4>f  potash  was  given  on  account 
of  the  salivation.  The  patient  was  walking  about  and  had  a  good  appetite  on  the  lidfh,  .and  was  doing  liglit  duty  in 
the  ward  on  October  3.     He  was  returned  to  duty  on  the  171  h. 

Fever  cases  from  regimental  records. — The  syinptoms  of  (\'plioitl  fever  assumed 
a  prominence  in  the  typho-mahirial  cases  of  the  Seminary  ILnspital,  ami  no  donht  in  those 
of  other  general  hospitals,  which  was  not  shown  in  the  cases  occiiri'ing  at  the  same  time  in 
the  field.  This  difference  in  character  was  a  consequence  of  the  greater  previdence  of 
remittent  fevers  at  the  front,  liemittents  seldom  reached  the  general  hospitals,  as  they 
proved  tatal  if  pernicious,  or  recovered  if  of  a  mild  type,  under  the  iiiHiience  of  quinine, 
at  the  regimental  or  Held  division  hospitals.  Similai'ly,  if  the  remittent  fever  masked 
an  existing  tvphoid,  the  notable  symptoms  in  a  rapidly  fatal  case  were  those  of  the  j»erni- 
cious  fever,  while  in  a  mild  attack  the  treiitment  j)rior  to  the  transfer  to  the  general 
hospital  had  its  eflfect  on  the  malarial  sym|)toms  and  left  the  case  for  the  records  of  the 
hospital  as  one  of  comparatively  unmoditied  typhoid.  P)Ut  even  in  the  febrile  cases  treated 
in  the  field  the  symptoms  of  typhoid  fever  were  sometimes  so  sti'ongly  developed  as  to  leave 
no  doubt  concerning  the  nature  of  the  disease.  Not  only  was  thi.s  the  case  in  local  epi- 
demics occurring  in  non-malarious  districts,  but  in  commands  which  at  the  same  time 
reported  numerous  cases  of  malarial  fever,  the  presence  of  which  led  to  a  routine  adminis- 
tration of  quinine  in  all  febrile  cases.  This  may  be  illustrated  by  a  .series  of  cases  from 
the  records  of  the  27th  Connecticut  Volunteers.  Fevers  hail  prevaih'd  in  this  regiment 
from  the  establishment  of  winter  quarters  at  Falmouth,  Va.,  tifter  the  battle  of  Fredericks- 
l)urg.  Thus,  in  January,  1863,  there  were  reported  on  the  monthly  report  of  sick  and 
wounded  six  cases  of  typhoid,  seven  of  typho-malarial,  three  of  intermittent  and  sixteen  of 
remittent  fever;  but  the  details  of  none  of  these  ctises  are  preserved.  In  February  and 
March,  the  months  during  which  the  recoi-ded  cases  were  treated  in  the  regimental  hospital, 
Med.  Hist.,  Pt.  Ill— 32 


250  CLINICAL    RKCORDS    OK 

no  typlio-malurial  oiiHes  were  reported,  tlie  fevers  being  entered  either  as  remittent  or  as 
typhoid.  The  liistories  of  thirteen  cases  of  typhoid  are  recorded;  one  of  these,  in  which 
the  hoily  was  exanuned  after  (U'atli,  is  presented  as  case  330  of  the  post-mortem  records  of 
the  eontiiuicd  fevers  ;'='  the  others  are  given  beh)\v  in  tlie  order  of  their  admission  for  treat- 
ment. Appended  to  tlie  record  of  tlie  first  case  is  a  remark  bv  the  regimental  surgeon, 
Wm.  0.  McDonald,  as  follows: 

I  roj^ard  this  as  a  purer  case  of  tyjihoid  fever  than  that -of  Dolph,  for  this  was  nucoinplicated.  Tlie  rose-spots 
a])peare(l  on  the  seventh  day  of  his  stay  in  hospital,  the  disease  having  jirobably  made  some  progress  before  any 
record  was  kept  of  the  case. 

Cask  1. — Dilirinni ;  inroluntarij  xtooh;  ahdomitud  tc)itlcnii'si< ;  rose-colored  xjmtn;  iiiiproreniiiit  from  the  end  of  the 
necniid  iveek. — Private  H.  K.  Knrnhani,  Co.  H,  27th  Conn.  Vols.,  having  been  complaining  for  two  or  three  days,  was 
admitted  Fell.  2,  18(5!^  The  pulse  was  11)2,  small  and  weak,  and  the  muscles  of  the  body  were  sore  to  the  touch.  On 
the  5th  the  tongue  was  dark-colored  and  there  was  some  delirium.  Sixty  grains  of  (juinine  were  administered 
in  three  doses  during  the  da5-.  On  the  7th  the  bowels  were  moved  twice  and  there  was  tenderness  over  the  Ciccuni 
and  ascending  colon.  Next  day  the  pulse  was  132,  tongue  dry,  red  and  cracked,  lips  black;  the  patient  was  very 
delirious  and  Iiad  several  involuntary  j>as.sages  from  the  Tiowels.  Stimulants  were  given.  On  the  9tli  the  pulse  was 
132,  tongue  a  little  mori^  moist,  bowels  ([uiet  and  delirium  lessened;  six  ro.se-colored  spots  were  found  on  the  abdo- 
men. The  patient  was  not  so  well  next  day;  the  tongue  was  dryer  and  darker;  the  abdomen  was  distended  and  gur- 
gled on  pressure  in  the  right  iliac  fossa,  and  there  were  several  ineffectual  attemjits  at  stool.  On  the  11th  the  tongue 
was  dry  as  ever  and  the  lips  as  black,  but  the  patient  was  able  to  talk  sensibly.  After  this  the  pulse  gradually 
fell  to  80,  the  tongue  became  clean  and  moist,  the  abdominal  tenderness  ceased  and  the  appetite  improved;  but  the 
return  to  health  was  slowly  effected. 

C\SK  2. — Low  ferer  and  luhetiide;  diarrhnu  and  ahdoininal  tenderness ;  niijlit-sweuls  tiiid  ledeniu  of  legs;  recovery. — 
Private  William  A.  Jlor.se,  Co.  H,  27th  Conn.  Vols.,  was  admitted  Feb.  2,  1S()3,  after  exposure  on  picket  duty  to  cold, 
wet  and  stormy  weather.  Diagnosis — typhoid  fever.  Stupor;  jiulse  9(i;  tongue  dry  and  red;  twelve  stools;  ten- 
derness in  the  right  iliac  and  hypogastric  regions.  3d;  Dvill  and  stupid;  pulse  88,  full,  soft;  skin  moist;  tongue 
dry  and  r«Ml :  one  stool;  tenderness;  pains  in  the  back  and  limbs.  4th:  Looking  better;  pulse  84;  tongue  dry; 
much  thirst;  two  stools.  5th:  Pulse  72;  tongue  red,  clean,  moist;  tenderness  below  umbilicus;  one  thin  watery 
stool,  fith;  Pulse  84;  tongue  red,  bare,  moist ;  one  stool;  less  tenderness.  The  patient  took  ten  grains  of  quinine 
five  times  a  day  during  the  first  four  days  of  his  stay  in  hospital.  7th:  Pulse  72,  dicrotic;  tongue  red,  dry,  glazed; 
odor  feverish  ;  eyelids  dusky;  iliac  and  hypogastric  tenderness.  8th:  Tongue  dry,  glazed;  face  dusky;  three  stools. 
Whiskey  was  prescribed,  tltli:  Pulse  78;  tongue  moister;  one  stool.  lOtli:  Two  stools.  13th:  Pulse  84;  tongue 
glazed,  bare;  one  stool.  For  some  days  anterior  to  this  date  the  patient  had  been  taking  solid  food.  On  the  27th 
aromatic  sulphuric  acid  and  quinine  were  given  on  account  of  night-sweats.  These  recurred  on  March  12,  but 
wen;  immediately  contndled  by  renewing  the  acid  medicine.  He  was  very  pale  and  aniemic;  iron  was  prescribed. 
After  this  his  legs  became  (Edematous.     He  was  not  returned  to  duty  until  May  24. 

C.VSE  3. — Felyrile  attack  dnrinij  conrahscence  from  jaiindice:\  diarrhou  and  riijht  iliac  tenderness ;  mental  dulness; 
moaning  respiration  ;  diiskg  slxin ;  great  prostration  and  treiniihinsness;  death  on  VMh  daij. — I'ri\ate  Jo.seph  Hull,  Co.  I, 
27th  Conn.  Vols.;  intemperate;  suffered  in  January,  18(;3,  from  an  attack  of  jaundice  from  which  he  convalesced 
slowly.  On  February  18  he  was  taken  into  hospital.  Fifty  grains  of  quinine  were  prescribed  for  administration 
during  the  day.  On  the  It'th  the  jiulse,  which  had  been  very  slow  for  some  days,  rose  to  60,  the  lips  were  black, 
tongue  red  and  dry,  bowels  quiet  and  free  from  pain.  The  (juinine  was  omitted  on  the  20th.  On  the  21st  the  patient 
was  drowsv,  mind  dull,  si>eech  thick,  bowels  moved  twice  and  abdomen  tender;  deafness,  which  was  probably  in 
jiart  induced  by  the  <|uinine,  became  somewhat  lessened.  Beef-tea  and  stimulants  were  ordered.  Little  change 
took  place  until  the  2(Jth,  when  the  bowels  became  more  relaxed;  on  this  da.y  four  wattay  stools  were  passed,  the 
tongue  was  dry  as  a  board,  pulse  81,  respiration  nujaning,  hands  tremulous.  Next  day  the  tongue  became  somewhat 
moist,  the  hearing  im2)roved  and  there  was  less  dulness  and  wandering  of  the  mind;  the  bowels  were  moved  three 
times  and  the  right  iliac  region  was  tender.  On  the  28th  the  pulse  rose  to  120,  the  respiration  to  27;  the  tongue  was 
dry  and  cracked  but  not  very  dark,  the  skin  dusky  or  purplish;  the  patient  slept  with  his  mouth  open  and  moaned 
with  each  lireath;  he  was  emaciated  and  extremelj'  inostrated.     Death  took  place  March  2. 

Ca.sk  4. — Bronchitis ;  slight  diarrhea  and  delirinm  ;  sordes ;  rose-colored  spots  about  the  lOth  dai/;  faroralile  signs  at 
end  of  second  week;  distention  anil  ecehgmoses  of  the  abdomen;  bed-sores ;  pneumonic  symptoms  and  death  at  the  end  of  the 
fourth  week. — Private  Charles  L.  Ailing,  Co.  H,  27th  Conn.  Vols.;  age  18;  a  slender  ))oy,  was  first  seen  Feb.  18,  1863, 
suffering  from  a  cohl  contracted  while  on  picket  duty.  Veratrnm  viride  was  giv«Mi  daily  until  the  2l8t,  when  it  was 
omitted  and  quinine  substituted,  sixty  grains  in  divided  do.ses  during  the  day.     He  was  admitted  to  hospital  on  the 


*  hi/ra,  pHge  408,  <:iu«  of  Privati-  K.  h.  Diilpli. 

f.'iurg.  .F.  T.  Wkbb,  aid  Ohio  ViiIr.,  in  ii  Ictti^r  diiteil  Feb.  10,  18»12,  at  Fayi'ttevilli',  Va.,  ami  ]illhlixhi'il  in  tlli'  Cmniiimli  Lnwel  nuil  IHiKnn;  Vol. 
Vj  p.  171,  makes  the  follnwiiig  statement :  ''At  the  ehwe  of  this  moDtli  .jaundii-e  made  its  apiH-arance,  ami  what  is  most  remarkable,  its  advent  among  ua 
apjtears  to  have  eradicated  all  the  different  forms  of  f<'ver,  and  since  the  loth  of  .lannary,  just  one  month  this  day,  not  a  Hingle  case  of  fever  of  any 
description  has  made  its  api^'arance.  *  *  *  For  the  first  time  since  we  hav(!  been  in  Western  Virginia,  a  littht  more  than  seven  months,  one  whole 
month  has  jiassed  without  a  case  of  camp-fever  occurring  in  our  midst."  .lauTidice  prevailed  in  tin-  camp  tjf  the  27th  Conn.  Vols,  at  Falmouth,  Va., 
during  .lanuary,  1803,  but  its  iircvaliMice  was  not  associated  witlt  that  disapjK-arancc  of  fever  which  occnrreil  in  the  experience  of  Surgeon  Wkbb.  See 
tn/ra,  p.  87o. 


THK    C'ONTINUK])    FKVKKS.  251 

22(1  as  a  case  of  typhoid  fever  with  bronchial  complication.  Small  doses  of  ipecacuanha,  opium  and  camphor  were 
administered.  On  the  23(1  the  pulse  was  !H)  and  the  bowels  tender  l)ut  ([uiet.  Three  ten-grain  doses  of  (|iiinine  were 
given  during  the  day.  On  the  2."ith  tlie  tongue  was  dark  at  the  ba.se,  red  at  the  tiji,  the  li])8  and  teetli  bhick,  the 
bowels  moved  twice,  the  mind  wandering.  He  liad  been  taking  beef-tea  and  nuiuiiu^  u))  to  this  time:  whiskey  was 
now  added.  A  few  indistinct  rose-colored  spots  appeared  on  tlie  27th;  siieecli  was  dillicult  and  inc(dierent.  There 
was  some  dysnria  on  the  28th,  relieved  by  hot  fomentations  to  the  abdonien:  the  tongue  was  dry.  dark  and  cracked: 
](ul.se  lUS.  The  jiatient  liad  coughed  more  or  h'ss  since  liis  admission,  but  at  this  time  the  chest  sy!upt(UMs  liccame 
more  ])rominent.  On  March  2  tlie  jiulse  was  12(1  and  dicrotic,  the  abdomen  tender,  the  liowcls  moved  three  times, 
llie  stools  thin  and  watery ;  the  hands  and  cliecks  were  jiurplish  in  color;  speech  somewhat  less  incoherent.  On 
the  4th  the  pulse  was  120,  tongue  slightly  moist  and  softer  than  heretofore,  face  pale;  the  jjatient  took  some 
interest  in  his  condition  and  suffered  much  from  abdominal  distenti(m.  Turpentine  was  ])rescribed.  On  the  .")th 
the  pulse  was  108  during  sleep,  132  while  awake,  respiration  23,  tongue  dry,  abdonu'u  distended  and  ecchymosed, 
skin  over  sacrum  congested.  On  the  tith  the  jmlse  was  111,  respiration  30,  tongue  dry,  cracked,  dark  and  bloody. 
No  material  change  took  j)lace  until  the  8th,  when  the  integuments  over  the  sacrum  formed  a  sloughing  bed-sore. 
On  the  10th  much  llatus  was  passed  from  the  bowels  with  great  relief  to  the  patient  :  dysphagia  was  noted  at  this 
time.  On  the  llth  the  |>ulse  was  128  to  132,  respiration  3t)  to  10,  i)uls(^  dicrotic,  cheeks  Unshed,  lips  and  nose  while, 
tongue  dry,  brown  and  cracked:  the  (listenti(Mi  of  the  alxhuuen  was  again  a  cause  of  much  suffering  and  prevented 
the  jiatient  from  taking  his  allowance  of  beef-tea  and  whiskey;  the  bowels  were  nu)V(^d  twice.  On  the  16th  tlie 
dicrotism  of  the  pulse  ceased,  the  tongue  became  more  generally  moist,  and  the  patient  smiled  in  answer  to  a  (jues- 
tion.  But  delirium  returned  on  the  19th,  respiration  became  reduced  to  21!  and  the  lower  jaw  moved  with  each 
breath;  the  expectoration  was  rusty.     Death  took  place  on  the  21st. 

Cask  5. — lli-oncliilix ;  Irndirncsx  nrcr  colon,  hut  n  larije  cathartic  (Iokc  produced  no  hiJKrioii^  effect ;  j)iiik  spols  on  client 
about  9lh  day;  no  cerebral  ni/mptoms  until  late  in  the  attack,  when  the  delirium  noted  wds  probablij  due  to  continued  pain 
in  the  feet  and  morpliia  ijiren  for  its  alleriation ;  gangrene  of  the  feet;  death. — Private  Wni.  F.  Hernhardt,  Co.  K,  27th 
Conn.  Vols.,  was  admitted  March  17,  1863.  Diagnosis — bronchitis  and  ])robablo  fever.  He  had  taken  veratrum 
viride  for  two  days.  On  the  18th  the  pulse  was  96,  respiration  20,  tongue  dry  in  the  centre;  there  was  some  cough 
with  expe(^toration  and  substernal  soreness,  and  the  right  iliac  and  umbilical  regions  were  tender.  During  the  live 
following  days  two  hundred  and  forty  grains  of  (|uinine  were  taken  in  ten-grain  dos(^s,  tlui  tongU(^  meanwhile 
becoming  red  at  the  ti]!  and  edges  and  soincwhiit  nu)ist  and  the  cough  and  scanty  mucous  expectoration  continuing. 
There  was  tenderness  along  the  track  of  the  colon  lint  no  movement  of  the  bowels.  Five  compound  cathartic  i)llls 
were  administered  on  the  21st,  and  two  stools  were  passed  on  the  following  day.  Koine  pink  spots  a])]ieared  on  the 
chest  on  the  23d.  On  the  2r)th  tlie  tongue  was  moist  and  cleaning,  the  abdomen  covered  with  Niidainina,  but  the 
right  foot  was  very  palnfuf  and  numb.  For  some  days  there  was  little  change  In  the  condition  of  the  jiatient: 
I'ulse  108;  res](iration  20,  with  slight  cough  and  expectoration  and  rales  posteriorly;  tongue  clean  and  moist ;  ui)petite 
good;  face  natural;  bowels  (|uiet  and  free  from  pain;  feet  v(My  jiainful  esiiecially  at  night,  rei|uiring  the  admin- 
istration of  large  doses  of  uu)r]>hla  to  give  n^st  and  relief.  Aconit(^  and  lurp(^nline  liniments  wen^  used  but  without 
benefit.  On  the  29th  the  dorsum  of  tli(^  right  loot  became  )iur|il(!  and  cold  and  the  leg  immediately  above  the  ankle 
puffy;  two  days  later  the  left  foot  became  similarly  atfe(^ted.  Small  doses  of  tincture  of  Iron,  (lulnlm^  and  sweet 
s|)irit  of  nitre  were  prescribed  and  great  attention  was  paid  to  the  diet  of  the  j»atlent;  hot  bricks  and  flannel  wrap- 
pings weie  applied  to  the  feet.  On  April  7,  in  addition  to  the  ecchyiimsls  on  the  dorsum  of  the  riglit  metatarsus,  a 
shuigh  extended  over  most  of  the  toes;  the  patient  was  delirious  during  the  night.  One  grain  of  8ul]ihate  of 
nuirjihia  was  prescribed  for  administration  at  bed-time,  the  done  to  be  i(|)eated  in  an  hour  If  r(M|ulred.  The  Idack 
lin(^  forming  the  margin  of  the  ecchymosed  and  pully  patches  spre.id  gradually  towards  the  ankles  and  toes;  bulla' 
formed  on  tlu^lr  surface.  On  the  16th  the  end  of  the  great  toe  and  ujiper  surl'a(^(!  of  the  toes  of  the  right  toot  were 
hard,  hoiny,  shiiinken,  dry  and  black,  whih)  tlui  dark  patches  W(U(!  slowly  extending  over  both  feet.  The  patient 
was  transferred  to  Stanton  hospital,  Washington,  D.  C,  on  the  19th,  where  he  died  June  10  of  "typhoid  fever  and 
gangrene  of  the  feet." 

('.\SK  6. — Date  oj  onnet  undefined;  rose-npota ;  iliac  and  umbilical  tendernc>i>i;  pneumouin  :  numerous  npotn  like  small 
blood-blislerx  ou  the  limbs  and  trunk;  duskg  skin,  low  delirium,  tremulousncss  and  subsiiltns:  romiling;  epistaj'is;  bed-sores; 
recorcr/i  of  inielligence  for  a  week  before  death. — Private  S.  II.  Plumb,  Co.  C,  27th  Conn.  \'ols.;  age  22;  had  been  treat(>d 
in  (juarters  for  (juite  a  long  time  before  his-admisslon  into  hospital,  March  23,  1863,  as  a  case  of  typhoid  fever.  The 
pulse  was  88;  respiration  16;  tongue  shrunken,  furred  ami  dry,  the  tlii  and  edges  red;  eyes  somewhat  yellow;  hear- 
ing dull;  chest  and  abdomen  covered  with  sudamina  and  a  large  crop  of  red  and  pink  spots,  dl8a])pearlng  on 
pressure;  bowels  moved  once  daily,  and  tender  in  the  iliac  and  umbilical  regions.  There  was  free  perspiration 
during  the  night  of  the  24th,  and  next  morning  some  of  the  sudamina  had  coalesc(Ml  into  bulhe  containing  turbid 
yellowish-white  Ihiuid;  one  loose  watery  stool  was  pas.sed.  Twenty-tive  grains  of  sulphate  of  ([uinine  were  given 
three  times  daily  with  aromatic  sulphuric  acid.  Next  day  there  was  no  sweating,  but  the  condition  was  otherwise 
not  much  changed;  ]iulse  108;  bowels  moved  twice;  no  abdominal  tenderness;  red  spots  di»ap|icariug  :  sonorous 
rales  ])osterlorly  on  both  suh^s  of  the  chest.  On  the  27th  the  iiuinine  was  continued  in  ten-grain  doses  three  times 
daily,  hut  the  acid  was  omitted;  the  expectoration  was  white,  slimy  and  adhesive,  with  intermixture  of  scarlet  blood; 
there  was  soreness  over  the  ascending  and  transverse  jwrtions  of  the  colon.  On  the  28th  tlie  jiatient  was  reported  as 
having  had  some  delirium  in  the  early  part  of  the  night;  the  skin  of  the  abdomen  was  dc'siiuamating.  Small  doses 
of  ipecacuanha  and  opium  were  given.  The  (luinine  was  omitted  on  the  29th;  the  chest  was  not  tender  on  percus- 
sion, but  the  sputa  contained  bright  blood.  On  the  .SOth  the  jmlse  was  96;  respiration  16;  tongue  cleaner  and  less 
dry;  bowels  moved  once;  abdomen  somewhat  sore  all  over;  sputa  thick  and  adhesive,  containing  bloody  masses; 


252  CLINICAL    HKcoiins    OK 

small  crepitation  was  heard  i!i  tlie  left  Imif;  iiiider  the  fourth  rib.  Cailionate  of  aiiniioiiiii  wiln  i)roscril)ed.  On  tlio 
3lNt  lie  WHS  afjain  reported  us  liaving  lieiMi  delirious  durinf;  the  nifjlit.  Some  nearly  pure  blood  was  expectorated  on 
Ajiril  1:  the  ton<j;ue  was  brown  at  the  tip  and  centre,  the  liiis  dry,  cracked  and  bleeding,  the  teeth  covered  with 
dark  iiatches,  the  liowels  moved  once;  the  i)atieut  was  a^aiu  delirious  during  the  early  part  of  the  night.  (Quinine 
in  tliree-grain  doses  was  given  three  times  <Uiily.  Avitli  small  doses  of  carbonate  of  ammonia  and  ipecacuanha  and 
a  full  dose  of  moridiia  at  bed-tiuu'.  He  persjiired  jirofusely  on  the  2d:  his  <heeks  were  somewhat  lliislied: 
uumy  spots  like  .small  blood-blisters  apjieared  on  the  limbs  and  shoulders  and  a  few  were  pres<'nt  on  the  trunk;  he 
was  delirous  and  wanted  to  get  out  of  bed.  15eef-tea  and  whiskey  were  given  at  intervals  during  the  day.  The 
pers]>irations  continued  on  the  3d;  on  this  day  some  nausea  was  develo])ed  and  the  appetite,  which  had  betni  very 
good  hitherto,  became  atfected;  the  expectoratiou  was  scanty,  rust-colored  and  contained  bloody  masses;  all  kinds 
of  nnirmuring,  bubbling  and  rattling  were  heard  in  the  chest;  i)ulse  10(1;  respiration  2l)  and  irregular.  On  the  Ith 
there  was  some  vomiting,  no  stool,  but  some  teiulerness  in  the  right  ilia<'  and  umbilical  regions;  the  small  puriilish 
ecchyniosed  spots  were  fading  from  the  arms,  but  those  on  the  abdomen  were  very  numerous  and  presented  a  pur- 
pura-like  appearance.  On  the  tith  the  pulse  was  120,  respiration  30  and  irregular,  tongue  dry,  brown,  hard  and 
fissured,  lips  dry  and  cracked,  cheeks  slightly  flushed  of  a  dusky-violet  color;  the  stomach  rejected  solid  food;  one 
natural  stool  was  pas.sed;  the  purpuric  eruption  appeared  on  the  back  and  hii>s.  On  the  7th  the  ecchyniosed  spots 
increased  on  the  abdomen  ;  there  was  freiiuent  but  scanty  vomiting  and  an  incoherent  muttering,  w  ith  tremulousness 
of  the  hands  and  incessant  subsultns.  Bed-sores  on  the  hips  and  sacrum  and  continued  vomiting  were  recorded  on 
the  Sth.  Next  day  the  eruption  had  nearly  faded:  the  pulse  was  9t)  and  resjiiration  '2X.  the  lower  jaw  participating 
in  the  respiratory  movement ;  a  copious  e]>istaxis  occurred  ;  the  stouuxch  was  less  irritable  On  the  lOth  the  face  was 
pale  and  sunken,  the  hands  and  jaw  twitched  and  there  was  occasional  moaning  on  inspiration,  but  the  lower  jaw 
did  not  move  as  on  the  previous  day.  Next  day  he  seemed  to  recognize  the  attending  pliysieian.  (Jn  the  12th  the 
tongue  was  somewhat  moist  and  the  ])atient  brighter;  he  talked  a  little.  From  this  time  until  death  on  the  IHth 
he  retained  his  intelligence,  sometimes  expressing  his  wants.  The  vomiting  ceased  and  he  swallowed  the  beef-tea, 
whiskey,  etc.,  ottered  him  without  objection  As  the  left  hip  and  back  were  raw  and  granulating,  he  lay  usually  ou 
the  right  side.  For  two  or  three  days  the  bowels  were  slightly  relaxed.  A  ]ieculiar  odor,  like  that  of  spoiled  meat, 
was  noticed  about  his  person.  Cough  was  troublesome  but  useless,  as  it  brought  up  nothing  from  the  lungs.  On 
the  day  before  death  the  respiration  suddenly  rose  to  44,  the  pulse  being  120;  on  the  day  of  death  the  pulse  fell  to 
60,  respiration  being  4S. 

Case  7. — lh'(ij'nc>i«;  dcHrii(m;  pempinttions;  rose-colored  upots;  diarrhwa;  recurcri/. — Private  Daniel  Doolittle,  Co. 
A, .27th  Conn.  Vols.,  was  adnutted  on  the  evening  of  March  23,  1863.  Next  day  the  pulse  was  84  and  dicrotic,  tongue 
clean  and  moist,  skin  moist,  conjtmctiva  of  right  eye  inflamed,  throat  sore;  one  thin  dark-colored  stool  was  passed 
and  the  abdomen,  which  was  full  and  soft,  was  somewhat  tender  over  the  track  of  the  colon  ;  the  patient  was  deaf 
and  tJilked  thickly  in  a  dull  delirium.  Quinine  in  ten-grain  doses  was  prescribed  for  administration  five  times  a  day 
and  thirty  grains  of  blue-i)ill  were  given  at  night.  On  the  25th  there  was  free  perspiration  but  no  sudamina;  one 
faint  rose-spot  was  found  on  the  chest ;  the  lower  eyelids  were  so  dark  as  to  seem  ecchyniosed ;  the  bowels  were  moved 
twice;  the  patient  was  sullen  and  ate  nothing;  during  the  night  he  had  been  violently  delirious.  No  medicine  was 
given.  On  the  26tli  the  jnilse  rose  to  108,  the  tongue  became  somewhat  dry  .and  the  delirium  of  a  jocose  character. 
Quinine  in  ten-grain  doses  was  given  three  times  a  day  with  morphia  at  night.  On  the  27tli  the  pulse  was  120;  the 
patient  rested  better  at  night,  and  although  dull  and  stupi<l  gave  rational  replies  to  questions;  one  thin  stool  was 
passed.  On  the  28tli  the  tongue  was  furred  at  the  base,  clean  at  the  tip  and  edges,  pulse  96;  delirium  had  returned 
during  the  night ;  two  stools  were  iia8s(Ml  and  the  abdomen  was  tender  over  the  ca'cum  and  the  ascending  and  Irans- 
ver.se  portions  of  the  colon.  The  prescriptions  of  the  26tli  were  repeated.  On  the  29th  the  pulse  was  72;  a  few- 
elevated  pink  spots  appeared  on  the  abdomen  and  the  upper  eyelids  .seemed  ecchyniosed.  Tlie  tongue  was  clean  and 
moist  on  the  30th;  three  stools  were  passed  and  the  bowels  were  tender.  On  the  31st  the  patient  was  rational  and 
the  spots  fading,  but  the  bowels  continued  loose  and  tender.  On  April  1  there  was  vomiting,  the  <'ondition  of  the 
bowels  remaining  unchanged.  Quinine  in  three-grain  doses  with  whiskey,  and  at  night  morphia,  were  i)roscribed  for 
administration.  On  the  2d  a  few  spots  ai)])eared  on  the  chest  and  abdomen;  five  stools  were  i)a8.sed.  On  the  3d 
three  stools,  resembling  pea-soup,  were  passed,  and  the  patient  was  very  thirsty;  but  after  this  the  diarrlnea  ceased, 
so  that  on  the  9th  a  compound  cathartic  pill  was  given,  which  was  not  followed  by  any  alviiie  movement  until  the 
11th.  Meanwhile  the  patient's  appetite  had  returned;  on  the  7th  he  had  been  permitted  steak  for  breakfast,  lie 
was  transferred  to  division  hospital  on  the  21st. 

Ca«E  8. — Diliriiim,  pirxpirations,  piiik-colorvd  upolx;  cdiixtipdliiiu  inilil  after  the  free  iidmhihiriition  of  piiryatire 
vudiciiics;  reeoreri/. — Privat(^  Amos  N.  Benton,  Co.  C,  27tli  Conn.  Vols.;  age  36.  This  patient  had  sutt'ered  from  jaun- 
dice, for  which  mercury  and  ipecacuanha  had  l)een  taken.  He  fainted  on  the  night  of  March  23,  1863,  and  was 
admitted  next  day.  He  became  very  delirious  in  the  afternoon,  expecting  to  die,  and  thinking  that  tlie  attending 
physician  had  killed  him.  On  the  2.5tli  the  pulse  was  96,  respiration  24,  tongue  moist  and  brownish,  skin  sweating 
constantly  and  freely;  he  had  a  slight  cough  which  hud  troubled  him  for  two  weeks  l)efore  his  admission.  The 
delirium  continued  during  the  night  but  abated  and  ultimately  ceased  towards  morning,  the  jiatient  becoming 
rational.  The  skin  was  bathed  in  iiersj)iration  on  the  26th,  but  was  free  from  sudamina:  the  abdomen  was  swollen 
and  there  was  some  gurgling  in  the  right  iliac  fossa.  Quinine  was  given  in  ten-grain  doses  three  times,  and  morphia 
ordered  for  use  at  bed-tiuie.  On  the  27th  some  faint  pinkish-colored  spots  were  found  on  the  abdomen.  As  the 
bowels  had  not  been  moved  since  admission,  four  compound  cathartic  pills  were  given.  Next  day  the  tongue  was  a 
little  dry  at  the  tip,  the  bowels  were  moved  twice  without  pain,  the  perspirations  continued  and  the  patient  was 
in  a  constant  delirium.     Two  stools  followed  on  the  29tli,  none  on  the  30th,  but  the  perspirations  and  delirium 


THE    I'liNTrNTKn    VF.VKI'.S.  2^>^> 

reiiiaimMl  miabatt'il.  Tlie  face  was  pale  <iii  tin'  olst  and  tlic  jiaticnt  suUi-n  altliongh  not  |iarticiilai'ly  ileliiious:  the 
I>ei\si)ii'atioii.s  liail  eeascd.  Next  day  the  suiatiiij;  was  leneweil  and  cDiit  inin-<l  until  the  liowi'ls  heeanie  distnrhed. 
He  was  rational  on  the  3<1  and  his  appetite  letnined  on  the  Itli:  he  eoniplaiiu'd  at  this  time  iif  his  hijis  lieinf{ 
sofe:  eij^ht  or  ten  sjiots  or  pinqdes  appeared  on  the  ahdonieii.  fading  on  the  lolhiwin.ij  day.  I'xeept  one  whieh 
develojied  into  a  pnstnle.  As  the  liowels  on  the  .">th  hail  not  heeii  moved  lor  six  or  seven  days,  three  eoinponnd 
cathartic  ])ills  were  given.  Next  day  two  stools  were  passed,  and  on  the  Ttli  six.  whiidi  were  small,  Idoody  and 
accompanied  with  tenderness  in  the  right  iliac  and  ei>igastric  rt'gions.  An  onnee  and  a  hall'id'siilphate  ot'  magnesia 
was  given,  producing  six  cojdons  watery  stools  on  the  ><th.  Dnring  the  three  follow  ing  days  the  howels  were  moved 
twice  daily.  On  the  llth  and  12th  the  pers])irations  recurred,  and  iiuiuine  in  three-grain  doses,  with  aromatic  sul- 
phuric acid,  was  administered.  On  the  liith  eight  stool.s  were  passed  and  the  ))atient  perspired  liut  little.  An  ounce 
and  a  half  of  .suli)hatc  of  magnesia  was  given,  and  inorpliiue  ])reKciilied  for  use  at  night  to  pro<hice  rest  and  (|uiet  the 
l)owels.  Four  stools  were  passed  on  the  14th  hut  none  on  the  liMh.  Again  on  the  llJth  the  howels  were  moved  four 
times.  Meat  and  vegetables  were  omitted  from  the  diet,  thi'  ])atient  being  placed  on  tea,  toast  aiul  rice:  one  ounce 
of  castor  oil  was  given.  On  the  ITtli  three  stools  were  passcil,  and  there  was  tympanites  with  gurgling  ami  some 
tenderness  of  the  abdomen.  After  this  the  bowels  were  nuived  twice  daily  until  the  close  of  the  record.  On  the  IHtli 
tincture  of  iron  was  prescribed,  and  bcefsti'ak  and  potatoes  allowed.  (In  the  20tli  the  patient  cmn|ilained  much  of 
pain  in  his  foot.  On  the  21st  he  was  transferred  to  division  hos|iital.  During  the  continuance  of  this  case  there  was 
some  cough  with  frothy  mucous  exi)ectoration,  and  at  times  some  acceleration  of  the  rospiratiou. 

Ca.sk  !t. — ■liiiin-lidd  and  iimhilical  Undcrnexs;  jmciimoma;  roxe-colorcd  yjo/s;  (Iclirium;  iptHtiixw;  rccorcc^.— Private 
Patrick  (ilinn,  Co.  (i,  27tli  Conn.  'N'ols.;  age  24;  was  admitted  from  (luarters  March  28,  ISICJ.  Next  day  the  pulse  was 
9r>,  respiration  pant  iug,  tongue  yellow,  furred  in  the  centre  and  nu)ist,  bowels  tender,  es|)ecially  in  the  umbilical 
region,  and  nu>ved  six  times;  the  ])atient  had  eaten  nothing  for  four  days.  A  full  dose  of  {'astor  oil  was  given.  On 
the  .SOtli  the  pulse  was  104  and  dicrotic,  the  lespiratioii  2K,  the  tongue  furred  white  or  yellowish-white  but  reil  and 
somewhat  dry  at  the  tip;  the  howels  were  nu)ved  live  times  and  continued  tender.  (Quinine  in  ten-grain  doses  was 
given  with  opium  three  times  a  day.  The  diarrluea  jiersisted,  giving  daily  three  to  five  stools  resembling  pea-soup, 
until  April  8,  when  it  ceased;  it  was  accompanied  by  tenderness  in  the  epigastric  region,  tenderness  and  gurgling 
in  the  umbilical  and  right  iliac  regions.  The  respiration  continued  somewhat  accelerated,  about  24,  and  on  the 
1st  the  sjiuta  becann^  rust.v,  changing  in  a  few  diiys  to  yellow  matter  mixed  occasiomilly  with  bloody  lumps,  and 
retaining  this  ehaiacler  until  the  loth,  after  which  the  j)\ilmoiiary  8ym])toms  lost  their  ]irominence.  .Some  indistinct 
ro.se-c<)lored  sjjots  ajipeareil  ou  Maridi  31 ;  eight  were  noted  on  the  abdonu'n  on  A|)ril  1,  and  about  fifty  on  the  follow- 
ing day.  On  the  1st  the  iiuinine  was  diminished  to  three  grains  three  times  daily,  with  whiskey  and  morphine, 
beef-tea.  toast  and  rice;  carbonate  of  ammonia  was  jircscribed  on  the  Titli,  but  as  it  seemed  to  cause  vomiting  its 
administration  was  susjjendcd.  No  delirium  or  other  head-symptoms  had  been  noted  up  to  this  time,  but  on  the  7th 
there  was  deafness,  and  although  the  pulmonary  sym])toms  were  improving,  the  respirations  being  but  18  per  minute, 
the  face  was  of  a  dusky-purjjlish  color.  On  the  8th  the  face  was  less  dusky  and  the  ajijx'tite  returning.  On  the  9th 
there  was  epistaxis  and  the  integtiments  over  the  sacrum  weri^  reddened.  Sudamina  appeared  ou  the  llth,  many  of 
them  occurring  on  the  site  of  rose-<-olore(l  s|)ots  which  were  yet  i)resent.  At  this  date  free  jierspiration  began  to 
occur  at  night  and  continued  to  the  end  of  the  ])eriod  covered  by  the  re(H)rd.  The  eyes  were  Janndii'ed  on  the  12tli, 
and  two  days  later  delirinm  occurred  for  the  first  tinn-  in  the  progress  of  the  case.  (Quinine  in  small  doses,  with 
aromatic  sulphuric  acid,  was  given  on  the  Kith.  On  the  18tli  the  luilse  was  72,  the  tongue  clean,  api)etite  good 
and  bowels  quiet ;  there  were  many  rose-colored  8])ots  on  the  abdomen  and  the  sudamina  were  shrinking.  Steak  was 
permitted  to  be  used  and  tincture  of  iron  prescribed.     Next  day  the  patient  was  transferred  to  division  liospital. 

Case  10. — ISroiichitis;  diarrhua  and  ahdomintil  tendenieim,  chicflji  iimhilical ;  febrile  movement  ulighl ;  rone-gpots  on  Sth 
and  16th  daya ;  recovery. — Private  Frederick  Buckley,  ('o.  A,  27th  Conn.  Vols.;  age  19;  was  taken  with  diarrlia'a 
Dec.  1,  18t)2,  and  sent  to  general  hospital.  On  his  return  to  the  regiment  the  disease  recurred  after  exposure  ou 
I>icket  towards  the  end  of  March,  1803.  He  was  admitted  to  hos])ital  on  the  28tli,  andon  the  follow  iug  day  the  pulse 
was  84,  respiration  20  to  24,  tongue  furred  white  and  its  papilhe  pro,jecting;  he  had  ten  stools  during  the  twenty- 
fonr  hours,  and  there  was  tenderness  over  the  entire  course  of  the  colon,  particularly  over  the  transverse  colon. 
Quinine  in  five-grain  doses  was  given  three  times  a  day.  On  April  1  the  bowels  were  (juiet,  the  tongue  red  at  the 
tip  and  edges  and  less  moist;  there  was  cough  with  thick  white  expectoration;  the  abdomen  was  full,  tender  in  the 
ei)igastrie  an<l  umbilical  regi<uis  and  tender  and  gurgling  on  i)ressure  in  the  right  iliac  region.  On  the  4th  two 
pink-colored  and  slightly  raised  papules  were  observed  on  the  abdomen.  After  this  the  patient  improved :  his  bowels 
were  but  slightly  relaxed  and  the  tenderness  diminished  daily;  the  cough  lessened  and  the  respirations  became  of 
normal  frequency,  though  continuing  somewhat  labored;  his  ajipetite  returned  and  he  was  allowed  meat  twice 
dail,v.  No  cerebral  symptoms  are  mentioned  as  having  been  present.  Perspirations  and  sudamina  were  noted  on  the 
12th,  as  also  a  few  rose-colored  spots  on  the  abdomen,  but  the  bowels  continued  quiet  and  free  from  tenderness  except 
in  the  umbilical  region  ;  a  cathartic  pill  on  the  llith  cau.sed  but  one  nujvement.  The  case  was  transferred  to  division 
hospital  on  the  19th.     [This  man  was  nltinuitely  returned  to  duty  from  the  Mower  hospital,  Philadelphia,  July  20.] 

Ca.sk  11. — Saiiwa  and  vomttinj/ ;  slii/hl  diarvhoti  and  tendernesn  in  the  umbilieal  and  iliae  veyionn;  pink  apotn  on  the 
abdomen  and  cheat;  recovery. — Private  Win.  A.  Beard,  Co.  C,  27th  Conn.  Vols.,  having  been  feeling  sick  for  a  week, 
was  admitted  to  hospital  April  5,  1863.  Next  day  the  pulse  was  96,  respiration  20,  tongue  brown  and  dry  in  the 
centre,  bowels  slightly  relaxed  and  tender  on  pressure  in  the  right  iliac  fossa;  he  had  anorexia,  thirst,  nausea  and 
vomiting  but  no  cough.  Quinine  in  five-grain  doses  was  given  three  times  daily.  The  tongue  became  dry  and 
rough  as  if  baked  or  toasted,  but  the  symptoms  did  not  change  much  for  the  worse.  The  bowels  were  moved  once 
or  twice  daily,  the  passages  thin  and  watery ;  sometimes  there  was  no  movement  during  twenty-four  hours,  but 


254  CLINICAL    RECORDS    OF 

tenderness,  cbietly  marked  in  the  nmbilical  and  iliac  regions,  was  iiroscnt.  On  tlie  10th  the  patient  was  reported  as 
looking  brigliter  and  huigliinf;.  On  the  lltli  one  red  pimple  was  found  on  the  abdomen;  it  faded  on  the  14th  ;  mean- 
while there  was  some  vomiting  oil  the  12th.  Three  pink  spots  ajipeared  on  the  abdomen  and  chest  on  the  15th,  fading 
on  the  18th.  Some  headache  was  reported  on  the  ITtli.  On  the  IPtli,  wlien  the  patient  was  transferred  to  division 
hospital,  the  tongue  was  sticky  and  Komewhat  furred,  the  appetite  fair  and  the  liowels  (juiet  and  not  tender.  Roasted 
apples  formed  a  part  of  the  dietary  tlironghout  the  pr<igress  of  this  case. 

Cask  113. — liirin-riiiij  chUh ;  nhdomen  coiicavi-  kiiiI  tender;  roHf-voIorcd  upotn ;  nociurnal  ddirium;  record  incomplHc. — 
Private  H.  K.  Isliell,  (Jo.  G,  27th  Conn.  V'ols.;  age  30;  was  admitted  April  H,  186.S,  having  been  sick  in  quarters  since 
March  20  with  chills  daily  in  the  afternoon  or  evening.  On  the  9th  tlic  inilse  was  72,  respiration  24,  li])S  cracked, 
tongue  moist  and  white  furred,  bowels  quiet  but  tender  in  the  nmbilical  and  left  iliac  regions;  the  jiatient  was  very 
nervous-looking  and  did  not  rest  well.  Quinine  in  four-grain  doses  was  given  three  times  daily,  with  diet  of  toast, 
roasted  a])ide,  tea,  rice  and  beef-tea.  On  the  lOth  there  was  continuous  headache  and  soreness  in  the  chest  in  deej) 
breathing.  Next  day  about  a  dozen  spots  api)caied  on  the  abdomen.  They  were  touched  with  nitrate  of  silver- 
On  the  12th  they  were  replaced  by  eight  fresh  spots;  eleven  otliers  appeared  next  day,  all  of  w  hich  were  touched 
with  nitrate  of  silver.  Tlie  abdomen  at  this  time  was  concave  and  tender  and  there  was  gurgling  under  pressure; 
sleep  was  disturbed  by  dreams.  On  the  14th  the  pulse  was  «8,  respiration  10,  tongue  raw  and  glazed  in  the  middle; 
three  thin  and  watery  stools  were  passed;  six  new  spots  ai)peared  on  the  surface;  the  patient  talked  in  his  sleep. 
While  in  this  condition  ho  was  transferred  on  the  liHh  to  Division  liospital;  [he  was  discharged  .Tuly  27.] 

Cask  13.— Fahrilc  coiidilion  aKSOciated  u-ilh  hroiichilix ;  slooh  hifmiiient  hut  loouc ;  trnderiicss  over  colon,  hut  no  tijm- 
panilcs  nor  roxe-colored  apots ;  cerrhnd  xi/mptoms  sliyht ;  clinical  hintory  not  nugycHtirc  of  the  typhoid  offcctiou. — For  this  case 
see  No.  330  of  the  poHt-mortem  records. 

It  is  difficult  to  determine  to  wliat  extent  tlie  freedom  of  these  cases  from  the  acute 
manifestations  of  malarial  disease  was  due  to  the  lavisli  use  of  Cjuinine  in  the  medical  serv- 
ice of  the  regiment.  AVe  may  suppose  that  this  treatment  would  have  prevented  cliills  and 
febrile  accessions  in  the  subsequent  progress  of  the  cases;  but  inflammatory  processes  fol- 
lowing malarial  congestions  of  tlie  intestinal  mucous  membrane  would  have  persisted  for 
some  time,  giving  rise  to  a  more  general  abdominal  tenderness  tlian  usually  characterized 
unmodified  typhoid  fever.  The  tenderness  so  frequently  noted  in  these  cases  in  regions 
other  than  the  right  iliac  may  therefore  be  accepted,  among  other  indications,  as  suggestive 
of  a  malai'ial  complication.  It  is  true  that  only  in  case  12  was  the  attack  ushered  in  by 
recurring  chills,  but  the  concurrence  of  remittent  fever  in  otlier  members  of  the  command, 
the  existence  of  fevers  reported  as  typho-malarial  during  the  preceding  month,  and  the 
method  of  treatment  adopted  by  the  medical  officers,  give  sufficient  countenance  to  the 
opinion  that  typhoid  fever  in  these  instances  occurred  in  those  who  had  been  exposed  to 
the  malarial  influence. 

If  tlie  practice  of  keeping  clinical  records  of  fever  cases  had  been  generally,  instead 
of  exceptionally,  followed,  there  would  have  been  ample  proof  that  in  a  large  class  of  cases 
the  symptoms  were  not  such  as  to  indicate  with  certainty  the  specific  typhoid  or  malarial 
origin  of  the  febrile  phenomena.  Fortunately  Surgeon  J.  F.  Dyer,  19th  Mass.  Vols.,  has 
preserved  in  his  regimental  case-book  a  series  of  sixteen  cases  which  illustrates  the  diffi- 
culty that  was  frequently  experienced  in  making  a  diagnosis.  Three  of  these  cases  have 
already  been  presented  as  Nos.  5,  13  and  41  of  the  malarial  series;  the  others  are  given 
below.  Cases  1  and  2  wei-e  regarded  as  remittents;  in  fact  typhoid  fever  appeared  to  be 
excluded  by  the  absence  of  symptoms  specially  indicative  of  that  affi'ction.  No.  3,  in 
which  no  diagnosis  was  entered,  was  of  a  similar  character.  In  case  4  there  was  in  addition 
some  broncliial  inflammation.  Xo.  5,  although  reported  as  remittent,  presented  certain 
symptoms — abdominal  pains,  diarrhoea,  faintings  and  continued  ill  healtli — which  become 
of  interest  in  connection  with  the  cases  accompanied  by  more  pronounced  indications  of 
typhoid  fever.  A  similar  remark  applies  to  the  deafness  in  case  6.  In  7,  8  and  9  the 
difficulty  in  discriminating  between  an  adynamic  remittent  and  a  specific  typhoid  fever 
sufficiently  accounts  for  the  absence  of  a  formally  recorded  diagnosis.      The  fatal  case,  10, 


THK    OuNTINn;!'     I'K.V  I'.KS.  2")") 

wliicli  in  point  of  tiiin'  was  tlio  lirst  of  tlio  sci'i.'s.  was  iv|iim1.'(1  as  a  rase  of  tv|'li<iiil.  ('aso 
11  was  ciitciVMl  as  a  r'Miiitti'iit,  allliuimli  iircMMuiiii:'  i'IH'  <>r  iwn  iMjiiivin-al  rox-cdlwi'dl  s|Mits. 
1)111  the  ros(^-col(irr(l  ci'iiiitiiin  in  1 1^  a|i|M'ai's  Im  have  suL:'ii;i'stfil  the  iircsciicc  nf  the  t vi'lmid 
[KiisdU  imt  only  in  it,  altlioHM-li  ili,.  I.owrls  w^i'c  not  rrlaxi'il,  Iml  in  tJn'  fatal  iMsc  \:\,  in 
wliidi  tliofc  was  no  i-oso-i-oIoit,!  ci'niition. 

(,'ask  1. — I'riviitc  Cliiulcs  ('.  I'drln's;  sliarpsluMiicr:  was  udiiiil  tcil  Oct .  L':{,  IStil.  wit  li  lr\  it  mihI  >li,L;lil  ilc-liriiiiii, 
yi'llow-furi't'il  tdlifjiit",  ('(msti]Piitt'il  liowils  ami  (iltiMisi\  c  l>ii  alli;  In-  liail  an  rizciiiatiiiis  i'i'ii)it  ion  hi'twccii  anil  iiiidrr 
till'  I'Vi'S,  anil  showi'il  a  nunliiil  ilcsiri'  to  lie  willi  his  hrail  rmiTcil  \t\  llir  ln'ilrlollirs.  (^iiiniin'  in  I  liii'f  yiain  ili>si'S 
was  nsi'il  I  lure  I  inii's  ilailv.  with  iicrasiona  I  pm  ;;at  i\rs  snili  as  i'iini|>i>iinil  cdliM'vnt  li  ]iills  ami  tlniil  rxtiart  iit'  siMina: 
milk  (lift  was  iiiiliTi'il.  On  Xovrnilirr  11  tlir  lunLtui'  licrami'  ilianrr  ami  the  ai>)iclit<'  ini|>ri>\  ril.  Timtnir  of  iron 
was  ]ires<iili('il  on  the  1  llli  ami  lucl'sri-aU  allow  ril  on  t  lir  llith. '  Itiil  I  lir  howids  a};ain  lii'cann'  ronst  ii>ati'il,  I  In-  tontjiii' 
riincil  anil  the  appetiti'  impaiird.  Conipounil  calliai  t  i>'  jiiUs  ami  ollirf  imijjativr  nirilicinrs  witi'  rmplovnl.  IK- 
w  alkfil  a  lit  til'  on  tlir  IStli  ami  sii'rniil  inipiovini;,  w  hrn,  on  tlir  i')tli.  Ills  t'l'i't  liccainr  iiainl'iil  anil  con  I  inncil  so  np  to 
DeccMilier  1,  the  date  of  liis  tiansfcr  to  general  hos]iiial. 

Cask  2. — I'livatc  William  Kcinnclls:  sharpsliootiT :  was  admitted  Oct.L'l,  lS(;i,witli  icnLittcnl  iVvcr.  lli>  had 
ln'i'ii  in  the  hospital  of  the  'JOt  h  Mass.  lej^iTncMl,  1ml  the  crowded  condition  of  that  CMtahllnhment  necesHitated  IiIh 
removal.  He  wasilnll  and  stupid,  had  headache,  tinnitus  anrinm  and  pains  in  the  linihs;  liis  tontt'ie  "as  thickly 
furred,  appetite  ea|)ricious  and  bowels  constilialed.  lie  was  treated  with  (|uiuine  in  three-ijraiu  doses  three  times 
daily,  with  nitrate  of  potash  and  occasionally  some  couf;h  mixture:  com]ionnil  cathartic  jiills  ami  other  ]>nr;;aliv<'8 
weri^  also  };iven.  On  the  Iltli  he  had  a  slight  purulent  dischar};e  froni  t  he  ear.  'I'im'l  ure  of  iron  was  ]irescril>cd  for 
daily  use  on  the  12tli.  lieefsteak  was  authorized  on  the  L'Hth.  I'ain  in  the  feet,  com|)lained  of  Decemliei-  1,  was  not 
relieved  on  the   Itli,  the  date  of  his  transfer  to  f;eneral  liosjiital. 

Cask  li. — Corporal  .John  Cushinfj;.  Co.  II,  lltth  Mass.  \'ols.,\vas  admitted  Nov.  Iti,  IWil,  havinj;  heen  unwell  for 
about  eight  days  with  chills  and  headache.  On  admission  tlu^  pulse  was  il(),  touf^uc  furred  and  bowels  painful  and 
tender.  A  lialf  drachm  of  ii)ccacuanha  was  given,  and  liftcen  grains  of  nitrate  of  iiotasli  prescribed  for  administra- 
tion three  t  inu's  daily.  On  the  17th  the  umbilical  region  w  as  tender,  the  i)ulse  72,  skin  warm  and  dry,  tongue  thickly 
furred  in  the  centre  and  red  at  the  ti])  and  cdgc^s,  appetite  deficient;  the  ))atient  had  headache  and  buzzing  In  tlio 
ear.s  but  no  e])istaxis.  His  condition  remained  unchanged  for  several  days.  KoineiitatioiiN  wore  applied  to  the 
abdomen,  and  castor  oil  and  extract  of  Honna  wefe  given  without  iiidutnng  a  inovtMiient  of  the  bowels.  On  the  21st 
a  half  ounce  of  (luid  extract  of  senna  and  two  drachms  of  fhiid  extract  of  rhubarb  produced  one  dejection,  and  on 
the  21th  castor  oil  was  followed  by  two  movements.  On  the  2,^th  the  nitrate  of  ]>otash  was  omitted  and  iininine 
given  in  three-grain  doses  instead.  Tlie  bowels  continued  constijiated  throughout  the  progress  of  the  case,  but 
were  moved  at  intervals  of  a  few  days  by  some  laxative  medicine.  For  about  a  week  follow  in g  the  2(!th  the  patient's 
feet  were  .so  painful  as  to  ])revent  him  from  slce|iing  at  night:  frictions  and  afterwards  ]ionlticcs  were  apidicd  to 
them.  On  the  29th  the  fur  began  to  clean  from  the  tongue  and  the  aiijM'tite  to  return.  Milk  diet  was  used  up  to 
December  8,  when  beefsteak  was  allowed.     On  the  l.'>tli  he  w  as  sent  on  furlough  to  promote  convalescence. 

Case  -1. — Private  F.  Chandler,  Co.  I,  19th  Mass.  Vols.,  was  admitted  Nov.  10,  1861,  having  been  ill  for  a  week 
with  weakness,  fever  and  headache.  On  admission  his  imlse  was  112  and  his  tongue  dry  and  streaked.  An  emetic 
of  ipecacmanha  was  given,  and  at  night  a  Dover's  powder.  During  the  night  sleep  was  disturbed  by  pains  in  the  bowels, 
which  had  not  been  moved  since  the  day  before  admission  :  his  tongue  on  the  lltli  was  dry  and  ]iatched  with  w  hitisli 
fur.  Three  comi)ound  colocynth  pills  were  given;  but  these  produced  no  effect  until  the  following  ilay,  when  one 
stool  was  passed.  Siiuill  and  paregoric  were  prescribed  on  account  of  cough.  On  the  15th  the  pulse  was  H6,  moist  and 
cleaning,  but  there  was  uo  appetite.  Nitrate  of  potash,  which  had  been  given  since  admission,  was  replaced  by 
three  grains  of  qninine  twice  daily.  From  this  time  until  the  23d  the  patient  became  weaker;  he  did  not  rest  well 
at  night;  cough  was  troublesome  and  was  accompanied  with  much  mucous  expectoration  streaked  with  blood;  the 
bowels  were  constipated,  reiiuiring  occasional  doses  of  castor  oil  or  extract  of  senna  to  relieve  them.  On  the  23d 
the  tongue  became  very  dry  and  cracked.  On  the  25th  the  nocturnal  restlessness  increased  to  delirium.  After  a 
free  passage,  induced  by  castor  oil  and  extract  of  rhubarb  on  the  2Hth,  the  ])atient  slejjt  well ;  but  next  night  he  was 
kept  wakeful  by  pain  in  the  feet.  This  pain  continued  during  November  30  and  December  1,  causing  loss  of  sleep 
and  slight  delirium.     His  condition  was  improving  on  the  4th,  when  he  was  sent  to  division  hospital. 

Case  5. — Private  F.  Lunt,  Co.  G,  19th  Mass.  Vols.,  was  admitted  Oct.  25,  1861,  with  remittent  fever  and  neu- 
ralgia of  the  right  side  of  the  face.  He  complained  mudi  of  cold  feet  and  for  some  days  of  a  faintness  at  the  epigas- 
trium, lie  was  treated  with  tliree  grains  of  <iuinine  threi'  times  daily,  but  on  November  9  Fowler's  solution  was 
substituted;  ])nrgativcs  were  used  to  move  the  bowels.  On  the  10th  he  complained  of  headache,  sore  throat  and 
coryza.  On  the  12th  he  fainted  on  two  occasions  when  attempting  to  rise;  tlu^  sounds  of  the  lieart  were  indistinct. 
Cam])hor  and  valerian  were  prescribed.  The  headache  continued,  and  on  the  13th  the  scalp  was  rubbed  with  tincture 
of  aconite  diluted  with  alcohol.  On  the  lUh  he  had  colicky  pains  and  diarrluea.  The  Fowler's  solution  was 
omitted  on  the  15th,  four  grains  of  iininine  three  times  daily  being  substituted  for  it.  On  the  16th  the  patient  fainted 
on  rising  to  stool.  The  headache  became  somewhat  lessened  next  day;  three  greenish  stools  were  passed  with  much 
colicky  pain.  Fotrr  similar  stools  were  recorded  on  the  18tli.  A  ten-grain  dose  of  calomel  followed  by  castor  oil 
caused  frequent  dejections,  some  being  greenish  in  color  and  bloody.  Opium  was  prescribed,  but  the  colicky 
l>ains  did  not  cease  nor  the  blood  disappear  from  the  stools  for  several  days.    On  the  27th  headache  was  again  com- 


256  CLINICAL    KKCORDS    OF 

plained  of,  and  as  tlic  bowels  liad  beoome  iiiiictive,  coiiiixiuiul  oolocynth  and  lilno-])ills  were  <;iveii.  A  blister  was 
.  ai)j)lieil  to  tlie  liaek  of  tlie  iieiU  on  tlu'  :^()tli.  I  >ii  December  3  there  was  pain  and  di.seonifoit  in  tlic  stoniacli  with 
aeid  enietations,  for  wliieli  rlnibarl)  and  liiearlxmale  of  soda  were  prescribe(L  Next  day  the  patient  was  transferred 
to  j;eneral  hospital.     |IIe  was  discharj;ed  on  the  llitli  on  account  of  neuialf^ia.] 

Case  H. — Corporal  ,1.  C.  Cronan,  Co.  (i,  19th.  Mass.  Vols.,  took  cold  abont  Nov.  11,  ISIil,  and  had  been  constipated, 
withont  aii])etitt^  and  troubled  with  a  eoiigh  since  that  time.  He  had  taken  jiurjjative  pills  with  effect.  He  was 
admitted  on  the  IKtli.  Dover's  ))ow(1<m' was ';iven.  On  the  littli  the  coufj;h  was  nrijent;  the  i)atient  was  deaf  andbad 
tinnitus  but  no  hea<la(die  nor  epistaxis;  the  bowels  were  quiet  and  not  tender  but  ap|>etite  was  wantiufj.  Small 
doses  of  tincture  of  opium,  wine  of  antimony  aiul  chloroform  were  i)reseril)ed,  with  extract  of  valerian  at  night. 
Next  day  the  teeth  were  covered  with  sordes  and  the  tongue  with  a  thin  black  fur.  Fluid  extract  of  senna  was 
given.  The  patient  had  nausea  on  the  21st;  the  jnescription  of  the  liltii  was  omitted  and  i|uinine  in  three-grain 
doses  substituted.  This  was  omitted  on  the  2Sd,  as  it  a]ipeared  to  increase  the  nausea;  nitrate  of  potash  in  fifteen- 
grain  doses  was  given  iiistea<l.  The  tongue  became  gleaner  and  the  patient  felt  better  on  the  2<ith,  but  occasional 
purgatives  were  reciuired  for  some  time  after  this  date.  On  the  :?Oth  he  was  able  to  sit  up  and  his  ajipetite  was  go<i(l. 
He  was  fuiloughed  December  12. 

Cask  7. — Ejiliraim,  a  colored  servant,  was  admitted  Nov.  9,  1801.  He  had  been  troubled  with  a  cough  for  two 
or  three  days,  anorexia,  headache  and  pain  in  the  back  and  limbs.  On  admission  the  tongue  was  thickly  white- 
coated,  the  pulse  90  and  full;  the  headache  had  ceased  but  there  was  much  thirst  and  restlessness  at  night.  Nitrate 
of  i)otash  in  lifteen-graiu  doses  was  given  three  times  a  day  with  Dover's  powder  at  night.  One  loose  dejection  was 
passed  on  the  lOth  and  another  next  da.y.  Thirst  was  a  ])rominent  sym|)toni;  currant-jam  with  water  was  used 
as  a  drink.  On  the  evening  of  the  11th  the  skin  becauu'  hot  and  dry  and  the  tongue  dry.  white  in  the  centre  and 
red  on  the  edges.  The  i)atient  was  delirious  during  the  night,  and  on  the  12th  was  stupid;  sordes  appeared  on  the 
teeth;  the  jinlse  was  100  and  feelile.  (Quinine  in  three-grain  doses  was  given  three  times  a  day  and  a  half  ounce  of 
brandy  every  two  hours;  the  nitrate  of  potash  was  omitted.  During  the  night  he  escaped  in  his  delirium  from  the  ward 
and  returned  to  ([uarters.  Next  day  he  hadepistaxis,  and  in  the  evening  one  involuntary  bloody  dejection.  Small 
doses  of  carbonate  of  ammonia  were  given  every  two  hours.  Four  loo.se  and  bloody  stools  were  pa.ssed  during  the 
night  of  the  13th  and  three  on  the  following  day;  the  extremities  were  cold  and  there  was  some  muscular  trembling. 
The  carbonate  of  amnu)nia  was  replaced  by  turpentine.  On  the  15th  the  stools  were  frecjuent,  thin  and  mixed  with 
blood-clots  or  consisting  chiefly  of  blood,  but  the  delirium  was  somewhat  lessene<l.  On  the  l(5th  he  became  finite 
rational  towards  morning;  his  i)ulse  was  scarcely  perceptible  at  the  wrist,  <^xtr(^mities  cold;  stools  fre(iueut,  scanty 
and  bloody;  tongue  cleaner  and  more  moist.  He  rallied  well  on  the  17th,  and  next  day  his  appetite  was  voracious; 
but  on  the  19th  he  had  pain  in  the  bowels,  headache  and  furred  tongue,  and  there  was  some  mental  wandering, 
especially  at  night.  This  condition  persisted  for  a  week,  during  which  the  bowels  remained  unmoved.  On  the  25th 
his  back  was  found  to  be  excoriated,  but  on  the  30th  the  excoriations  were  reported  as  healing.  His  bowels  con- 
tinued confined  and  he  did  not  rest  well  at  night,  but  hi.s  appetite  was  excellent  and  his  strength  returuing,  when 
on  December  1  he  was  sent  to  division  hospital  on  account  of  the  removal  of  the  regimental  camp  from  Poolesville 
to  Muddy  Branch,  Va. 

Cask  8. — Private  .John  Koss,  Co.  I,19tli  Mass.  Vols.,  was  taken  sick  about  Nov. 8,  18(U,  with  chills,  pains  m  the 
head  and  bowels  and  slight  diarrhrea.  On  entering  hospital  on  the  13th  the  patient  was  in  a  general  perspiration : 
his  tongue  was  red  at  the  tip  and  edges  and  furred  in  the  centre ;  he  had  no  appetite,  no  epistaxis  and  no  tinnitus; 
he  said  he  usually  felt  better  in  the  morning  than  at  night.  Quinine  in  five-grain  doses  was  given  three  times  a  day. 
He  had  three  or  four  dejections  during  the  night,  with  jjain  in  the  bowels,  but  next  morning  felt  very  well.  The 
diarrhu'a  was  not  restrained  by  Dover's  powder  or  tincture  of  opium.  On  the  night  of  the  Kith  involuntary  watery 
discharges  were  passed,  and  during  the  17th  the  patient  slept  nujst  of  the  day,  nuittering  dreamily.  On  the  18th 
his  face  was  flushed,  eyes  suft'used,  tongue  red  and  cracked;  he  groaned  and  talked  in  his  sleep  and  was  easily 
awakened;  he  had  nmch  headache,  a  short  cough  and  pain  in  the  umbilical  region  ;  the  watery  discharges  persisted; 
the  pulse  was  96;  skin  hot  and  without  any  rose-colored  spots.  He  had  scune  nausea  after  taking  an  opiate  on 
the  19th.  He  continued  to  sleep  most  of  the  time  with  his  eyes  half  closed,  moaning  and  muttering,  but  always 
rational  when  arou.sed.  On  the  23d  he  did  not  moan  so  much.  On  the  24th  nausea  and  vomiting  followed  the 
use  of  quinine,  which  was  thereuiion  suspended.  In  the  course  of  a  few  days  the  diarrluea  becanui  somewhat 
restrained,  but  the  cough  increa.sed  and  was  attended  with  much  expectoration  ami  some  pain  in  the  side;  the  tongue 
continued  brown  and  cracked,  the  ai)])etite  failed  and  thirst  increased.  By  December  2,  however,  he  was  able  to  sit 
up,  and  on  the  13th  he  was  returned  to  ([uarters. 

Case  9. — Sergeant  J.  Q.  A.  Ferguson,  Co.  B,  19th  Mass.  Vols.,  was  admitted  Nov.  2(),  18G1.  He  had  been 
unwell  for  a  fortnight,  during  which  he  had  lost  strength,  and  more  recently  liad  become  stupid  and  ])artially  deaf. 
On  admission  his  face  was  flushed,  eyes  suft'used.  skin  hot  and  dry,  tongue  moist  and  slightly  coated,  lips  jiarclied, 
pulse  80;  he  had  some  cough  and  8ul)sternal  pain.  Small  doses  of  oi>ium  and  ipei^aciianha  were  prescribed.  On 
the  27th,  as  the  bowels  had  not  been  moved  for  three  days,  fifteen  grains  of  compound  (extract  of  colocynlh  were 
given:  two  dejections  followed  its  use.  The  tongue  became  clean  and  the  patient  walked  about  a  little;  his  appetite 
was  good,  but  he  did  not  rest  well,  his  pulse  was  accelerated  and  his  lijis  ])arched.  On  December  1  h<^  was  deliiious 
and  deaf;  on  the  3d  he  had  epistaxis.  In  this  condition  he  was  transferred  to  division  hospital  on  the  4tli  on  account 
of  the  breaking  up  of  the  regimental  camp.     [His  name  does  not  appear  on  the  register  of  deaths.] 

Cask  10. ^Private  Ellas  W.  Phelps,  Co.  (i,  19th  Mass.  Vols.,  was  admitted  Oct.  1,  1861,  having  l)een  suffering 
for  several  days  from  fever,  lassitude,  want  of  appetite  and  ])aius  in  the  head  and  bowels.  On  admission  the  patient 
was  somewhat  delirious,  his  pulse  96,  tongue  thickly  covered  with  a  dark  fur  and  bowels  unmoved  for  three  days. 


TIIK    CU^'TINUKD    KKVKRS. 


257 


An  iiiocacuauha  emetic  was  given,  lie  was  restless  duriuf;  the  nifjlit.  talkinfj  in  liis  sleep  anil  ineoheient  when 
awake.  A  purjrative  consisting  of  one  blue-pill  and  one  eouiponnd  cathartic  pill  jiniduced  one  free  dejection;  but 
in  the  evening  the  tongue  was  darker  and  the  jjatient  indifferent  to  everything  when  not  sjiecially  addressed.  On 
the  3d  the  delirium  was  increased,  the  stools  involuntary,  the  iiulse  120  and  the  tongue  dry  and  dark.  No  rose-colored 
spots  were  discovered,  lirandy  was  given  at  intervals.  The  diarrlnva  and  delirium  continued;  the  teeth  and  li])8 
became  coated  with  sordes ;  the  muscles  twitched  ilnd  the  pulse  increased  in  fre(]Ueiicy  while  losing  in  strengtli  until 
it  became  imperceptible.     Death  occurred  October  ">. 

Case  11. — Private  J.  Fitzgerald,  Co.  I,  19th  Mass.  \'ols..  was  admitted  Nov.  1,  ISIll,  witli  wi'U  nuirked  remittent 
fevfir,  for  which  three  grains  of  quinine  were  given  three  tiuu-s  daily,  lie  coni))laincd  of  not  sleeping  well  at  night. 
Valerian  and  Hoffnutuu's  anodyne  were  prescrlhed  for  use  at  bedtime.  On  the  r2th  the  tongue  was  thickly  coated, 
the  teeth  covered  with  sordes,  pulse  itii  and  feeble;  one  stool  was  passed  during  the  previous  twenty-four  hours;  the 
ap])etite  continued  fair.  Oiu>  stool  was  passed  on  the  l^th,  but  there  was  no  gurgling  nor  tenderness  in  the  iliac 
region:  one  or  two  equivocal  rose-spots  were  observed;  th(<  tongue  was  dry;  the  jiatient  slei)t  a  little  during  the 
day  and  muttered  in  his  sleej).  Hrandy  and  tincture  of  iron  were  prescribed,  lie  was  somewhat  delirious  during 
the  14th;  his  face  livid,  hands  cold,  tongue  red  at  the  tip  ami  edges,  respiration  short  au<l  loud,  imlselKi;  on  this 
morning  he  tried  to  support  himself  and  fell:  one  stool  was  )>assed.  On  tlie  l.-itli  the  jiatient  was  stupid,  spoke 
with  difficulty  and  had  muscular  twitchings;  the  bowels  were  (juiet.  Next  day  he  was  delirious;  the  tongue  was 
black,  dry  and  cracked,  the  pulse  very  feeble,  and  the  bowels  unmoved.     Death  took  place  on  the  18th. 

Case  12.— Private  Edward  Brailey,  Co.  I),  lilth  Ma.ss.  Vols.,  was  admitted  Oct.  11.  IWil.  He  had  been  on  picket 
duty  on  the  banks  of  the  Potomac  and  duriiig  tlie  last  two  days  had  felt  cold  .ami  feverish,  lie  came  to  camp  in  a 
baggage  wagon.  His  face  was  flushed,  pulse  90,  tongue  covered  with  a  thick  wliitc  fitr;  he  was  restless  at  night 
and  talked  a  good  deal  in  his  sleep.  An  emetic  of  ipecacuanha  was  given  on  admission  and  a  Dover's  powder  at  night. 
Next  day  the  pulse  was  96,  skin  hot,  face  flushed,  eyes  siifl'u.sed,  tongue  dry  and  wldto,  teeth  covered  with  aordes, 
bowels  nu)ved  twice,  stools  thin  and  watery.  Sweet  spirit  of  nitre  was  ])rescribed  and  quinine  in  two-grain 
doses  three  times  a  day.  On  the  13th  the  patient  pers))ired  a  little  at  tiuw's  and  tlu;  skin  of  the  abdomen  showed 
some  rose-colored  spots ;  he  had  one  jiassage  and  the  al>douuMi  was  rather  full,  but  there  was  no  tenderness  nor  gurg- 
ling. Extract  of  valerian  was  given.  Delirium  came  on  gradually  and  continued  until  the  19th,  when,  after  a 
good  sleep,  he  awoke  feeling  better  and  more  rational.  During  this  period  the  bowels  were  rather  constijiated  ;  the 
rose-colored  spots  were  very  thickly  set  and  bright  on  the  abdomen.  He  took  jmrt-wiue  and  chicken-broth;  brandy 
was  rejected  by  the  stomach.  On  the  20th  he  sat  up  in  bed  with  aid  to  read  a  letter.  After  this  his  condition 
improved  for  some  days,  but  the  bowels  remained  unmoved  and  the  tongue  furred.  An  enema  was  given  on  the  23d, 
with  castor  oil  in  the  eveiung  and  extract  of  senna  on  tlie  following  day;  one  alvine  dejection  was  thus  ])rocured  on 
the  25th,  after  eight  days  of  torpidity.  On  the  2(itli  the  face  was  duslied,  eyes  suffused,  pupils  dilated,  mouth 
dry  and  tongue  covered  with  patches  of  thick  white  fur;  headache  was  also  luest^nt.  Next  day  the  tongue  was 
clean  but  rather  abnornurlly  red  in  color;  the  patient  complaiiu-d  of  soreness  from  lying  so  long  in  bed.  The  bowels 
continued  constipated,  stools  being  obtained  only  at  intervals  of  three  or  four  days  l)y  the  use  of  extract  of  senna,  but 
about  the  middle  of  November  four  to  six  figs  were  eaten  daily  and  under  their  use  the  bowels  became  more  regular. 
On  the  9th  of  this  month  complaint  was  made  of  tender  fei^t,  and  this  was  continued  until  the  17th,  when  the  ten- 
derness diminished.  He  sat  up  for  a  short  time  on  the  18th  and  during  most  of  the  day  on  the  19th.  Beefsteak  was 
now  allowed  in  the  dietary  instead  of  the  soups,  broths  and  soda  crackers  to  which  he  had  been  restricted  up  this 
time.     He  was  furloughed  December  12. 

Case  13. — Private  James  Kelly,  Co.  D,  19th  Mass.  Vols.,  was  admitted  Dec.  13, 181)1,  having  been  sick  for  three 
or  four  days  with  slight  cough,  anorexia  and  pains  in  the  head  and  limbs;  his  tongue  was  dry  and  brown  in  the 
centre,  pulse  80,  bowels  constipated.  Ten  grains  each  of  blue-mass  and  colocynth  were  given  at  night.  On  the 
morning  of  the  14th  it  was  reported  that  the  patient  had  groaned  during  most  of  the  night;  his  face  was  flushed 
and  breathing  short.  Next  day  diarrha-a,  epistaxis  and  tinnitus  aurium  were  recorded  as  present.  Tannin  in  five- 
grain  doses  was  prescribed  three  times  daily.  On  the  19th  the  passages  became  involuntary.  C>n  the  20th  the  tongue 
was  dark-colored,  the  teeth  black  with  sordes,  diarrho-a  profuse,  pulse  100,  respiration  short  and  mind  wandering. 
No  rose-colored  sjiots  were  found  on  the  skin.  Turi)entine  was  substituted  for  the  tannin.  [The  case-book  gives  no 
further  information,  but  on  the  register  of  deaths  this  man  is  reported  as  having  died  of  typhoid  fever  Dec.  20,  1861, 
at  the  regimental  hospital,  Muddy  Branch,  Va.] 

Fever  cases  from  various  records. — The  following  cases  have  been  selected  from 
the  case-books  of  various  hospitals  and  from  the  medical  descriptive  lists  to  further  Illustrate 
the  character  and  consequences  of  the  fevers  which,  although  reported  as  typhoid,  were 
probably  in  many  instances  more  or  less  modified  by  the  malarial  influence. 

Cases  1-5  are  presented  as  specimens  of  a  large  class  of  records  which  give  an 
account  of  the  condition  of  the  patient  at  some  period,  usually  that  of  admission  into  hos- 
pital, but  fail  to  carry  out  in  detail  the  daily  progress  of  the  case.  It  is  not  difficult, 
however,  to  appreciate  the  course  of  such  cases,  especially  when  aided  by  a  study  of  those 
which  have  been  recorded  in  full;  for,  in  addition  to  the  result,  there  is  given  generally 
Mkd.  Hist.,  Ft.  Ill— 33 


258 


CLINICAL    RKCORBS    OF 


some  sliort  statement  as  to  progvess,  or.  in  tlie  absence  of  tliis,  sdiiio  liint  as  to  the  patient's 
condition  is  conveyed  liy  reconlcd  diaiiuvs  in  tlic  medication  or  diet. 

Ca.sk  L— St'ificaut  Xahuiii  L.  ILiywanL  Co.  F.  iJth  Conn.;  age  30;  was  adniitti^il  fioni  tho  field  .May  L':),  ]S()4, 
with  typlioid  fever.  He  was  nnalile  to  give  a  satisfaetory  aceount  of  Iiiniself.  I[i^  had  headaelie,  restlessness  and 
anxiety  of  expression,  ineessant  thirst  and  niiieh  diarrluea;  his  tongue  was  daiU,  cracked  and  dry,  jiulse  feeble  and 
rapid,  abdomen  tympanitic  and  but  slightly  teuder.  The  surtiice  of  the  body  was  sponged  with  tepid  water;  cold 
was  applied  to  the  head  and  counter-irritation  to  the  back  of  the  neck;  turpentine  emulsion  was  given  with  niilk- 
puneh  freely,  beef-tea  at  short  intervals  and  anodynes  at  night.  The  symptoms  increased  in  violence;  the  patient 
became  noisily  delirious  and  died  .June  1. —  l/diiuiionil  Ho-ipitoi,  Point  Lookout,  Mil. 

C.\si-;  2. — Private  David  F.  Farr,  Co.  K,  J<th  Me.;  age21;  was  admitted  Aug.  17,  18(51.  having  been  sick  since 
July  27  with  tyjihoid  fever.  He  was  much  prostrated,  tongue  furred  and  dry,  conjunctivie  injected.  (Quinine 
with  brandy-punch  and  turpentine  emulsion  was  given.  lUarrluea  supervened  on  the  18th,  but  was  checked  two 
days  later.  The  turpentine  was  omitted  on  the  23d,  the  brandy  on  the  25th,  the  iiuinine  on  the  2Xth.  The  patient 
was  able  to  sit  up  on  the  27th.  He  was  furloughed  September  3  and  returned  to  duty  November  28. — Srdtcrlfe  IIos- 
jntal,  rhilmldphia,  Pa. 

Case  3. — Sergeant  Kdwin  A.  French,  Co.  B,  17th  Pa.  Cav..  was  admitted  July  8.  18t)3,  witli  typhoid  fever. 
Countenance  dusky:  pain  in  back;  abdomen  slightly  tympanitic:  sndamina  aiul  taehes  rouges;  gurgling  on  i)ressure 
in  right  iliac  fossa;  pulse  90;  tongue  furred  l)ut  moist:  diy  rales  tliroughout  chest;  jiatient  stupid.  Cave  Miu- 
dererus'  spirit,  (juinia,  beef-essence  and  milk-punch.  22d :  Steadily  improving,  taking  nine  grains  of  quinine 
daily.     August  1,  convalescent.     November  13.  returned  to  duly. — SdhIIi  simt  Ilo.tjiitul,  I'hUndelphia,  I'a. 

Case  4. — Sergeant  Walter  A.  Brooks,  Co.  I,  53d  Mass.,  admitted  Aug.  Ki,  1863;  mind  dull;  abdomen  tympa- 
nitic and  covered  with  sndamina  and  jietechiie,  gurgling  in  right  iliac  fossa;  tongue  dry  and  fissured,  protruded 
with  difficulty;  teeth  covered  with  sordes;  face  sutiused ;  subsultus  tendinum;  nuich  delirium.  Cave  an  ounce  of 
sherry  wine  every  hour;  beef-tea  freely.     Died  August  20. —  Union  Hoxjiitiil,  Monjihis,  Tcnn. 

Cask  5. — Private  Fabian  Liszt,  Co.  C,  llUh  Pa.  Cav.;  age  22;  was  taken  sick  Aug.  10,  18()3,  a  few  weeks  after 
enlistment,  and  was  admitted  on  the  17th  much  exhausted,  with  brown  furred  tongue,  hot  and  dry  skin,  pulse 
120  and  a  diarrhoea  of  three  or  fotir  stools  daily.  Dover's  powder,  neutral  mixture  and  sweet  spirit  of  nitre  were 
prescribed.  On  the  20th  the  pulse  was  100,  the  tongue  moist  and  the  bowels  not  so  loose.  Milk-punch  was  given. 
Small  doses  of  blue-pill,  opium  and  ipecacuanha  were  prescril)ed  on  tlie  22d,  for  which,  on  the  2(ith,  neutral  mixture 
was  substituted.  On  September  10  full  diet  was  allowed  and  small  doses  of  <juinine  prescribed.  He  was  returned 
to  duty  October  21. — Tnrnir's  Lane  Hospital,  Pliiludtlpliid,  Pa. 

In  cases  6  and  7  the  fever  began  to  dechne  about  the  end  of  the  second  week;  in 
case  8  it  was  prolonged  for  another  week,  apparentlv  in  connection  with  the  intestinal  lesion. 

Case  (i.— Private  E.  T.  Ellsworth,  Co.  C,  IGth  N.  Y.;  age  19:  was  admitted  Oct.  10.  1801.  having  been  treated 
for  three  days  before  admission  with  astringents  and  nutrients.  The  attack  commenced  with  a  chill.  On  admission 
he  had  pain  in  the  head,  back  and  aVidomen,  a  slow  and  feeble  jnilse,  hot  and  dry  skin,  heavily  coated  white  tongue 
with  clean  tip  and  slightly  reddened  edges,  thirst,  slight  cough,  somewhat  labored  respiration  an  I  scalding  during 
micturition.  Next  day  the  characteristic  eruption  came  out  on  the  face  and  abdomen.  His  appetite  was  improved 
on  the  12th :  the  tongue  natural  and  the  skin  perspiring  on  the  13th.  Two  da.ys  later  the  skin  became  dry  and  hot, 
the  tongue  white  at  the  base  and  red  at  the  tip  and  margins,  the  pulse  full,  but  there  was  no  diarrhoea;  next  day  the 
febrile  action  abated.  On  tlie  22d  he  was  considered  convalescent,  and  on  Novemlier  I  he  was  returned  In  ilnty.^ 
Hospital,  Altxunihia,  Vu. 

Case  7." — Private  Thomas  J.  Bitzer,  Co.  P.,  1st  Pa.  Res.,  was  admitted  Sept.  3, 18(i2.  with  tyidioid  fever.  On  the 
4th  he  had  diarrluea  and  profuse  epistaxis.  On  the  tith  the  fever  ran  high;  the  pulse  120,  full  l)ut  compressible,  the 
skin  hot  and  dry,  tongue  moist  and  heavily  coated,  of  a  dirty  l>rowu  color  but  red  at  the  edges  and  tip;  lie  had  tym- 
panites, mostly  over  the  colon,  anorexia,  some  headache  and  backache.  Small  doses  of  sweet  spirit  of  nitre  and  lluid 
extract  of  ipecacuanha  were  given  every  hour  and  five  grains  of  blue-pill  with  Dover's  powder  at  bedtime.  On  the 
7th  the  tongue  was  moister,  the  pulse  full,  slow  and  strong,  the  appetite  better  and  no  stool  had  been  jiassed  for  two 
days;  but  on  the  forenoon  of  this  day  the  fever  returned  and  steadily  increased;  delirium,  jactitation  and  tympa- 
nites over  the  small  intestine  were  noted  in  the  afternoon.  Oil  of  turpentine  and  camphor-water  were  given  every 
second  hour,  alternating  with  a  diajihoretic  mixture.  In  the  evening  the  tongue  became  moist,  the  pulse  soft, 
feeble  and  compressilde  and  the  skin  bathed  in  perspiration.  Next  day  there  was  retention  of  urine.  A  grain  of 
quinine  was  given  every  hour  and  beef-tea  and  milk  freel.y  used.  A  few  poorly  defined  rose-colored  spots  were 
found  on  the  chest  and  abdomen  on  the  9th,  and  the  right  iliac  fossa  was  tender  and  gurgled  on  pressure;  the 
delirium  increased  in  the  afternoon  of  this  day,  but  after  a  full  dose  of  morphia  and  HotTmann's  anodyne  the  patient 
slept  well,  a:id  next  morning  his  apjietite  was  better  and  there  was  an  abundant  crop  of  sndamina  on  the  back  and 
chest.  On  the  15th  he  was  manifestly  improving.  On  the  20th  liis  appetite  was  excellent  and  the  bowels  had  not 
been  moved  for  five  days.  Powdered  rhubarb  in  small  and  repeated  doses  was  jirescribcd.  He  was  returned  to  duty 
November  21. — Hospital  IGth  and  I'llhert  streets,  I'hilaililphia,  Pa. 

Case  8. — Private  David  Old,  Co.  A,  9th  Iowa  Cav.;  age  17;  was  admitted  March  22,  1864,  with  bronchitis,  and 
became  sick  with  typhoid  fever  on  the  30th.  The  pulse  was  small,  105  to  110,  the  tongue  furred;  the  patient  was 
restless  and  had  headache,  giddiness,  chilliness,  an  unpleasant  taste  in  the  mouth,  no  appetite,  scanty  urine  and  no 
diarrhd'a.     During  the  second  week  the  pulse, was  strong,  118  to  122,  skin  warmer,  tongue  dry,  red  at  the  tip  and 


TUK    roMIM'KI.)    KKVKK8.  2-~)9 

ciIj^cn:  tliiir  \v:i.-,  al.-ii  m-vimc  Ii<-mi1;u1ic.  with  sjiiiial  ami  muse  uhir  pains  and  symjuoins  iif  |)m'Mm()uiii  in  the  U)\vt'r  h)lio 
of  lln'  1  ii;hl  lunu  At'lci'  tlie  tent  h  ihi.v  miiiiiti'  rnsi'-U'd  ,s|hiIs  aii|ii'aie(l  im  tlic  lucast  and  ahdcimcn.  and  there  was  Homu 
diailhiea.  I'liriini  tlic  thiid  week  tlu'  tnni;ne  was  div.  lnnwn  and  smiinlli.  tln>  teelli  and  i;nms  eoveied  with  sordes, 
the  lips  di'\ .  the  skin  liot  and  diy.  the  jnilsi'  IL'S  to  InL':  didirium.  espeeiall\  al  nii;lit .  deat'iii'ss.  pain  in  the  rij;ht  iliac 
leijion,  tympanites,  diarrhd-a.  disturlied  sleeii.  anoiexia  ami  i;reat  lliiist  were  jiresenl.  In  the  lonrtli  and  iiCtli  weeks 
the  tongue  was  moister  and  (deaner.  the  pulse  !tO  to  SO.  the  eountenanee  hrinhtei,  llw  e\aenalions  natural  and  the 
aplietite  imjildvinj;.    ( )n  May  L'  tin'  pat  lent  was  sent  to  Kei  dink,  low  a.  as  a  eon\  ali'seeni .  —  /.,(»■»<)»  Il(i.-.]iitiil  .St.  /.oin'.v,  .Vo. 

Caf^os  i'-17  illustrate  the  (n-curiTiiee  of  iutrsiinal  liniKirrlia^c,  df  |nTl'i>ratioii  ut'  tlie 
intestine  and  i>l   eomplicatinu-  i>v  sfijumt  erv<ipi'la~.  |iin'Uiiiciiiia  ainl  diari'luea. 

t'.^sK  !t. — Iiitislinal  hfmorrhtuji. — I'vivate  ]\'(diert  11.  Howe.  Co.  I!.  lIDlh  I'a.:  aii'eL'l':  was  admitted  from  llare- 
woiul  hospital,  Washin.!;toii,  May  ti.  l!St!2,  as  a  eonvalescent  from  ty|ihoi(l  fever.  On  the  lOtli  lie  had  hemorrhage 
from  the  bowels.  Sulldiate  of  iiuinine,  tincture  of  iron  and  milk-pnnch  wcr<Mised  in  the  treatment.  Severe  hemor- 
rhage continued  n]i  to  .June  11.  On  .luly  18  he  was  niU(  h  hi'ltc-r.  Medicine  was  omilted  on  the  {ilst.  'I'he  patient 
was  fiirlotighed  August  8  and  returned  to  duty  December  Id. — Suit,  rUi-  lldsjiiUil.  I'liiUidiljiliui.  I'a. 

C'.\SK  10. —  I'iolnit  (liiinhiid  mid  iiiloiliiitil  licmorrliitiii . — I'l  is  ate  l>avi(l  .Ia<'oliy.  Co.  ('..  17th  I'a.  Cav.:  age  24:  was 
admitted  .Inly  7.  18(i:i ;  he  hail  lieen  siek  ami  under  treatment  in  the  hospital  of  his  regiment  since  .lanuary  for  rheu- 
nuitism.  On  admission  he  had  fever,  in.jeeted  and  watery  eyes,  e]>igastiic  temU^rness,  nausea  and  vomiting,  eight 
sto(ds  in  the  twent.y-lbiir  hours,  abdominal  jiaiu  and  a  thickly  eoate<l  tongue,  red  a  I  it  sedges  A  poultice  was  applied; 
mercury  with  chalk  and  Dover's  powder  was  i)rescribed  every  four  hours,  ami  aci^tate  of  ammonia  with  syrup  of  squill 
three  times  a  (lay;  beef-tea  and  w  ine-whey  were  also  oideied.  On  the  11th  the  stools  weri^  occasionally  bloody.  A 
pill  of  acetate  of  lead  and  opium  was  given  three  times  and  oil  of  turpentine  twice  daily.  The  pain  was  relieved  on 
the  12th  and  13th,  but  retnrned  on  the  14th,  with  vomiting  and  dull  headache:  pulse  94.  .Siibnitrate  of  bismuth  was 
given.  On  the  l.")th  the,  ])ulse  w  as  110  and  feeble;  the  vomiting  had  ceaseil,  but  the  headache  continued  with  tinnitus 
anrium  and  eiiistaxis.  Opiate  eiiemata  were  used  in  addition  to  tlie  jiills  of  lead  and  opium.  On  tln^  Kith  the  stools 
became  less  freiiiieiit,  but  severe  pain  in  the  back  and  legs  was  reported.  The  diarrliii'a  becauie  worse  again  next  day. 
On  the  20th  the  pulse  was  11,5  and  very  weak:  tongue  dark  and  thickly  coaled:  stomach  irritable  and  the  ejected 
matters  bilious.  On  the  2l8t  the  patient  was  somewhat  deaf  and  on  the  22d  delirious,  with  profuse  diarrho'a,  cold 
extremities  and  hemorrhage  from  the  nose  and  mouth.  The  stoids  were  involuntary  and  bloody  on  the  23d,  and 
death  occnrred  on  the  morning  of  the  24th. — Mnwir  Hospital,  I'hiladelphiti,  I'a. 

Case  11. — FirfDvatiou  of  the  iiit(<»thie. — I'rivate  Thomas  A.  Watson,  Co.  C,  .">8th  I'a.;  age  37;  was  admitted 
Aug.  17,  1801,  from  Petersburg,  Va.,  having  been  sick  since  Jiil.y  20.  He  was  very  weak  and  much  exhausted  ;  tongue 
dry  and  thickly  furred:  snbsultns  tendinura.  (juinia  and  aromatic  sulphuric  ai^d,  with  bran<ly-])unches  and  turpen- 
tine emulsion  were  given.  Next  day  he  was  seized  with  a  severe  jiain  in  the  abdomen,  which  became  worse  on  the 
lOtli;  his  pulse  was  thready;  he  picked  at  the  bedclothes.  He  died  on  the  morning  of  the  21st. — Sdtlfrlee  Ifonpital, 
I'liildtklphid,  I'd. 

C.v.sE  12.— Iiitercnrrent  evyHipelas. — Corp'l  Daniel  Austin,  Co.  (i,  16th  N.  Y'.;  age  2.5;  was  taken  about  Aug.  7, 1861, 
with  diarrluea,  which  becatne  worse  and  was  accompanied  by  pain  in  the  head,  back  and  abdomen.  He  was  admitted 
on  the  22(1  as  a  case  of  .gastro-enteritis.  Next  day  his  tongue  was  heavily  coated  in  the  centre  but  bright-red  at  the 
sides,  teeth  black  with  sordes,  pulse  lOtI,  fiuick.  bowels  tympanitic  but  not  tender,  yielding  frei|ueut  watery  stools. 
In  the  evening  the  fever  increased  and  the  patient  was  at  times  dcdirions.  On  the  2ltli  tlii^  erii]ition  appeared  on  the 
face  and  abdomen;  the  tongue  became  dry  and  brown:  the  stools  continued  freciuent.  He  was  restless  at  night, and 
next  day  the  tongiio  was  fissured,  ab(b)men  iirominent  and  mind  disturbed.  The  eyes  were  tix(;d,  the  exjitession  vacant 
on  the  2(>th  and  the  patient  raved  about  Mount  Vernon  on  the  27th,  Imt  became  rational  again  on  the  28th.  On  .Sep- 
tember 1  an  erysipelatous  blusli  appeared  on  the  nose  and  extended  over  the  cheek.  Tincture  of  iron  was  given  every 
three  hours  and  the  face  painted  with  tincture  of  iodine.  The  swelling  increased  and  by  the  6th  aft'ected  the  hairy 
scalp ;  at  this  time  there  was  some  cerebral  excitement.  Wine  and  nourishment  were  given  and  the  iodine  reapplied. 
He  was  improved  on  the  13th  and  able  to  sit  up  on  the  15th.  Hed-sorcs  were  jiresent  on  the  right  hip  and  on  the 
sacrum.     This  patient  was  discharged  May  31  because  of  disabilit.y  from  t.yphoid  fever. — llin^pitdl,  AU-xdndria,  Va. 

C.\SK  13. — Iiitirviirreut  pniiiiiionid. — Private  Michael  Laly,  Co.  K.  2d  .Mich., was  admitted  Oct.  21.  1861,  as  a  case 
of  tyjdioid  fever.  This  man  had  been  sick  with  continued  fever  for  six  days  prior  to  his  admission,  during  which 
time  he  was  treated  with  diaphoretics  and  tonics.  On  the  22d  his  pulse  was  84,  tongue  dry  and  brown,  skin  hot  and 
dry.  Three  live-grain  doses  of  (juinine  were  given  ^vith  blne-inass  and  ipecacuanha.  Next  da.v  the  pulse  was  80,  the 
skin  cool  and  the  tongue  moist.  Four  two-grain  doses  of  quinine  were  given  with  Dover's 'powder  at  bedtime. 
There  was  a  diarrhtea  of  two  or  three  stools  daily  fnun  the  24th  to  the  28th,  and  the  tongue  became  dry  and  brown 
in  the  centre.  On  the  29th  the  pulse  was  90  and  quick,  the  tongue  dry  and  tremulous,  tlu^  skin  hot:  stupor,  much 
delirium,  freiiueut  dry  cough,  some  uneasiness  on  inspiration  and  crepitation  in  the  lower  part  of  the  left  side  of 
the  chest  were  among  the  symptoms  recorded  on  this  da.v.  Calomel,  iiiecacuanha  and  (|iiiuine  with  turpenti"ie 
emulsion  and  chlorate  of  potash  were  prescribed,  and  a  blister  apjilied  to  the  left  side.  Next  day  there  was  cough 
with  bloody  sputa;  the  patient  could  be  roused  from  his  muttering  delirium  to  answer  questions,  but  he  replied 
slowly  and  protruded  his  tongue  with  hesitation;  the  diarrhcea  ceased  during  this  attack.  The  cough  became  less 
freijueut  and  the  expectoration  viscid  and  rusty  on  November  1.  Wine  was  ordered  four  times  daily.  During  the 
following  night  a  profuse  epistaxis  occurred.  The  tongue  became  moist  (Ui  the  3d  and  next  day  the  expectoration 
was  more  abundant  and  the  drowsiness  lessened;  pulse  76;  respiration  24.  A  blister  was  applied  to  the  front  of  the 
chest.     Ou  the  7th  the  cough  was  lt;ssened,  the  expectoration  mucous,  the  counteuauce  bright,  the  bowels  regular. 


260  CLINICAL    RECORDS    OF 

Milk  diet  was  ordt-red  with  an  ounce  (if  lnnndy  every  four  liours.  lie  recovered  January  10,  1862,  ami  was  returned 
to  duty  Marcli  7. — Kanii'ttnl,  Ahsumliin,  I  it. 

Cask  II. — Si'(iucnt  pncumunUi. — I'livate  .lames  A.  Evcrs,  Co.  C,  1st  DeL  Art.;  age  18;  was  admitted  Aug.  20, 
186;^,  liaving  been  attacked  with  fever  on  hoaid  a  transport  from  Alexandria  to  \ew  York  about  tlie  18th.  On 
admission  the  febrile  action  wa.s  marked,  but  the  mind  was  clear  and  there  was  uo  diarrhu-a,  although  the  liowels 
were  free;  pulse  90.  Profuse  ]ierspiration  occurred  on  the  Hist.  Noernptiou  was  obseived.  On  September  4  dulne.ss 
and  fine  cre|>itati()n  wen^  marked  over  the  riglit  lung,  and  on  the  litli  two-thirds  of  the  left  lung  w  as  implicated.  In 
the  evening  <if  this  day  the  febrile  action  becauui  heightened  but  free  persiiiration  broke  out  towards  morning;  the 
expect(«ation  was  rust-colored,  the  tongm^  clean,  jinlse  Sli.  (Jn  the  9th  the  condition  of  the  patient  had  imjirovod, 
although  jihysical  examination  revealed  no  ajiparent  chaiig(>.  l!y  the  10th  tlie  area  of  dulness  was  much  diminished 
and  the  expectoration  free  and  without  viscidity.  Ten  (lays  laler  the  patient  was  able  to  walk  out,  and  on  October 
15  be  was  reported  for  duty. — Central  I'urk  JlaejiiliiL  X.  V.  ('ihi. 

Case  15. — Sequent  dUirrhaii  from  injudicious  diet. — I'rivate  Albert  Hill,  Co.  I,  12()th  N.  Y.,  was  admitted  Dec.  12, 

1862,  from  Kmory  hos|iital,  Washington,  I).  C,  as  a  convalescent  from  tyjihoid  fever.  He  was  placed  on  full  diet. 
On  the  14th  a  diarrluea  of  two  to  six  stools  daily  set  in  and  continued  until  tlie  21st.  On  Jan.  5,  1863,  the  diarrhiea 
recurred  after  eating  ajiples.  The  jiatient  was  restricted  to  milk  diet  and  the  intestinal  trouble  ceased.  Full  diet 
was  restored  on  the  12th;  Imt  on  the  Kith  there  was  a  recurrence  of  the  diarrluea,  necessitating  treatment  until 
February  7.     He  was  returned  to  duty  Maich  4. — '^iitterla  Uiiijiitiil,  I'liihtdelphia,  I'u. 

Ca.se  16. — Sequent  diurrhaa  and  dehililii. — i'rivate  Sylvester  Chesebro,  Co.  K,  lliJth  Fa.;  age  23;  was  admitted 
June  18,  1863,  from  Stanton  hospital,  Washington,  1).  C,  having  sutiered  from  typhoid  fever  since  May  6.  He 
was  much  emaciated  and  so  debilitated  that  he  was  unable  to  stand  without  the  aid  of  crutclies;  he  had  pain  in 
the  back,  and  his  mouth  and  throat  were  slightly  ulcerated.  He  was  placed  upon  extra  diet;  a  chlorate  of  potash 
gargle  was  prescribed.  On  .June  20  the  diarrluea  recurred  with  }iain  in  the  abdomen :  but  by  the  2()th  this  condition 
was  relieved  and  the  patient  was  evidently  gaining  strength.  All  medication  was  omitted  and  he  was  allowed  full 
diet  July  17.  On  the  28th  he  assunu'd  light  duties  about  the  ward,  and  on  August  18  was  returned  to  duty  with 
his  command. — Satterlee  Hospital,  I'tiiladeliiliKi.  I'a. 

Case  17. — Sequent  diarrhou  and pulnionurij  affection. — Private  Clinton  Dayton,  Co.  I,  17th  Conn.,  a  convalescent 
from  typhoid  fever,  was  admitted  Dee.  16,  1862,  with  diarrhu'a  and  shooting  pains  in  the  chest.  Pills  of  lead  and 
opium  were  given  three  times  daily,  and  on  the  21st  the  diarrlnra  was  restrained.  Tincture  of  iron  was  then  ordered, 
but  the  diarrhtea  returned  on  the  26th.  SnuiU  doses  of  an  emulsion  of  castor  oil,  laudanum,  mucilage  and  turpentine 
were  prescribed.     On  the  30tli  the  diarrluea  was  coutiolled,  but  its  recurrence  with  some  abdominal  pain,  Jan.  12, 

1863,  called  for  opium  twice  a  day.  On  the  14th  ten  grains  of  blue-pill  were  given;  on  the  18th  the  opium  was 
omitted.  Meanwhile,  as  the  cough  was  troublesome,  an  exiiectoraut  mixture  was  ordered  on  the  loth,  and  croton 
oil  applied  to  the  chest  from  February  2  to  the  6th.  The  expectorant  was  omitted  on  the  9th,  but  was  renewed  on 
the  17th  and  continued  until  the  22d.  On  March  27  he  was  placed  on  guartl  duty;  he  was  furloughed  April  1,  and 
returned  to  his  conmiand  June  28. — Satterlee,  Hospital,  miadelphia,  I'a. 

Cases  18-29  sliow  debility,  bed-sores,  deafness,  oedema,  anasarca  and  ulorbid  condi- 
tions of  the  lungs,  liver  and  kidneys  consequent  on  fever. 

Case  18. — Protracted  debility. — Private  Samuel  Watson,  Co.  K,  63d  Ind.;  age  39;  was  admitted  April  6,  1865, 
debilitated  from  typhoid  fever.  [This  man  contracted  tyjihoid  fever  in  August,  1863,  at  Shephardsville,  Ky.;  he  was 
admitted  to  hospital  No.  1,  Louisville,  Ky.,  Jan.  26,  1864,  with  lumbago,  and  transferred  to  Madison,  Ind.,  where 
his  case  was  entered  as  chronic  rheumatism;  on  March  23  he  was  assigned  to  <;o.  K,  ISHh  Veteran  Reserve  Corps. 
He  entered  Judiciary  S(iuare  hospital,  Washington,  D.  C,  Ajiril  9, — diagnosis:  intermittent  fever — and  on  the  26th 
was  furloughed.  He  returned  to  Judiciary  Si[uaro  hos])ital  March  23.  1865,  and  on  April  6,  as  above  stated,  was 
transferred  to  Satterlee.]  He  was  treated  with  (luinine,  iron,  cod-liver  oil  and  iiorter.  and  discharged  from  service 
May  26  on  account  of  chronic  pleurisy  and  protracted  debility. — Satterlee  Hospital,  I'liiladeljjhia,  I'a. 

Case  19. — Debility  and  phthisis. — Private  Charles  McCormick,  Co.  D,  4th  Mich.;  age  20;  was  admitted  Aug.  10, 
1862,  debilitated  from  typhoid  fever.  On  December  9  he  became  affected  with  diarrha-a,  which  was  checked  l)y 
chalk,  opium  and  catechu  on  the  17th.  A  few  days  later  bronchitis  was  manifested.  In  February,  1863,  there  was 
dulness  with  sonorous  rales  over  the  apex  of  the  left  lung.  He  was  discharged  on  the  28th  on  account  of  phthisis. — 
Satterlee  Hospital,  Philadelphia,  Pa. 

Case  20. — Debility,  deafness  and  lied-sores. — Private  John  D.  Magee,  Co.  D,  133d  N.  Y.,  had  typhoid  fever  in 
June,  1861,  followeii  by  an  enormous  bed-sore  involving  all  the  supra-sacral  tissues;  he  had  not  done  any  duty 
since  the  occurrence  of  this  fever.  He  was  admitted  from  Fairfax  Seminary  hospital,  near  Alexandria,  Va.,  Dec. 
16,  1862,  and  was  placed  on  special  diet  with  beef-essence  and  milk-punch.  His  appetite  was  impaired,  bowels 
irregular;  he  complained  of  pain  about  the  joints  and  of  a  slight  cough.  He  was  treated  with  sinapisms  and 
expectorant  syrups.  On  Feb.  9,  1863,  it  was  noted  that  the  |>atient  had  beconu-  partially  deaf  in  one  ear.  He  was 
discharged  March  27  because  of  general  debility  and  partial  deafness  of  the  right  ear  following  typhoid  fever. — 
Satterle*  Hospital,  Philndelj)hia,  Pa. 

C.kss.  21. — Otorrhira. — Private  H.  Harpster,  Co.  K,  88th  Ind.;  age  21;  while  in  hospital  for  an  injury  to  his  back, 
caused  by  a  fall  from  a  wagon,  was  taken  with  typhoid  fever  in  April,  1863,  and  had  a  long  and  serious  illness, 
during  whicli  he  was  mnch  troubled  with  a  purulent  discharge  from  his  ear.  He  was  treated  with  turpentine  emul- 
sion, brandy  and  beef-tea.  When  transferred  to  Cami>  Morton,  June  9,  he  was  improving  rapidly  and  gaining  in 
flesh. — Hospital,  Quincy,  III, 


THE    CO'N'TIXrKD    FKVERS.  261 

Case  22. — Dch'ditu,  (hafncsn  and  aduna  nf  ffd. — I'rivato  Allicrt  Friedlaiuler,  Co.  1\  ir.Trli  Pa.:  ajjc  2S;  was 
admitted  Feb.  23,  ixti'i.  with  aiiMiiiia.  (lraliii>s  and  n'dema  of  tlu'  feci,  and  was  discliarj^ed  liy  older  of  the  A.  (i.  O. 
datf<l  May  'M.  [Tliis  man  had  a  se\rn'  attark  of  tyjihoid  ievrr  in  January,  ISti.'i,  and  iias.scd  throiijjli  tlm  Fifth 
Army  Corjis  lio.spital  at  City  l'oiiit.\  a.,  to  I'attiMxm  Park  lios]>ital,  P>altinion'.  Xld..  wlurc  hf  arrived  Fidiniary  8  and 
was  entered  as  a  case  of  imeinnonia.    On  the  2i)il  he  was  removed  to  Philadeljdiia.] — Sullcrhc  Hanpitiil,  rhihuliljihin,  Pa. 

C.\SE  2li. — Sirclliiiii  of  Idircr  ijlrimity. — Piivate  David  I>.  Cliiio.  Co.  I.  ISOtli  Ohio;  a^e  HI:  was  admitted 
Mareli  24.  18t>."),  liis  left  lej;  lieinj;  a<lematons.  lie  had  an  attaek  of  tyjvhoid  fever  in  .lannary.  and  iliirint;  his  eon- 
valescenee  tlie  lefjj  became  swolh'B.  Arsenie  and  eompression  by  bandaii'es  failed  to  removi'  tlie  tumefaction.  He 
was  discliaiffed  from  service  .June  5. —  Triphr  llDHpiidl,  t'liliiiiilinn,  Oliin. 

Case  21. — Dehiliti/  tiiiil  uilmui  of  loinr  vxti-iniilirs. — Corjioral  IIui;li  MeCrossen,  Co.  .\.  llSth  I'a.:  a>je  2t;  was 
admitted  Oct.  25,  1808,  with  debility  followliii;  tyi)lK>id  fever;  he  had  also  some  coni;li.  On  the  'MHU  his  legs 
became  (pdematons  and  continued  in  this  condition  until  November  22.  with  variable  apiH'tile  and  (x'casional  fever- 
ishness  and  cough.  For  some  days,  about  the  end  of  this  nionlli,  he  sulVered  from  tymjianitie  distention  of  the 
abdomen.  On  December  G  there  was  much  i)ali)itation  of  the  heart  after  exertion.  On  the  Ttli  the  cou}j;h  continued 
and  the  (edema  of  the  lejis  rea|i]ieared,  but  on  the  8tli  there  was  an  im])rovemenl  which  ]iroj;ressed  steadily  until  the 
patient's  transfer  to  the  In\  alid  Coi'its.  In  his  tri'atmeiit  (luinine  in  small  ilosi's,  citrate  of  iron  ami  (juiniiu',  coni- 
potind  tincture  of  cinchona,  wild  cherry,  S(|Uill.  moridiine.  Dover's  jiowder,  cod-liver  oil,  nulk-]>niu'h  and  porter 
were  employed. — Siillirhc  lloxjiilnl,  J'liilodiljiliin.  I'n. 

Case  25. — Seqiioit  ilidnhoK  uiul  uiliiiui  of  fed. — Private  ,)ohn  \'ans,  Co.  C,  82d  111.;  af;e  ;i5;  was  .i<lmitted  June 
18,  1863,  from  Stanton  hosi)ital,  Wasliiii<;ton,  D.  C.,  as  a  convalescent  from  typhoid  fever.  He  had  been  taken  with 
the  fever  in  March;  diarrluva  followed,  and  about  June  1  his  feet  begiin  to  swell.  He  was  ])laeed  on  i|uinine  and 
tincture  of  iron  in  small  doses,  and  due  attention  was  jiaid  to  his  diet ;  but  the  diarrlnra  recurring,  pills  of  Dover's 
I)owder  and  sulphate  of  iron,  and  afterwards  tuiiKiitine  in  mucilai;e,  were  tried.  Medication  was  coutinueil  to 
August  1,  and  the  i>atient  was  returned  to  duty  on  the  2(itli. — Sdtln-tic  Jloxiiiliil,  I'liil(i(ltl])hiii,  I'ti. 

Case  2t). — Si<iiinit  (lioi-rhmi  and  (iiian<i)Ti(. — Piivate  Robert  II.  Davis,  Co.  A,  78th  III.;  age  27;  was  admitted 
Se])t.  10,  1804,  having  sutferetl  from  a  severe  attack  of  t.v])lioid  level. luno  10,  180S,  followed  by  a  ]ierHisting  diarrlKP.a. 
On  admission  he  had  ascites  and  (cdematcms  legs.  He  was  discharged  as  wholly  disabled  December  8,  1864. — 
Honpital,  Qtihicii,  111. 

Ca.se  27. — Knhtrgemvut  of  lircr  and  iincitcs. — Private  Henry  C.  Packard,  Co.  K,  6th  Vt.,  was  admitted  Aug.  10,- 
1862,  with  typhoid  fever.     On  October  3  the  left  lobe  of  the  liver  was  enlarged  and  the  ])atient  att'ected  with  ascites. 
Jfitro-muriatic  acid  and  saline  cathartics  were  used  in  the  treatment.     His  ajipetite  became  very  good,  but  otherwise 
there  was  little  improvement.     He  was  discharged  December  20  because  of  enlargement  of  the  left  lolx^  of  the  liver, 
with  ascites. — Sattirlii'  IfoxpilaJ,  riiihuldphut,  I'a. 

Case  28. — Inflammation  of  \irir  and prohahle  ahsccst:  dincliari/inii  into  colon. — Private  lienjamin  M.  Kichardson,  Co.  C, 
93d  N.  Y.;  agiv24;  was  admitted  Dec.  15,  1862.  Diagnosis — diarrluea.  [He  had  contracted  diarrhcea  at  Williams- 
burg, Va.,  in  Ma,v.  This  lasted  ten  days,  after  which  lie  was  confined  to  bed  for  four  weeks  with  typhoid  fever; 
during  convalescence  he  was  much  troubled  with  pain  referred  to  the  liver  and  stomach.]  Hy  January  12,  1863,  the 
diarrhiea  was  cheeked,  lint  the  skin  became  yellowish  and  on  the  lilth  .jaundice  was  well  marked  and  the  liver 
enlarged.  Small  doses  of  mercurials  were  given.  Diarrlui'a  recurred  on  F<'bruary  1,  but  was  i|uieted  on  the  0th  by 
the  use  of  krameria  and  iiaregoric.  After  this  the  stools  became  clay-colored,  and  on  the  '.Hh  pain  was  developed 
in  the  right  hyiiochondrium,  which  became  so  acute  on  the  15th  t^iat  the  ]>oultieing  which  had  been  emjiloyed  was 
discarded  and  a  blister  applied  with  relief  to  the  patient  for  a  day  or  two.  On  the  21st  the  iiain  returned  and  on 
the  21th  a  sharp  diarrlnea  set  in,  yielding  from  two  to  eleven  stools  daily  until  the  28th.  After  this  lu^  improved 
under  the  use  of  quinine,  carbonate  of  iron  and  nitro-niuriatic  acid.  He  was  placed  on  hospital  guard  April  10  and 
■was  returned  to  his  command  August  27. — Sallirlci'  Hospital,  riiiladdphia,  I'a. 

Case  29. — Disease  of  the  kidney. — Private  Thomas  Buckley,  Co.  D,  Otli  Conn.;  age  21;  stated  that  he  had  never 
been  intemperate  in  the  use  of  liquors  au<l  was  perfectl.v  health.y  before  enlistment.  In  September,  180:i,  ho  had 
had  typhoid  fever  and  was  sent  to  general  hospital  at  Hilton  Head,S.  C.  Two  months  elapsed  before  convalescence 
was  established.  A  week  after  his  return  to  dut.v  he  was  admitted  to  the  regimental  hosjiital  with  <edema  of  the 
lower  extremities.  In  about  a  month  he  was  fiirloughed  to  his  home,  where  he  remained  until  his  admis.^ion  into 
this  hospital,  April  19,  1864.  His  face  was  pufty  and  pallid,  his  feet  and  legs  a'dematous;  the  urine  was  albuminous 
and  contained  granular  casts.     He  was  discharged  from  service  August  12. — CenU-al  Park  Hospital,  N.  Y. 

Cases  30-50  illustrate  the  occurrence  of  inflainmatory  processes  in  various  parts  of 
the  body,  but  especially  in  the  lower  extremities  and  parotid  glands. 

Cash  30. — Muscular  ])ain.i. — Corporal  Emanuel  Davis,  Co.  K,  137th  N.  Y.;  age  36;  was  admitted  June  20,  1863, 
convalescing  from  typhoid  fever  which  had  disabled  him  since  March  10.  On  admission  he  was  troubled  with 
subacute  muscular  pains  aft'eeting  the  left  arm  and  leg  and  sometimes  the  right  thigh.  These  pains  were  not  con- 
tinuous, but  came  on  at  intervals  without  premonitory  symjitoms  or  accompanying  fever  and  lasted  about  twelve 
hours.  Dampness  and  cold  appeared  to  act  as  exciting  causes.  The  joints,  large  and  small,  were  also  occasionally 
affected.  The  pains  were  increased  by  motion  and  relieved  by  pressure:  the  warmth  of  bed  aggravated  them.  The 
patient  was  much  debilitated,  emaciated  and  low  spirited.  He  was  treated  at  first  with  a  pill  containing  one-half 
grain  each  of  powdered  iron  and  extract  of  mix  vomica  and  one-sixth  of  a  grain  each  of  quinia  aaid  calomel,  given 
three  times  a  day,  with  a  liniment  of  ammonia,  soap  and  chloroform ;  but  after  a  few  days  the  pills  were  omitted  and 
a  teaspoonfnl  of  a  mixture  consisting  of  one  drachm  of  iodide  of  potassium,  one  fluid  drachm  of  oolchicum  wine  and 


262 


CT.r\T(\-VI;    RKCORP^;    OF 


two  onnops  of  compound  tiuctmp  of  geutian  was  prescribed  instead.  Two  weeks  after  this  treatment  was  insti- 
tuted the  iiatieut  liefjfan  to  iuijirove,  and  on  August  11  he  was  retnrue<l  to  duty. — Act.  Js>i't  Simj.  Ofto  1,'iiliriii,  U. 
S.A.,  SattahT  HoKpiUil,  riiiltKMjihia.  I'<(. 

Cask  31. — Hhviumtiic  jntiiis. — ('(>r]ioral  Dudley  .s.  Cutler.  Co.  F,  S'M  Fa.:  age  20;  was  received  June  12,  IStili, 
from  Lincoln  hospital,  Washington,  D.  C.  [He  liad  lieeu  treated  for  typhoid  fever  in  regiuu'Utal  hos])itJil  until  April 
20,  when  he  was  transferred  to  Lincoln  hospital.]  On  admission  he  complained  of  a  <lull  heavy  pain  in  the  left 
hip  and  leg  and  seemed  to  have  lost  a  good  deal  of  rtesh.  Cups,  blisters  and  liuiment.?  were  employed  witli  tmi>en- 
tiiu;  emulsion  intern.-illy.  [On  -August  1  he  was  removed  to  Sixteenth  and  FiUjert  streets  hospital,  I'hiladelpliia, 
I'a.  Diagnosis — chronic  iheuuuitism.  He  was  transferred  to  the  1st  Battalion,  X.  II.  C,  September  2;i.J — ^ulfirlcf 
Hospital,  riiiladclphia,  I'd. 

Ca.se  32. — Pain  and  mcellini/  <if  fett. — Private  Peter  (iates,  Co.  K,  1st  Mich.:  age  25;  was  admitted  March  2,  1S()2. 
This  man  became  affected  with  iutennittent  fever  In  November,  1861,  and  contiuiu'd  in  ill  health  from  that  time. 
From  the  daily  entries  on  the  hospital  record  which  cover  the  period  to  March  29,  it  is  found  that  the  case  was 
regarded  as  one  of  typhoid  fever,  and  that  the  patient  was  unable  to  walk,  having  a  bed-sore  on  each  hi|i  an<l  much 
swelling,  tenderness  an<l  pain  in  his  feet,  but  his  tongue  was  moist  and  clean,  appetite  good,  bowels  regular,  skin 
natural  and  i)ulse  of  fair  strength.  Stimulants  and  citrate  of  iron  and  quinine  were  given,  but  for  some  tiuu'  there 
was  no  improvement  in  the  condition  of  the  feet.  Severe  frontal  headache  was  noted  as  having  been  iireseut  on  tlu^ 
10th  and  11th  and  as  having  recurred  on  the  luth,  20th  and  29th.  Quinine  was  prescribed  on  the  15th.  At  the 
time  the  last  entry  was  nuide  the  bed-sores  were  healing  and  the  swelling  of  the  feet  had  subsided.  The  patient  was 
discharged  from  service  May  3. — Seminarii  Hnnpitat.  Georgetown,  D.  C. 

C.vSE  33. — J'ain  in  foot  and  le;/. — -Private  William  Camp,  Co.  D,  122d  Ohio:  age  19:  was  admitted  Sept.  11, 
1803.  Diagnosis — intermittent  fever.  He  had  l>een  sick  for  tive  days,  during  which  the  bowels  were  constipated. 
Three  couiponud  cathartic  ]iills  gi\-cn  on  admission  produced  two  copious  stools  at  night.  On  the  12th  the  ))uIso 
was  90.  full  and  strong,  tongue  coated,  appetite  deficient,  skin  hot  and  nuiist  and  urine  scanty:  there  was  pain  in  the 
head,  limbs  and  back.  .Sweet  spirit  of  nitre  was  prescribed.  By  the  15th  the  skin  had  become  cooler  and  the  head- 
ache diminished;  ejiistaxis  occurred  twice  on  tliis  day.  Diarrhoea  set  in  on  the  Itith,  the  stools  being  liquid  and 
yellowish  and  the  tongue  dry  and  coated.  Drowsiness  and  delirium  were  develojied  on  the  18th  and  recurred  partic- 
ularly at  night;  the  pulse  ran  up  to  110  and  the  respiration  to  32.  Milk-punch  was  given  and  a  blister  aiii)lied  to 
the  chest;  s(iiii!l  and  .seneka  were  also  prescribed.  The  diarrho'a  meanwhile  persisted,  and  on  the  22d  three  iuvol- 
untary  stools  were  passed,  Subnitrate  of  bisnuith  was  given.  The  patient  rested  well  on  the  27th,  and  next  day 
was  more  rational;  the  chest  sjinjitoms  also  were  much  improved.  The  diarrho>a  continued  at  the  rate  of  three 
to  five  stools  daily,  with  sometimes  severe  pain  in  the  bowels,  until  October  Ki,  and  during  this  period  the  tongue 
was  more  or  less  coated  and  sometimes  dry  and  the  appetite  poor.  Wine,  brandy,  porter,  milk-punch,  wine-whey 
and  whiskey  with  quinine  were  iised.  The  appetite  returned  on  the  23d,  but  the  diarrhoea  recurred  on  the  26tli  and 
again  on  November  17,  its  appearance  on  the  latter  date  having  been  attributed  to  the  use  of  apple-sauce.  Al)out 
October  1  the  foot  (side  not  stated)  became  very  painful,  but  no  further  mention  is  made  of  this  until  November 
13,  when  the  leg  was  reported  as  nnich  swollen,  and  hop  fomentations  were  prescribed.  On  the  25th  the  left  leg 
and  foot  were  swollen  and  fomentations  of  pepper  and  hops  were  used.  On  the  27th  chloroform,  arnica  and  aconite 
were  mi.xed  with  olive  oil  as  a  liniment  for  the  left  leg  and  foot,  but  after  this  no  more  infcnniatiou  is  given 
concerning  their  condition.  The  patient  was  furloughed  Jan.  25,  1861.  He  returiu'd  February  21.  and  w;is  sent  to 
his  command  for  duty  May  3. — Third  lJiri.iion  ffuspitut,  Alexandria,  Jo. 

Ca.sk  34. — Scorhutic  complication ;  pain  in  feet  and  Icejx ;  lyoils. — Private  J,  IL  Penny,  Co.  A,  1st  S.  C;  prisoner 
of  war;  age  19;  was  admitted  Nov.  1(1,  1863,  as  a  case  of  continued  fever.  The  tongue  was  red,  streaked  with  white, 
the  gums  jiale  and  swollen,  the  pul.se  frequent;  he  was  very  weak  and  had  much  pain  in  the  limbs.  On  the  14th  the 
bowels  were  moved  tive  times  and  the  tongue  was  dry,  red  and  brown;  nevertheless  he  began  to  improve  from  this 
date,  so  that  liy  the  21st  the  tongue  was  moist  and  cleaning  and  the  bowels  regular.  On  the  27th  the  patient's  condi- 
tion continue<l  favorable,  but  he  had  a  troublesome  bed-sore.  On  Deceml)er  20  lie  remained  weak  and  emaciated  and 
had  large  unhealthy  boils  on  various  parts  of  the  body  which  appeared  in  successive  crops  until  January  6,  1864, 
when  the  last  boil  ceased  to  discharge.  He  also  at  this  time  suffered  great  j)ain  in  his  feet  and  legs,  which  were 
swollen  and  cold;  this  was  considered  due  to  the  severity  of  the  weather.  After  January  9  this  pain  ceased  and 
he  steadily  improved  until  April  27,  when  his  exchange  was  effected. — Act.  Axx't  Snrg.  JT.  A.  Harreij,  V.  H.  A..  Ham- 
mond Hoxpital.  Point  Lookonty^.Md. 

Case  35. — Superficial  almcexxrn. — I'livate  William  Dundass,  Co.  C,  11th  N,  .1.:  age  25;  was  admitted  from  Sum- 
mit Hou.so  hosjiital,  Philadelphia,  Aug.  18,  1864,  as  a  convalescent  from  typhoid  fever,  suffering  froiri  diairluea  and 
abscesses  in  the  right  hypochondrium  and  over  the  epigastrium;  his  fever  dated  from  June  10.  Not  until  Decem- 
ber 1  was  the  diarrhiea  checked,  by  which  time  the  abscesses  were  healed  and  the  general  health  much  iuqiroved. 
He  was  then  j)laced  on  full  diet  with  cod-livci  oil.  iron  and  quinine.  On  Feb.  16,  1865,  he  began  to  do  guard  duty, 
and  on  May  20  was  di.seharged  by  order  of  A.  (■.  (»..  dated  May  3. — Satti-rhr  Iloxiiital,  Philadelphia,  Pa. 

Cask  36. — Ahficess  and  cuntraction  of  leij. — Private  Aar(Mi  t'liuldiuck.  Co.  (',  2d  I'a.  Heavy  Art.;  ag(^  18;  was 
admitted  Aug.  12, 1864,  convalescing  from  a  tedious  attack  of  typhoid  fever  [regarded  as  remittent  dining  the  patient's 
stay  at  Harewood  hospital,  Washington.  D.  ('.],  which  had  left  him  with  absce.s.ses  in  the  left  thigh  near  the  buttock. 
The  leg  was  partially  flexed  and  could  not  be  extended  without  much  pain.  Iron  and  <iuinine  were  administered 
with  full  diet;  pressure  was  applied  to  the  leg  from  December  3  to  January  5,  1865.  On  the  15th  the  log  was 
reported  as  much  contracted,  discharging  and  so  painful  as  to  be  unabh^  to  bear  extension  on  splints.  On  Feliruary 
4  another  abscess  was  reported  as  forming;  this  discharged  on  the  20th.     On  March  23  the  patient  suffered  from  a 


THE    CONTINUED    FEVERS.  263 

slight  attack  of  varioloid.  On  June  '20  he  was  discliarged  from  Kervicc  on  account  of  laiiicnuHS  of  the  left  leg. — 
Satterhe  Hospital,  Phihiilrlpliid,  Pii. 

Case  37.—  U1crr<(ti(,ii  of  to<s.—Vv\\ate  Israel  J.  tiroiuoMe.  Co.  I.  UMi  Pa.;  age  \H:  wan  admitted  Sejit.  2.'^.  1863, 
from  Finley  hosj)ital,  Washington.  I).  C.,  as  a  convalescent  from  tyidioid  fever.  On  the  2t>th  four  of  the  patient's 
toes  were  found  to  be  nlcenited  and  much  congested.  Incisions  were  made  around  the  ulcers  ami  warm-water  dress- 
ings prescribed,  with  tincture  of  iron  internally,  porter  and  extra  diet :  a  wash  containing  sugar  of  lead  and  opium 
and  an  alcohol  and  water  lotion  were  subsequently  employed.  On  October  18  the  ulcers  were  granulating.  All 
treatment  was  omitted  on  the  25th,  and  on  November  10  tlie  patient  was  icturned  to  duty. — Moircr  Ilonpilnl,  Phil- 
udclplda,  Pa. 

Case  38. —  lUcfratioii  of  Icij. — Private  James  .\.  Humes.  Co.  II.  l.'idtli  I'a.;  age  20:  was  admitted  Dec.  12,  lSfi2. 
from  Carver  hospital,  Washington.  I).  C.  as  a  convalescent  from  typhoid  fever.  He  was  weak  and  emaciated  and 
liad  slight  tenderness  in  tlie  riglit  iliac  region.  Nux  vomica  in  compound  tincture  of  gentian  was  ordiTcd.  On 
Feb.  10,  1863,  he  had  fever-sores  <mi  the  leg,  whicli  were  treated  tirst  witii  llaxsee<l  poultice  and  afterwards  with 
oakum  dressing.  On  the  27th  the  patient's  hair  was  falling  out.  On  Marcli  I  tlie  nux  voiuica  was  omitted.  A  lotion 
of  sulphate  of  zinc  was  applied  on  the  20th  and  pills  of  carbonate  of  iron  and  (|uinine  were  given  three  times  a  day, 
under  which  treatment  the  ulcers  healed.  On  April  IT  all  medication  was  omitted  and  the  jiatient  was  put  on  light 
duty.     He  was  returned  to  liis  command  June  28. — Saltcrlii-  IIonpUul,  Pliiladilphia,  I'a. 

C.A-SE  39. — Sloiitjhiiiii  of  cornea. — Private  William  A.  ('base,  Co.  F,  16Ist  N.  Y.,  was  hd't  uiuler  the  care  of  a 
nnrse  in  regimental  hospital  on  the  dejiarture  of  his  connuand.  He  had  been  sick  for  several  weeks  and  was  believed 
to  be  dying.  He  was  exceedingly  emaciated  and  had  delirium,  diarrluea,  dry  tongue,  blackeiu'd  with  sordes,  cough 
and  jerking  respiration.  Ho  was  admitted  Dec.  4.  lSti2.  for  lietter  attendance  and  treatnuMit.  He  was  not  reumved 
from  bed  during  the  transfer,  but  was  carried  by  relays  of  nuMi,  and  was  well  jirotected  from  the  cold  by  blankets,  hot 
bottles  and  wliLskey  toddy.  He  was  extremely  weak  but  was  restless  and  picked  at  the  bedclothes;  his  breath  was 
very  oflfensive.  The  left  cornea  sloughed  with  escape  of  the  contents  of  the  anterior  chamber,  but  the  case  progressed 
without  much  suffering  and  a  cicatricial  staphyloma  was  formed.  On  Jan.  9,  1863,  he  w.as  fairly  convalescent,  and 
on  March  16  was  discharged  from  service  on  account  of  debility  and  loss  of  vision  of  tlui  left  eye. — Klmira  Hospital,  X.T. 

C.\SE  40. — Siipirficial  ijatiijrfninis  patches. — Corji'l  .T.  II.  Kourtz,  Co.  C,  130th  Pa.;  age  19;  was  admitted  April 
20,  1863,  having  been  sick  since  the  1st.  He  was  considerably  enuiciati^d  and  in  liad  nervous  condition;  his  pulse 
90,  appetite  poor,  tongue  white-coated,  dry  and  cracked,  and  bowels  moved  five  or  six  tiuu^s  during  thi>  twenty-four 
hours;  he  had  a  slight  cough  with  thin  gray  sput.a  mixed  with  semi-solid  ma.sses  of  a  dark-brown  color,  and 
there  was  dulness  and  slight  crepitus  in  the  right  infraclavicular  region.  Suitable  nourishment  was  ordered  with 
sweet  spirit  of  nitre  and  Dover's  jiowder  at  hedtiiru^.  On  the  24th  two  small  pustules  with  inflammatory  areoliB 
were  observed  above  the  left  knee.  A  two-grain  dose  of  quinine  in  sherry  was  given  every  two  hours.  Jly  the  29th 
the  centre  of  these  spots  had  become  gangrenous  and  evolved  a  very  oftensive  odor;  a  similar  but  larger  spot  had 
also  developed  on  the  right  forearm  three  inches  above  the  wrist.  (.'hlori<le  of  ziuo  solution  was  used  locally.  The 
spots  enlarged  slowly,  and  on  May  3  a  pustule  with  a  large  inllammafory  base  appeared  on  the  mucous  nieuibrane  of 
the  left  side  of  the  lower  lij).  On  the  ,")th  there  was  low  diOiriiim;  the  left  side  of  the  face  was  swollen  and  the  gan- 
grenous spot  on  the  lip  was  as  large  as  a  penny  and  increasing  rapidly;  the  diarrluea  meanwhile  continued.  The 
patient  became  unconscious  anddii'don  the 8th. — .ict.  Ass't  Siinj.  ().  P.  Sweet,  U.  S.  A.,  Lincoln  Hospital,  Jf'a,shinijton,  D.  C. 

Case  il.—Gamjreiie  of  /dcs.— Private  William  Wollcott,  Co.  H,  12th  N.  Y.;  age  153;  was  admitted  June  23, 1863, 
fiom  Harewood  hospital,  Washington,  D.  C.  [The  records  show  that  this  man  had  typhoid  f<(ver  at  White  Oak 
Church,  Va.,  in  Jlarch,  and  that  he  was  recei\<d  into  Harewood  hospital,  April  21,  whence  he  was  transferred  to 
>Satterlee  hosiiital,  Philadelidiia,  Pa.,  as  stated.]  On  admission  he  was  found  to  Imvc  a  diarrhoea  causing  four  or 
five  stools  daily,  and  a  gangrene,  attributed  to  frost-bite  while  on  picket,  involving  four  of  the  smaller  toes  of  the 
right  foot  and  two  of  those  of  the  left  foot;  he  had  also  an  ulceration  of  the  left  buttock  which  was  supposed  to  have 
resulted  from  riding  in  ambulance  wagons.  On  the  27th  the  sphacelated  parts  of  the  right  toes  separated  leaving 
clean  ulcers,  and  on  July  4  the  first  joints  of  the  second  and  third  toes  of  the  left  foot  were  removed  by  operation. 
Water  dressing  was  applied.  On  the  29th  the  patient  was  furloughed.  On  September  i  he  was  transferred  to  the 
Invalid  Corps. — Saiterlce  Hospital,  Philadelphia,  Pa. 

Case  i^.—Ganfjrcne  of  ?(■(/.— Private  p:.  D.  Ellis,  Co.  H,  2d  Vt.;  age  20;  was  admitted  June  29,  1862,  with 
chronic  bronchitis  following  typhoid  fever.  The  patient,  although  lightly  built  and  not  very  rol)Ust,  had  always 
enjoyed  good  health  until  attacked  by  typhoid  fever  on  the  Y'orktown  p(^ninsula,  where  he  remained  in  hospital 
until  conveyed  to  this  place.  While  on  board  the  transport  he  noticed  a  pimple  on  the  outer  side  of  his  left  leg 
about  two  and  a  half  inches  above  the  ankle.  As  it  did  not  create  annoyance  at  that  time  the  attention  of  the 
attending  surgeon  was  not  called  to  it  until  about  a  week  after  his  admission.  It  was  then  i)ainful  and  presented 
the  appearance  of  an  ordinary  boil  which  had  broken;  wiirm  fomentations  were  applied.  In  a  day  or  two  the  edges 
began  to  slough,  but  under  the  intiuence  of  good  diet  aiul  tonics,  witli  the  continuance  of  warm  applications, 
the  slough  separated  with  but  little  loss  of  tissue,  leaving  a  healthy  iilcer.  (Iranulation  proceeded  kindly  and 
cicatrization  was  nearly  completed  when  the  surrounding  tissues  became  red,  swollen  and  painful.  The  general 
treatment  was  not  changed,  but  a  bread-and-water  poultice  was  applied  to  the  sore  with  much  relief  to  the  patient. 
The  ulcer  remained  for  a  time  quiescent,  but  thereafter  the  edges  again  took  on  violent  inflammation  and  became 
gangrenous.  Nitric  acid  was  freely  applied  to  the  whole  surface,  but  the  processes  of  separation  and  granulation 
were  carried  on  slowly.  Gradually,  however,  the  patient  improved;  his  cough  subsided;  he  gained  flesh  and  became 
able  to  take  exercise  in  the  open  air.  Towards  the  end  of  December  the  ulcer  was  quite  small  and  looked  well; 
but  at  this  time  the  patient  partook  freely  of  liquor  while  absent  on  pass,  and,  perhaps  as  a  result  of  unnoticed 


264  CLINICAL    EECORDS    OP 

violence,  the  gangveuo  ieai)poare(l  and  spread  more  rapidly  than  before.  Caustic  iiotash  was  applied,  but  the 
slough  began  to  spread,  involving  the  skin,  fascia,  nuisclcs,  tendons  and  even  the  bone.  The  general  health  became 
much  impaired;  the  stomaeh  loathed  food  and  rejected  whatever  was  takeu  into  it;  opiates,  even  in  large  doses, 
were  insufficient  to  induce  sh'c]),  so  that  the  jiatient  rapidly  lost  liesli  and  became  exceedingly  irritable.  To  the 
whole  gangrenous  surface  snliihate  of  zinc  was  freely  applied  and  carefully  retained  in  position  by  dry  lint  and 
strips  of  adhesive  ])la8ter:  for  an  hour,  or  a  little  more,  there  was  an  increased  aching  in  the  parts,  but  comparative 
ease  followed.  In  twelve  hours  a  poultice  of  slippery  elm  was  applied.  Next  day  the  slough  began  to  soften, 
free  suppuration  took  place  and  the  patient's  appetite  and  sleej)  imiiroved.  In  a  week  nearly  all  the  slough  had 
separated  and  the  granulations  were  progressing  satisfactorily.  The  lower  edge  of  the  deeper  portions  of  the 
ulcer  still  looked  suspicious  and  required  a  re-application  of  the  zinc  suli)hate,  diluted,  however,  on  this  occasion 
by  the  addition  of  an  equal  part  of  jiowdered  gum  arable.  The  result  was  beneficial,  and  at  the  date  of  the  rei)ort 
the  whole  ulcer  was  filled  with  healthy  granulations.* — Satti'rhe  Hospital,  Vhiladdphiu ,  I'd. 

C.\SES  4:?-.50. — Disor(jan)::iiiion  of  the  parotUI  i/hoid. — Cask  lo. — Private  Edward  J.  Wilson,  Co.  I,  i;-!8th  111.; 
age  18;  was  admitted  Oct.  1,  18(it,  with  typhoid  fever.  lie  had  high  fev<'r,  dry  skin,  brown  and  dry  tongue, 
sordes,  anore.xia,  occipital  pain,  mental  duluess,  epistaxis,  yellow  watery  stools  seven  or  eight  times  a  day  and  tym- 
panites aud  tenderness  of  the  abdomen.  Dover's  powder,  ([uinine  and  calomel  were  given  every  four  hours,  and 
the  skin  was  sponged  three  times  a  day  with  alkaline  water.  On  the  11th  the  skin  and  tongue  had  become  moist, 
the  diarrhtea  lessened  and  the  appetite  better,  but  the  left  parotid  gland  was  swollen  and  painful.  On  the  14tU 
the  patient  was  delirious  aud  refused  food.  On  the  l.jth  there  was  much  dysphagia  and  the  radial  pulse  was  hardly 
perceptible.     lie  died  on  the  18th. — Hospital,  Qiiiiicy,  III. 

Case  44. — Private  15.  F.  Koss,  Co.  C,  78th  111.,  was  adnutted  Sei)t.  19,  1862.  A  severe  diarrhiea  complicated 
this  febrile  case.  The  jiatient  had,  moreover,  recovered  from  an  attack  of  mumps  only  a  short  time  before  his 
admission.  Two  or  three  weeks  after  admi.ssion  and  while  under  treatment  for  the  fever  the  parotid  of  the  left 
side,  which  had  been  most  affected  during  the  previous  attack  of  mumps,  became  painful  aud  swollen,  increasing 
gradually  to  an  immense  size  and  remaiuing  for  some  time  very  hard  and  resisting.  When  it  had  softened  under 
continuous  poulticing  it  was  lanced  in  several  places,  and  again  after  a  few  days  more,  without  other  issue  than  a 
few  drops  of  dark-colored  blood.  After  this  the  tumor  began  to  discharge  through  the  ear  and  then  through  the 
openings  made  with  the  lancet,  the  whole  of  the  gland  finally  suppurating.  Meanwhile  Ji  harassing  cough  set  in 
and  the  diarrhoea  could  not  be  controlled.    The  patient  died  October  29. — Hospital  So.  1,  Quincy,  III. 

Case  45. — Private  James  E.Taylor,  Co. A,  111th  N.Y.;  age  18;  was  admitted  Jan.  8,  18(32,  with  an  abscess  of 
the  parotid  gland  following  an  attack  of  typhoid  fever.  He  was  much  emaciated.  As  the  abscess  discharged  from 
the  auditory  meatus,  an  incision  was  made  below  the  car  to  give  exit  to  the  pus.  Nutrients,  tonics  aud  stimulants 
were  employed,  but  the  patient  died  on  the  21st. — Third  Division  Hospital,  Alexandria,  la. 

Case  46. — Private  John  Kiunisou,  48th  Ind.,  a  nurse,  was  placed  on  sick  report  July  13, 1863,  on  account  of  an 
attack  of  duodenitis,  with  hepatic  comiilications,  supervening  upon  a  diarrlnca  of  two  weeks'  standing.  Rest  in 
bed,  mild  uourishitient  and  Dover's  powder  were  prescribed.  During  the  next  five  days  the  bowels  improved  and 
pain  on  pressure  ceased,  but  after  this  the  left  parotid  became  painful  and  swollen.  There  was  severe  dysphagia 
on  the  19th.  An  abscess  at  the  angle  of  the  jaw  was  opened  on  the  24th  and  discharged  freely;  there  was  also  a 
copious  discharge  from  the  external  auditory  meatus.  Iron,  (juinine,  opium,  strong  wine  and  good  diet  were 
employed.     On  August  20  he  was  furloughed.— f/Hiott  Hosj>ital,  Memphis,  Tenn. 

Case  47. — Private  Abram  W.  Pearl,  Co.  H,  9th  N.  H.;  age  45;  was  admitted  Dec.  11,  1862,  from  Carver  hos- 
pital, Washington,  D.  C,  where  he  had  been  treated  for  typhoid  fever  since  October.  He  had  parotitis  of  the  right 
side.  Simple  cerate  was  applied.  On  Jan.  30,  1X63,  he  had  some  diarrluea.  He  was  placed  on  guard  duty  Feb- 
ruary 7,  but  three  days  later  returned  to  the  ward  on  account  of  severe  pain  in  his  feet.  On  the  13th  he  had  some 
vertigo  and  on  the  16th  a  recurrence  of  diarrluea,  which  was  not  checked  until  the  26th.  The  pain  iu  the  feet  con- 
tinued until  April  10.  Shortly  after  this  ho  was  i)!aced  on  duty  in  the  kitchen  and  was  not  returned  for  field  service 
until  September  26. — Satterlee  Hospital,  Fhiladelphia,  Pa. 

Ca8e  48. — Private  Kobert  Powell,  Co.  D,  10th  III.  Cav.,  was  admitted  Sept.  10, 1863,  much  emaciated  and  very 
weak  from  fever  and  diarrluca;  he  could  scarcely  speak.  He  had  a  freely  sujjpurating  parotid  abscess  which  opened 
externally  and  also  into  the  external  auditory  canal.     He  died  on  the  21st. —  I'nioii  Hospital,  Mctnj>his,  Tenn. 

Case  49. — Private  William  Lyons,  Co.  I?,  34th  Ohio:  age  17;  robust  and  athletic;  was  admitted  Aug.  11, 1864, 
having  had  diarrha-a  for  several  days,  causing  five  or  six  liquid  stools  daily.  Astringents  were  employed,  and  next 
day  he  had  but  one  stool,  but  the  abdomen  was  tender,  the  skin  hot  and  dry,  the  tongue  moist  and  very  glossy  and 
the  appetite  lost;  there  was  also  some  faintness.     Quinine,  iron  aud  whiskey  were  prescribed.     The  bowels  remained 


*  Act.  Ast-'t.  Surg.  I.t.<iTD  DoEsEY,  U.  S.  A.,  Me'l.  and  Siny.  ReporU'f,  V\\\hv\iA\i\&,{,  Vol.  X,  18(j:J,  ji.  :t8.5,  in  a  series  uf  ctiniciil  notes  gives  the  history 
of  a  case  reported  as  scurvy  with  luurtification  of  the  left  foot.  The  case  had  a  decideiily  fdirile  character  tliroujriiout.  The  patient,  B.  VV.,  (^o.  G,  ;i:iii 
Mass.  Vols.;  age  17  ;  was  admitted  to  Harewood  hospital  \ov.  V.\  lS(i2,  with  an  urethi'al  affeetion  of  two  months'  standing.  Treatne-nt  entirely  rtdieved 
his  ailment  when,  on  Deceud»er  7,  lie  was  takeu  with  deliility,  diarrhrea  and  fehrile  symptoms.  (In  tlic  morning ctf  the  9th  there  was  great  delirium  ;  the 
pulse  12<J,  weak  and  irregular;  the  skin  hot  and  dry;  the  tongue  dry,  rough  and  coated  with  sordes.  Turitentine  emulsion,  (luinine,  w'ine  and  ijeef-tea 
were  prescribed.  During  the  two  following  days  the  symptoms  showed  little  change.  On  the  r2th  the  fever  was  subsiding  and  tin;  delirium  lessened, 
but  both  feet  were  greatly  swollen,  painful  and  covered  with  blisters  of  various  sizes,  while  tlie  legs  were  ecciiymosed  and  the  hands  purplish  ;  there 
waa  no  hemorrhage  from  the  mucous  membranes  and,  aside  from  an  excessive  twlor,  nothing  peculiar  was  noticed  iu  the  stools,  .\rter  :i  few  days  the  fact 
became  less  tumid,  the  vesications  collapsed  and  th(i  ecchymoses  faded  somewhat;  hut  on  the  21st  the  left  foot  began  to  slough  anil  this  morhirl  action 
continued  to  the  close  of  the  ca»'.  Jleanwhile  blotches  apiH-ared  on  the  surface  of  the  binly,  the  pulse  became  feeble,  the  stools  iuvoluntjiry,  and 
delirium  recurred,  ending  this  time  in  stupor.    Death  took  place  Jan.  3,  18G3. 


TTTF.    f•0^'TT^nTE■D    FEVERS.  265 

(jiiiet,  liut  on  the  19tli  two  stool.s  wore  ol)taiut'<l.  castor  oil  and  turiii'iitiiio  haviiiij  lioen  };iveii  on  the  previous  day. 
On  the  21st  the  j>ul.se  was  llti,  tongue  moist  anil  with  a  sliniv  white  eoat,  skin  hot  and  dry,  aj>i)etitc  delicieut  and 
Ktomaeh  irritable,  bowels  uuived  live  times;  rose-eolored  s]iots  appi-ared  ou  the  alidonien:  rough  and  sibilant  riles 
were  heard  in  the  ujijier  lobes  of  the  lungs.  Turjientine,  scjuill  and  i))eeaeiianha  were  given,  with  warm  brieks  to  tbo 
feot,  a  blister  to  the  chest  and  sinaiiisms  to  the  eiiigastriiiiii.  On  tlie  '2',Ul  sordes  ajiiieaied  on  the  teeth  and  there  was 
freiiueut  epistaxis;  the  abdomen  was  tympaiiitie  and  covered  with  dark  sjxits:  the  mind  so  dull  that  questions  were 
answered  with  reluctance  and  indistinctly;  both  parotids  were  inllamed  and  iiaint'ul.  The  patient  was  very  rest- 
less and  delirious  ou  the  2ritli;  his  pulse  was  182  and  he  was  evidently  sinking  rapidly.  He  died  on  the  morning  of 
the  26th. — Ciimhcrlund  Hospital,  Md. 

C\sE  .50. — Private  Melvin  Hrown,  Co.  G,  23d  Ohio;  age  IS;  was  admitted  Oct.  17,  IStil,  having  been  sick  for 
four  months.  Ho  was  much  emaciated  and  unable  to  walk;  he  had  no  api>etite;  his  ;ibdoiuen  was  lynipanitic  and 
tender,  bowels  loose,  tongue  smooth,  dry  and  shining,  lips  dry  and  iiarched.  skin  dry  and  hot,  pulse  112.  l^uinine, 
iron,  Dover's  powder,  beef-essence  and  stimulants  were  ordered,  and  glycerine  aiiplied  to  the  tongue  and  lips.  On 
the  22d  crei)itu8  was  heard  over  the  middle  parts  of  both  lungs.  On  the  21th  epistaxis  recurred  about  every  two 
hours  and  the  jiarotid  glands  began  to  swell.  The  submaxillary  glands  lieeaino  involved  on  the  27th.  I'us  was  dis- 
charged from  the  left  ear  on  the  2!lth.  Nevertheless  the  patient  rested  well  at  night,  had  some  appetite  and  was 
hopeful.  Carbonate  of  animonia  was  given  on  account  of  the  cough,  i'us  was  discharged  from  the  right  ear  ou 
the  31st  and  the  eye  of  that  side  was  closed  by  the  increasing  swelling.  Next  day  there  was  a  bed-sore  on  the 
sacrum.     The  pulse  became  very  weak  and  almost  imperceptible.     He  died  November  5. — Ciimlhrhiiid  Hotiintnl,  Md. 

Iniuiy  to  the  nervous  system  is  suggested  on  more  or  less  definite  testimony  by  the 
eleven  cases  numbered  51-61. 

Ca.se  .51. — (FAlemu  uud  partial  panilj/sh  of  rif/ht  Ici/. — Private  Ernest  liowman,  Co.  B,  ittli  I'a.  Rea.;  ago  20;  was 
taken  sick  at  Harrison's  Landing  with  typhoid  fever,  July  18,  lH(i2,  but  when  admitted,  August  10,  was  so  far 
recovered  as  to  have  no  fever  and  but  little  diarrhiea.  Shortly  after  admission  his  right  leg  became  jiainful  and 
swolh'n  from  o'deina.  In  two  weeks  the  swelling  disap]>eared,  but  a  jiartial  paralysis  remained  for  a  considerable 
period. — Sattirlcc  Hospital,  I'hitadilpliin,  I'a. 

Case  .52. — Partial  parapleyia. — Private  Richard  H.  Martin,  Co.  1),  16th  Maine;  age2K;  was  admitted  May  28, 
1864,  as  a  convalescent  from  typhoid  fever.  [About  Dec.  1.5,  1863,  while  near  Cnlpeper,  Va.,  he  was  taken  with 
fever  and  delirium  and  became  very  w-eak;  ho  was  treated  in  tho  field  division  hosjiital  and  transferred  Feb.  1, 
18(>4,  to  Stanton  hospital,  Washington,  D.  C]  On  admission  his  health  was  ini])air(Ml  and  his  lower  extremities 
partially  paralyzed;  he  could  walk,  but  slowly  and  unsteadily.  He  was  discharged  August  15  ))ecause  of  this  disa- 
bility.—  TnriHi-'n  fAtitf  llonpilal,  Vliitadvlphia,  I'a. 

Cask  53. — raraplciiia  icitli  atroj)lii/  of  right  hij. — Private  Chauncey  lirown,  Co.  15,  !)7th  N.  Y.,  was  admitted  Sept. 
3,  1862,  as  a  convalescent  from  typhoid  fever.  He  was  much  emaciated  and  debilitated  and  had  a  large  bed-sore 
over  the  sacrum,  severe  pain  in  the  back  and  paralysis  of  the  lower  limbs.  By  November  1.5  he  could  go  about  a 
little  on  crutches,  for  which,  on  December  4,  he  was  able  to  substitute  a  cane,  the  bed-sore  having  healed,  though 
there  still  remained  some  tenderness  and  wasting  of  the  right  leg.  He  was  returned  to  duty  on  the  26th. — South 
Street  Hospital,  Philadelphia,  Fa. 

C.\SE  .54. — Paraplei/ia. — Corporal  .John  Mctiiunis,  Co.  C,  42d  N.  Y.,  was  admitted  Aug.  7,  1862,  as  a  convales- 
cent from  tyiiho-malarial  fever  contracted  on  the  Peninsula.  He  did  well  under  tonic  treatment  till  September  .30. 
Loss  of  power  and  sensation  in  the  lower  limbs  gradually  increased  to  an  almost  total  paralysis.  During  the  winter 
iodide  of  potassium  and  strychnia  were  given  and  the  galvanic  battery  apjilied.  'I'lie  iiatieni  im])roved  very  much, 
but  as  he  was  unable  to  do  duty  he  was  discharged  March  20,  1863. — South  Street  Ilomiital,  Philadelphia,  I'a. 

Case  55. — Partial  hemiplegia  with  contraction  of  right  leg. — Private  William  Criswell,  Co.  I,  12th  Ky.;  age  30;  was 
admitted  March  3,  1863,  with  some  diarrhiea,  a  bad  cough,  pain  in  the  back  and  partial  hemiplegia.  He  suffered 
from  typhoid  fever  in  November,  18t)2,  and  had  never  fully  recovered  from  the  conse(|uences  of  the  attack.  Cups 
were  applied  to  the  back  and  strychnia  and  capsicum  administered.  He  improved  rapidly,  but  continued  lame  in  his 
right  leg,  which  was  somewhat  contracted  at  the  time  of  his  transfer  to  Louisville,  Ky.,  .June  it. — Hospital,  ()uincy.  III. 

Case  56. — Hemiplegia. — Private  Nathan  Smith,  Co.  M,  1st  Wis.  Cav.;  age  34;  was  admitted  Dec.  8,  18(i4,  suf- 
fering from  paralysis  of  the  left  side,  which,  according  to  the  statement  of  the  patient,  was  the  result  of  an  attack 
of  typhoid  fever.  He  was  treated  with  one-fifteenth  of  a  grain  of  strychnia  and  two-thirds  of  a  grain  of  capsicum 
three  times  a  day,  but  there  was  no  improvement  in  his  condition  at  tho  time  of  his  discharge,  April  8,  1865. — Act, 
AssH  Surg.  D.  Lewis,  U.  S.  A.,  Hospital,  Quincg,  III. 

Case  .57. — Hemiplegia. — Private  Uilbert  Leonard,  Co.  D,  27tli  .V.  V.,  was  admitted  Oct.  30,  1861,  having  been 
sick  for  several  weeks  with  typhoid  fever.  He  had  some  diarrhiea  and  congh  on  admission,  liut  the  respiration  was 
natural.  On  the  evening  of  November  4  the  respiration  Iiecaine  increased  to  26,  the  tongue  dry,  the  pulse  accel- 
erated, and  cre])itation  was  detected  in  the  lower  jiart  of  the  right  lung.  The  sputa  became  streaked  with  blood  on 
the  5th  and  rusty  on  the  6th.  On  the  9th  the  patient  was  very  weak  and  swallowed  with  difficulty;  he  was  scarcely 
alile  to  expectorate;  he  slept  with  his  eyes  half  open  and  was  unable  to  speak.  He  was  stronger  on  the  lltli  and  his 
bowels  were  quiet,  but  the  right  side  of  the  body  was  paralyzed.  On  the  12th  he  was  much  stronger  and  asked  for 
food;  his  countenance  was  bright,  tongue  nearly  clean  and  bowels  regular.  He  gradually  rallied  from  this  low 
condition  but  the  paralysis  continued.  Strychnia  was  given  on  December  1.  On  Jan.  1,  1862,  ho  was  able  to  walk 
with  a  cane;  sensation  in  the  arm  was  much  improved  but  motion  was  impossible.  He  was  discharged  for  disability 
on  February  18. — Hospital,  Alexandria,  Pa. 
Med.  Hist.,  Pt.  111—34 


266  CLINICAL    REroilPS    OF 

Case  58. — rinydiimx  of  .-'kjIiI  arm  inul  lifl  hij.  trilh  iitrnjilii/  of  llir  hitlir. — Piiviitf  Jnme.s  Willininson,  Co.  (J,  l()9th 
Pa.;  iiKc  IS:  wa.s  aduiittt'd  A])iil  'M.  18(i."i.  a.s  n.  coiivalcsceiit  I'loiu  tvplioid  t'cviT.  [He  was  taken  sick  Sept.  2,  1864, 
at  Cuiii))  Taylor,  Ailiiigtou  Hci;,'lits.  ami  treated  in  Anjjnr  hospital,  near  Al<'xanilria,  \'a.,  for  two  months.  He 
was  nneons(MoiiH  for  two  weeks,  diiiin;;  wliieli  he  lost  the  (lower  of  niovinj;  his  rii;ht  arm  and  left  lej;.  Ho  was 
afterwards  transferred  suecessively  to  the  Lincoln.  Cnyler  and  Tumor's  Lane  hospitals.]  f>n  admission  Iiis  >;eneral 
Iiealth  was  good  and  lie  had  ieeov<-ii'(l  the  use  of  his  arm.  hnt  he  conld  not  Hex:  the  left  foot:  the  left  calf  was 
atrophied  to  the  extent  of  two  inches  and  a  half  and  there  was  some  atrophy  of  the  thijih.  Me  was  transferred  May 
10  to  McClellan  hosjiital.  I'hiladelpliia  [whence  ho  was  removed  to  Mower  hos])ital  on  .Inly  I'd  and  to  Uarrisl)nrj{ 
for  muster  ont  on  Seiitember  15]. — Tiinivi-'x  f.<inc  llasjiild!,  riiiliitlilpliiii,  I'd. 

Cask  5!>. — I'drdh/^in  dijitdiis. — Private  Thomas  l)unla]>.  Co.  K,  ()8th  Pa.;  aj;e  2:);  was  perfectly  healtliy  liefore 
enlistment,  and,  so  far  as  could  be  ascertained,  liad  no  hereditary  ])re(lis]iosition  to  disease.  He  was  admitted  Dee. 
12,  1862.  as  a  convalescent  from  typhoid  fever,  much  deliilitate<l  and  with  a  constant  trembling  of  the  whole 
body.  Under  treatment  by  qninine  and  iron,  beef-essence,  iidlk-pnnch,  oysters  and  eggs  he  increased  in  strengtli, 
but  the  paralysis  agitans  continued  undiminished.  He  was  discharged  Feb.  11, 1863,  on  account  of  jiaralysis  agitans 
and  general  debility  supervening  on  typhoid  fever. — Sultirhc  IfoKpitdl,  Vhiladdphid,  I'd. 

Case  6U. — Sequent  cerebro-.'ijihidl  ferer. — Private  Arthur  Potter.  Co.  J[,  1st  X.  .T.  Cav.;  age  19;  was  admitted 
Aug.  20,  1861,  with  severe  uncomplicated  tyidioid  fever,  from  which  he  convalesced  ra])idly.  Hy  Sejitember  2;i  he 
was  walking  about  the  ward:  but  on  October  15  he  was  seized  witli  headache,  fever  and  constipation.  Castor  oil 
and  turpentine  were  given  and  the  urine  withdrawn  by  catheter.  He  be(^anie  semi-comatose  <ui  the  17th  and  died 
comatose  next  day. — Sdtterlve  HonpUdl,  I'ltiliidelpliid,  I'd. 

C'ask  ()1. — Inflammation  of  spinal  cord  uilh  jxirdpJci/id. — Privat<'  William  J.  Pool.  Co.  A,  126th  X.  Y.;  age  23; 
admitted  Dec.  12,  1862,  as  a  convalescent  from  tyjdioid  fevei.  He  was  much  emaciated,  pale,  greatly  prostrated, 
but  without  apparent  organic  lesion:  he  had  little  ap])etite  and  slept  badly,  but  under  the  use  of  (|iiiniue  and  com- 
l)ound  tincture  of  cinchona,  with  generous  diet  and  jiorter,  his  general  health  and  strength  aftera  little  while  began 
to  improve.  In  about  two  weeks  he  expressed  Iiims<'lf  as  feeling  much  lietter,  l>iit  complained  of  great  weakness  of 
the  legs,  which  gave  way  under  him  when  he  atteni]ited  to  stand.  Regarding  this  as  a  local  exjuession  of  general 
debility,  extract  of  mix  vomica  was  given  in  ((uarter-grain  doses  three  times  daily;  but  this  medicine  was  soon 
discovered  to  be  injurious  and  its  use  was  suspended.  It  was  found  that  even  when  in  bed  the  patient  had  very 
little  power  over  liis  lower  extremities,  for  when  raised  by  the  hand  of  an  assistant  they  would  fall  by  their  own 
weight  when  the  sujiport  of  the  hand  was  removed.  The  sensibility  of  the  skin,  as  tested  by  pressure  and  pinching, 
was  found  to  be  remarlvably  deficient,  but  pressure  in  the  lumbar  region  of  the  spine  revealeil  great  tenderness. 
These  sym])toms,  with  the  experience  furnished  by  the  use  of  the  mix  vomica,  were  believed  to  indicate  an  inflam- 
matory condition  of  the  cord  or  its  membranes,  and  the  case  was  treated  in  accordance  with  this  diagnosis.  Blood 
to  the  amount  of  six  ounces  or  more  was  immediately  removed  bv  cn])]iing  the  loins;  free  catharsis  was  induced  by 
comi)Ound  jiowder  of  Jahxp,  which  was  continued  in  doses  of  twenty  grains  night  and  morning  for  two  or  three 
days;  dry  cupping  was  used;  the  patient  was  restricted  to  a  vegetable  diet,  and  tonics  and  stimulants  were  with- 
drawn from  the  system  of  treatment.  In  a  short  time  improvement  was  manifested  by  increased  power  in  the 
lower  limbs  and  by  the  return  of  the  sensibility  of  the  surface.  On  Feb.  H.  186;i,  he  was  able  to  raise  both  his  legs 
in  Ijed;  in  a  fortnight  or  more  he  endeavored  to  use  his  legs  out  of  bed,  an<l  with  assistance  was  alile  to  rest  a  little 
upon  them  but  could  not  exercise  any  directing  or  controlling  power.  Week  by  week  improvement  Avas  noted  by 
the  manifestation  of  some  power  regiuiied,  but  the  pressure  of  the  feet  upon  the  floor  continued  weak  and  uncer- 
tain for  a  time.  On  March  22  the  patient  was  allowed  a  pass  to  go  to  the  city  partly  on  foot  and  partly  on  tlie 
passenger  railway  car.  On  April  25  he  was  transferred  to  the  military  hospital  nearest  his  home  in  the  State  of  New 
York.  At  this  time  he  was  able  to  make  very  good  use  of  his  legs  and  was  strong  and  healthy  in  his  general  con- 
dition.— Sattcrlee  Jlonpital,  I'liiladelphia,  I'd. 

A  spasmodic  astliiiiu  appeared  as  ;i  sequel  in  tlie  following  case: 

Case  02. — Private  James  Harnes,  Co.  C,  71st  Pa.;  age  17:  a  convalescent  from  typhoid  fever;  was  admitted 
Dec.  8,  1864,  with  deafness  and  spasms  of  the  diapliiagin.  He  was  much  debilitated  and  aiuemic.  The  diaphrag- 
matic spasm,  which  occurred  at  first  nearly  every  night,  produced  constriction  of  the  chest  and  .seriously  interfered 
with  the  breathing;  there  was  also  some  spinal  tenderness  between  the  shoulders.  He  was  given  salines,  tonics 
and  antispasmodics,  and  a  blister  was  applied  between  tlie  shoulders;  but  the  spasms  continued  to  recur  until  the 
following  powder  was  tried:  Cream  of  tartar  half  an  ounce,  muriate  of  ammonia  one  drachm,  citrate  of  iron  and 
quinia  twenty-four  grains,  aloes  twelve  grains,  strychnia  one  grain,  mixed  well  and  divided  into  twelve  powders; 
one  three  times  a  day.  This  Anally  controlled  the  spasmodic  action.  He  was  returned  to  duty,  still  slightly  deaf, 
April  13,1865. — Je^  Jsa't  Surg.  A.  J.  Diekerhnff.  V.  S.  A.,  Hoxpital  .Vo.  5,  Qiiincy,  III. 

Cases  63-65  are  presented  as  instances  of  relapse  in  typhoid  fever;  in  65  the  diagnosis 
of  tvphoid  does  not  appear  to  lutve  l)een  clearly  estahlislied. 

Case  ()3. — Private  Edwin  <).  .lohnson,  Co.  I,  8th  Mass.,  was  admitted  .lune  17, 1863.  This  patient  liad  siitrered 
from  typhoid  fever  at  Port  Koyal,  but  had  so  far  recovered  as  to  be  able  to  be  removed  by  steamer.  On  admission 
he  was  anaemic  and  had  diarrhoja.  Two  days  afterward  he  had  fever  and  typhoid  symptoms  were  gradually  devel- 
oped; the  tongue  became  dry,  the  mind  dull,  an  eruption,  disappearing  under  pressure,  was  found  on  the  abdomen, 
there  was  some  epistaxis  and  the  pulse  became  frecjueut  and  feeljle.  Involuntary  stools  followed,  but  there  was  no 
hemorrhage  from  the  bowels  until  the  24th,  on  which  day  the  patient  died. —  Lddiex'  Home  Hospital,  N.  Y.  City. 


THE    COXTIIsrET)    FEVERS. 


267 


Case  01.— Private  Jolm  Tliaycr.  Co.  1.  '.ttli  Mich.  Cav.,  was  ailiiiitti'd  .liily  1(!,  11>!0H,  with  tyi>boi(l  fever.  An 
expectorant,  a  tonic  laxative,  a  diaphoretic  anil  a  niouth-wash  of  elilorate  of  |)()tatsU  were  pre.ieriheil.  Tlie  j)atient 
was  delirious  ou  the  nij;ht  of  the  21st  and  passed  live  copious  watery  yellow  stools.  Next  day  his  pulse  was  111'  and 
tongue  covered  with  sordes:  the  delirium  was  le.sseued:  three  stools  were  pas.sed :  there  was  some  eou;;h  and  mucous 
rales  were  beard  over  the  lun<;s.  The  deliritim  recurred  on  the  foUowiu';  night:  the  stools  were  passed  involun- 
tarily; pulse  100  and  very  feeble:  skin  cool.  He  rested  well  on  the  '2'M  and  was  free  fVoni  ihdirium  next  day,  but. 
the  diarrluea  continued  until  the  27th,  the  tongue  meanwhile  cleaning  and  th<'  lung  syuiplonis  a1)ating.  After  this 
his  progress  was  satistactory  until  about  August  17,  when  a  violent  diarrluea  set  in.  On  the  L'dth  the  tongue  was  dry 
and  yellowish-white  in  color,  the  pulse  had  risen  from  SI  to  110,  the  bowels  wi^re  tender  and  had  been  nu)ved  twelve 
times  in  the  jirevious  twenty-four  hours,  the  stools  being  large,  watery  and  sanguinoleut.  Stimulants  and  astrin- 
gents were  employed,  but  death  took  place  on  Septeiulier  5.  —  MV.sf  End  Iloxpiliil.  ('hiciiindii,  Ohio. 

C.\SE  65. — Private  Peter  DickerhoH.  Co.  E,  ll.'iih  Ohio:  age  20;  was  admitted  with  typhoid  fever  Nov.  10, 
1862.  On  the  3d  he  had  been  exposed  to  cold  night-air  after  being  overheated  by  marehing  at  double-quiek  time. 
A  rigor  followed  and  diarrlnea  set  in  causing  f(Mir  to  six  stools  daily.  Quinin?  was  given.  On  admission  his  face 
was  livid  and  anxious,  eyes  dull,  skin  dry  and  hot  but  without  erujition,  tongue  somewhat  furred,  thirst  urgent, 
appetite  delicient,  stools  watery,  pulse  lOt  and  C(MU]iressible;  he  had  severe  fr<uital  beadacbe,  ]iaius  over  the  whole 
body  and  twitchings  of  the  muscles,  \eutral  mixture  was  ])rescribed.  On  the  llth  tlu^  stools  becaiue  less  fre([nent 
and  nuire  fa'cal  in  character  but  very  fetid.  Next  day  the  i>atient"s  eyes  were  brighter,  pulse  ill,  soft  and  regular, 
tongue  moist  but  much  furred,  skin  moi/it,  cool  and  without  eruption:  four  fa'cal  stools  were  i)assed.  Stimulants 
and  chicken-broth  were  given.  Little  change  occurred  until  the  21st,  when  there  was  an  iucreaseof  the  fever  towards 
night.  Ou  the  22d  there  was  less  fever  and  the  tongue  was  moist  and  less  furred,  pulse  90  and  com])ressible.  Frontal 
headache  and  five  stools  were  reiu)rted  on  the  23d,  and  next  day  the  headache  was  characterized  as  ])eri(>dic.  (Quinine 
was  given  on  the  2.")th  and  2(ith,  but  brown  luixtnre  was  sul)stituted  on  the  following  day,  as  there  was  some 
cough  with  scanty  ex]>ectoration.  The  patii'ut  continued  to  improve  until  December  (!.  w  hen  he  relajised  somewhat 
in  conse(iuen<'e  of  a  frightful  railroad  accidi'Ut  near  tbi'  building.  On  the  Sth  he  was  quite  drowsy  ami  bad  sub- 
snltus;  pulse  90,  weak  and  compressible:  skin  hot  and  haisb:  tongue  furred.  .Sul]diate  of  (juinia  in  one-grain  doses 
was  prescribed  for  u.se  every  tw-o  hours.  On  the  9th  he  was  less  drowsy,  the  bowels  were  more  regular  and  the  sub- 
snltus  lessened.  On  the  14th  there  was  difficulty  in  hearing,  but  after  this  he  improved  steadily  ami  was  sent  to 
general  hospital  at  Camp  Dennison  Feb.  12,  1863. —  ll'est  End  Hospital,  Cincinnati,  Ohio. 

Two  oases,  represented  as  second  attacks  of  the  s])cciHc  fever,  are  also  submitted: 

Cask  66. — Corp'l  William  H.  Lake,  Co.  K,  126th  \.  Y.,  was  admitted  Dec.  12,  1862,  on  account  of  a  sprained 
atikle.  A  few  days  after  a  case  of  typhoid  pneumonia  was  transferred  to  the  ward;  he  complaini'd,  ,Jan.  13,  1M63,  of 
some  headache  and  nausea,  and  next  day  was  in  bed  at  the  morning  visit  with  vomiting,  diarrluea,  coated  tongue 
and  anxious  countenance.  Mercurials  were  given  and  a  Dover's  jxiwdor  at  night.  On  the  l.")th  astringents  were 
ordered  with  (|uinlne  in  two-grain  doses  font  times  daily.  He  jiassed  a  very  restless  night,  and  on  the  Kith  tlii'  ]iulso 
was  120,  skin  dry  and  hot,  tongue  dry,  face  Hushed  and  right  iliac  region  tender.  The  ()niuiue  was  continued  w  ith 
turpentine  and  stimulants  adiled.  Kose-colored  s]>ots  appeared  on  the  20tb,  on  which  day  there  was  also  epistaxis, 
Hieteorism  but  no  diarrlnea;  the  inilse  was  still  rajiid,  about  100,  the  tongue  soimnvhat  dry  but  moist  on  the  edges, 
the  mind  clear.  [The  patient  stated,  and  his  father  subsequently  corrobonited  tlu^  statcuu'nt,  that  he  had  at  a 
previous  period  sutfered  from  typhoid  fever  with  a  relai)S<'  and  a  prolonged  convalescence.]  On  beef-tea,  chicken 
and  oyster-sou]),  milk-punch,  etc.,  with  (juinine,  he  progressed  favorably,  and  was  able  to  walk  on  February  12.  Ho 
was  furloughed  on  the  19th. — SattcrU'e  Hospital,  I'hUndi'lphiii,  I'a. 

Ca8E  67.— Private  David  Lacy,  Co.  K,  136th  Pa.;  age  31;  was  admitted  Dec.  16,  1862.  He  had  suffered  from 
pain  in  the  breast,  cough  and  Inenuijitysis,  weakness  and  diarrluea  since  October  3.  lie  stated  also  fliat  two  years 
before  he  had  been  atfectcd  w  itli  what  was  calle<l  typhoid  fever  by  his  ]ihysi<ian.  This  attaik,  which  had  lasted 
several  weeks,  was  characterized  by  delirium  and  diarrlnra,  with  tymiianites,  ]>aiii  in  the  bowels  and  an  eruption  on 
the  abdomen,  great  weakness,  emaciation  and  prolonged  convalesct^nce.  On  December  22,  a  few  days  after  his 
admission,  he  had  a  chill  which  was  followed  next  day  by  fever,  diarrluva,  debility,  headache  and  hebetube,  and  on 
the  24th  by  epistaxis  and  great  thirst  but  no  nausea.  On  the  27th  he  had  another  aguish  paroxysm,  and  three  grains 
of  quinine  were  given  three  times  daily.  On  the  30th  he  was  reported  as  having  been  somewhat  delirious  during  the 
preceding  night,  walking  undressed  in  the  waitl,  trying  to  urinate  into  the  stove,  insisting  that  the  doctor  had  sent 
for  him,  etc.  On  the  31st  his  tongue  was  cleaner,  his  pulse  nearly  natural:  there  had  been  no  delirium  during' the 
previous  night  but  six  liijuid  sto(ds  had  been  voided.  The  same  general  condition  was  found  on  .Ian.  1,  1863,  but 
the  expression  was  dull  and  next  day  the  touguc  was  rather  dry.  On  thi'  3(1  the  eyes  were  injected,  the  skin  harsh^ 
the  bowels  nearly  natural,  pulse  84.  The  patient  coughed  much  during  the  previous  night  and  brought  up  mucus 
dotted  with  blood;  percussion  gave  a  dull  sound  and  respiration  was  feebly  heard  over  the  lower  third  of  the  left 
lung,  but  there  was  no  crepitus  nor  bronchial  respiration.  The  quinine  was  suspended.  Next  day  numerous  ro.se- 
colored  .spots  appeared  on  the  skin  of  the  abdomen  luid  chest;  the  skin  of  the  face  had  a  varnished  look;  the  mind 
was  clear,  the  hearing  slightly  obtuse  and  there  was  slight  headache.  Sudamina  appeared  on  the  .5th  in  the  iliac 
region  and  on  the  neck;  the  abdomen  was  moderately  distended;  one  stool  was  passed;  the  matter  expectorated 
was  thick  and  rusty.  The  hearing  was  improved  on  the  6th  and  the  tongue  more  moist.  The  progress  of  the  case 
was  steadily  towards  convalescence;  dulness  of  hearing  was,  however,  very  noticeable  until  the  llth.  The  patient 
was  able  to  leave  his  bed  on  the  23d,  after  which  he  gained  rapidly  in  flesh  and  strength. — Satterlee  Hospital,  Phila- 
delphia, Pa. 


268  CLINICAL   RECORDS   OP 

m— TYPHUS  FEVER, 

Aliliough  2,501  cases  of  typlius  fever,  850  of  which  were  fatal,  were  reported  among 
the  white  troops,  and  123  cases  with  108  deaths  among  the  colored  troops,  the  case-books 
contain  particidars  of  only  six  cases  that  were  recorded  under  this  lieading,  while  the  med- 
ical descriptive  lists  of  but  ten  cases  have  been  placed  on  file.  Cases  1-6  from  the  case-books 
are  submitted  in  full;  cases  7-13  ai-e  abstracted  from  the  descriptive  lists.  Three  cases 
treated  in  September  and  October,  1863,  at  the  St.  .lames  Hospital,  New  Orleans,  La.,  are 
aot  presented,  as  the  official  papers,  signed  by  J.  V.  (J.  S^niii,  Act.  Ass't  Surg.,  U.  S.  A., 
give  no  information  except  as  to  names,  dates  and  results, — death  in  one  instance,  recovery 
in  a  second  and  transfer  to  anothei"  ward  on  account  of  an  attack  of  erysipelas  in  the  third. 

Case  1. — Private  Ira  Martin,  Co.  I,  1st  Mich.  Sharpshooters;  age  23;  on  his  recovery  from  a  gxmsliot  injury  of 
the  arm  was  placed  on  light  duty  in  tlie  kitchen,  and  while  thus  employed  was  seized,  Jan.  7, 1865,  with  a  severe  chill 
followed  by  high  fever;  his  tongue  was  coated,  mouth  clammy,  liowels  constipated,  aud  he  had  severe  headache  and 
pain  in  the  back  and  limbs.  lilue-i)iU  and  (|iiinia  were  given.  The  fever  abated  but  recurred  at  noon  next  day  with 
increased  violence.  On  the  lOtli  the  fever  had  become  continuous:  the  eyes  and  skin  were  injected,  and  the  latter 
presented  spots  on  the  chest  and  abdomen  which  were  neitluu'  true  petechiic  nor  the  (diaracteristic  rose-colored  spots 
of  typhoid  fever.  Xext  day  the  pulse  was  frecjuent,  small  and  irregular,  the  tongue  coated  l)rown  and  the  patient 
delirious.  Quinine  and  stimulants  were  prescribed:  but  on  the  12th  the  stools  became  involuntary  and  the  surface 
livid.  Death  occurred  on  the  13th.  {Actiiifi  Assistant  Surgeon  Wm.  H.  Graftox,  U.  S.  Aniti/,  the  attending  physician, 
at  first  regarded  this  as  a  case  of  typhoid  fever,  but  the  injection  of  the  surface  and  the  subsequent  collapse  led  him 
to  change  the  diagnosis  to  typhus,  the  more  so  that  the  patient  had  access  to  a  ward  in  which  was  a  well-marked 
case  of  this  fever.] — Hosjiilid,  .tiiu(ii)()lis.  Mil. 

Case  2.— Private  William  E.  Tullis,  Co.  C,  134th  Ohio;  age  19:  was  admitted  May  17,  1864,  with  measles. 
He  recovered  and  was  returned  to  duty  June  25th,  but  being  seized  with  acute  diarrhoea  and  high  fever  was 
re-admitted  on  the  28th:  pulse  110;  face  Hushed;  eyes  suffused;  mind  confused  and  anxious.  Astringents  were  pre- 
scribed. Next  day  he  was  restless,  anxious,  feverish  and  had  several  discharges  from  the  bowels.  On  the  30th  the 
pulse  was  116,  tongue  red  and  smooth,  face  flushed  and  spotted,  mind  anxious,  stools  frequent  aud  watery.  Turi)en- 
tine  emulsion  was  prescribed.  On  July  2d  the  patient  lost  twelve  ounces  of  blood  by  epistaxis ;  he  was  much 
exhausted;  the  delirium  and  diarrhiea  contiinu?d.  The  nostrils  were  plugged  anteriorly  with  lint  saturated  with 
persulphate  of  iron  and  tincture  of  iron  was  prescribed  for  internal  use.  On  the  4th  brandy  was  given  every  three 
hours.  The  diarrho'a  ceased  on  the  7th;  the  tongue  became  moist  and  tlm  mucous  and  salivary  secretions  increased 
in  <iuantity  and  were  of  healthy  appearance,  but  the  dcliiium  continued  and  the  exhaustion  was  very  great.  On  the 
9th  there  were  involuntary  discharges  from  the  l)Owels  and  Idadder.  Death  occurred  next  day. —  Citmlxrland  Hos- 
pital, Mil. 

Case  3. — Private  Isaac  H.  Starr,  Co.  F,  119th  111.;  age  23;  was  admitted  Oct.  25,  1862,  having  been  sick  for 
about  four  weeks  with  fever.  Diagtiosis — typhus  fever.  On  admission  the  tongue  was  dry  and  red,  dark  in  the 
centre,  pulse  92,  skin  dry  and  hot,  bowels  not  painful  but  moved  three  or  fonr  times  in  twenty-four  hours;  he 
had  much  thirst  and  some  cough.  Turpentine  emulsion  and  syrup  of  ipecacuanha  were  prescribed.  He  was  rest- 
less aud  somewhat  deliriou.s  during  the  night  but  perspired  slightly  towards  the  morning  of  the  26th;  during 
the  day  he  had  occasional  but  slight  epistaxis.  Small  doses  of  opium  and  i|uinine  were  added  to  the  treatment. 
The  skin  continued  moist,  the  stools  became  less  frequent,  and  on  the  30th  the  tongue  lost  its  dryness  and  began  to 
clean,  but  the  patient  talked  incoherently  and  was  seized  with  a  general  tremor  on  moving.  On  November  1  he 
seemed  somewhat  better;  the  tongue  was  moist,  pulse  78,  but  the  tremors  of  the  hands  continued.  The  dose  of 
turpentine  was  ii>crea.sed  and  whiskey  was  added  to  it.  There  was  a  slight  improvement  up  to  the  6th,  when  the 
mind  again  wandered  and  the  tongue  became  dry,  red  and  cracked  transversely  in  the  centre;  the  bowels  were 
neither  loose  nor  tender,  but  the  recti  muscles  were  somewhat  tense.  Next  day  there  was  tremulousness  of  the 
muscles  of  the  face  with  subsultus;  the  patient  was  drowsy  and  his  mind  feeble;  the  bowels  became  loose  on  the 
afternoon  of  this  day  but  were  controlled  by  tannin  aiul  morphia.  On  the  8th  the  intelligence  returned.  The  tongue 
and  skin  were  moist  on  the  9th,  but  the  former  became  somewhat  dry  nex;t  day,  and  in  the  afternoon  while  per- 
spiring profusely  a  copious  bloody  dejection  was  jiassed  from  the  bowels.  Similar  bloody  stools  recutred  on  the  11th, 
after  which  the  pulse  became  feeble  and  tin!  general  ajipearance  of  the  patient  unfavorable.  Opium,  tannin,  qui- 
nine aud  capsicum  were  given  with  whiskey,  beef-souj)  and  egg  mixture;  but  the  stools  continued  bloody  or  wine- 
colored,  though  less  frequent ;  the  pulse  was  very  feeble  and  the  features  shrunken.  Opiate  enemata  were  also  used. 
On  the  14th  there  was  nausea  and  a  quantity  of  green  liquid  was  vomited.  Death  occurred  on  the  15th. — Hospital, 
Quincy,  III. 

Case  4. — Private  Isaac  Howell,  Co.  D,  119th  111.;  age  20;  was  admitted  Nov.  1,  1862,  having  been  sick  for 
eight  days.  Diagnosis — typhus  fever.  He  had  pain  in  the  back  and  breast;  his  tongue  was  red  and  rather  dry, 
pulse  88,  skin  warm  and  l)owel8  open.  Small  doses  of  quinine  and  Dover's  jiowder  were  prescribed.  On  the  2d 
the  patient  was  incoherent  and  somewhat  deaf;  the  stools,  thin  and  dark-colored,  were  not  accompanied  with  pain. 
Turpentine  emulsion,  sweet  spirit  of  nitre  and  paregoric  were  prescribed  in  addition  to  the  quinine  and  Dover's  . 


THK    COKTIXITED    FKVEES.  269 

])f)\v(lcr.  On  the  4th  he  was  very  wild  during  tlie  niglit  and  attempted  to  leave  niM  lied.  Wino  was  added  to  the 
treatment.  The  patient  slept  oeeasionally  but  his  sleep  was  iiiterruiited  liy  startiiigs:  the  month  and  lips  Ijeeauie 
covered  with  sordes,  the  tongue  foul  and  the  liody  emaciated.  Tin'  skin  was  moist  on  the  Tth,  hut  delirium  of  ;i 
violent  character  eontluued  :  his  in>iiiiai  ions  wcve  dec]!  and  inclini'il  to  lie  sti-rtorons.  On  the  Hlh  ho  was  exceed- 
ingly wild  and  incoherent;  the  pulse  im.  tongue  uu)re  moist  hut  covered  with  soriles,  skin  hathed  in  a  eo|)iou.s 
sweat,  bowels  fjuiet.  Quinine,  chlorate  of  potash  and  ca]isicum  were  ]>rescrilied  with  stimulants  and  beef-souii. 
In  the  evening  he  had  involuntary  stools  and  red  sjpots  aiijieared  (ui  his  body  and  face:  he  was  much  prostrated 
ami  his  features  very  haggard.  On  the  i'th  lie  seemed  nunc  natural  and  could  jirotrude  his  tongue  with  less  dilli- 
I'ulty.  He  persjiired  copiously  on  the  11th,  and  recognized  his  nuither  who  had  come  to  see  him;  his  bowels  weri' 
quiet.  On  the  12th  and  llith  there  was  delirium  with  no  favorable  change  in  the  giMU'ral  api>earauce;  tlie  tongue 
was  moist  but  red,  raw  and  rough.     Ili-  died  on  the  1  lib. — llii^ii\l<il.  (Jiiiiivji.  lU. 

Case  5. — Private  Sauford  C.  I'ruilt.  (d.  F.  l.'.">th  Ind.:  age  Sit:  was  adnutled  Feb.  2,  IMtio,  with  chronic 
rheumatism.  April  28:  Pulse  104  and  full:  tongue  red  and  nuiist  :  i>ain  in  back;  eruption  overbody;  thirst;  anorexia; 
slight  Intadache.  Diagnosis — ty])hus  fever.  Oave  neutral  mixture,  milk  and  beef-lea.  2!hh:  Pulse  II.")  and  full; 
skin  hot  and  dry;  tongue  red  and  dry  in  centr<-;  thirst;  one  stool,  (iave  two  grains  of  <iuinine  every  two  hours. 
HOth:  Pulse  116,  feeble  and  irregular:  tougU(>  moist  and  red;  no  stool.  Omitted  (juiniiu'.  May  1:  Pulse  III  and 
feeble;  tongue  a  little  coated :  no  stool.  2d:  Pulse  110;  tongue  natural :  I  innitus  aurium;  no  stool,  lid:  I'ulse  112; 
tongue  moist;  skin  natural;  urine  natural:  no  stool.  4tli:  Pulse  104  and  regular;  tongue  dry;  skin  n:ilural.  (iavo 
oil  of  turpentine  in  emulsion.  5th:  Pnlse  100;  tongue  dry  and  furred;  skin  hot;  no  stool.  6th:  Pulse  ST)  and  reg- 
ular; tongue  moist;  one  stool.  Tth:  Pulse  78  and  rather  feel)le;  tongue  moist  at  edges,  a  little  furred;  no  stool; 
free  pneumonitic  expectoration.  8th:  Pul.se  86;  tongue  moist;  no  stool;  listless  ;ind  dull,  lltli:  Pulse  70;  tongue 
clean;  skin  moist;  one  stool;  convalescing.  lOlh:  Transferred  to  Mower  hospital,  Philadelphia. — Cin/li-r  JI(}H})ilal, 
Philadelphia,  Fa. 

Ca.se  6. — Elijah  Watts,  contract  nurse.  A]iril  2II,  1865:  Tongue  (boated  but  moist;  ])ulse  102;  skin  dry  and 
warm;  eruption  over  liody;  three  stools;  thirst:  restlessness;  nervous  trenuirs.  <)r<lered  neutral  mixture  and  hniinly 
every  two  hours  and  a  tablespoonful  every  three  hours  of  a  mixture  of  a  half  dra(dim  of  ipiinino  in  one  ounce 
each  of  syrup  of  rhubarb  and  water;  arrow-root  and  milk  diet.  30th:  Delirium;  ])ulse  12."),  feeble  and  irregular; 
tongue  dry;  skin  hot;  one  stool.  May  1:  Pulse  as  before;  tongue  moist;  skin  warm;  profuse  epistaxis;  tinnitus 
anriuin.  Discontinued  brandy;  gave  a  teasjioonful  every  two  hours  of  one  drachm  of  oil  of  turpentine  in  two 
ounces  of  mucilage.  2d:  Pnlse  11.5;  tongue  dry  and  <lean ;  skin  imtural.  Hd:  Pulse  lO");  tongue  moist;  skin  mit- 
ural ;  delirium.  Gave  occasionally  a  teaspoonful  of  a  mixture  containing  one  drachm  of  chloroform  in  one  ounce 
tind  a  half  of  alcohol.  4th:  Pulse  100;  tongue  parched;  urine  drawn  olf  hy  catheter.  ,"ith:  Pulse  100;  tongue  and 
mouth  very  dry;  inability  to  speak  or  protrude  tongue;  dull,  sonu^what  comatose;  eyes  and  mouth  open,  (ith: 
Pulse  98;  tongue  and  mouth  dry .  7th:  Pulse  80;  tongue  and  mouth  moist;  could  protrude  tongue  and  speak ;  rested 
better.  8th:  Pnlse  79;  tongue  cleaning;  skin  moist;  breath  and  passages  very  fetid.  9th:  Pu1b<i90;  tongue  cleaning: 
skin  natural.     The  patient  recovered.     Contract  annulled  May  23. — Ciii/lcr  IlnnjiiUil,  I'hilnilcljthin,  I'n. 

Cask  7. — Private  Rndolphus  (irant,  Co.  li,  10th  N.  Y.;  :ige  23;  was  admitted  May  27,  186.'t,  jirescnting  all  the 
diagnostic  characters  of  tyi)hu8  fever  inclusive  of  the  eruj)tion.  Treatment  consisted  (d'  twenty  drops  of  diluted 
sulphuric  acid  every  two  hours,  with  alcoholic  stimulants  and  nourishment.  On  .Iune30  he  was  <|uite  well  excejit- 
ing  that  he  complained  of  headache  and  debility.  lie  stated  that  he  had  been  in.sane  and  an  inmate  of  the  Utica 
asylum  for  six  months  three  years  ago.  He  was  delirious  during  the  course  of  the  fever  and  during  convalescence, 
but  he  did  not  show  evidence  of  insanity.  He  was  returned  to  duty  July  23. — Act.  Asu't  Surg.  Aiintiii  Flint,  f '.  S.  .•>., 
Lexington  Arcniie  Honpital,  K.  Y. 

Cask  8. — Private  John  McManns,  Co.  C,  2.5th  N.  Y.;  age  29 ;  was  wounded  in  the  right  arm  at  the  liattle  of  Fred- 
ericksburg, and  had  the  forefinger  of  the  left  hand  carried  away  by  a  shot.  He  was  treated  in  Pcllevuo  hospital, 
which  he  left  well  as  regards  his  wounds  March  28,  1863;  but  although  without  definite  aihuents,  his  general 
health  was  not  good.  On  April  1,  while  at  his  home  in  this  city,  he  was  ohliged  to  take  to  bed,  having  at  this  time 
chills  followed  by  febrile  movement.  He  soon  became  delirious,  and  in  this  condition  was  received  into  this  hospital 
on  the  22d.  He  talked  incoherently  and  made  freiiuent  attempts  to  got  out  of  bed;  the  pulse  was  120  per  minute 
and  feeble;  there  was  no  diarrhoea  and  the  abdomen  was  not  tympanitic  nor  tender  on  pressure;  the  body  and 
extremities  were  thickly  covered  with  an  eruption  ])resenting  the  distinctive  characters  of  the  typhus  eruption,  dusky 
in  color,  not  elevated  and  the  redness  not  disappearing  on  jiressure.  Whiskey,  half  an  ounce  hourly,  with  essence 
of  beef  and  milk,  were  prescribed.  His  condition  remained  unchanged  on  the  23d  and  the  treat  uu'iit  was  continued. 
Next  day  there  was  less  delirium;  pulse  100;  skin  moist.  The  whiskey  was  diminished  to  half  an  ounce  every  two 
hours.  The  improvement  continued  on  the  25th;  the  pulse  had  fallen  to  85  and  the  eruption  had  faded  considerably. 
The  whiskey  was  reduced  to  half  an  ounce  every  three  hours.  On  the  27th  the  febrile  movement  and  delirium  had 
subsided  and  the  eruption  was  nearly  gone.  The  i)atient  desired  food.  Convalescence  progressed  without  any 
unfavorable  symptoms,  and  on  May  1  his  case  was  reported  as  cured,  but  some  diarrhwa  delayed  his  return  to  duty 
until  .June  29. — Act.  Ass't  Surg.  Au.ftin  Flint,  U.  S.  A.,  Ladien'  Home  Hoxpitul,  \.  Y.  City. 

Case  9. — Private  Martin  Walker,  Co.  C,  10th  N.  Y'.  Cav.,  was  admitted  Feli.  11,  1864,  with  typhus  fever.  The 
eruption  apiieared  soon  after  admission.  He  was  treated  with  diluted  sulphuric  acid  and  wliiskey,  and  a  diet  of 
beef-tea,  eggs  and  milk.  He  was  convalescent  on  the  26th  and  was  reported  for  duty  on  March  1. — Act.  Axx't  Surg. 
L.  L.  Tozier,  U.  S.  A.,  Lexington  Avenue  Hospital,  N.  Y.  City. 

Case-  10. — Sergeant  Ebenezer  C.  Talcott,  4th  Me.  Battery;  age  about  35;  was  admitted  July  11, 1863,  in  a  semi- 
comatose condition  ascribed  doubtfully  to  typhus  fever.     A  companion  stated  that  the  patient  was  delirious  when 


270  rtYMPTOMATOLOoy    OF 

I>ut  on  hoard  tlie  Ixiat  at  Sandy  llni.k,  Md.     'I'lic  stuixii-  >;iadu!ill,v  Ikcmiih'  iiiorc  inofoiind  and  <l(!atli  tiidk  |daci!  on 
the  Ifith. — .1(7.  .Ihk'I  Surf/.  John  II.  Iliiiloii,  I'.S.J..  Hiispifiil,  Lrj-imjloii  .Irciiiic.  X.   i'.citii. 

(;ask  11.— I'livat)^  Abraliain  Koof,  Co.  M,  lOlli  X.  Y.  Art.:  aijc  !':>;  wa.s  a<linitted  Juuu  10,  liSOS,  with  typhus 
frvci'.  'riic  f(!ver  oontiniii'd  twenty  days  al'ti'V  his  .•idniissidn.  and  diiriiis^  this  tinu)  there  was  ninch  (h'afness  and 
deliriuni.  The  eruption  was  marked  and  (lisap)>earod  under  pnwsure.  Tlicro  was  {'onsideralih"  tyinpanitesand  diar- 
rhoea l>ut  no  lieniorrha^e  from  the  bowels.  Kjiistaxis  occurred  sevtnal  tinu'S  durinj;  tlu^  early  part  of  the  attack  He 
suffered  fnun  bronchitis  but  not  in  a  marked  dei^ree.  On  July  1  he  was  able  to  sit  up  and  on  the  iltli  was  aroun<l 
the  ward  aUhoufjh  suiferinj;  considerably  from  diarrhiea.  Tonics,  stinuiUints  and  opium  with  camphor  were  admin- 
istered. On  August  15  tlie  diarrlnea  continued  and  the  patient  was  ainemic;  he  was  able,  however,  at  this  time  to 
walk  in  the  yard.     He  was  returned  to  duty  November  L'!'. — Act.  .Is-s't  finrij.  F.  Krirts,  U.  S.  ./.,  Cciilral  I'dii:  IfonjiiUil, 

X.  y.  citij. 

Ca.se  12. — Recruit  .John  Talbot,  unassii.jne(l ;  ai;e  20;  was  admitted  Oct.  1,  IWil,  with  tyi)hus  fever.  He  was 
treated  with  ah-oholic  stimulants.  On  the  Stli  the  patient  becauu'  delirious:  pul.se  120;  an  erni)tion  appcare<l  on  his 
chest.      Two  days  later  ])neunu>uia  set  in  and  dtuith  tocdi  jdace  on  the  loth. — Iloxjiitnl,  Khnira,  X.  Y. 

(^A.SK  13. — I'rivate  William  A.  Wood,  Co.  K,  21st  Mich.:  a,i;e  2;"):  was  admitted  May  20,  l!SOr>,  as  a  case  of 
tyjdius  fever.  On  .June  8  lie  Iiud  lieadache,  pain  in  the  back  and  pain  with  some  soreness  in  the  rijjht  hypochon- 
driuin;  the  tongue  was  slightly  coated  but  ((uite  red  on  the  edges  and  tip:  ])ulse  110.  Soon  after  this  delirium  sot 
in,  and  on  the  11th  the  patient  was  nearly  i)ul.seless.  his  jaw  quite  stiff,  subsultus  strongly  marked  and  skin  covered 
with  cold  perspiration,  lirandy  and  llofl'mann's  anodyne  were  given.  Next  day  he  recovered  his  mind  and  seemed 
stronger,  but  the  improvement  was  temporary.  He  died  on  the  Kith. — Ad.  Ass'lSiinj.  C.  A.  Burnham,  U.  S.  A.,  Hospital, 
Fairfax  Seminar;/,  Fa. 


III.— SYMPTOMATOLOGY  OF  THE  CONTINUED  FEVERS. 
I.— COMMON  CONTINUED  FEVER. 

From  tlio  uhst'iici.;  of  I'linicul  liisturios  of  cases  of  coiiuiioii  continued  fever  it  is  inipossi- 
Lle  to  speak  from  the  records  (.■oiic(.'riiiiig  tlie  svmptoms  of  the  many  cases  wliieli  were 
reported  under  tliis  title  during  the  first  fourteen  months  of  the  war.  The  single  case  of 
simple  continued  fever  and  the  s(!ven  cases  of  eoatiaucd  fever  tliat  have  been  presented  are 
iiisufrici(\nt  to  illustrate  the  disease. 

It  has  alreiidv  heen  shown  that  typhoid  fever  was  recognized  as  the  common  continued 
fever  of  the  United  States,  and  that  the  teiideiiev  of  medical  (.i]>inion  at  the  outhreak  of  the 
war  was  to  regard  all  cases  of  continued  fever  which  were  not  distinctly  specific  in  their 
cliaracter  as  due  to  the  poison  of  typhoid.'-'  JUit  the  indefinite  term  common  continued, 
which  at  one  tinn'  included  typhoid  among  other  possiljle  fevers,  remained  on  the  army  sick 
reports,  after  the  dilFerentiation  of  typhoid,  as  a  standing  suggestion  of  the  existence  of 

_  .  .^     _   .^_  ._  _- 

♦This  opinion  seems  to  have  biTonu!  niorc  cxti'iiHively  diffused  Anvf  tliat  tiim- l.otli  in  ftiis  ((.uiitry  sniil  in  ISritaiii ;  MACi..\r,AN  pvi*s  rxpiv.-^sioii 
to  thin  vimv,  Kdiuhurg  Med.  and  Siirg.  Jour.,  A|iril,  lti~\,  whore  he  BH,Vf,  {>.  SVo :  "  Iiidi'cil,  I  tliink  it  may  In.'  stiiti^i  gfjiierally  that  a  fcbriln  attai^k  which 
itt  too  hiiig  to  bo  fchricuia,  wliich  in  not  ujjud  ami  which  is  not  duo  to  local  disoaw,  must  be  .■nriric.*'  \cvcrtb(d('ss  Mi'nrinsoN,  altlioUKh  rp^ardiii;^  as 
typhoid  fcvnr  most  of  the  cases  calltMl  l>y  Ibitit^h  practitioners  siniplo  continti'il  fivcr,  ilr.sriHirs  flh'  clinical  hisrnrics  of  four  non-spci'ittc  varititiow  :  The 
first,  rjihonerdl  ftfiT,  is  elniilar  to  a  sinf;;]o  iiaroxysni  tif  iiijnc.  Chills  or  rij,^ors  an'  foljnwi'il  liy  ii  i|iiiiU  t'lill'pul.-'c,  fluflicd  face,  di-y  hot  wkin,  white  furred 
toripno,  thirst,  anorexia,  constipation,  scanty  hi^^h-colored  urine,  seven'  ln-iulaclie,  restlc^-ness  and  sleeiijessiicss  vr  sunietimcs  drowsines.s  ami  puius  in 
the  limbs.  The  syiriptoms  Hnb.sirle  suddi'oly,  ftfteti  with  JH■rspiration^  in  tw'-lvc,  twenty-four  or  rliirty-.<i.\  hours.  In  the  wrond,  corre-spoiidiny;  to  tlie 
nynochal  pradc  of  the  intlanimatory  fevers  of  the  old  writers,  tho  febrile  action  continues  from  fmir  tn  ten  days;  the  pulse  is  full,  rapid  and  often  hard 
or  bounding; ;  tlu!  headache  ucutf!  and  throbbing;  munetiniew  tliero  is  delirium,  Itefervesccuce  is  atttuided  with  peispiratlons,  cpistaxis,  vomiting-  or 
diarrho'a,  and  is  .<<>  freipiently  asso^-iatid  with  hcriM-s  on  the  li|>s  tn-  nose  that  the  disease  has  been  oalleil  herpetic,  fi-nr.  The-  urd'n/  vinUhnud  fenr  of  the 
tropics  constitutes  his  third  variety,  which  is  re;^ani"'d  as  an  exufrirerated  form  of  the  .-iyniKha  of  Britain.  Ari  seen  among  the  ICuro|H'an  troops  nt  '*al- 
tutbi  in  bsr»;i  and  in  hurmah  in  ls.'>4,  the  ilisease  mostly  aflected  yiuinj:  i)Iethoric  rei-ruits  recently  arrived  from  Eiiroi>e,  and  prevaileil  in  the  hut,  dry 
months,  when  the  temi«'raturt>  wjis  never  below  84^^  Kahr.  The  symptoni-s  wliii.h  in  many  cases  commenc-d  immediately  aftiT  incautious  exinrsure  to 
tho  direct  rays  of  tin-  sun,  wen-  chilliness*;  nausea  or  vomitinsr ;  acc-elerat'd,  full  and  (irm  pulse;  dry  burning  skin;  flusheil  face;  giildiness;  intense 
hcadat^he  ;  riui^inj;  in  the  ears;  intolerance  of  light ;  inu.Si;jo  volitantes  ;  restlessness  and  sfeeplessncss  ;  yellow  furred  ton<i;He  ;  jKirehcd  lijis;  thirst;  i-on- 
HtiiHition  ;  scanty  high-colored  urine.  Acute  delirium  occurreii  abtuit  the  f(uirtii  or  fifth  day,  fullt>wed  by  uneonsciousues.s,  contraction  of  the  pupils 
and  sonietim<!S  ctimidete  coma,  which  ended  in  death  hetwoen  the  sixth  and  ninth  days  if  convalescence  was  not  nieanwbih'  established  hy  a  t  o]ii..M< 
[nTsjiiration.  He  cites  5IouKHE.\n  and  M.\ietix  in  support  of  his  assertion  tliat  the  subsidi-nce  of  the  fever  was  occasionally  followed  by  sudden  or  e\eii 
fatal  collapse.  Tho  fourth  variety  is  intn«Iuced  ratlier  as  a  suggestion  than  as  a  clinically  defim-d  entity.  It  is  called  astltmic  niuiple  fn-er,  and  is  said  to 
be  ciiaracterized  by  loss  of  aprK-tite  and  strength  ;  pulse  rather  feeble,  ranging  from  OO  to  120;  slightly  furred  tongue;  confined  bowids ;  headache  and 
disturlK'd  sleep.  The  symptoms  continue  for  two  or  three  weeks  without  any  groat  change  exci-jit  increasing  prostration.  It  is  evident  that  the  diffi- 
culty of  discriminating  between  this  variety  and  mild  typhoid  attacks  would  be  very  great,  in  fact,  clinically  the  discrimination  is  impossible.  The 
distinction  could  only  bo  effected  by  tlio  aid  of  etiological  considerations. — A  Trentifw  on  the  (Jonilnued  Fevers  of  Great  Britain,  London,  187:3,  p.  079  et  seq. 


THK    CONTINUED    FEVEES.  .  271 

otlier  nou-sviiiptomatic  febrile  eonrlitions.  It  seems  ]>r(.1i;il)l(',  however,  that  the  coininoti 
continued  I'ever  of  the  monthlv  reports  consisted  in  great  part  of  anomalous  eases  of  tyj'hoid. 
When  the  characteristic  symptoms  of  typlu/ul  were  present  in  a  given  case  its  entry  under 
the  specific  heading  was  assured:  but  when  these  were  absent,  obscured  or  moditied,  the 
term  common  continued  fever  afforded  a  convenient  escape  from  a  positive  and  specific 
diarfnosis.  When  a  febrile  case  did  not  run  tlie  prolonged  course  of  typhoid;  when  it  was 
unmarked  by  rose-colored  spots  and  free  from  relaxation  of  the  bowels  or  tenderness  in  the 
rio-ht  iliac  reo-ion;  especially  when  in  addition  the  cerebral  symptoms  did  not  appear  to 
justify  the  appellation  of  typhoid,  the  indetinite  term  accommodated  it  with  an  appropriate 
position  on  the  official  record 

It  is  equally  probable  that  there  wi^re  reported  under  this  heading  maii\'  i'ehrih^  cases 
of  short  duration  which  were  treated  in  ipiarters  or  in  tln'  regimiMital  hospitals.  Such  cases 
correst^onded  with  the  simple  continued,  ephemeral  or  irritative^  fevers  of  medical  writers, 
presentino-  languor,  lassitude,  muscular  weakness,  headache,  inability  to  collect  the  thoughts, 
wakefulness  or  dreamful  sleep,  perhaps  even  slight  nocturnal  delirium,  constipation  or  diar- 
rhoea, white-coated  tongue,  hot  skin  and  feeble  and  rapid  pulse.  This  condition  lasted 
one  or  inore  days,  was  followed  by  perspirations  or  a  gradual  subsidence,  and  was  seldom 
characterized  by  the  tedious  convalescence  of  the  typhoid  attack. 

If  it  be  allowed  that  cases  of  this  character  occurred  among  the  troops,  some  of  them 
must  have  assumed  an  adynamic  form  and  I'epresented  with  more  or  less  fidelity  the  general 
outlines  of  the  clinical  picture  of  typhoid  fever;  for  the  influences  to  which  the  adynamic 
condition  is  usually  attributed  were  in  strong  force  in  our  camps  antf  garrisons  during 
the  war.  As  distinguishing  between  such  cases  and  typhoid  fever  there  would  have  been 
the  absence  of  rose-colored  spots,  a  want  of  connection  between  the  diarrhoea]  attack  and 
the  febrile  condition,  perhaps  also  the  character  of  the  alvine  evacuations  and  the  location 
of  the  intestinal  tenderness,  with  the  short  duration  of  the  primary  fever  in  cases  that  had 
been  closely  watched  from  the  commencement.  These  would  have  been  correctly  reported 
during  the  early  months  of  the  war  as  cases  of  common  continued  fever,  although  from  the 
concurrent  prevalence  of  undoubted  typhoid  they  were  liable  to  be  regarded  as  expressions 

*  T^Tnlor  the  titlr  frrilitfire  FertT,  Dr.  Gedrge  K.  Wonn  inrhu!<>s  all  caso.s  of  idiopHthic  fevtT  rt'sulting  from  non-MiM'cific  caiiscF  of  irritation.  A»  ovnr 
excitement  of  one  or  more  of  the  funrtions  is  intluced,  and  this  heing  ])roi<agate(l  to  dilferent  iwrts  of  the  system  ma.v  throw  all  tin-  funetions  into  a  state 
of  derangement  capable  of  sustaining  itself  after  the  direct  cause  haseejised  to  op(M-ate.  There  must  be  a  iire-existing  disposition  in  the  s.vstem  to  the  feltrilo 
movement  that  it  may  he  thus  iudei)endently  sustained.  There  is  occasionally  slight  intlaniination  associated  with  the  fever,  most  fre(piently  in  the  fauces 
or  in  some  portion  of  the  alimentar.v  or  puimonar.v  mucous  membrane,  but  this  is  wholly  insufticient  to  account  for  the  symptoms  anil  is  often  wanting 
entirely;  moreover,  a  truly  s.vmptoniatic  fever  subsides  inmiediately  with  the  subsidence  of  the  inflammation.  lie  oba-rvcs  that  when  the  feltrile  action 
is  prolonged  to  the  seventh  or  tenth  day,  it  is  apt  to  l«'come  somewhat  remittent,  relaxing  in  the  morning  and  undergoing  exac-erbation  in  the  afternoon 
or  evening.  It  is  usually  sthenic.  "Hut  occasionally  the  general  actitins  of  the  s.vstem,  tlmugh  excited,  have  tln^  taint  of  feebl'-ncss.  A  low  fever  some- 
what of  the  tyijhus  character  is  developed,  though  infinitely  less  dangerous  than  the  genuin(!  typhiis.  The  jireviously  debilitated  condition  of  the 
patient,  a  depraved  state  of  his  blood  from  bad  living,  or  exposure  for  sonu'  time  to  depressing  inflnenr-cs,  as  of  certain  epidemics,  exhalations  from 
privies,  etc.,  ma.v  account  for  this  adynamic  character."' — .1  Trerttm^  on  the  Pmvtiif.  nf  Medii-inf,  IMiiladelphia,  IH-IT,  Vol,  T,  p,  'J:i\.  I'nder  the  term 
Cess-pool  ferer,  Dr.  jVlonzo  Cl-^rk  describes  a  febrile  disease  which  has  been  traced  in  almost  ever.v  instance  to  foul  water  or  water  made  foul  by  the 
admixture  of  human  excrement  or  to  neglected  privies.  It  is  not  always  ushered  in  by  a  cliili,  but  there  is  alwa.vs  a  certain  amount  of  fever  and  a 
diarrhoea  lasting  two,  three  or  more  weeks.  The  illustrative  cast!  which  ho  records  had  no  liea<lache,  epistaxis,  tenderness  or  juiin  in  tin;  abdomen  or 
iliac  region,  tympanites,  sordes,  nor  rose-colored  sjiots ;  delirium  was  moderate,  the  [latient  trying  to  get  out  of  I>e,l,  saying  he  wanted  to  go  home  ;  the 
pulse  became  small  and  feeble,  and  the  diarrhcea  continuing,  death  took  pl:u!e  from  exhaustion  about  the  end  of  the  third  week.  Ca,ses  of  this  kind 
occur,  according  to  tiic  experience  of  Pr,  Cl.ark,  in  every  region  of  the  coiintr.v;  and  he  holds  that,  so  far  as  we  can  .judge  from  the  s.vmptoms,  they 
are  not  cases  of  the  t.vplioid  affection. — See  J/c</,  Seconl,  Vol,  XIH,  New  York,  1K78,  p,  303,  Itr,  I.  .\.  W.\t.^ox  of  New  Hampshire,  in  the  Uejmrtof 
the  Stale  Board  of  Heallh,  1884,  regards  as  cess-pool  fever  certain  cases  which  originated  in  a  poisoned  well  at  Little  Boar's  Head.  They  seemed  to  bo 
instances  of  blood  jioisouing,  in  their  last  stage  resembling  t.vphoid  fever.  \  wealthy  Phiiadelphian  who  had  siK'tit  many  summers  at  Little  Boar's  Head 
built  a  handsome  residence  there  on  an  elevation  about  fift.v  feet  above  the  sea-level  and  but  a  short  tlistance  from  the  water.  The  elevation  consisted  of 
seamy  ledges  with  only  a  few  feet  of  soil  covering  theiu.  Instead  of  building  a  sewer  to  the  cK?ean  he  constructed  a  cess-pool  forty  feet  from  tlie  hous<\ 
Sixty  feet  from  this  cess-pool,  and  api»arently  on  the  same  level,  was  dug  the  well  which  was  to  suiiply  the  residence  with  water,  but  before  a  free  supply 
of  water  was  obtained  it  was  necessary  to  dig  ten  feet  into  the  ledge.  The  well  and  cess-pool  were  both  constructed  at  the  same  time,  and  two  weeks 
thereafter  the  well-water  became  polluted ;  but  the  family  not  recognizing  the  source  and  nature  of  the  pollution  continued  to  use  the  water  until  it 
became  so  tainted  as  to  be  repulsive.  The  owner  and  a  lady  visitor  died  from  the  febrile  attack  ;  the  owner's  daughter,  a  servant  and  a  guest  of  the 
family  recovered  after  a  severe  illness. 


272  SYMI'TOMATOJ.OilY    OF 

of  the  presence  of  tlio  poison  of  tliat  disease  modified  by  peculiarities  of  individual  const! 
tutiou  and  local  hygienic  conditions.  Durinu;  tlic  latter  part  of  t!io  war  it  may  In?  assumrd 
that  they  were  reported  among  oHicr  niKiHinafic  ih-Heases  hy  those  who  regarded  tlirin  an  due 
to  an  unknown  miasm,  or  that  they  were  added  to  the  typlioid  or  typho-malarial  list,  accord- 
ing to  the  views  entertaiiUMl  hy  the  reporting  ofiicers  of  the  absence  or  pn-sence  of  a  malarial 
factor  in  cases  essentially  enteric.  The  lollowing  extracts  from  sanitary  reports  have  a 
bearing  on  this  subject: 

Surgeon  Thomas  C.  Bakkh,  1th  Me.,  Camp  Lijon,  Baltimore,  Md.,  OvI.  1,  IHIU.— From  the  tiiut!  tlie  ref^iiiieiit 
was  mustered  into  service  at  Augusta  till  the  close  of  the  quarter  cmliiig  Sei>teuil)er  30  ouly  one  death  occurred. 
'I'lils  was  a  case  of  tyi)hoid  fever.  Auioiifj  other  dixeiixes  of  this  vlaxs,  in  the  class  of  fevers,  are  eisht  cases,  all  of  fever 
or  feverisliuess,  souie  of  which  ai)l)roachu<l  common  coiitin\'jd  .'.'a/er  in  their  {general  characteristics. 

Surgeon  W.  W.  Ijiiowx,  7th  X.  II.,  St.  .lugiiHtiiie,  ,<i.^  .March  31,  18liH. — 1  u<'slcctcd  to  mention  a  variety  of 
fever  which  seems  rather  peculiar  to  this  place,  and  which  maile  its  appearance  in  our  regiment  in  December  last 
and  continued  to  affect  us  somewhat  during  January  and  Fehrmiry,  but  entirely  disai)pearcd  about  the  first  of  the 
present  month.  It  usually  commenced  with  the  general  symptoms  of  fever,  and  in  most  cases  assumed  the  common 
continued  type.  It  had  no  appearance  of  having  had  a  miasmatic  origin,  but  seemed  to  have  been  occasioned  by  the 
frequent  and  sudden  variations  of  temperature  which  we  exi)erienced  during  those  months,  and  to  which  all  places 
on  the  Atlantic  coast  are  subject,  althoui;'.!  tlu^  range  of  the  thermometer  may  be  small.  About  four-fifths  of  the 
cases  were  mild  and  rcc|uirc(l  little  tr'atnicnt  othi'r  than  low  diet  and  n-st  after  having  the  primal  via- thoroughly 
evacuated.  The  remaining  fifth  tcndi^d  to  a  t.vphoid  condition,  with  diarrluca,  and  some  of  them  assumed  a  very 
grave  eliaracti'r,  although  all  recovered  with  one  exce|)tion.  The  typhoid  cases_  were  treated  on  general  principles, 
but  earl.v  rc(iuired  stimulants  and  nourishing  diet,  with  occasional  opiates  to  allay  nervous  irritation.  There  was 
more  or  less  pulmonary  inlhimmation  in  the  severe  cases,  and  the  diarrlKPa  was  very  intractable.  Stimulants  were 
well  borne,  but  quinine  was  neither  required  nor  well  adapted  except  during  convalescence.  We  had  in  all  over 
one  hundred  cases;  in  the  fatal  case  involuntary  evacuations  with  low  delirium  and  subsultus  of  the  tendons  came 
on  early,  and  our  most  actives  exertions  prov(!d  unavailing. 

Surgeon  .J.  T.  Caliioiix,  l\lh  X.  Y.,  near  .ite.ramtrid.  ]'((.,  .Turn-  30,  1862. — Hut  the  stench  from  the  battle-field 
[Fair  OaksJ  was  most  disgusting;  and  in  such  an  atmosphere,  in  the  montli  of  .lune,  were  our  nu'ii  living.  Every 
third  day  the.y  were  on  jiicUet,  and  in  the  interval  tliey  were  freiiuently  (employed  in  the  trenches.  Skirmishing  was 
of  dail.v  occurrence,  and  night  ahirms  fie(iuent  and  harassing;  I  seldom  passed  a  day  without  having  a  wound  to 
dress.  The  nu'u  were  ill  fed,  overworked,  exposed  to  freciucnt  alarms  and  living  in  an  atmospliere  largely  composed 
of  poisonous  gases  exhaled  from  the  imperfectly  buried  dead.  A  peculiar  form  of  fever  presented  itself,  character- 
ized by  an  extremel.y  weak  pulse,  great  prostration,  sutt'uscd  eyes,  vertigo  and  anorexia.  Its  duration  was  generally 
from  four  to  five  days.  The  treatment  was  usually  a  mercurial  cathartic  followed  by  ten-grain  doses  of  ijuiniue  three 
times  a  day.* 

Surgeon  M.  K.  (iAiiK,  'Z'tth  Win.,  Cum})  UanditU,  TTis.,  Vec.  31,  IXfi'J. — ^We  have  met  with  cases  of  continued  fever 
which  might  pro|)erly  l>e  tiunied  ])assivc  in  character  in  contradistinction  to  those  of  a  niori!  absolute  and  active 
grade.  These,  although  manifesting  but  little  activity,  it  l)eing  in  fact  scarcely  jiossible  to  determine  th»^  exist- 
ence of  fevtu'  in  many  of  tlie  cases,  are  liable  to  indefinite  protraction.  The  treatment  most  efli(^acious  in  this  class 
of  cases  consists  of  a  calomel  cathartic  and  thou  a  .judicious  alterative,  diaphoretic  and  refrigerant  course.  Recovery 
generally  ensues  as  soon  as  the  specific  effect  of  the  mercurial  is  produced.  A  full  dose  of  calomel  in  the  incipiency 
of  the  cases  goes  far  towards  interrupting  and  controlling  the  period  of  their  continuance;  the  hepatic  derangement 
is  overcome,  the  pulse  reduced,  and  tlu^  skin  having  resumed  its  natural  function,  a  march  is  stolen  upon  the  disease 
and  convalescence  is  (jnickly  induced.  A  stimulating  plan  has  not  been  recjuired;  that  generally  pursued  has  been 
mildl.v  antiphlogistic.  During  convalescence  tonics  and  a  more  generous  dietare  allowed:  in  many  instances  at  this 
jjeriod  remedial  agents  are  entirely  withdrawn  and  the  patient  left  to  the  recuiierative  forces  of  his  purified  and 
regenerated  organism,  together  witli  tlu^  invigorating  infiuencos  of  a  generous  ))ut  carefully  selected  diet. 

.IhkH  Surg.  IIexuy  S.  Sciiei.i.,  U.S.A.,  .Miner's  Hill,  I'a.,  Sept.i,  18(i2. — Cases  of  fever  were  of  constant  occur- 
rence during  the  quarter,  and  under  whatever  name  registered,  they  were  all  of  the  same  general  asthenic  character. 
So  far  as  I  can  determine,  few  if  an.y  of  those  which  assumed  a  decided  periodic  form  originated  primarily  in  this 
localit.y.  Miasmatic  atl'ections  seemed  in  most  instances  to  be  the  result  of  the  seeds  of  disease  which  had  remained 
in  the  s.ystem  from  last  year  and  were  now  ([ui(^kenedinto  activit.v  by  cxjiosure  to  the  vicissitudes  of  a  (Campaign.  The 
prevailing  form  of  febrile  disease  I  regarded  as  an  ordinary  irritative  fever  of  an  adynamic  type,  and  many  of  the 
cases  marked  as  remittent  fever  in  the  statistical  rejjort  were  of  this  kind:  they  assumed  a  sort  of  periodicit.y 
which  was  not  well  defined,  but  which  rendered  it  ditiicult  to  decide  ui»m  tlieir  true  nature.  Every  case  which  I 
have  registered  as  common  continutid  ft-ver  was  of  the  same  character  as  those  which  other  surgeons  in  the  di\  ision 
re])orted  remittent  fever,  but  which  on  several  grounds  I  considered  independent  of  malarial  infiuences.  1st:  Tlu^ 
atl'ectiou  usuall.y  followed  exposure  to  sudden  changes  of  weather,  hard  duty  or  rapid  and  exhausting  nuuching — as 
for  instance,  the  expedition  to  Hanover  Court  House.  In  the  light  batteries  the  fever  did  not  follow  exposure  on 
picket  duty  in  the  swamps  of  the  Chickahominy  because  the  men,  once  upon  the  ground,  stretched  the  tarpaulins 
to  make  shelters  for  themselves  and  went  as  regularly  and  comfortably  to  bed  as  when  in  camp.     With  the  infantry 

*  In  the  Mrdind  and  tinnjiml  lltporler,  Phila.,  Pa,  Vol.  IX,  p.  399,  Dr.  Caijiock  refers  to  this  fever,  and  considers  the  nanie  typbo-malarial  an 
appropriate  one  for  it. 


TIIF.    CONTIM'KD    FEVERS.  273 

pickets  it  was  difffrent;  they,  peiliaps  at  a  distaiuo  of  nut  oiio  liniidreil  yards  from  tho  1>atterie8,  stood  in  water  to 
the  knees  during  the  long  watches  of  tlie  niglit.  and  retnrni-d  to  camp  after  forty-eiglit  hours  utterly  exhausted,  and 
ill  a  few  days,  it  may  lie  the  next  day,  were  hiiriiing  witli  fever.  2(1:  The  cases  l)egan  witli  languor,  dehility  or  utter 
prostration,  aud  in  all  instances  gradually:  the  tongue  was  coated  with  a  white  fur.  tin;  howels  mostly  loose,  but 
sometimes  there  was  alarming  diairlio'a  wliich  clung  to  tlie  jiatient  long  after  tlie  fever  liad  disa|ii)eared  and  occa- 
sionally threatened  to  destroy  him;  there  was  conslderahle  heat  of  surface,  jiulse  about  100  or  110;  in  a  few  cases 
derangenu'iit  of  the  liver  was  present ;  there  was  invariably  a  tendency  to  debility,  w  hich  renderi'd  the  use  of  stim- 
ulants necessary  from  the  heginning;  towards  the  close  of  the  disease  the  kidneys  were  often  alfected,  and  the  miml 
was  always  implicated  if  the  sickness  became  seiions.  M:  Most  of  the  cases  were  cured,  if  properly  treateil,  in 
from  four  to  ten  days  without  the  administration  of  (piiiiine.  which  drug  usually  retarded  recovery,  wlien  given 
in  antiperiodic  doses,  by  ])i(iiluciiig  a  diairlKcal  aggiavatiou  of  the  existing  debility.  4th:  The  treatment  wliich 
I  found  most  eft'ective  was  to  enjoin  jierfcct  rest  and  kee))  the  bowels  in  as  natural  a  condition  as  possible.  Dover's 
pow<ler  was  administered  as  a  dia]>horetic  w  lien  there  was  much  miiscnlar  soreness:  the  citrate  of  potassa  was  some- 
times given.  Ill  all  cases  the  piitient  was  sustained  with  milk-pnmli,  eggs,  beef-essence,  etc.  Under  this  plan  he 
was  usually  able  to  return  to  duty  in  a  week  or  two  alter  being  attacked. 

Ill  estimating  the  causes  of  this  disease  I  should  enumerate  the  pre(lis]iosing  and  the  exciting.  Among  the 
former  were  the  constant  heat,  to  which  the  men  were  unaccnstomed ;  the  debilllating  acti(Mi  of  fatigues  and  jiriva- 
tions;  exposure  to  the  ellliivia  of  badly  regulated  sinks,  half  or  totally  unburied  oll'al  frcmi  slaughter-pens  and  excre- 
ment deposited  in  improper  places,  and  the  contimu'd  occujiation  of  the  same  camping  ground.  The  chief  of  the 
exciting  causes  were  extraordinary  toil,  jirivations  and  vicissitudes  of  weather. 

Surnrftu  (jKOHCK  W.  Cl.ll'i'lxciKll,  14//I  luil.,  Cheat  Miiiiiitaiii,  I'd.,  Dec.  HI,  l^tll. —  The  sickness  was  of  a  peculiar 
type,  cliaracteriz<'d  by  exhaustion  i>(  the  nervous  system  with  stagnation  of  the  (■aidllary  circulation.  This  was 
attended  by  blneiiess  of  tlu^  skin,  which  might  bii  considered  iiathogiiomoiiic.  The  fact'  was  of  a  dull  leaden 
color  and  the  features  bloated  .and  swollen.  The  particular  visi'us  receiving  th(^  largest  proportion  of  the  blood 
thrown  in  from  the  surface  of  the  body  became  at  once  the  seat  of  disease?,  'i'his  was  accompanied  by  fre(|Ueucy  of  the 
pulse,  great  lassitude,  muscular  aud  articular  pains,  anorexia,  <Iry  aud  husky  skin,  great  thirst,  red  and  parched 
tongue  aud  violent  ]>aiii  in  the  head  with  more  or  less  incohere'-.cc.  Tliese  cases,  known  familiarly  as  "catnp- 
fever,"  were  officially  rejiorted  as  "('ontinued  fever.''  The  causes  were  un(|uestionably  protracted  aud  exhausting 
labor,  exposure  to  cold  and  incessant  rains,  insullicieiit  clothing  and  sameness  of  food. 

Tlie  tn^atment  had  in  view  the  removal  of  congestion  and  restoration  of  the  capillary  circulation.  When  this 
was  acconi]ili.she(l  convalescence  was  hastened  by  the  administration  of  tonics.  Siil]>hate  of  magnesia  with  ipecac- 
uanha was  beiieticial,  particularly  in  the  early  stages.  Tlie  fatal  cases  assumed  t\u:  gravest  appearances  of  typhoid 
fever;  tenderness  of  the  colon  supervem^d,  with  gurgling  in  the  ca'cuiu  and  sigmoid  tlcxiire;  intestinal  betnorrhage 
occurred  in  many  eases  and  in  all  that  were  fatal. 

Jux't  Siirg.  II.  M.  SriiAGiiE,  U.  S.  A.,  Sept.  80,  1801. — About  September  1,  after  having  been  encamped  for  a 
week  in  an  exceedingly  foul  locality,  there  broke  out  a  severe  epidemi<'  which  has  given  us  our  only  fatal  cases  of 
disease.  When  this  e])id<Miiic  aii))eared  there  was  nothing  formidable  in  its  external  fi-atiires.  The  men  looked  simply 
debilitated.  Their  history  was  that  for  several  days,  often  two  weeks,  they  liad  been  sntferiiig  from  diarrhn'a,  yel- 
lowish and  watery,  attended  sometimes  with  griping  and  accompanied  with  deliility,  listlessness,  drowsiness,  jiain  in 
the  liones,  wliite  tongue,  slight  heat  of  skin  morning  or  evening  and  some  acceleration  of  pulse,  ranging  from  iM  to 
106.  The  disease  liad  the  appearance  neither  of  typhoid  nor  of  remittent  fever.  I'osl-mortcm  examination  of  two 
bodies  revealed  some  congestion  of  the  bowels,  with  moderate  (uilargement  of  the  mesenteric  glands;  no  ulceration 
of  Peyer's  patches;  no  destruction  of  the  mucous  membrane;  no  inflanimation  of  the  rectum;  the  spleeu  was  slightly 
engorged  ;  the  other  organs  healthy. 

IL— TYPHOID  FEVER. 

Tt  lias  been  a  matter  of  some  difficulty  to  tlie  writer  to  present  the  symptoms  of 
typhoid  fover  as  distinct  from  tliose  of  the  so  called  typho-inalarial  fever.  This  has  arisen 
from  the  want  of  records  to  show  what  constituted  the  characteristics  of  the  cases  reported 
under  the  latter  lieading.*  But  as  Dr.  Woodward  in  November,  1863,  expressly  stated 
that  the  term  typho-malarial  was  meant  to  include  only  those  cases  in  which  typhoid  fever 
had  its  symptoms  more  or  less  masked  by  the  coexistence  of  manifestations  of  malarial 
poisoning,^  the  detailed  cases  presented  in  the  "Clinical  Records  of  the  Continued  Fevers" 

*  See  jMigc  '212,  mipra. 

f  .T.  J.  Woodward,  .IssV  Snrg.,  U.  S.  A.,  OittJineJi  of  the  Chief  Camp  Diaenf^s  of  the  rnitnl  Stnten  Anntj,  IMiila.,  1863,  p.  74:  ''I'mliT  the  (lesignation  of 
f 'fillip  Ferera  may  be  iiu-ImltHl  *  *  (yphns;  *  *  yelJoir  ferer ;  *  *  typ>hn\fl  f-ver  with  <\v  without  scnrhutio  fornplicutiuns  ;  imtinri'd  reniittfjit  ftrvr  with 
or  without  Sfoiltutic  cninijlicatiuiis ;  an<l  a  vawt  group  cif  mixi-d  rases,  in  whith  the  luahirijil  auil  typhoid  eU-iucnts  an-  variouHly  corul'iucil  with  eadi  other 
and  with  tlie  umi-hiitii'  taint,  and  for  which  tlii-  author  jiruposiil  the  name  of  typln>-nialarial  fever."  *  *  But,  on  p.  110,  in  discussing  the  nature  of 
the  disease,  be  gives  utterance  to  the  opinion  that  tlio  Mi-called  typhivnuilarial  fever  was  not  a  merely  mtxlified  typhoid,  but  a  ooniposite  disease  <ir  new 
hybrid.  *"(>u  the  one  hand  typho-malarial  fever  is  not  to  bo  regarded  as  a  new  dit«*ase  in  the  ordinary  aeceptation  uf  the  term,  that  is,  as  an  affeetivm 
characterized  by  some  new  pathognomonic  tdement.  Nor,  on  the  other  hand,  is  it  just  to  look  upon  it  inendy  as  a  nullified  enteric  fever,  since  the  mala* 
rial  and  scorbutic  phenomena  wliich  accompany  it  are  iiredominant  in  many  rases — perhaps,  on  the  wliole,  in  the  greater  number.  Much  rathershould 
it  be  considered  simply  as  a  new  hybrid  of  old  and  well-known  jiathological  conditions,  in  which  the  exact  train  of  symptoms  is  as  variable  as  the  degree 
of  preponderance  attained  by  each  of  the  several  concurring  elements." 

Med.  Hist.,  Pt.  Ill- 35 


274  SYMPTOMATOLOGY    OF 

affordod  tlio  materials  for  detcrinining  the  symptoms  not  only  of  the  cases  regarded  as 
ty[»lioid  by  the  attending  physicians,  but  of  those  which  Dr.  Woodward  would  have  classi- 
fied as  typho-malarial.  In  the  chapter  on  malarial  disease,  in  this  volume,  the  cliaracter- 
istics  of  malarial  fevers  have  been  illustrated.  By  studying  tlu^se  in  connection  with  the 
fully  recorded  typhoid  cases  treated  in  the  Seminary  hospital,  the  latter  have  been  divided 
into  cases  of  pure  and  of  modified  typhoid. 

The  paroxysmal  tyj)e  of  the  malarial  fevers  stands  prominently  forth  as  a  diagnostic 
mark  of  the  complicated  disease,  manifesting  itself  by  recurring  chills  and  febrile  exacerba- 
tions alternating  with  perspirations  or  a  moist  condition  of  the  skin  at  a  period  of  the  clinical 
history  when,  in  pure  ty{)lioid  fever,  the  febrile  action  is  continued  and  the  skin  dry  and 
husky.  But  these  signs  of  undoubted  complication  are  liable  to  be  lost  in  two  directions. 
On  the  one  hand  typhoid  fever  is  marked  by  daily  remissions,  which  may  be  detected,  in 
the  absence  of  thermometric  records,  by  notable  changes  in  the  pulse,  general  surface, 
tongue,  secretions,  etc.;  on  the  other  hand,  the  remissions  in  remittent  fever  may  be  so 
slight  or  transitory  as  to  escape  uimoted.  Hence,  although  the  absence  of  the  paroxysmal 
type  does  not  exclude  the  possibility  of  the  coexistence  of  malarial  disease,  its  slightly 
marked  presence  cannot  be  accepted  <as  indicating  malarial  complications  unless  supported 
by  other  and  less  indefinite  evidence.  It  is  impossible  to  determine  in  all  cases  that  an 
evening  exacerbation  is  due  to  malarial  influences,  but  when  the  paroxysmal  feature  is 
strongly  developed  a  remittent  or  intermittent  fever  may  be  regarded  as  associated  with  tlie 
progress  of  the  typhoid  affection.  The  frequency  of  this  coincidence,  especially  in  men  who 
had  previously  suffered  from  acute  malarial  disease,  leads  to  the  supposition  that  the  typhoid 
onset  itself  or  the  exposures  and  unhygienic  conditions  which  predisposed  to  it,  acted  as  the 
determining  cause  of  a  recurrence  of  the  paroxysmal  fever.  Moreover,  it  is  generally 
accepted  that  in  malarious  subjects  diseases  which  are  not  occasioned  by  malaria  oftentimes 
exhibit  a  tendency  to  periodicity.  Nevertheless  there  are  not  wanting  on  the  records  cases 
of  ap[)arently  unmodified  typhoid  in  which  the  previous  history  of  the  patients  embraced  a 
series  of  aguish  attacks  or  other  indications  of  malarial  poisoning. 

When  the  com])licating  element  failed  to  manifest  itself  by  paroxysms  and  perspira- 
tions, which  do  not  belong  to  the  history  of  typhoid  fever,  its  expression  was  found  in  hepatic 
tenderness,  gastric  irritability,  epigastric  pain  and  other  signs  of  interference  with  the 
normal  action  of  the  liver  and  upper  portion  of  the  alimentary  tract.  In  the  absence  of 
these  from  the  record  a  modification  of  certain  of  the  symptoms  of  typhoid  fever  may  some- 
times be  attributed  to  the  malarious  condition  of  the  patient.  If,  for  instance,  the  malarial 
poison  has  not  been  productive  of  intestinal  congestion,  diarrhcea,  which  is  one  expres- 
sion of  the  local  lesion  of  typhoid,  may  not  be  prominent  as  a  symptom,  and  this  is 
especially  the  case  when  the  malarial  influence  is  manifested  by  frequently  recurring 
perspirations;  the  character  of  the  stools  may  also  be  altered.  At  the  same  time  it  is 
to  be  remembered  that  diarrhoea  is  not  present  in  all  cases  of  distinctly  pure  typhoid  fever; 
its  absence  does  not,  therefore,  constitute  an  indication  of  malarial  complication  except 
when  in  conjunction  with  other  testimony  of  a  more  or  less  suggestive  character.  On  the 
other  hand,  if  the  malarial  influence  has  expended  its  force  on  the  mucous  lining  of  the 
intestinal  canal,  there  may  be  diarrhoea  and  tenderness  with  other  strongly  marked  signs 
of  the  abdominal  lesion  of  typhoid  fever;  the  tenderness,  however,  is  general,  or  specially 
noted  in  regions  other  than  the  right  iliac, — frequently  over  the  tract  of  the  colon, — and 
the  stools  are  often  of  a  dysenteric  character.     But  here  again  there  is  a  want  of  value  for 


THK    (-■O.XTIXUKD    FEVKRS.  275 

diagnostic  pnqioscs  iua,?^iimcli  iis  typhoid  fever  engrafted  on  an  antecedent  diarrhoea  or 
dysentery  may  give  rise  to  sucli  svniptonis. 

Tlie  recorded  condition  oi'  tlie  tongue  furnislies  in  many  instances  satisfactory  evi- 
dence of  tlie  presence  of  a  mahirial  complieation.  In  Ivphoid  fever  it  had  at  first  a  sliglit 
coating  of  a  wliite  or  yellow  color,  hut  redness  of  tlie  tij)  and  edges  was  generally  manifested 
even  at  tliis  period,  an<l  as  tlie  tengue  dried  and  darkened  on  the  dorsum  the  redness 
hecamo  moi'e  noticeable.  When  a  midarial  (■lenient  was  present  this  eduditinn  of  the  tongue 
did  not  generally  obtain ;  it  was  |iale,  llabb\-  and  variously  eoated  not  only  during  the 
progress  of  the  febrile  phenomena  but  during  I'oiivalrseence. 

The  pneumonitic  tendencies  of  ty}ilioid  i'rvfv  were  seldom  altered  by  the  presence  of 
the  malarial  poison,  although  the  latter  hail  appaicntly  a  greater  proclivity  to  the  develop- 
ment of  sudden  and  dangerous  pulnion:ir\'  (•(niLi.'i'stions.  Nov  were  the  cerebral  symptoms 
of  tyjihoid  materiallv  changed  by  the  prcsfiH't"  of  the  complicating  element  except  \v\wn 
this  was  prominently  and  perniciously  developi'd,  masking  the  continued  type  by  its  irregular 
paroxysms  and  changing  the  muttering  <leliriuni  of  the  febrile  condition  into  tlie  coma  of 
malarial  congi^stion . 

Kxtravasations  of  blood  undei-  the  skin,  (-(instituting  ju'tecliite  and  vibicea,  were  com- 
mon {<)  the  contiinuMl  dpci'alidn  n\'  both  p()is(jns;  but  an  earlv  a]>])earaiice  of  such  spots  in 
typhoid  cases,  when  conibimMl  with  either  testimony,  is  suggestive  of  malarial  complication. 
Deterioration  of  the  blood,  li'(;in  seurvy  or  oehlesis,  was  also  occasionally  concerned  in  the 
development  of  these  spots. 

Lastly,  a  rapid  issue  in  fatal  cases  is  indicative  of  malarial  disease,  since  typhoid  cases 
usually  ran  a  ])rogressive  course  while  the  paroxysmal  fevers  were  often  fulmmant. 

l)y  giving  weight  to  these  considerations  the  febrile  cases  treated  at  the  Seminary 
liospital  have  been  arranged  into  two  series,  one  of  pure  typhoid  and  the  other  assumed, 
on  more  or  less  satisfactory  evidence,  to  have  been  com|jlicated  by  the  malarial  poison. 
From  these  ami  otlier  cases  submitted  above,  as  also  from  a  series  of  fatal  cases  to  be  pre- 
sented hereafter  in  connection  with  tlu;  ]>ont-nuyrtevi  aj)pearances,  tlie  following  general 
description  of  the  (Tmical  progress  of  the  typhoid  fever  of  the  war  lias  been  written. 

Oases  regarded  and  reported  as  typhoid  fever  Ijegan  with  feverishness,  depression  of 
spirits,  muscular  debility  and  unusual  relaxation  of  the  bowels.  Oftentimes  the  soldier 
suffered  in  this  way  for  several  days,  attributing  liis  condition  to  some  particular  exposure 
or  indiscretion  in  diet,  the  effects  of  which  he  hoped  would  speedily  subside.  Ultimately 
headache,  pain  in  the  back,  aching  in  the  bones  and  muscles,  loss  of  appetite  and  increas- 
ing weakness  wholly  incapacitated  him  for  duty  and  led  him  to  report  as  sick.  As  the 
patients  were  mostly  young  and  inexperienced  soldiers,  it  frequently  happened  that  they 
did  not  realize  their  loss  of  health,  but  continued  their  usual  occupations  in  an  apathetic 
manner  until  their  appearance  led  to  inquiries  by  more  experienced  comrades  or  company 
officers,  when  they  were  sent  to  the  regimental  surgeon.  In  nearly  one-half  of  the  cases 
the  disease  was  ushered  in  by  a  chill  which  was  immediately  followed  by  fever  and  perhaps 
diarrhoea,  but  not  by  perspiration:  Of  fifty-one  typhoid  cases  found  in  tlie  records  of  the 
Beminary  hospital  the  onset  was  by  chill  in  twenty,  without  chill  in  eleven,  while  in  the 
remaining  twenty  the  manner  of  the  attack  was    not  recorded.*     Of  the  twenty  cases 

*  of  sixty -three  cases  in  which  Mtjrcuirok  noted  the  commencement,  paiua  in  the  head  and  limbs,  commonly  aching  hnt  sometimes  neuralgic,  were 
among  the  earliest  symptoms  in  fifty-t<ix,  and  most  of  these  patients  also  suffered  from  irregular  chills,  languor  and  giddiness;  rigors  occurred  in  only 
three  of  the  cases.  But  in  several  iustauces,  not  included  in  the  analysis,  he  obeen'ed  decided  rigors  and  in  fact  all  the  phenomena  of  ague  during  the 
first  few  days.— Op.  cil.,  p.  546. 


276  SYMPTOMATOT-ODY    OF 

that  had  an  initiatory  cliill  five  were  niilil,  eii;lit  severe  and  sevon  fatal;  of  the  ehn'en  that 
began  witli  no  marked  sensations  of  chilliness  three  proved  mild,  six  severe  and  two  latal. 
These  nund)ers  are  not  lai'ge,  hut  so  far  as  they  go  they  indicate  that  the  eoui'sc  of  the 
disease  is  not  affected  by  the  mode  of  onset.  It  may  be  owing  to  an  appreciation  of  this 
fact  that  few  waiters  advert  to  the  prognostic  value  of  chill  as  an  initial  symptom  of  typhoid 
fever.  Nevertheless  Lours  was  inclined  to  regard  a  severe  chill  as  suggestive  of  a  severe 
attack,  for  his  observations  showed  a  greater  frequency  of  chills  among  the  sevei-e  than 
among  the  mild  febrile  cases.* 

The  course  of  the  disease  after  this  onset  by  defined  chills  or  gradual  accession  differed 
much  in  individual  cases.  In  some,  probably  in  a  majority  of  those  which,  anterior  to  the 
issue  of  the  order  removing  common  continued  fever  from  the  list  of  diseases  on  the 
monthly  sick  reports,  would  have  been  reported  under  that  heading,  the  febrile  c(jndition 
did  not  at  any  time  l)ecome  more  marked  than  during  the  first  few  days.  The  tongue  was 
somewdiat  furred  or  white-coated,  with  the  edgc^s  and  tip  of  a  deeper  red  than  natural  and 
with  some  tendency  to  dryness  at  the  base  and  centre;  the  skin  was  dry,  the  face  slightly 
flushed  and  the  eyes  injected,  especially  in  the  evening;  the  urine  was  scanty  and  the 
bowels  relaxed  or  unusually  suscej)tible  to  the  action  of  laxative  medicines;  the  pulse  was 
seldom  rapid,  full  or  tense,  but  was  occasionally  (bcrotic;  slight  epistaxis  occurred  at  times; 
the  cerebral  manifestations  were  restricted  to  headache,  restlessness,  drowsiness  and  inabil- 
ity to  concentrate  the  attention  or  follow  up  a  train  of  thought;  a  bronchial  cough  often 
accompanied  these  symptoms.  In  a  few  days  the  febrile  action  subsided,  the  improved 
condition  being  first  noticed  after  a  sound  and  refreshing  sleep,  coincident  with  a  cleaner 
tongue,  diminished  thirst  and  recovered  appetite;  occasionally  perspirations,  epistaxis  or 
slight  diarrhoea  marked  the  defervescence.  The  patient,  however,  remained  weak  for  a  long 
time  after  the  attack. 

But  in  a  majority  of  the  cases  the  disease  was  prolonged  for  two  or  more  weeks,  during 
which  time  certain  of  the  symptoms  assumed  a  special  gravity.  The  intestinal  symptoms 
in  some  became  especially  noteworthy,  consisting  of  a  more  or  less  active  diarrhoea,  with 
pain  in  the  abdomen,  tenderness  on  pressure,  particularly  in  the  right  iliac  region,  gurgling 
and  some  tympanitic  distention.  The  diarrhoea  often  subsided  at  the  end  of  the  second 
week,  and  this  improvement  was  usually  associated  with  an  amelioration  of  the  general 
symptoms,  free  pers])irations  and  the  appearance  of  sudamina.  But  when  defervescence 
was  effected  gradually  and  without  the  occurrence  of  [lerspiration,  relaxation  of  the  bowels 
was  prone  to  continue,  with  diminishing  tenderness,  perhaps  for  eight  or  ten  days  longer, 
during  which  recrudescence  was  not  uncommon.  The  patient  continued  weak  after  the 
subsidence  of  the  active  symptoms,  and  at  any  period  of  the  prolonged  convalescence  he 
was  liable  to  dangerous  recurrences  of  the  diarrhoea  from  slight  indiscretions  in  diet  or 
other  faults  in  the  sanitary  regimen. 

The  cerebral  symptoms  in  other  eases  constituted  apparently  the  special  characteristic 
of  the  disease,  for  they  were  often  present  in  the  absence  of  diarrluea  and  abdominal  ten- 

*  chills  occurred  ^n  thirty -oinj  i»f  thirty-three  fatjil  ciiri;'!4  in  which  he  was  aMe  to  learn  anything  definite  nn  this  point ;  of  forty-five  severe  thoiif^h 
not  fatal  castas,  all  except  three  had  chill.-*  or  a  greater  .^ensiliility  to  cold,  wiiile  in  thirty-one  mild  cases  chills  were  reported  in  twenty-fiMir  only. — 
^jRechercheH  Anutijmiipifx^  l'alhii}(i(j'u{neit  ei  Tfn'rapeutifiuen  /tiir  lit  nmlfiilie  i-omwe  xoitu  h'/t  nrtiiig  dt'  OuMro-eiitt'rUe,  Fi'rri;  pntridi',  tubiunni'upte,  akuiiiue,  typlniide, 
etc.  Ch.  a.  Levis,  Paris,  1821>,  t.  II,  p.  251). )  Nevertheless,  if  the  fifty-eight  eas<?s  recorded  in  the  work  jtust  cited  are  e.xauiined  in  reference  to  this 
point,  it  will  Im;  found  that  chills  am  not  recorded  as  freciuently  as  the  above  statements  would  lead  us  to  anticipate.  Forty-five  of  these  cases  are 
regarded  as  unilouhted  typhoid,  the  observations  4fi-58  Iwdng  variously  classified  us  doubtful,  simulatt^d,  etc.  In  twenty-two  of  the  forty-five  cases  chills 
are  noted  as  having  occurnid  at  the  beginning  of  the  attju:k,  and  in  one  on  the  fourth  ilay  of  the  fever ;  in  tht!  remaining  twenty-two  cases  either  no 
mentioD  is  made  of  the  symptom  or  it  is  positively  stated  that  it  was  not  present. 


TIIK    CONTINUED    FKVKRS.  277 

Jerness.  Tlio  wakefulness  and  n'stlossness  wliicli  aflVctfil  tiio  patient  during  the  first  week 
of  the  disease  increased  at  night,  until  sl(.'C'p  became  disturbed  by  incoherent  niutterings. 
During  the  day  he  was  drowsy,  and  wlien  aroused  was  found  to  be  dull  and  stupid,  held  at 
attention  for  the  moment  but  relapsing  innncdiately  into  a  semi-somnolent  or  mildly  deli- 
rious condition.  In  such  cases  the  tongue  became  drv  and  dark-colored,  retaining  how- 
ever  the  redness  of  its  margins,  and  with  diarrluea  pn'sent  the  stools  were  often  passed 
without  the  consciousness  of  the  sufferer;  the  urine  was  also  sometimes  evacuated  involun- 
tarily, or  retained,  causing  hypogastric  distention  and  jniin  until  removed  by  the  catheter. 
In  most  cases  at  this  period  sordes  accunuilated  on  the  teeth  and  gums.  Hut  at  the  close 
ot  the  second  week,  coincident  with  a  moist  condition  of  the  skin,  e})istaxis  and  sudamina, 
the  tongue  became  moist,  the  mind  clear,  the  appetite  improved,  and  refreshing  sleep,  enjoyed 
for  the  first  time  since  the  occurrence  of  the  attack,  ushered  in  the  period  of  convalescence. 

Generally  in  cases  which  ran  a  two  weeks'  course  to  defervescence  the  rose-colored 
eruption,  viewed  by  most  of  our  medical  officers  as  characteristic  of  tlie  disease,  was  dis- 
covered on  the  chest  and  abdomen  from  the  seventh  to  the  fourteentii  day.  In  several 
instances  the  appearance  of  tliis  eruption  about  the  end  of  the  second  week  was  associated 
with  im|)rovement,  and  was  the  only  concomitant  of  defervescence  entered  on  the  record. 

Dt'atli  seldom  occurred  before  the  fourteenth  day  except  as  the  result  of  accident  con- 
nected with  the  febrile  condition,  as  in  case  41  of  the  Seminary  series,  in  which  the  patient 
was  killed  by  jumping  from  a  window  in  his  delirium,  or  by  some  intercurrent  attack,  as  in 
20  of  t\ie  posf-)/iortct/i  records,  in  wliich  pneumonia  proved  fatal  on  the  thirteenth  day. 

When  defervescence  failed  to  take  place  about  the  fourteentii  day  the  protracted 
course  of  the  disease  was  usually  due  to  the  occurrence  of  intestinal  or  pneumonic  compli- 
cations. DiarrluBa  became  aggravated  and  prolonged  the  duration  of  tlie  case  for  several 
weeks,  or  an  exhausting  attack  was  speedily  followed  by  collapse  and  death.  Intestinal 
hemorrhage  increased  the  prostration  of  the  patient,  adding  gravity  to  otherwise  mild 
attacks  and  sometinuis  leading  directly  to  a  fatal  issue.  The  suffering  occasioned  by 
abdominal  distention  a|)peared  in  some  cases  to  bo  the  cause  of  the  failure  to  convalesce  at 
the  end  of  the  second  week;  indeed  death  at  a  later  period  was  occasionally  due  to  exhaus- 
tion induced  by  a  continuance  of  the  abdominal  distress.  Peritonitis  supervened  in  many 
cases,  the  mesentery  becoming  affected  by  the  condition  of  the  glands  or  the  peritoneal  coat 
of  the  intestines  by  the  inflammatory  processes  in  their  interior  tunics;  but,  more  frequently, 
in  cases  protracted  by  the  unfavorable  progress  of  the  abdominal  lesions,  the  occurrence  of 
exc|uisite  pain,  vomiting,  hiccough,  cold  perspirations,  collapse  and  death,  indicated  perfora- 
tion of  the  intestine  and  the  escape  of  its  consents  into  the  peritoneal  sac. 

With  or  without  the  continuance  of  diarrhoea  the  course  of  the  disease  was  often 
prolonged  by  the  development  or  aggravation  of  cough,  pain  in  the  chest,  hurried  breathing 
and  the  physical  signs  of  pneumonitic  processes.  Patients  subject  to  bronchial  cough 
from  the  early  days  of  the  attack  were  specially  liable  to  this  complication;  the  mucous 
expectoration  became  purulent  and  bloody,  sometimes  viscid  and  rust-colored.  In  favorable 
cases  the  duration  of  the  sickness  was  mucli  lengthened  by  these  attacks,  and  if  no  serious 
intestinal  or  cerebral  symptoms  were  present,  the  lung  disease  assumed  a  prominence  which 
led  in  many  instances  to  a  diagnosis  of  pneumonia  by  medical  officers  who  had  not  observed 
the  case  from  its  commencement.  In  others  in  which  an  extensive  and  manifest  implication 
of  the  lung  was  coincident  with  low  delirium  and  great  prostration  the  disease,  in  the  absence 
of  a  knowledge  of  its  previous  history,  was  frequently  reported  as  typhoid  pneumonia. 


278  SYMPTOMATOLOGY     OP 

Nevertheless,  in  most  of  the  cuscs  in  which  dciervescence  at  the  end  of  the  second  week 
was  prevented  by  intestinal  or  pneumonic  comiiHcatiuns,  a  close  studv  of  the  details  of  the 
daily  record  of  progress  reveals  an  effort  on  the  part  of  nature  to  establish  convalescence  at 
that  period.  The  tongue  became  less  dry,  the  skin  moist,  the  pulse  less  frequent,  delirium 
subsided,  or  the  patient  was  recorded  as  being  more  intelligent  or  less  stupid  or  drowsy  or 
as  having  passed  a  better  night  than  usual.  lUit  tliis  favorable  change  in  sucli  cases  was 
transitory:  with  some  aggravation  of  the  existing  cough,  pain  in  the  chest  and  accelerated 
respiration,  or  with  increased  tenderness  and  distention  of  the  abdomen,  with  or  without  an 
exacerbation  or  recurrence  of  the  diarrhoea,  the  tongue  became  again  dry,  the  skin  Iiot,  and 
a  febrile  condition,  proportioned  to  the  extent  and  severity  of  the  local  lesions  and  the 
depressed  vitality  of  the  patient,  was  re-established. 

When  cerebral  symptoms  were  specially  |)rominent  during  the  third  week,  the  exist- 
ence of  serious  Intestinal  lesions  miglit  not  be  manifested  by  their  usual  symptoms;  gen- 
erally, however,  stools  passed  without  the  consciousness  of  the  patient  woih;  loose  and 
frequent  and  in  a  [H'oportion  of  tlie  cases  hemorrhagic.  Under  similar  ccn'ljral  conditions 
extensive  congestion  of  the  lungs  or  numerous  foci  of  catari'hal  })neumonia  were  at  times 
deveIo|)ed  without  expressing  their  existence  by  local  symptoms. 

When  complications  prolonged  the  febrile  condition  into  the  fourth  week  the  patient 
became  greatly  emaciated,  his  pulse  rapid  and  weak  and  his  prostration  extreme.  At  any 
time  during  the  course  of  the  disease  sudden  death  from  failure  of  the  heart's  action  or 
heart-clot  was  a  pc^ssible  occurrence.  Fatal  syncope  not  unfrequently  attemled  the  effort 
to  rise  to  stool  or  followed  the  unconscious  impulses  of  an  active  delirium.  During  or 
before  this  time  there  often  occurred  a  swelHng  of  the  parotid  glands,  which  usually  termi- 
nated in  suppuration  and  extensive  disorganization,  if  the  death  of  the  ])atient  did  not  mean- 
while interfere  with  the  progress  of  the  lo(;al  alTection.  Not  unfrequently,  also,  at  this  time 
deafness  and  headache,  botli  of  which  were  often  obscured  by  the  presence  of  delirium  or 
stupor,  indicated  the  probable  occiu'renco  of  inflammatory  j)roGesses  in  the  ear,  a  complica- 
tion which  sufficed  of  itself  to  prolong  the  apparent  duration  of  the  original  febrile  attack,  for 
the  untoward  syni[)toms  sometimes  disappeared  and  convalescence  was  establislied  on  the 
free  issue  of  purulent  matter  IVoin  the  affected  organ. 

If  the  conditions  mentioned  did  not  prove  fatal  by  the  fifth  week  the  activity  of  the 
morbid  processes  referable  to  the  direct  action  of  the  typhoid  poison  in  the  blood  appeared 
to  subside;  diarrhoea  became  less  active  or  ceased;  pneumonic  symptoms  im[)roved;  delirium 
and  other  cerebral  manifestations  abated.  Sometimes  the  return  of  consciousness  about 
this  time,  after  many  days  of  low  delirium  or  stupor,  gave  rise  to  hopes  of  a  favorable  issue 
which  were  not  realized,  the  patient  dying  shortly  afterwards  of  asthenia  but  retaining 
his  recently  recovered  intelligence  to  the  last.  In  other  cases  the  tongue  became  clean, 
usually  of  a  lighter  red  than  in  health,  and  sometimes  patched  with  white  or  yellow  fur; 
the  appetite  returned,  and  the  patient  showed  a  languid  tliougli  increasing  interest  in  the 
affixirs  of  life.  But  he  was  generally  extremely  prostrated,  and  bed-sores,  whicli  had  formed 
latterly,  were  slow  to  heal  and  caused  much  suffering;  in  fact  liis  condition  was  such  that 
the  slightest  adverse  influence  was  sufficient  to  precipitate  a  fatal  issue. 

Irrespective  of  the  direct  influence  of  the  typhoid  poison  on  the  blood  a  morbid  quality 
of  this  fluid  necessarily  resulted  from  the  continuance  of  the  febrile  condition  by  its  inter- 
ference witli  the  healtliy  action  of  the  blood-forming  and  blood-purifying  organs.     This 


THE   CONTIKUED    FEVERS.  279 

cletorioration  was  occasionally  manifested  at  a  late  period  of  the  typhoid  attack  by  the  devel- 
opment of  i)etochial  spots  and  even  of  larger  extravasations.  Abscesses  were  formed  in 
various  situations,  and  sometimes  these  became  gangrenous  in  character.  Gangrene  of  the 
toes  and  feet,  simulating  that  from  frostbite  and  necessitating  amputation,  was  recorded  as 
a  consequence  of  the  typhoid  aflfection. 

Even  in  favorable  cases  convalescence  was  tedious,  and  in  its  duration  generally  pro- 
portioned to  the  severity  of  the  antecedent  attack.  Muscular  strength  and  mental  pow(;r 
alike  required  a  long  period  for  the  return  of  their  former  vigor.  Nor  was  the  conva- 
lescence progressive:  Dianhoea  was  a  frequent  and  oftentimes  dangerous  accident. 
Chronic  pneumonia  resulting  from  ])rocesses  set  up  during  the  febrile  attack  often  proved 
fatal  as  a  sequel.  Pain  in  the  muscles  retarded  the  return  to  health,  kee{)ing  the  patient 
for  months  in  hospital  under  treatment  for  so-called  chronic  rheumatism.  Various  paralyses 
also  appeared  in  the  list  of  the  sequela).  Rarely  a  well  defined  rela})se  occurred  marked  by 
the  presence  of  rose-colored  spots  on  the  chesfe  and  abdomen,  diarrhoea,  tenderness  in  the 
right  iliac  region,  tympanites,  epistaxis,  tinnitus  aurium,  deafness,  delirium  and  such  other 
symptoms  as  were  present  during  the  primary  attack. 

J3ut  an  analysis  of  the  sym])toms  presented  by  certain  of  the  cases  that  have  been 
submitted  will  be  of  more  value  than  the  above  generalizations  in  conveying  correct  impres- 
sions of  the  typhoid  fever  which  affected  our  troops. 

Temterature. — -At  tlu)  present  day  the  course  of  a  case  of  typhoid  fever  may  bo  represented  liy  a  temperature 
chart  with  a  few  notes  to  indicate  tlie  ((rominence  of  a  parti<ular  class  of  symptoms  and  exi>lain  anomah)UN  devia- 
tions in  the  temperature  curve.  Tliis  curve  is  generally  divided  into  tlireo  stages:  In  the  first,  that  of  gradual 
accession  or  ascending  oscillations,  the  temi)erature8  on  eacli  morning  and  evening  are  aliout  a  degree  of  Fahrenheit's 
scale  higher  tlnm  tliose  of  tln^  jireceding  day,  hut  the  morning  temperature  is  usually  ahout  two  degrees  lower  than 
the  temperature  of  the  previous  evening.  The  daily  rise  begins  about  noon  and  reaches  its  height  between  7  and  12 
1".  M.;  the  fall  begins  at  midnight,  and  between  6  and  8  a.  m.  the  lowest  temperature  of  the  day  is  recorded.  The 
highest  evening  temperature  is  usually  attained  from  the  fourth  to  the  eighth  day,  and  is  generally  104°,  1().">°  or  11M)°. 
The  second  stage  is  that  of  stationary  oscillations  in  which  the  morning  and  evening  temperatures  remain  at  about 
the  same  height  on  each  day,  the  former  being  a  degree  or  more  lower  than  the  latter.  This  continues  in  mild  (tases 
until  about  the  twelfth  day,  when,  coincident  with  absori)tion  of  the  deposit  in  the  intestinal  glands,  the  morning 
remission  is  stidiigly  emphasized,  and  the  third  stage  or  that  of  descending  oscillations  commences.  During  this 
stage  the  febrile  heat  is  that  of  a  declining  remittent  fever.  In  its  latter  part  the  morning  temperature  may  be  at  or 
lower  than  the  normal,  rising  in  the  (<veniiig  considerably  above  it,  and  constituting  an  intermittent  period  in  the 
defervescence  of  the  tyjjhoid  fever.  In  more  severe  cases,  with  ulceration  of  the  intestine  taking  place  about  the 
twelfth  day,  the  second  stage,  that  of  stationary  oscillations, is  prolonged  into  the  third  week;  but  after  that,  in 
favorable  cases,  the  temperature  declines,  as  in  the  milder  cases,  by  remitting  and  intermitting  stages.  Accidents 
and  complications  are  manifested  by  deviations  of  the  curve  from  this  tyi)ical  course. 

A  consideration  of  the  thennoinetric  chart  and  of  its  anomalies  in  complicated  cases  shows  the  clinical  ther- 
mometer to  be  an  instrument  of  value  not  only  for  diagnostic  but  for  prognostic  purposes.*  Hut  the  thermometer 
was  unfortunately  not  in  use  in  our  hospitals  during  the  war.  The  records  do  not  show  at  a  glance  the  gradual 
accession  of  the  fever  by  evening  increments  and  morning  remissions,  its  vibratory  continuance  between  its  morning 
and  evening  maxima  nor  its  decline  by  remittent  and  intermittent  stages.    To  place  on  record  an  appreciative  view. 


*  ColiHiiltThiK  it  in  the  former  liglit,  Lif.bkkmkister,  in  Ziettim-ns  Vyclnpetiia,  American  translation,  New  Yorli,  1H74,  Vol.  I,  p.  77,  8ay« :  "The 
diaf2;nrMis  of  fever  can  usually  Im-  made  from  the  fev<'r-<-urve  alone,  and  this  is  true  not  only  of  the  simple  cases,  hut  also  of  the  ithscnre  and  complicated 
ones,  provided  that  the  jihysiciau  is  acquainted  with  the  ordinarv  deviations."  One  of  the  rules  of  thermomctric  diagnosis  deduced  Ity  WrNnKKLicii 
fnun  his  ohservations,  was  that  the  disi>ase  in  which  the  temiwrature  has  not  risen  in  the  evening  of  the  fourth  day  to  '.V.K'P  Cent.  (Ui;i.l°  Fh.)  is  not 
t.yphoid  fever. — See  ('.  A.  WvNnERLlCH  On  the  Temperature  in  hisea^,  Sydenham  Stx-iety's  Transjictions,  London,  1871,  p.  '21t;j.  lint  Mnti'UisoN  teacln'S  that 
a  liiagnosis  of  typhoiil  must  not  he  excluded  if  the  tcmi)eniture  <ioes  not  reach  W-P  Fh. — See  his  treatise  (hi  the  i!imlmned  Fevers  <>/  HreiU  BrUntii,  second 
i-ditiou,  Lontlon,  lft7:{,  p.  riK;.  Considering  the  teniiH-rature  as  an  element  of  prognosis,  Likbermkistkr,  op.  n'/.,  p.  l:t:l,  sa.vs  that  the  histories  of  nutre  than 
'HH»  caws  iu  the  hospital  at  B:isil  were  tuhulated  w  itii  reference  to  the  maximum  axillary  temis-niture.  and  that,  "(.»f  lhos<*  [tatients  in  whom  ll4°  or  more 
was  not  observed,  9.fi  is-r  t'ent.  died  ;  of  thos*-  in  wlioni  104°  was  reached  and  [Mu*sed,  li'.l.l  iter  cent.;  tinally,  <if  those  in  whos<'  axilla  the  teniin-niture  rofle 
to  Ktri.H^  and  over,  more  than  half  died."  And  he  insists  also  on  the  prngnttstic  value  of  tin-  daily  flm-tuatious  on  the  grounii  that  a  fever  which  shows 
notahle  remissions  is  more  easily  liorne  than  one  wliich  remains  at  the  same  height.  In  this  connection,  E.  Seocin's  volume  on  Medienl  Thenitotnetry, 
New  York,  1.S76,  p.  Ill,  may  he  quoted :  "The  temperature  indicates  the  tieverily  of  the  disease  about  the  middht  of  the  s<'Cond  week,  rarely  earlier.  A 
single  observation  do<'s  not  do  it,  a  whole  day's  ol>Borvation  gives  it ;  but  two  or  thn'e  days  are  still  better.  It  indicates,  best  of  all  signs,  the  irreijnlarities  in 
the  course  ;  the  complictitiofts  that  no  other  means  can  detect ;  a  relapue  after  the  patient  has  begun  to  recover ;  wanis  of  the  lemifniey  towards  death  ;  regu- 
lates the  ptfteticy  of  therapeutic  operations ;  shows  the  tewteticij  in  com-dtescenee  with  great  detiniteness,  etc. ;  besides  the  most  important  fact  that  a  large 
thermometric  exjM'rience  in  typhoid  fever  has  rendered  possible  the  knowledge  of  its  course  and  the  certainty  of  its  diagnosis  and  prognosis,  which  were 
absolutely  impotisible  with  the  previous  means  of  observation." 


2S0  SYMPTOMATOLOGY     OF 

of  the  proi;i0KH  in  a  niveii  case  our  medical  oHict'is  bad  to  ol)si'rvc  and  note  the  changes  wliicli  took  place  in  the  gen- 
eral condition  of  the  patient  an  manifested  liy  tlie  state  of  the  surface,  the  tongue,  puls(^,  respiration  and  muscular 
system,  and  hy  the,  extent  and  intt;nsity  of  the  cerehral  implication  as  well  as  the  intlueuco  exercised  on  the  general 
condition  by  the,  progress  of  visceral  and  other  local  inflammatory  processes.  Enough  of  carefully  detailed  work  of 
this  cliiiracter  was  luirfornied,  especially  by  the  officers  of  the  Seminary  hospital,  to  authorize  the  stiitemeut  that  in 
their  cases  of  typhoid  fever  the  essential  or  primary  fever  tended  to  defervescence  at  the  end  of  the  second  week.  In 
many  of  the,  cases  liorne  on  the  Mrdiciil  DiKcrijitiri'  lAxts  wlii(di  give  little  infornuition  other  than  that  embraced  in 
names  and  dates,  imi)rovement,  (|uickly  followed  by  convalescence,  is  noted  about  the  fourteenth  day.  In  one 
hundred  and  twenty-one  recoveries  from  typhoid  fever  in  Hospital  No.  1,  Nashville,  Tenn.,  there  were,  according  to 
a  report  of  A(^t.  Ass"t  Surg.  li.  15itANl)lKS,  U.  S.  A.,  sixteen  cases  in  wliich  convalescence  was  j)rimounced  at  the  end 
of  the  second  week;  these  presented  ro.se-colored  spots  and  other  symptoms  regarded  as  pathognomonic.  In  twenty- 
five  of  the  fifty-one  cases  of  ninnodified  typhoid  fever  found  in  the  records  of  the  Seminary  hospital  the  date  of 
defervescence  can  bo  ascertained,  and  in  eight  of  these,  cases  2,  4,  7,  8,  9,  10,  13  and  27,  a  decided  and  permanent 
improvement  was  manifested  about  the  period  stated.  But  although  defervescence  may  be  said  to  ha\e  begun 
about  this  time,  its  progress  was  so  gradual  that  convalescence,  as  marked  hy  the  ability  of  the  patient  to  walk 
about  the  ward,  was  dcdayed  for  a  week  later.  In  these  cases  it  must  be  assunuid  that  the  spe(Mtic  intlamnuitory 
processes  in  progress  in  the  intestinal  canal  at  this  stage  of  the  disease  were  so  limited  in  their  extent  or  degree  that 
the  constitutional  disturbance  accomi)anying  them  was  insutlicient  to  maintain  the  febrile  condition,  while  at  the 
same  time  Ihi;  patient  remained  free  from  accidental  or  secondary  lesions  which,  if  present,  would  have  been  mani- 
fested by  a  maintenance  or  recurrence  of  the  pyrexia. 

It  (Iocs  nut  follow  from  tlic  facts  stated  that  tlie  iiiild  ami  uiico!ii[>licated  cases  of  typhoid 
among  our  troops  differed  in  their  pi.'riod  of  duration  from  those  observed  in  civil  practice 
before  or  since  that  time.  Dr.  Jas.  K.  JIkkves,  of  Wheeling,  West  Va.,  in  his  delineation 
of  the  enteric  fever  of  Virginia  as  presented  to  the  practitioner  shortly  before  the  war, 
gives  a  table  of  the  duration  of  the  disease  in  sixty-four  mild  cases,  i.  e.,  ca.ses  in  which, 
in  the  ab.sence  of  serious  intestinal  or  pulmonary  lesions,  the  attack  ended  with  the  cessa- 
tion of  the  primary  fever,  or  was  prolonged,  but  in  a  mild  form,  by  the  existence  of  limited 
intestinal  inflammation.  The  calculation  was  made  from  the  time  when  the  patients 
became  unable  to  j)ursue  their  ordinary  vocations  to  the  cessation  of  febrile  symptoms  and 
the  return  of  appetite.  The  duration  was  from  nine  to  fourteen  days  in  twenty-four  cases, 
from  fifteen  to  eighteen  days  in  tliirty-seven  and  over  eighteen  days  in  three  cases. '=' 

Observations  of  this  kind,  were  open  to  error  at  both  extremes  of  the  period.  The 
insidious  aj)proach  of  the  disease  in  many  cases  rendered  the  date  of  onset  obscure,  and  in 
the  absence  of  more  delicate  means  of  determining  the  cessation  of  the  febrile  movement 
than  were  used  by  our  medical  ofKcers  during  the  war,  and  by  our  medical  men  before  that 
time,  it  was  im[)Ossible  to  assign  a  date  in  all  cases  as  that  on  which  convalescence  was 
establishetl.  The  return  of  the  patient  to  the  state  of  health  was  so  gradual  and  unmarked 
by  striking  phenomena  that  arbitrary  lines  had  to  be  drawn.  Tlius,  Louis  considered  the 
patient  convalescent  when  he  commenced  to  eat  a  little  bread.f  But  on  the  other  hand 
the  onset  was  often  distinctly  marked  by  chills  and  other  notable  bad  feelings,  as  headaclie, 
pain  in  the  limbs  and  weakness,  and  although  the  date  of  convalescence  might  not  be  indi- 
cated with  certainty,  there  was  usually  no  difficulty  in  assigning  a  particular  day  as  that 
on  which  the  patient  showed  the  first  manifestations  of  improvement.! 

Since  the  war  the  duration  of  mild  cases  of  typhoid  fever,  as  usually  stated,  is  three 

*  A  l^racikttl  Treatixe  im  Enteric  Fever,  by  J.\ME8  E.  Reeves,  M.  D.,  PtlUadelpbia,  IS.'iO,  p.  Ift2  et  neq. 

fCH.  .\.  L0VI8,  Hevherfhea  Anatomii/iteii,  dr.,  t.  11,  note  to  jMlgp  I'L 

\  Dr.  AcsTiN  Flint  in  Iuh  Clhtiral  liepmtx  an  Ctmtinin^d  FeiTr,  Buffalo,  18.'i2,  p.  lit',,  ar^m-d  ttiat  ttie  day  of  convalesceuce  might  be  deterrnilii'd  from 
the  general  syniptums  with  Huflicicnt  accuracy  for  all  practical  purpof*en.  "  If  a  febrile  movement,  a(*  detennined  by  the  to-at  of  the  skin,  acceleration 
of  pnlse,  etc.,  have  cejised,  {-learnetiK  of  tiie  intellect  returning,  with  refreshing  sleep,  and  the  patient  bas  a  desire  for  and  a  relish  of  food,  he  may  lie 
proniuinced  convalescent.  Some  one  or  more  of  the  above  conditions,  in  some  instances,  may  be  wanting,  and,  still,  the  other  circumstances  be  such  that 
convalescence  may  l>e  proiwrly  declared.  Judgment  and  some  experience  are  requisite  to  decide  correctly;  and  with  every  qualification  on  the  i)art  of 
the  observer,  it  will  not  infrequently  be  a  matter  of  some  doubt  as  to  the  particular  day  which  should  limit  the  termination  of  the  tet)rile  career.  Dif- 
ferent practitioners  would  not  fix  upon  the  same  day  in  all  cases,  owing  to  tliffen-nc<*s  in  the  mtsie  of  estimating  the  circumstances  upon  which  the 
opinion  is  based.  Perfect  exactitude  and  entire  uniformity,  in  short,  as  respects  this  point,  are  ncft  practicable;  and  yet  sensible  physicians,  in  the 
majority  of  instances,  will  act  with  sufficient  correitness  for  all  practical  purposes,'" 


THK    CONTIXUKD    KKVKR8. 


281 


weeks,  or  three  periods  of  five  or  more  davs,  corresponding  with  the  ascending,  stationary 
and  declining  stages  as  marked  out  by  therniometric  observation.  The  cHnical  thermom- 
eter iias  defined  the  date  of  convak'scence  as  tliat  on  which  i\\v  temperature  does  not  rise 
above  the  normal  at  the  hour  of  its  usual  post  meridian  increase.  This  instrument,  by 
exactly  defining  the  close  of  the  febrile  movement,  has  addi>d  to  the  duration  of  the  disease 
as  stated  by  physicians;  but  at  the  same  time,  by  determining  with  erpial  delicacy  and 
exactitude  the  heginniiKj  of  the  period  of  defervescence,  it  has  shown  the  accuracy  of  our 
medical  officers  in  noting  slight  changes  indicative  of  improvement  in  mild  and  uncom- 
plicated cases  about  the  end  of  the  second  week.  In  point  of  duration  there  was  no  dilTer- 
ence  between  tliese  cases  and  those  that  since  then  have  been  studied  thermometrically  by 
the  profession. 

Cases  in  'which  the  disease  ran  a  longer  course  may  be  divided  into  two  classes.  The 
first  were  characterized  by  the  occui'rence  of  a  short  interval  between  the  commencement 
of  the  decline  of  the  primary  fever  and  the  accession  of  a  ftn^er  symptomatic  of  secondary 
lesions.  The  second  presented  no  sign  of  impi'ovenient  at  the  end  of  the  second  week, 
the  symptomatic  fever  having  been  developetl  prioi'  to  the  subsidence  of  the  specific  or 
primary  attack.  The  former  were  usually  cases  in  which  the  recurrence  of  the  fever  was 
due  to  a  late  development  of  pulmonary  complications.  The  latter  comprised  those  in  which 
diarrhoea  or  in  some  instances  pneumonic  sym|)toms  were  prominent  from  an  early  perioil, 
as  in  17,  26  and  39  of  the  Seminary  series,  i^ut  sometimes  the  progress  of  the  intestinal 
lesion  was  such  as  to  permit  a  manifestation  of  temporary  improvement  to  be  shown  about 
the  usual  time,  an  improvement  which  was  speedily  lost  in  tiie  constitutional  disturbance 
attending  the  progress  of  ulceration  or  sloughing  of  the  agminated  glands.  Thus,  in  case 
21,  the  tongue  became  moist  on  the  thirteenth  day,  but  tiie  skin  continued  dry  and  the 
diarrhcfia  was  prolonged  until  the  twenty-ninth;  in  47  a  marked  improvement  was  man- 
ifested on  the  twelfth  day,  corresponding  with  the  occurrence  of  rose-colored  spots,  epistaxis 
and  a  moist  condition  of  the  tongue,  but  a  mild  degree  of  febrile  action  was  continued  for 
some  time,  and  the  case  had  a  fatal  issue  by  a  sudden  aggravation  of  the  diarrhoeal  symp- 
toms. In  other  instances  the  condition  of  the  kidneys  appeared  to  exercise  an  influence  in 
the  prolongation  of  the  febrile  movement:  In  case  28  a  tendency  to  improvement  about  the 
sixteenth  day  was  followed  by  fever  symptomatic  of  inflammatory  [)rocesses  in  the  intes- 
tines, kidneys  and  lungs;  in  12  the  fever  declined  in  part  at  an  earlier  date  than  the  four- 
teenth day,  although  convalescence  was  delayed  until  the  twenty-eighth  day,  a  result  chiefly 
due,  so  far  as  indicated  by  the  symptoms,  to  the  condition  of  the  kidneys. 

Pulse. — The  pulse  during  the  primary  fever  was  not  much  accelerated.  In  many  cases  it  ranged  from  80  to  90, 
in  others  from  90  to  100,  but  it  seldom  rose  above  100  per  minute,  even  wlien  the  fever  was  at  itsacnie.  Tlius  in  twenty- 
seven  of  the  Seminary  cases  the  pulse  did  not  exceed  100  at  any  period  of  the  attack,  while  many ,  characterized  during 
their  later  stages  by  rapidity  of  pulse,  recorded  a  less  frecjuent  l)eat  in  tlio  progress  of  the  primary  fever.  In  eleven 
of  the  twenty-seven  cases  the  rate  did  not  exceed  90;  in  seven  the  rate  was  Ix'tween  90  and  100,  biU  did  not  reach 
the  latter  number,  while  iu  nine  100  was  reached  l>ut  not  exceeded.  This  sliglitly  accelerated  pulse  was  generally 
(luick;  indeed  the  febrile  condition  was  manifested  rather  by  sharpness  or  increased  impulse  than  by  acceleration. 
It  was  oftentimes  small  and  weak,  rarely  full  and  strong,  and  if  so,  only  for  a  short  tinm  preceding  the  appearance 
of  the  eruption  or  the  occurrence  of  a  free  perspiration,  which  changed  its  rate  and  ipiality.  When  defervescence 
took  place  toward  the  close  of  the  second  week,  the  jiulse  lost  its  sharimess.  becoming  a(  the  same  time  less  frecnient 
and  more  feeble,  Itut  regaining  strength,  volume  and  sometimes  fre(juency  as  convalescence  advanced.  When  the 
luimary  fever  was  associated  with  a  pulse-rate  of  100  or  more,  there  was  generally  a  notable  suffusion  of  the  face, 
injection  of  the  eyes  and  not  unfrequeutly  epistaxis,  especially  if  the  pulse,  as  in  cases  12,  21  and  28,  was  at  the 
same  time  strong  and  full.  In  seven  of  the  Seminary  cases  in  which  the  jmlse-rate  exceeded  100,  the  acceleration 
was  chiefly  due  to  the  primary  fever,  although  sometimes,  as  in  47,  the  prostration  caused  by  an  active  diarrhoea 
rendered  the  pulse  rapid  and  weak  at  an  earlier  period  than  usual. 
Med.  Hlst.,  Pr.  Ill— ;!(} 


282  SYMPTOMATOLOGY    OF 

It  would  seem  from  those,'  analytical  results  that  in  the  typhoid  cases  of  the  war,  as 
illustrated  Ly  those  treateil  in  the  h^eminary  hospital,  the  average  frequency  of  tlie  pulse 
was  considerably  less  than  in  the  disease  as  it  attacks  civilians.  Murchison  has  publislied 
some  statistics  which  may  be  used  in  effecting  the  comparison.*  The  pulse  exceeded  100 
in  85  per  cent,  of  the  cases  mentioned  liy  him,  but  in  only  43  per  cent,  of  the  Seminary 
cases.  Most  authorities  agree  that,  excluding  certain  exceptional  instances,  the  gravity  of 
the  disease  is  proportioned  to  the  frequency  of  the  pulse.f  This  would  imply  that  the 
typhoid  of  our  soldiers  was  of  a  milder  ty[)e  than  is  generally  encountered,  a  deduction  which 
is  negatived  by  the  positive  testimony  furnished  by  the  percentage  of  fatality.  The  rela- 
tively slow  pulse  must  therefore  be  attributed  to  some  other  cause  than  the  mildness  of  the 
aflPection. 

Tlie  Seminary  hospital  records  show  that  when  the  febrile  condition  was  pi'olonged 
beyond  the  second  week  the  pulse  became  frequent  and  feeble  in  proportion  to  the  increas- 
ing prostration.  Symptomatic  fever  was  manifested  l)y  quickness,  but  occasionally,  and 
especially  in  some  pneuinonitic  cases,  the  frequent  pulse  was  full,  soft  and  irritable.  During 
the  persistence  of  low  delirium,  subsultus  and  involuntary  passages,  the  pulse  was  rapid, 
120-130,  small  and  weak;  occasional  exceptions  occurred,  as  in  48,  in  which,  with  typhoid 
delirium,  it  was  95  shortly  before  death.  Usually  in  delirious  cases  the  condition  of  the 
pulse  was  an  index  of  the  patient's  strength;  but  in  some  exce])tional  instances,  as  in  42, 
violent  muscular  efforts  were  associated  with  an  almost  imperceptible  radial  beat. 

Perspirations  and  opistaxis  occurring  at  the  end  of  the  second  week  lowered  the  pulse- 
rate  and  lessened  its  impulse;  but  their  I'ccurrence  at  a  later  date,  especially  if  frequent  and 
profuse,  induced  the  rapid  pulse  of  typhoid  prostration.  This  prostration,  when  the  disease 
was  prolonged  by  secondary  fever,  was  as  manifest  in  the  action  of  the  heart  as  in  that  of 
the  voluntary  nuiscles.  Slight  exertion  was  followed  by  aching  in  the  limbs,  great  weari- 
ness and  exhaustion;  the  patient's  legs  trembled  under  his  weight  when  he  rose  from  bed, 
and  when  unable  to  rise  tremors  miglit  be  seen  in  the  movements  of  the  hands' or  in  the 
protruded  tongue.  Correspondingly  the  pulsations  at  the  wrist  became  weak  undulations 
tlnit  could  not  be  counted;  hypostasis  occurred  in  tlio  lungs  and  the  activity  of  the  capillary 
circulation  in  the  skin  became  diminished;  the  hands  and  feet  were  cold  and  clamniy, 
the  face  pale  and  features  shrunken.  This  condition  of  prostration  is  well  outlined  in 
case  31  of  the  jwst-viortevi  records.  In  some  instances,  as  in  150  of  the  same  series,  col- 
lapse occurred  with  a  slow  and  imperceptible  pulse.  Many  of  the  sudden  deaths  recorded 
as  having  taken  place  when  the  patient  was  at  stool  or  subsequent  to  some  violent  delirious 


*  Ho  statcH  that  tlie  pulse  oxcoodcd  tlio  normal  Ktaiiclaril  of  frcqnt'iicy  in  all  but  ono  of  ont^  huntlred  castis.  It  exceeded  iH)  in  ninety-seven  cases; 
lOfJ  in  eighty-five  cast's  ;  110  in  seventy  cases  ;  120  in  thirty-twii  cases;  l:iO  in  twenty-five  cases  ;  140  in  ten  cases  ;  and  150  in  two  cases. — />;».  cU.,  p.  518. 

t  I*r.  James  Jackson,  in  his  Hf^pm-t  on  /be  raxtfi  of  iijphoitl  j'en^  or  Ihf  common  roHtiitio'il  fcrrr  of  Xetr  Emjhinii,  irliu'h  occinreit  in  fht'  Momv^hitM^tts  General 

HogpUal  from  tH-ptemhcr^  1821,  to  the  aid  of  1825,  Uostuu,  1838,  gives  on  i>age  41  the  fuUuwing  table  of  the  frequency  of  the  pnlse  in  this  fi'ver: 

.  „         f       Least  fre-    l    Most  fre- 

Average  of.-__  |     ,j„^,„j  ,„,|„..l  ,juent  pulse. 

In  2nOca8es,  in  all  of  which  the  pulse  was  sufficiently  noted 77.07  10l).44 

In  cases  which  terminated  favorably,  taken  alone  ._-.__.....--..  74.  IG  Hi2. 08 

In  thr>so  which  terminated  untVivorably,  taken  alone    ---------------  (11.88  12i).2'.l 

In  the  males  among  the  fatal  casi'S -        -  M.  50  124.2'.( 

I.ir.iiF.RMEisTFB  states  tluit  tli(^  tVciiucucy  of  the  pulse  runs  a  course  [laiitllel  to  the  height  of  the  temperature. — Op.  cjV.,  p.  S2.  RlUKcnisoN  gives 
positive  data  on  this  question  :  ".\s  a  rule  those  cases  are  most  severe  in  which  the  pulse  is  qnickest,  and  the  prognosis  is  usually  bad  when,  in  an  adult, 
the  pulse  persistently  exceeds  120.  Of  thirty  ca-ses  where  I  found  the  pulst'  never  exceeded  110,  not  one  died ;  whereas  of  seventy  eases  where  it  was 
above  IKi,  twenty-one,  or  30  per  cent.,  died  ;  of  tliirty-two  cases  whore  it  was  above  120,  fiftt.-en,  or  47  per  cent.,  died  ;  of  twenty-five  cases  where  it  was 
above  130,  thirteen,  or  52  jier  cent.,  died,  and  of  ten  ca.ses  where  it  was  above  140,  six  dieil.  Two  of  the  patients  who  n^covered  after  the  pulse  exceeded 
140  w^eunilcr  ten  years  of  age." — (^).  rif.,  \i.  510,  Hut  I.ot;is,  in  considering  the  fact  that  in  8  of  41  fatal  cases  and  in  21  of  57  severe  but  not  fatal  cases 
the  pulse  did  not  rise  above  ninety  beats  jwr  minute,  came  to  tlu'  conclusitm  that  a  motlcrately  accelerated  pnls<'  is  of  favorable  omen  as  suggesting  that 
the  attack  will  not  be  prolonged,  while  a  r-low  pulse  awakens  fear  as  to  the  length  of  the  disease  and  its  issue. — See  his  Wcc/terc/(c«,  t.  IF,  p.  27*>. 


THE    CU>iTINrKD    FKVKKS.  283 

efloi't  are  attributable  to  lailiiM'  ul'  the  lieart's  action.     Deatli  from  tliis  cause  also  oceurred 
unexjieeteJly  during  eouvalesceuce. 

EPISTAXIS  was  noted  in  sixtfeu  of  tlie  filty-oiu'  St'iiiiiiaiy  lnis]iital  oases.  In  six  it  oceuned  (luiiiif;  the  early 
part  of  the  attaek  ami  in  tliree  (Inrinj;  tlie  seeonil  week:  in  none  of  tlieiii  did  I  lie  loss  of  likmd  apiiear  to  intliieiiee  the 
progres.s  of  the  disease.  Xevertheles.s,  in  seven  easi'S  in  whieh  it  took  jihiee  or  reeiirred  at  the  end  of  the  seeond 
week  or  later,  a  favorable  change  was  coincident.  Tlieso  cases  were  Nos.  12,  18,  L'5,  28,  15,  17  and  19.  lu  the  tirst 
three  cases,  as  also  in  the  relapse,  lit.  the  epistaxis  was  closely  as.sociated  with  general  symptoms  of  defervescence. 
In  28  and  47  the  improvement  was  of  a  transitory  character,  as  the  secondary  affections  nUiinately  caused  death.  In 
15  the  loss  of  lilood  was  so  ])rofnse  that  the  pulse  could  not  h^^  connteil;  yet  the  ]iatii'nt  rallied  satisfactorily.  The 
improvement  in  this  case  must  lie  referred  to  a  fri'c  discharge  of  ])us  from  the  ear  rather  than  to  the  epistaxis,  for 
previous  losses  had  been  followed  by  no  amelioration  of  the  patient's  condition. 

This  proportion  of  cases  is  similar  to  that  recorded  in  civil  life  by  Fllnt  and  Mitrciii- 
SON ;'''  epistaxis  was,  however,  of  moi'o  frequent  occurrence  in  the  experience  of  Louis.-j- 
In  many  cases  the  quiintity  lost  was  so  small  as  to  be  without  iiiHuence  on  the  condition  of 
the  jiatient;  sometimes  it  am(.)Uiitfd  only  to  a  few  drops.  When  it  took  place  in  the  early 
period  the  febrile  accession  was  iiniiiternn>ted  by  its  occurrence.  The  cases  in  which  there 
is  a  probtible  connection  between  the  loss  of  blood  and  the  defervescence  which  speedily 
folhnved  are  of  interest  in  view  of  the  positive  assertions  of  so  many  observers  that  epistaxis 
occui's  without  relief  to  the  ,symj)tonis.J  When  th(!  febrile  movement  was  at  its  height,  the 
pulse  full  ami  comparatively  strong,  the  skin  hot,  cheeks  Huslietl  and  I'yes  injected,  it  is 
difficult  to  dissociate  the  flow,  if  sufficient  to  create  an  impression  on  the  system,  fi'om  the 
improvement  which  followed.  But  defervescence  was  in  these  cases  about  to  commence, 
and  would  have  commenced  irrespective  of  the  occurrence  of  the  epistaxis,  as  is  indicated 
by  the  progress  of  those  cases  in  wiiich  the  fever  declined  without  an  accompanying  loss  of 
blood.  The  epistaxis  must  therefore  be  regarded  as  essentially  a  coincidence  which  may 
have  emphasized  the  first  remission  of  the  declining  stage  of  the  lever  and  rciidcn'd  the 
improvement  that  subsequently  followed  more  marked  than  it  would  otherwise  have  been. 

Of  the  few  'j>()st-')norfevi  cases  which  are  preluded  by  a  summary  of  symptoms,  epis- 
taxis is  mentioned  only  in  six,  in  all  at  a  late  period  of  the  disease.  The  loss  of  blooil  does 
not  appear  to  have  in  any  instance  materitdly  all"et;ted  the  progress  of  the  case;  the  quantity 
was  not  estimated,  but  in  17  and  2i>7  it  would  seem  to  have  been  small  and  mainly  induced 
by  the  patient  picking  the  nostrils  with  his  lingers. 

Condition  of  tiik  Skin. — In  the  majority  of  the  Seminary  cases  the  skin  is  said  to  have  been  hot  and  dry, 
and  this  condition  persisted  to  tlie  subsidence  of  the  primary  fever. 

In  the  typhoid  cases  of  civil  life  the  skin  is  not  unfrequently  moist  or  perspiring, 
especially  at  night  or  towards  morning,  even  before  the  occurrence  of  the  strongly  marked 
remissions  which  indicate  the  decline  of  the  fever.§  There  is  here  a  distinction  between 
the  typhoid  fever  of  the  war  and  the  disease  as  seen  in  civil  practice.  But  it  may  be  saitl 
that  this  distinction  is  an  arbitrary  one;  that  the  Seminary  cases  did  not  in  fact  present  this 
continued  dry  state  of  the  skin,  but  only  that  proportion  of  them  which  has  been  sepa- 
rately submitted  as  illustrative  of  unmodified  typhoid.      If,  however,   those  cases  which 


*l)r.  Flint  found  epistaxis  in  8  of  30  cases.  ITsually  it  was  s]ip;ht,  occurring  at  an  parly  jwriod,  and  producing  no  appreciable  effect  on  the 
progress  of  the  discaw. —  O^i.  «"/.,  |>.  97.  Mi;r('HISon  noted  ittt  presenri'  in  l.^t  of  .58  caisps  :  "All  ohwrverH  aKrei-,"  he  sjiys,  "  in  stating  that  the  bleetling  in 
never  followed  l>y  any  relief  to  the  symptoms,  while  tin  the  other  hand  it  may  Ix'  so  profuse  as  to  l»e  the  innnediate  cause  of  death."  Several  examples 
of  death  from  epistaxis  eanie  under  his  notice.  —  Op.  fU.,  p.  54:j. 

f  Lot'is  says  that  the  epistaxis  was  less  frequent  in  mild  than  in  st^vero  cases.  It  was  present  in  II  of  24  mild  cases  ;  27  of  34  severe  cases,  and  U 
of  16  fatal  cases,  and  was  nearly  always  without  the  slightest  relief  to  the  symptoms. — '>jj.  <'i/.,  t.  If,  p.  2iy. 

J  See  the  opinions  expressed  in  the  last  two  notes. 

gLouis  says  that  the  skin  was  almost  always  dry  in  one-fourth  of  his  fatal  eases,  and  was  eovored  with  nn)re  or  less  perspiration  in  the  others 
after  the  evening  exacerl>ation  or  during  sleep  at  night;  in  the  severe  hut  not  fatal  cases  similar  conditions  prevailed,  and  also  in  the  niihi  t-ases, 
although  the  heat  was  less  intenw. —  Oji.  cj7,,  t.  II,  p.  2ti.'t.  .\ccording  to  I.iF.iiritM kistkh :  "The  skin  is  usually  dry;  sometimes,  es[)eeially  in  the  morning, 
it  is  moist  and  even  covered  with  sweat,  but  this  latter  circumstance  has  no  favorable  signitieanee."  (>■  '■>"■ 


284  SY.Ml'TUMATOLUdV    OF 

were  characterized  by  softness  of  the  skin,  moisture  or  free  and  recurring  perspirations,  be 
closely  exanuiicd,  tlie  majdritv  will  be  found  to  have  presented  other  symptoms  of  malarial 
implication.  Mureover,  in  many  of  these  the  perspirations  had  a  notable  influence  on  the 
pulse  and  general  fcljrilc  condition;  wliilc  most  antliors  agree  that  the  occasional  moisture 
on  the  skin  of  typhoid  patients  does  not  exercise  any  controlling  influence  on  tlie  course  of 
the  fever.*  It  would  seem,  therefore,  that  a  hot  and  dry  condition  of  the  skin  was  in  reality 
a  characteristic  of  the  cases  of  unmoditled  typhoid  among  our  soldiers. 

During  the  continuance  of  the  jirimary  fijver  the  rose-colored  eruption  made  its 
appearance  usually  from  the  seventh  to  tlie  fourteenth  day.  The  skin  rarely  became  cool 
or  moist  before  the  eruption  appeared;  but  it  frequently  ha])[)ened,  especially  in  the  milder 
cases,  that  defervescence  associated  with  free  perspiration  coincided  with  the  discovery  of 
rose-colored  spots  on  the  chest  and  abdomen. 

In  cases  prolonged  by  the  existence  of  secondary  lesions  the  skin  generally  retained  its 
febrile  heat  and  dry  liusky  state;  but  at  times  a  moist  condition  alternated  with  this,  and 
free  })erspirations  were  not  uncommon.  In  this  respect  these  cases  did  not  diil'er  from  sim- 
ilar cases  of  typhoid  as  delineated  by  medical  authorities.  The  perspirations  were  sometimes 
of  nightly  occurrence  and  so  copious  and  exhausting  as  to  suggest  the  necessity  of  special 
medication  for  their  suppression.  Occasionally  improvement  dated  from  their  occurrence, 
but  in  other  instances  their  favorable -impoi't  was  not  so  manifest,  although,  as  will  be  shown 
hereafter,  they  may  have  exercised  a  beneficial  influence  on  the  morbid  processes  in  pro- 
gress in  the  intestinal  canal.  In  cases  characterized  by  extreme  prostration,  as  in  47  of  the 
Seminary  cases,  and  in  19,  150  and  199  of  the  post-mortem  series,  profuse  perspiration 
attended  the  fatal  issue. 

An  eruption  of  SUtlatnilia  wiih  occa.sionall.v  noted  as  an  acconii)aniinont  of  the  iieisiiirations,  especially  of 
those  occurrinfj  at  the  befjinnin;;  of  defervescence.  'I'liese  niiliaiy  vesicles  are  mentioned  in  thirteen  of  the  fifty-one 
cases,  and  in  eight  of  these  they  were  aHsociated  with  a  moist  or  i)erspirinj!;  state  of  the  skin.  It  does  not  appear, 
however,  tliat  this  condition  was  essential  to  their  development,  for  in  four  of  the  cases,  7,  25,  30  and  45,  the  skin 
was  not  moist  at  the  time  of  their  appearance,  nor  had  it  been  moi.st  at  any  previous  i>eriod  of  the  attack,  and  in  46 
the  skin  was  dry  at  the  time  of  the  eruption  and  had  l)een  dry  for  some  days  l)efore  its  a]>pearance. 

This  eruption  may  not  lie  rcj;ardcd  as  of  special  sif^uilicauce,  allhoui;h  it  occurred  occasionally  as  one  of 
the  concomitants  of  defervescence,  for  it  often  apjiearcd  in  tlie  liistory  of  fatal  cases.  It  was  present  in  case  39  of 
the  necrosco|)ic  series;  th<^  breast  and  abdomen  were  covered  with  sudamina  in  103,  while  tlie  [latient  was  in  a  coma- 
tose condition  from  which  he  did  not  recover;  the  vesicles  were  noted  as  a punt-mortiin  appearance  in  170;  they  were 
present  also  in  other  cases,  as  in  7,  38  and  118. 

There  is  nothing  in  these  facts  to  suggest  a  difference  between  the  typhoid  fever  of  our 
camps  and  that  described  by  medical  writers.  Most  authors  and  observers  refer  to  sudamina 
as  of  more  frequent  occurrence  in  this  than  in  any  other  acute  disetise.f  The  eruption  is 
therefore  regarded  as  possessing  diagnostic  value  in  so  far  as  it  tends  to  confirm  a  diagnosis 
already  made.     As  an  element  of  prognosis  it  is  evidently  valueless;  although  the  opinion 


*  Dr.  Fr.ixT  found  tliiit  free  iicrnpirationB  occurred  once,  twice  or  several  times  in  ;J;i  of  'in  cases.  These  were  e.xclusive  of  the  instances  in  which 
sweating  was  coincident  with  or  occurred  shortly  liefore  convalescence  or  as  a  procur.sor  of  death.  He  at  first  concluded  that  "we  arc  not  warranted 
in  predicating?  exfKK'tatiims  of  speedy  convalescence  or  of  recovery  upon  either  of  these  syiiiiituni.s  [nu)ihture  and  free  perspiration]  dis^-onnected 
from  other  circumstances,  nor  do  the.se  results  alfoni  any  j^rouuds  for  supposing  that  to  induce  moisture  or  sweatin;;  hy  thenipcutical  means  will  he 
likely  to  prove  beneficial."  This  conclusion  was  derived  from  the  observation  that  a  moist  condition  of  tlie  sliin  was  in  a  larjji^  proportion  of  instances 
not  succeeded  at  a  short  interval  by  convalescence,  and  that  persiiirations  cjecurred  in  nearly  one-half  of  his  fatal  casi's.  Hut  he  subset|uently  (changed 
this  opinion  on  finding  that  free  perspirations  were  followed  liy  a  fall  in  the  pulse-rate,  ami  that  the  averaj^c;  severity,  as  niariifesteil  by  thit  pulse  and 
the  duration  of  the  attack,  was  less  in  cases  chanicterized  by  an  occasional  moist  condition  of  the  skin  than  in  the  febrile  ca.«es  tft-nerally. — Op.  '-il.,  p. 
XW.  I'nfortunately  tits  ob.servations  on  this  hea<l  were  not  extensive.  The  opinion  of  Likukkmeisteh,  jiiven  in  the  last  note,  is  that  of  the  profession 
generally.    See  also  i«ige  2i>.5,  infra,  on  the  protmhie  infiuence  of  iierspirations  on  the  diarrhiea. 

+  Enoch  Hai.e,  in  his  linnnrliti  on  the  PiUholinjn  of  thr  Tjipkoitl  Ffi-er  of  Nftr  Knfjltiii'l,  read  at  the  annual  meetiiif;  (d'  the  MassJlchusetts  .Medical  Society 
May  2tt,  \WA\),  and  published  in  the  Transactions  of  tlie  Society,  says,  ji.  10:t,  tliat  this  erni)tion  was  present  in  T.S  of  lli7  cases  treated  in  the  aia.s.sachu- 
setts  General  Hospital,  absent  in  1."),  while  in  107  tiie  recorils  madii  iu>  reference  to  its  appearance.  Mi'Rchison  noted  it  in  about  one-third  of  his 
cases,  p  51.'). 


THE    CONTINUED    FKVKR^i.  285 

generally  expressed  by  r.'cont  writers   tliat   it  is  assorial.-.l  with  perspiration   and  has  no 
special  ediineetion  will)  tla'  p(.)is()n  ot   tv|ili('itl  fever  inav  Wf^il  l)e  doultted.* 

l)uriii«j:  the  i)rini:iry  W'm^v  tin'  i';i(M*  was  <j:tMii*rally  lliisbcd.  a  cDiiditioii  wiiicli  in  some  iiistanot'.s  was  iu)te<l  as 
aggravated  at  tlu-  evening  \  i-^il  •  SonieTinies  tlie  ilnsh  was  (Jesciilu-d  as  dark-red  or  diiisky,  uk  in  It),  27,  2i<,  '.<'J  and 
38  of  the  Seminary  canes  and  in  17.  l^  and  So  (if  the  po-^f-imtrlan  serii's.  At  a  lati-r  stage  the  face  hceaine  jiale  and  the 
featnres  sliriinken. 

Jiose-eolored  spots  were  ohserved  in  forty  of  the  Jifty-one  oases  treat4'd  in  tlie  Seminary  liospital. 
They  usnaUy  ma(h'  their  first  and  in  some  mild  cases  tlieironly  noted  apiiearanee  Just  hetore  tlie  moistening  of  the 
skin  and  the  ahatenient  of  the  fever  towai'ds  the  close  of  tiie  second  week.  'J'he  erui)tion  may  have  heen  i>resent  in 
some  of  the  eleven  cases  in  whi(di  no  recoid  of  its  existence  was  made,  for  in  one  case,  1,  the  history  is  ine<tni]dete; 
in  2  and  5  the  record  hegins  ahont  the  period  of  defiTvesci'iiee:  in  U  the  patient  died  on  the  twtdfth  day  from  the 
effects  of  a  fall;  in  43  the  record  does  not  l)egin  until  the  sixteenth  day:  in  l!t,  20  and  51  tln^  patients  were  not 
admitted  until  late  in  the  ])rogres.s  of  the  disease,  and  in  :!o  and  :!.'»  the  results  of  the  fever  and  not  the  fever  itself 
were  under  observation:  even  in  Hi  there  was  time  for  the  spots  to  have  a])peared  and  faded  unnoticed,  as  the 
patient  was  not  examined  until  the  twelfth  day.  Thus  in  torty  eases  which  were  observed  daily  during  tlie  greater 
portion  of  the  fehrile  continuance  this  eruption  was  jnesent  in  all. 

In  the  cases  recoided  in  the  Ixudvs  of  other  lutspitals  and  <m  the  medical  descriptive  lists  the  existence  of 
lenticular  spots  is  fre,(|uently  noted,  although  uu)re  frciinently,  owing  to  insunieiency  of  detail,  no  nu-ntion  is  nuide 
of  their  ]>resence:  hut  only  in  two  eases,  -Hi  and  :ili()  of  tin'  pihst-)norlnit  re<ords,  is  their  absence  specially  reported. 
In  the  former  the  patient  was  n()t  examined  until  the  twidfth  day:  the  latter  is  therefore  the  only  case  in  which  it  is 
stated  that  rose-colored  sixits  were  not  observed,  although  the  i)atien(  was  under  medical  supervision  during  the 
whole  course  of  the  <lisease.  It  is  woilhy  of  remaik.  howe\ri-.  that  the  soldier  in  this  exceptional  case  was  treated 
in  (quarters  for  six  weeks  as  a  <-ase  of  brou(diitis  hefore  he  was  taken  into  hospital:  that  after  Ids  a^lmission  the 
H(dicitnde  of  his  medical  attendant  was  mainly  aroused  by  the  comlition  of  llu'  ]mlnionary  mucous  membrane,  and 
tliat  tlu^  diagnosis  of  typhoid  fever  was  eonse(|uent  on  necros<*opi<'  n'vehitions.  I'nder  these  circumstances  the 
statement  that  rose-coh)red  spots  were  not  oliserved  in  the  jirogress  of  the  ease  does  n(tt  Iiave  a  ])ositive  value. 

We  nuist  eoiii'ludc  from  tliesi^  laeis  that  cases  of  typlaad  fevei*  wliicli  weiv  not  char- 
acterized l)y  the  a[)iiearan('e  ol"  rose-('()|()red  spots  were  exceptional;")'  and  that  our  medical 
officers  were  fullv  warranted  in  reyardinii;  the  eruption  as  pathognomonic,  since  its  occur- 
rence had  not  Keen  ohst.M'Ved  iii  connection  with  any  other  disease. J     That  it  was  look(Ml  for 


*  Lniis  r(K;()t;iiiz('ii  tluit  the  miliary  vcsit-Ics  witp  not  alwayn  proiiortioned  to  tlic  iRTMpiration  ;  in  fact,  ho  Rumptimcs  found  them  numerous  whew 

tliert'  hail  Iioon  little  |)iTspiratioii  ami  al).s{'iit  wlii-ii  tlicn-  had  hi-i'ii  niiirli.  Mort'oviT,  in  fnrty  caKCH  of  acute  (tiwi-asi^  other  than  tyiihoid  fever,  utteiideil 
witli  free  j»t'r.s|)i  ration,  siidamiria  were  fmind  in  bnt  three  eases,  aItliouy;li  s|«'<-ial  at  tent  it  m  wuh  ilimted  to  their  <leteetlon.  llirtnliscrvatioHH  led  him  alsu 
to  consider  them  nnue  numerous  in  Kevero  tlnin  in  mild  attacks  cif  t^pltoid  fever.  '  He  tlierefure  jotiked  ni»on  these  vesieU-s  asuf  mueli  impiirtaiiee  in 
the  liistory  nf  tlie  f.ver,  etmeeivin^  tlieni  to  lie  <le|H'nilent  on  sume  unknown  corulition  of  the  skin  whieli  was  mure  pronctiineed  in  serinus  than  in  slij;ht 
ruses. — Oji.  rit.,  t.  1 1,  j».  244 ;  see  also  second  ed.,  1S41,  t.  H,  p.  110.  This  ojiinion  no  douht  gave  rise  to  the  impression  that  they  were  nf  rritieal  impor- 
tance. Stime  pnietitioner,"!  have  hioked  for  tliem  with  anxiety  aliout  tlie  jH-riiHl  uf  defervescence;  Hkkvks,  p.  oil,  instances  this  fact,  althnn^jh  himself 
attaching;  little  inijmrtance  to  tlie  eruption.  Indeeii  the  frenr'ral  tenor  <if  medical  opinion  repards  it  aw  having  no  s|«'eial  significance:  See  riioMEi., 
p.  25,  and  Wiion,  p.  :J20.  I.iKiiKiaiKrsTKit  ^ays  that  it  is  found  in  patients  who  Iiave  nut  iM-i-spired  vt-ry  fn-ely,  p.  Ii4.  MfRcinsov,  on  the  otiier  hand, 
p.  515,  believes  that  it  usually  appears  with  perspirations,  and  is,  pei'haps,  etpially  common  in  all  fehrih^  iliseaseH  attended  with  swt-ating.  M.  J.  Vir 
MONTois,  in  his  thesis  Du  I>hu/mn<fic  rf  dti  TmiU-iuvitt  de  hi  Fuvre  Tijphiiid*.;  5Iont|Rdlier,  1ST7,  emhudies  the  present  view  of  the  eruption  as  deduced  from  the 
literature  <if  the  suhject,  where  ho  says:  **  Ijcs  sndamina  ne  cnnstitnent  pas  un  canicti-re  sj>t-clfi(pie  de  la  maladie  :  ils  n'ont  jms  une  gninde  valenr  diag- 
nusticjue  ;  on  les  a  rencontres  dans  Iwanconp  (fitutres  nialadii'S  :  imeumoiiie,  rhumatisme  aiticnlaire  iiigu.  Cette  ^rujition  est  tout  simplement  liee  a«x 
sueurs  plus  on  moins  abondantes  du  niaiade,"  J.  C,  Wilson  has  expressed  the  prevailing  opinion  in  this  country  in  his  Treatitte  »m  tfn-  Cindiuiifd  Fererf, 
New  York,  1881,  p.  Ifi!),  where  he  sjiys :  "They  [the  sudainina]  are  very  C(tnimon  in  typhoid  fever,  but  are  without  siK'cific  cliaracter.  and  ix-curwith 
p<^rhaps  e(pial  frequency  in  other  fehrile  affections."  In  the  absence  of  observations  on  the  frequency  of  sndamina  in  acute  diseasj's,  such  as  intermittent 
fever,  pneumonia,  acute  rheumatism,  etc.,  attended  with  per!^piratii.»ns,  the  statenii'iit  of  their  eonnectto?i  with  jK'rsjiimtions  is  hanily  warranted; 
while  the  acknowledged  frequency  of  the  ernptii'ii  in  typhoid  fever,  ami  its  apj«'anince  in  that  disease  when  the  skin  is  not  even  ntoist,  wenis  to 
authorize  the  doulit  wliich  has  been  expressed  in  the  t<'xt. 

t  Loiis  found  the  t'lrheM  roses  b^nticiduhrs  in  'Jli  of  :!'>  fatal  cases,  but  acknowledged  that  they  may  have  been  present  in  more  than  this  number,  as 
many  of  the  patients  came  to  the  hospital  at  a  ])eriod  when  perhaps  tlie  spots  had  disappeared.  In  57  severe  hut  not  fatal  cases  they  were  present  in  all 
but  3,  in  two  of  which  the  patients  did  not  come  under  observation  until  late  in  the  disease,  and  in  the  third  no  examlnati<m  of  the  surface  was  made  except 
between  the  seventh  and  eleventh  dayp, — t.  II,  p.  2:U.  Enoch  Hait,  believed  them  to  be  always  present.  He  .ijiys— in  bis  lieimtrltt  on  the  PnthtUujy  *>f  Ute 
Typhoid  Fei^er  of  Xeic  Enghtnd,  Trans.  Mass.  5Ied.  S^k*.,  183!',  p.  191 — "Of  the  lli7  cases  that  I  have  analyzofl  for  this  paper,  rose-spots  are  recorded  in  177. 
In  the  greater  part  of  the  remaining  20  it  is  apparent  from  tlie  record  that  sufficient  attention  was  not  given  to  them  to  render  it  by  any  means  certain 
tliat  they  did  not  exist.  Jlost  of  the  omissions  are  in  the  earlier  part  of  the  peritwi  I  have  specifie<],  before  tlie  imijortance  of  this  appearance,  as  a  diag- 
nostic mark,  was  fully  appreciated.  In  a  few  cases  the  jwitient  was  bnnight  to  the  Imsjatal  at  too  late  a  period  of  the  disease  for  them  to  be  visible. 
With  this  exception  I  have,  for  a  long  time  past,  seen  no  case  that  could  with  any  propri<'ty  he  regarded  as  decidwlly  the  typhoid  fever,  in  wliich  rose- 
spots  were  not  found,  and  I  think  it  is  not  assuming  too  much  to  consider  them  a  ctiiistant  attendant  upon  tliat  disea-^e."'  In  three  series  of  cases 
reported  by  Dr.  Flint  the  eruption  was  present  in  2'.i  of  30  cases,  in  12  of  20  castas  and  in  all  of  14  cases.  Uarti.ett  nirely  failed  to  iind  it  when  projH-rly 
ktoked  for, — p.  Gfi.  According  to  ^IiiiriiisoN,  these  spots  wen?  ob.'wrved  in  4,r»(H)  of  5,nfi8  cases  <ir  in  7r».<.t2  per  cent,  of  the  tyiihoid  cases  admitted  iiiti* 
the  London  Fever  Hospital  during  tweiity-three  years,  hut  in  some  of  the  remaining  cases  the  fact  of  the  spots  not  being  ol)9erved  was  perliajis  due 
to  their  not  having  been  looked  for  with  sufficient  care, — p.  511.  Rkfvks  seldom  failed  to  find  them  at  some  i>eriod  of  the  disease, — p.  57.  IjIEukk- 
ME18TER  says  they  are  frequently  entirely  wanting  in  slight  undeveloiied  cases;  but  "  whether  there  are  well  developed  cases  without  any  roseola  through- 
out the  entire  course  of  the  disease  I  am  unable  to  decide;  in  all  cases  which  1  examined  sufficiently  often,  I  have  found  at  least  a  few  spots," — p.  iU. 

JChomel — Lei^ons  de  Cliniqtie  Mt'dicaley  Paris,  1834 — probably  influenced  by  the  positive  statement  niadt-  by  Loris  in  1829,  as  to  the  occurrence  of 
rose-spots  in  certain  diseases  other  than  typhoid  fever,  siteaks  of  their  eruption, — p.  21— as  "aussi  mre  dans  les  autres  affections aigues  qu'elle  est  com- 
mune dans  la  tievre  typhoide,  et  que  dans  lescas  rares  on  on  I'observe  dans  le  cuurs  d'une  pneuuionie,  d'une  ent^rite,  ou  d'autres  affections  aigues,  jamais 


286  SYMPTOMATOLOGY    OP 

with  cure  in  folirilc  cases  is  evidenced  by  such  reports  as  7  of  tlie  27th  Conn,  rccoi'd  ami  10 
of  the  Keminary  series,  in  whicli  one  or  two  rose-spots  were  recorded  as  having  been  discov- 
ered on  tlie  cliest,  or  1 1  of  the  19th  ^lass.,  in  which  one  or  two  equivocal  spots  are  said  to 
have  been  seen.  (Jccurring  in  connection  with  an  otlierwise  satisfactory  complexus  of  symp- 
toms, the  presence  of  a  few  doubtful  spots  might  be  accepted  as  constituting  a  specific'  mani- 
festation; but  in  obscure  cases  sui'h  an  appearance  could  hardly  be  regarded  as  of  diagnostic 
value.  Chomej.  did  not  consider  the  eruption  present  unless  fifteen  or  twenty  spots  appeared.* 
When  TiOUis  first  looked  for  thes(?  farhes  roses  IcnUcuJaircs  in  acute  diseases  other  than  the 
typhoid  affection,  he  discovered  them  in  twelve  of  fifty  cases — once  in  two  cases  of  pneu- 
monia, twice  in  twelve  of  diarrluea,  once  in  three  of  rheumatism,  three  times  in  eiglit  of 
catarrh,  once  in  Ibur  of  gastro-enteritis  and  four  times  in  ten  of  gastric  embarrassment;"]" 
but  he  afterwards  concluded  that  he  had  in  these  instances  mistaken  ordinary  pimples  for 
the  spots  in  question. J  Since  this  close  observer  had  to  acknowledge  an  error  of  this  kind, 
some  hesitation  may  l)c  shown  in  accepting  one  or  two  spots  as  a  specific  eruption  unless 
the  diagnosis  has  been  completed,  irresj)ectivc  of  their  presence,  by  the  concurrence  of 
other  synq>toms. 

The  spots  generally  presented  tlieir  usual  well-known  characters.  They  wei-e  circular 
or  somewhat  oval  in  (Outline,  half  a  lin<'  to  two  lines  in  diameter,  rose-red  in  color,  slightly 
elevated  and  with  well-defined  margins;  tliev  disappeared  on  pressure.  Their  customary 
site  was  the  chest  and  abdomen,  l)ut  occasionally  tlun'  were  noted  on  the  back  and  thighs. 
They  were  observed  for  the  lirst  time  usually  duiing  the  second  week,  but  in  some,  as  in 
cases  7  and  17,  they  appeared  as  eai'ly  as  the  sixth  day.§  fn  many  instances  the  records 
take  note  of  but  one  ci'op,  which  fad.ed  as  defervescence  progressed;  frcsli  spots  may,  how- 
ever, have  erupted  in  these  cases  without  having  been  noticed  or  I'ecorded  by  tiie  medical 
officer,  for  his  interest  would  naturally  have  diminished  as  the  favorable  issue  of  the  case 
became  a  certainty.  In  mild  cases,  when  the  spots  appeaivd  at  an  earlv  dav.  fresh  cro]>s 
were  develo[>eil  during  the  second  week  as  those  iirst  formed  were  fading;.  In  prolon^red 
cases  a  succession  of  spots  was  the  rule,  lasting,  as  in  case  37,  from  the  thirteenth  to  the 
thirty-first  day,  or  as  in  20,  from  the  eleventh  to  the  thirty-fourth  day. 

It  does  not  appear  that  this  eruption  had  a  prognostic  value  or  was  connected  with 
any  special  condition  of  the  skin,  for  although  in  some,  as  in  the  case  last  mentioned,  its 
recurrence  corresponded  with  fever,  delirium  and  diiirrhcea,  in  otiiers  the  symj)toms  durino- 
its  continuance  were  by  no  means  grave:  In  37,  rose-colored  spots  and  abdominal  tenderness 
were  for  some  days  before  convalescence  the  only  symptoms  explanatory  of  existing  weak- 
ness and  disability,  while  in  4  the  patient  was  able  to  walk  and  was  in  a  fair  way  to  recovery 
when  the  eruption  appeared  on  the  fourteenth  day.  Nor  did  the  number  of  spot?  present 
at  a  given  time  bear  any  relation  to  the  character  of  the  attack:  The  eruption  was  profuse 

olio  n'lst  iiiisfii  iitiiinilante  que  daii«  la  fljvre  t.rplioTiIo,  on  conccvra  pimrquoi  nous  att.achons  A  cetto  cniption  uno  si  grande  valeur  ponr  lo  diajinoHtic 
do  la  ti.'vrc  typluMilc."  Lijvis  hinhsolf,  as  indlrated  in  the  text,  after  a  longer  exiMTience  in  the  etuily  of  the  rose-colored  spots,  eoncluded  that  ho 
had  mistaken  siinple  pimples  for  this  eruption  in  the  cases  mentioned;  for,  after  the  puhlii-ation  of  the  first  edition  of  his  work,  he  vainly  sought 
for  the  spots  in  jiatients  afTecteil  with  otln^r  aeute  diseases.  Mirchisox,  after  describing  the  specific  characters  of  the  rose-colored  spots,  Kiys,  p.  r>l:t— 
".\t  the  I.on<ion  Fever  llospital  I  have  h:ul  occasion  to  examine  many  thousivnd  cases  of  acute  diseases  of  every  form,  and  my  opinion  is  that  an  eruption 
which  presents  all  the  characters  alu've  mentioneil  is  pe<-uliar  to  enteric  fever." 

♦ClloMEl.,  lage  18.  fl'tn'is,  Ed.  18211,  t.  II,  p.  242.  {Kd.  1841,  t.  II,  p.  107. 

?  MrncHlsos  says  the  spots  appear  from  the  7th  to  the  12th  day  (inclnsive)— p.  .111.  According  to  Chomf.i.,  p.  211,  they  erupted  in  twenty- 
seven  cases  88  follows :  In  two  cases  from  the  Gth  to  the  8th  day;  in  thirteen  from  the  8th  to  the  ir.th  day;  in  si>ven  from  the  l.^'th  to  the  aJth  day;  in 
four  from  the  20th  to  tlio  30th  day,  and  in  one  on  the  ;!7th  day.  Jex.ner,  On  Tiiphoiit  ,md  Tuphm  IWir—MoMly  J,mr.  Med.  fiinice,  Kdinh.,  Vol.  IX, 
184'J,  p.  676— has  expres-sed  the  opinion  that  exi-e|pt  in  ca,st«  of  relapse  rose-spots  never  api»-ar  after  the  30th  day,  hut  Mi-rchisos  met  with  several 
instances  in  which  they  appeared  daily  as  lute  as  the  3.ith  day,  and  in  one  mild  case  he  noted  tin-  alin,.st  .laily  apis-aranee  of  fresh  smta  from  the  Uth 
to  the  anh  day— p.  .147. 


Till-:  *-(»NTiM"i:i-   Ki:vKi:s.  00*7 

in  tlio  mil'l  case  12  of  the  Seiniiiarv  Imspiial  us  wrll  as  in  11  ..f  i\u^  j>n.sf-morfcfn  sorios;  it 
was  soaiitv  in  tlu'  iniM  oases,  i)  ami  10  ut*  tlie  loi-nu-r.  ami  equally  seanty  in  eases  31  and  41 
of  tlio  latter  series/-^ 

Oceasionallv  tlio  eruption  was  of  a  darker  enlor  tlian  usual:  In  27  and  2S  of  iho  Smi- 
iuarv  series  it  was  dark-red  in  cnlwr  and  did  imt  disappear  on  pr.'ssure;  in  these  eases  the 
deet")ly  Hushed  faee,  suH'used  eyes,  heavy  expr.'ssi.Mi  and  intensity  <»f  the  een-hral  symptoms 
were  suiz^'-ostive  of  a  lvi»lious  condilinn.  In  other  instances  the  spots  diil  not  present  what 
was  re^-TU'ded  as  their  nnnnal  eharaeterislies:  In  2  of  \\\o  po.sf^fnortnii  series  some  red 
blotcht^s  were  observed  on  the  face,  arms  and  eliest,  aial  in  i\  iA'  the  Heniiuary  cases  the 
tv))hoid  rash  was  preceded  hy  an  anomalous  eru])tion.  Kxeludinj^^  the  duskiness  of  llie 
spots  preseided  hy  Certain  of  the  eases  there  is  nothing  in  these  facts  to  base  a  distinction 
between  the  tyi)lioid  castas  of  the  army  and  thos**  seen  els(^\vher(\  FniNT  obs(U"ved  that 
some  tvplioid  spots  disaj)]>earcd  but  ])artially  on  pi-essunsf  luid  many  authors  refer  to  erup- 
tions  whi<-h  [ireeedo  or  accompany  the  rose-colored  spots.J 

In  nnm^  of  the  records  of  typhoid  fever  is  mention  made  of  the  pale-bluish  spots,  the 
tachi^s  hlriuUrrH  of  the  French  writei's. 

PefechiiV  seldom  nitnran'd  on  tin'  skin.  Tlu'v  juc  iiu'iiti<uuMl  in  case  ;i2  of  t!ie  Seminary  series,  in  whirli 
they  were  notrd  on  the  Hfteentli  <l:iy,  or  one  (lay  alter  the  eini»ti<»n  of  the  tyi)lioiil  spots;  this  ease  re<u)vered.  They 
were  also  notecl  in  21,  'M\,  ir>  and  IM  of  tlie  pasi-mortrm  series,  situated  usually  on  the  cdiest  and  ahdonien,  !»nt  in  tlie 
last-mentioned  case  extending  t<t  t!ui  tliij^lis:  thtii  nuuiher  w  us  not  recorded.  Eechymotic  spots  of  larger  size, 
reported  as  vihirvN,  appean'd  at  a  late  pei  ind  of  the  atta<"k  in  several  cases,  fjenerally  <lnrin^  or  after  the  f(»nrth  week. 
They  must  Ite  considered  ;i  ^j^rave  proj^nostie:  of  the  Seminary  cases  in  which  they  were  iu)ted  thre*^  cases,  lit,  I^fi  and 
49,  wer*^  severe,  an<l  three,  K!,  17  and  51,  were  fatal. 

As  the  i";iritv  of  eeejiymotie  s])ots  in  typhoid  fever  is  g(Hierally  conceded, §  the  frequency 

*  Fnlluwiri^'  Li-ris,  wl I.s.-im-.I  ttiiit  in  tlircc-foinilis  uf  his  futul  cases  tin*  rosi'-i^iihHTd  simts  wrni  lew  in  iitinilH-r,  VA.  is-^'.t,  t.  II,  p.  'iil,  A.  1*. 

Stewart — in  liis  jirticU*  ontitlot  S»nn'  amsiilfratious  nu  Ih-  iuiliiiv  and  puthnhnjn  nf  tijphui*  ttml  fifphoiU  frver,  ttppHnt  to  tin-  mtint'um  *>f  th-  i/fWHti/ni  «/  ulrntiiif  ur 
iii'ii-iihiifity  uf  the  tiro  dm-usrs.  Kiltiiiumjh  Mai.  Jimr,,  LIV,  1840,  p.  :(2fi — was  Icil  to  coiiwiiitT  tliat  tin-  mcin!  rnpimis  tlir  crnptiim  tht-  lcf*s  tlic  wvcrity  of  tlio 
case.  III'  found  tin;  wjiots  f(^w  in  nnnilKT  or  absent,  although  carefully  lookcil  for,  in  a  ilciidly  cjiidtunic  wliicli  jircvailcd  in  (Jlasfrow  in  iKttl,  and  after- 
wanls  iihsci^i'd  thcin  inon^  or  less  luiincrons  in  Hporadic  cjihi's  prcscutinjj;  u  much  less  intense  form  of  the  affectioji.  lint  afti'r  fui'ther  irupiiry  he  came  to 
the  eonclustnn  that  this  opinion,  aUliouj^h  to  a  certain  4'xtent  correct,  was  not  of  peneral  appIicatioTi.  Tuns.  H.  l*K\i'orK  tfhserved — Mniiml  Thiien  nmt 
(iazHfe,  XXXIV,  Londfin,  ISofl,  p.  IS'2— tliat  the  cases  in  whicli  there  is  u  copiouH  eruption  are  of  a  wtheiiic  ly|»e  and  terminate  favombly;  hut  ho 
ackiiowtedyies  tlnit  in  many  cases  in  wliicti  tliere  is  no  eniptioii  at  all  the  disease  is  alsu  niiltl,  whili^  in  others  it  in  severe  and  often  proves  fatal.  Mur- 
CHISON  disposi'S  of  tlie  ([uestion  liy  the  statement  that  tliere  Is  no  relation  hi'tweeii  th<*  presence  or  absence  of  the  eruption  and  th<*  severity  of  the  fever, — 
p.  r»12.  Jn  this  country  Hit.  .I.\s.  V..  Hkk.vks  considered  tiiat  the  number  of  spots  diminished  in  proportion  to  the  extent  of  tlie  intestinal  chanpen. 
Wilson  Kummaii/cs  thi>  prevaiiin^'  opinion  of  tht-  profession  at  tJie  present  day  in  liis  assertion  that— '"'rhcre  is  no  relation  bi-twi-en  the  iibundanre 
of  the  eruption  and  the  severity  of  the  symptoms," — p,  ItiH.  As  J{kevks'  ex|MTieiice  was  drawn  from  llie  ii>untry  districts  of  u  State,  Virj^inia.  which 
afterwards  furnished  llu!  Seminary  hospital  with  its  typhoid  cases,  his  remarks  on  the  eruption  may  be  of  inten-st :  "  In  mild  cases  of  thi'  diseas)',  in 
which  the  (liarrlnea  is  not  tronblesomi-j  I  have  several  times  Hi-en  t!u'  iwitient  spotted  from  head  to  foot.  At  other  times  the  i-ruptiou  was  priuciimlly 
confined  to  tlie  ab(himen,  chest  and  inner  part  of  the  tbijihs.  In  otlier  instam-ert  it  was  watti-red  u|Kin  the  extremities,  even  to  tlie  titip-n*  and  toes, 
while  up(pn  the  trunk  it  was  eitlier  entirely  abs<'ut  or  only  a  spot  here  and  there  to  be  found.  A^iiin  I  have  wen  it  thickly  set  upon  the  back  :  anti  I  am 
inclined  to  believe  that  it  more  fretpiently  (K-cupies  this  locality  than  is  generally  supposed.  It  is  not  so  c<invenieutly  sonjtht  for  in  this  refjion  as  uiH>n 
the  abdomen,  chest  and  extremities;  and  then-fore  results,  jK-rhaps,  the  rarity  of  itH  bein^  spoken  of  as  iK'cupyiuK  this  region.  All  this  I  have  olwerved 
in  mild  cases  of  the  tliseasc.  Tn  tlie  intermetliate  form  of  the  disease  I  have  <M-ca.si(frialIy  (diserved  it  largely  spread  over  the  ditfereut  i>;irts  of  tin' 
surface,  but  this  was  rare  when  comi«ired  with  its  fre(|nency  in  milder  cases.  In  this  form  it  is  mainly  cotdined  to  the  alwlomen,  with,  jierhaiw.  a  i«tch 
now  an<J  then  to  be  seen  upon  the  breast  and  shoulders.  It  is  also  somewlmt  later  in  its  apitearam-e  than  in  the  mild  form.  In  cases  of  still  jjreater 
severity — those  belonging  to  the  malignant  form — it  is,  as  a  genenil  rule,  still  more  tardy  in  its  appearance,  and  d<K's  not  (H-cupy  as  much  surfao'  at  a 

time  as  is  usually  seen  in  the  preceding  forms.     It  has  I u  in  the  worst  cases  of  the  disease  that  I  have  i.liserved  the  smallest  ainonut  of  this  eruption. 

In  a  very  few  instances  I  have  seen  it  thickly  spread  up<in  the  alidomen,  chest  Jiiid  sbouldiTs,  with  a  few  spots  on  the  back  and  tliigbs;  but  in  the 
majority  of  severe  casi's  it  occupied  only  tlie  region  of  the  abdomen.  It  doi-s  not  always  make  its  apiM-arance  nptui  all  4»f  the  several  iwirts  of  the 
surface  named  at  the  sjinie  time,  but  conies  out  in  successive  crojts — sometimes  abundant  in  one  region,  and  at  other  tinn-s  only  one,  tw<t,  three  or  four 
spots  in  the  next  locality.  When  the  first  iHitch  begins  to  faile  a  wcond  will  make  its  apix-anuice,  and  so  on,  until  the  i-ruption  ceases  or  is  li*sl  in  tlie 
larger  and  more  livid  discolorations  known  as  petechia,  which  in  very  grave  C!u*es  show  themselves.  The  time  ot'cnined  in  this  fading  and  recurrence  of 
the  eruption  may  vary  from  five  to  twenty-tive  days.  The  greatest  duration  of  this  jins-ess  I  have  noti<-ed,  almost  invariably,  to  ix-cur  in  those  eases  which 
passed  through  the  milder  forms  to  the  malignant,  and  particularly  in  those  cases  which  terminateti  in  deuth.  In  the  majority  of  these  nises  but  few 
spots  could  be  found  at  a  time  after  the  most  careful  search." 

+  Flint,  op.  cU.,  p.  322. 

JThus  H.M.E — p.  102 — says  that  in  some  instances  there  are  interspersed  with  the  rose-colored  s[»ots  true  lajnila'  tif  the  same  color  but  larger, 
slightly  elevati'd  and  hardened  and  not  disipiwaring  on  pressure  ;  they  are  generally  quite  numerous,  extending  to  other  i>arts  of  tlie  btnly  than  the 
aotlomen  and  chest,  and  are  occasionally  attended  witli  considerable  itching.  Jknnkr— On  the  uleiUity  or  mn-ithntitij  of  TijphoUl  awl  Tiiphtis  Fcivrs,  Lon- 
don, 1850,  p.  12— called  attention  to  a  i»ale  and  delicate  scarlet  tint  of  the  skin  whicli  sometimes  preceded  the  typhoid  eruption  but  never  lasted  more 
than  a  day  or  two;  the  skiu  resembling  in  tint  that  of  a  p<'rs<ui  shortly  after  leaving  a  liot-bath. 

gMuRCHKSoN  met  with  pdecnial  spots  and  vibi<-es  in  rare  cases,  several  of  wliicli  recovered.  Tu  sujiport  his  own  testimony  he  cites  TRtussEW, 
Cliniqu^  Midicale  tk-  V Hotel  X*iV»,  Paris,  18(11,  p.  I'l'.t,  as  having  recorded  a  rase  in  wliieli  there  were  extensive  vibices, — p.  515.  W'lLStiN,  who  has  given  to 
the  profession  in  this  country  the  latest  complete  view  of  the  fever,  S(iys  that  true  iH.'techia;  are  rare,  and  docs  not  even  refer  to  the  occurrence  of  larger 
eccbymutic  patches. 


288  KYMPTOMATOI.oriY    OF 

of  their  appearance  in  tlieseSetniiiarv  liospital  cases  suggests  a  Jiflerence  between  them  and 
the  typlioid  fever  cases  of  civil  Hfe. 

ContiniKMl  pressure  and  fh<^  lowered  vitality  of  tlic  jiatii'iit  led  to  the  formation  of  hefl-SOI'es  over  the 
sacrum,  trochanteris  and  other  liony  ])romineiices  during  or  after  the  fourth  week  of  the  attaek.  Cases  L'l,28,3t;  and 
51  of  the  Seminary  records  may  h(!  mentioned  as  illustrations;  but  these  ohservations  are  j)erhai)S  eiiually  common 
in  the  clinical  history  of  tyi)hoid  as  seen  (dsewhere.* 

MEerpen  luhitll itt  is  not  mentioned  as  having  been  present  in  any  of  the  cases. t 

A  peculidf  Oflttr  from  the  body  was  noted  in  case  19  of  the  Seminary  records;}  but  the  ammoniacal  odor 
from  the  patient  in  some  of  the  poxt-mortini  series  was  probably  due  to  involuntary  micturition. 

■fHK.  Xkhvocs  System. — lliodtuhe  was  the  nn)st  fre(|ueut  cerebral  numifestation  observed  in  cases  of  unmod- 
ified typhoid  fever.  It  is  mentioned  in  tliirty-si.\  of  the  Seminary  cases;  tUJirium  was  recorded  in  twenty-nine, 
deafiifHs  in  tweiity-eifjlit,  more  or  less  Hliipor  in  twenty-seven,  (IrowxiiiaK/i  in  fifteen,  tiniiifiin  Hiiriiim  in  si.xti^en,  and 
dizzincus  in  eleven.  Jiut  tliese  numbers  do  not  express  the  ridative  frei(uency  of  such  cerebral  develojunents.  When 
delirium  alone  was  noted,  it  is  probable  that  at  some  period  of  its  course  the  case  presented  lunidache,  drowsiness, 
hebetude  of  mind  or  deafness,  wliich  was  not  recorded  or  perhaps  observed  on  account  of  the  greater  prominence  of 
the  delirious  condition  and  the  higher  importance  attached  to  it  as  an  indication  of  gravity. 

Headache  was  generally  frontal;  hut  in  38  of  the  S(Mninary  series  its  seat  was  the 
temples.  It  was  usually  dull;  in  case  1  it  was  reduced  to  a  mere  sense  of  fidlness,  and  in 
13  to  a  heaviness  over  the  eyes;  hut  in  manv  it  was  severe  and  distressing.  Head  pain 
was  a  symptom  of  the  period  of  accession;  in  hut  one  ctise,  40,  is  it  ex|)r('ssly  stated  that 
there  was  no  headache  during  this  period.  Occurring  after  or  without  chilliness  it  was 
accompanied  by  pains  in  the  limbs  and  back,  thirst,  anorexia  and  other  general  symptoms 
of  the  febrile  condition.  It  usually  persisted  during  the  first  week,  and  was  not  unfre- 
quently  associated  with  dizziness,  restlessness  and  inability  to  shiep.  During  the  second 
week  it  subsided  or  was  obscured  by  drowsiness,  mental  hebetude  or  delirium,  which  set  in 
about  that  time.  It  is  probable  that  in  most  instances  there  was  a  real  abiitement  of  this 
pain,  for  exceptionally,  in  some,  as  22  and  25,  it  was  a  source  of  complaint  when  delirium 
was  present.§  Hometimes  headache  was  reported  at  a  later  stage;  in  29  it  occurred  without 
delirium  in  the  third  week,  subsiding  as  the  last  crop  of  eruption  faded,  smd  in  47,  in  con- 
junction with  dizziness  and  deafness,  it  ])reluded  a  recurrence  of  delirium. 

Drowsiness,  which  genendly  terminated  th(>  period  of  wakefulness  and  headache,  was 
developed  gradually;  the  patient  became  dull  and  stupid  and  was  aroused  with  increasing 
difficulty.  .  Frequently  tinnitus  aurium  and  deafness  were  associated  with  this  mental 
dulness.  In  more  sevt're  cases  delirium,  usually  of  a  quiet  and  asthenic  character,  was 
developed;  drowsiness  during  the  day  gave  place  to  restlessness  at  night,  the  patient  mut- 
tered in  his  sleep  and  was  incoherent  for  some  time  after  he  awoke,  and,  td'terward,  this 
condition  of  muttering  delirium  ])ecame  continuous. 

Iteliriutn  was  ])re8ent  in  twenty-nine  of  the  fifty-one  cases — in  eight  of  ten  fatal  cases  and  in  twenty-ouo 
of  forty-one  recoveries.  In  the  fatal  cases,  44  and  46,  in  whicli  delirium  was  not  reported  the  records  are  not 
carried  out  in  detail  to  the  end.  Of  the  twenty  favorable  cases  in  wliich  there  was  no  delirium,  the  cerebral  symp- 
toms in  two  cases,  3  and  14,  consisted  of  headache  only;  in  7  and  12  there  was  also  drowsiness,  to  wliich  tinnitus 


*  *' Vitulity  is  Bo  ft'oMe  in  ttie  skin  ttiut  Idistert'il  surfaces  often  slougii,  ami  gangrenous  eschars  are  protiuced  in  parts  exposed  to  continued  preB- 
Hure,  as  over  ttie  sacrum  and  upon  ttie  hiiw." — Wonn's  Prtu-Ufe,  Vol.  I,  p.  :^17. 

f  The  nirity  of  fifr}}fs  Ud>ialiM  in  typhoid  cases  is  acknowled-^ed  liy  Flint  where  he  says:  "An  herpetic  eruption  ahout  tlie  mouth  was  ol)S(^rved  in 
one  case.  Lest  the  occurrence  of  this  symptom  may  sujf^^est  a  suspicion  that  tlie  disease  was,  in  this  case,  remUlimj  fever,  in  which  heriM*tic  erui»tiolis  in 
that  situation  are  apt  to  occur,  it  may  he  stateii  that  no  douht  could  e.\ist  as  to  the  diagnosis,  the  clianicteristic  )iiarnl:jE,  together  with  other  distinguish- 
ing traits  lieing  jiresent," — p.  75. 

JChomel — p.  40 — sitys  the  whole  cutaneiius  surface  exhales  a  fetid  odor.  Baktlett — p.  fJl — frecpieiitly  noted  a  semi-cadaverous  and  musty  odor, 
esiwcially  in  the  later  stages.  Flint — p.  2Kt — was  unal)le  to  sjitisfy  himsidf  as  to  the  existence  of  this  (slor.  "Thi'  sisters  at  the  hospitll,  and  some  of 
the  stuiIeMts,  have  frequi-ntly  assured  me  that  tliey  were  seusihle  uf  a  distinctive  mior  arising  from  tlie  bodies  of  fever  (Kitients  under  my  charge,  hut  I 
liave  always  failed  to  verify,  to  my  own  sjitisfaction,  this  diagnostic.  Jt  would  lie  assuming  too  much  to  distrust  the  ability  of  others  to  recognize  the 
disease  by  the  olfactory  senst%  and  the  proliahle  as  well  as  the  more  modest  inference  is,  that  the  ill  success  which  has  atteiuled  my  efforts  is  tlue  to  a  want 
of  Buflicient  acuteness  to  appreciate  impressions  received  from  that  source."  Wihid  says  ttiat  a  iieculiar  unpleasant  mlor  often  exhales  from  the  body. — 
Vol.  I,  p.  :U7.     Murchison's  statement  is  that  there  is  rarely  any  jHu-uliar  odor  given  off  by  the  skin  in  enteric  fever, — p.  .M8. 

g  Loris  argued  that  the  cessation  of  headache  on  the  development  of  somnolence  or  delirium  is  not  always  to  be  attributed  to  an  incomplete 
perception,  for  many  of  his  iKitieutM  complained  of  |Miins  in  other  juirts  of  the  l)o<ly  w  hile  giving  assurance  that  they  were  free  from  headache,  — t.  II,  p.  132. 


TlIK    coMIMKli    KKVK 


289 


wjis  lidded  in  2  iiiid  dizzini'ss  in  1,  K!  .iiid  \x:  di/zim'ss  uiid  (iiiiiitus  wi'ic  jiii'sriit  in  !<,  stupor  in  10  iiiid  I!' witli  di//i- 
licss  in  the  Ibi-nicr:  di'atncss  in  li,  \\  illi  I  inn  it  ns  in  !'!•.  di/zinc^ss  in  !l.  tinnitns  nnd  dizziiioNw  in  11.  tinniln.s,  dizziness 
;ind  stnpor  in  Hil  and  stniior  in  1(1  and  17.  (  asi's  :i3  an<l  li.".  slicmld  ncii  lie  admitted  into  tliis  ennnii'iatiiin,  as  delirinni 
is  not  known  to  liave  been  absent  tVom  llieif  liistcny. 

fUfnfufioil  oy  the  ptipil  ace(ini]ianied  didiiinin  in  L'D  and  US:  lint  in  121  it  was  assoeiated  with  dniwsi- 
uess,  inuldlity  to  aitieiilalo,  and  otluT  s\  niiitoms  ot'tlu'  comatose  eoudition,  in  eonneetion  with  which  it  is  mentioned 
in  some  of  the  piist-iiuirlim  series,  as  in  eases  1)S,  117,  -!t7  an<l  L",I9.  Xcveitheless  tlicre  was  no  nnmilest  obseniation 
of  the  mental  facnlties  in  ease  31  (d'  tliis  series  not  wit  list  audi  ni;  the  i;r<'at  pvost  ration  of  the  pa  lien  I  and  t"lii^  dilatation 
of  liis  pupils.* 

Cerel)ral  8viii])toiiis  which  did  nut  fuhiiiiuile  in  delirium  usually  ceased  with  the  decline 
lit'  the  |iriiiinry  fever,  drowsiness  becoming  dissipated,  the  hetirinc;  less  obtuse  and  the 
ex[)ression  intelligent.  Tinnitus  anrium  was  in  sonic  instances  no  doubt  caused  by  the 
jidministration  o'i  quinine. 

The  delirious  condition  lasted  I'roni  one  to  many  days;  in  case  28  there  was  an  almost 
continuous  delirium  for  three  weeks.  Usually  it  wtis  manifested  by  (juiet  incoherent  niut- 
terings,  although  sometimes  the  patient  biu-ame  possessed  with  a  desire  to  get  uji,  and 
rcfjuired  constant  watching  but  seldom  restniint  to  keep  him  in  bed.  The  soldier  in  case  41 
was  killed  for  want  of  this  watchful  care.  Fn  mild  cases  delirium  was  of  short  duration, 
subsiding  with  the  other  cerebral  symptoms  at  the  close  of  the  primary  fever.  In  pro- 
tracted cases  it  oftentimes  alternated  with  periods  of  stupor,  from  whicii  the  patient  w;is 
aroused  to  incoherency  with  difticulty.  The  return  of  intelligence  was  frequently  observed 
in  the  morning  after  a  less  trouliled  night  than  usual:  on  such  occasions  the  patient's  face 
was  pale  and  shrunken,  his  eyes  clear  and  bright.  In  other  instances  the  delirium  left  head- 
ache with  more  or  less  of  stupor  and  deafness  for  some  time  in  its  train,  and  in  this  event  its 
recurrence  was  probable  as  an  accompaniment  of  lung  complication,  aggravation  of  intestintd 
.conditions,  aural,  parotid  or  other  iiinammations.  But  even  when  the  intelligence  was 
apparently  unimpaired  delirium  was  prone  to  return  on  the  advent  of  these  untoward  com- 
plications. In  I'atal  cases  with  strongly  developed  cerebnd  svtnptoms  death  occurred  by 
coma  iind  exhaustion ;  the  patient  becoming  unconscious  and  greatly  prostrated,  the  pulse 
almost  imperceptible,  the  eyes  glassy  and  half  exposed,  the  lower  jaw  dropped,  and  the  only 
visible  movements  those  of  res|)iration  and  muscular  spasm.  SuhsuJtua  tcndinum  was  fre- 
iiueiitly  associated  with  the  delirious  condition.  Occasionally,  in  protnicted  ctises,  when 
delirium  had  given  place  to  unconsciousness  or  coma  vigil,  the  mind  became  clear  for  a 
short  time  during  the  extreme  pipstration  which  preceded  death:  50  and  51  of  the  Semi- 
nary series  are  cases  in  point.  In  the  post-viortem  series  death  from  coma  is  occasionally 
noted,  as  in  17,  18,  163,  171  and  235.  Generally  the  cerebral  symptoms  of  this  series 
were  similar  to  those  observed  in  the  Seminary  hospital,  but  one  or  two  anomalous  cases 
may  be  noted:  In  119  the  restlessness  which  preceded  the  delirium  persisted  during  its 
continuance  in  the  aggravated  form  to  whicli  the  term  jactitation  has  been  applied;  in  25 
there  was  extreme  nervous  agitation;  in  160  the  strangeness  of  the  patient's  manner  led  to 
the  supposition  that  he  was  crazy ,f  and  in  299  the  symptoms  were  referred  to  congestion  of 
the  bniin. 

*  sir  M'.  .Tenner  was  the  first  to  jioint  out  the  dilated  conditiun  of  the  pujiil  in  enteric  fever  hk  contrasted  with  tlie  small  pupil  of  typhns;  of  23 

fiitiil  raf*es  he  uliser\H'd  dilatation  in  7  and  contraction  in  2.  Mukchison — i'oiUhwed  Ferfm,  p.  fi-il— nays:  "In  fully  tliri'e-fourths  of  my  cases  the  pupils 
wi-H'  iilinornially  dilated  at  some  stage  of  the  fever,  and  Pr.  W.  T.  Gauipner  has  made  similar  olis«'rvations  at  Kdinlmrgh.  Dilatation  of  tlie  pupil 
niiiy  he  ohservi-d  after  the  tenth  day  in  cases  where  there  is  no  delirimn  or  im{)airm('nt  of  the  mental  faculties,  or  it  may  coexist  with  delirium,  and 
especially  with  that  condition  aiiiiriiachin^  to  hysteric  coma  already  deserilied." 

t.'^KooA  and  Oci'OLzER — /.e  Miiin-nnriil  Mi'>ti<-aJ,  1S72.  p.  \'A — say  that  it  is  not  rare  to  tind  typhoid  fever  presentinjr  only  nervous  iihennmcna  and 
simuhitiiig  a  mental  affection.     In  three  cases  in  which  MrucnisoN  was  consulted  the  iUiiess  ha'l  at  tirst  l,.-en  rcj,'ardi'd  as  acute  mania,  and  in  two  of  these 

the  removal  of  the  patients  to  a  lunatic  asylum  had  I n  cuiitemiiliited.     IIi-  cites  >I.  Motkt.  Anlin-.  t;  n.  <!•■  Mil.,  1st'.'*,  XI,  p.  .'.t4,  as  having   recorded  a 

case  of  this  kind  in  which  the  patient  was  actimlly  sent  to  an  itsylnm  hrfure  tlie  real  nature  of  th .'  malady  was  discovered, — p.  5;J5. 

Mei).  Hist.,  Pt.  Ill- 37 


290 


SYMPT0MATO].0(iY     OK 


At  first  sight  it  miglit  be  coiisiJcred  that  tlie  nervous  symptoms  of  the  Seminary  eases 
dill  not  clifTer  in  any  rcsj^ect  from  tlioso  generally  recognized  as  characteristic  of  typhoid. 
Headache,  restlessness,  confusion  of  thought,  giddiness,  hebetude,  somnolence,  deafness, 
incoherence,  muttering  <lelirium  and  coma  are  daily  under  observation  by  the  practicing 
physician.  In  the  frequency  of  delirium,  and  th<;  increased  gravity  which  attached  to  its 
occurrence,  the  typhoid  fever  of  our  camps  did  not  differ  from  that  described  by  observers 
elsewhere.'^'  Moreover  the  occasional  exceptional  or  anomalous  cases  which  have  been  men- 
tioned are  seen  to  have  their  parallels  in  the  literature  of  the  subject.  But  if  the  character 
of  the  delirium  as  it  occurred  among  our  troops  be  compared  with  that  of  typhoid  delirium 
as  usually  described,  it  will  be  found  that  the  former  was  generally  less  violent  in  its 
character  than  the  latter.  Murchison  says  delirium  is  at  first  often  active  and  noisy,  the 
patient  screaming  and  shouting  and  being  with  difficulty  kept  in  bed.f  In  Tenner's  cases 
it  varied  much  in  character,  being  sometimes  so  violent  that  the  patients  left  their  beds  and 
even  ran  screaming  through  the  wards,  while  at  other  times  it  showed  itself  by  slight  delu- 
sions only  discovered  to  exist  by  accident.J  Bartlett  states  that  in  many  cases,  partic- 
ularly such  as  are  rapid  in  their  march  and  of  great  severity,  delirium  is  attended  with  cries 
and  screams,  and  that  the  constant  presence  of  attendants  with  occasionally  no  slight  degree 
of  force  is  required  to  keep  the  patient  in  bed.  §  Among  thirty-eight  fatal  cases  recorded 
by  Louis,  delirium  was  accompanied  in  twelve  subjects,  especially  during  the  night,  with 
violent  agitation,  necessitating  the  use  of  the  straight-jacket;  it  was  so  considerable  in  one 
patient  that  the  strongest  means  barely  sufficed  to  keep  him  in  bed  on  the  tenth  day,  the 
day  preceding  death.  The  greater  number  of  his  patients,  ten  out  of  twelve,  uttered  cries 
so  loud  as  to  prevent  their  comrades  in  the  same  ward  from  sleeping. ||  Indeed,  the  straight- 
jacket  figures  as  one  of  the  essentials  of  treatment  in  the  practice  of  this  great  authority. 

Now,  although  watchfulness  on  the  ]>art  of  hospital  attendants  was  often  required  to 
prevent  a  patient  from  attempting  to  rise  under  the  influence  of  some  incoherent  fancy, 
restraint  was  seldom  needful  in  the  wards  of  our  general  hospitals  during  the  war.  The 
intense  prostration  which  characterized  the  attack  rendered  force  unnecessary,  even  when 
the  patient  developed  a  persistence  in  the  attempt  to  carry  out  his  delirious  impulses. 
Usually  he  was  docile  as  a  child,  requiring  only  a  kindly  hand  to  be  laid  on  him  to  allay 
his  fears  or  soothe  his  irritation.  Certainly  the  violent  agitation  which  was  a  characteristic 
of  so  many  of  the  cases  instanced  by  the  authors  cited  formed  no  part  of  the  general  clin- 

*The  reconUHl  exiKTionce  of  Loris  shows  delirium  to  Imvo  Itoen  present  in  .TB  of  40  fiitul  cilfies;  in  :in  of  .5fi  severe  cases,  and  in  none  of  :U  mild 
cases, — t.  II,  p.  150.  Jackson  noted  its  existence  iu  1U8  of  30:!  cases,  and  of  these  7o  liad  a  favorable  and  :i3  a  fatal  issue;  the  fatality  amonj^  the 
delirious  cases  being  30.0  per  cent,  as  against  13.80  per  cent,  among  the  cases  as  a  whole.  Ho  considered  it  probable,  Iiowever,  that  slight  delirium 
occurreil  at  night  iu  many  cases  iu  which  it  was  nnobserved  and  remained  in  conseiiuence  unuote<l  as  a  symptom, — p.  47.  Sli'ariiisoN  found  07  of 
UK)  cases  to  present  delirium  or  mental  confusion,  but  in  many  of  these  the  delirium  was  slight  and  occasional,  (M-curring  chieliy  at  night,  while  at 
other  times  the  iwtient  w.as  quite  rational ;  of  the  ti7  cases  18  were  fatal,  but  in  only  22  cases,  of  which  11  were  tatai,  was  there  at  any  time  ctimidetc 
nnconscituisness, — p.  5;i4.  According  to  I.ifbkrmkistkk,  among  the  tyjihoiil  iiatients  treated  in  the  hospital  at  Basle  in  the  years  180.')-08,  there  were  1)83 
in  whom  the  disease  ran  its  course  without  any  specially  noteworthy  brain  symptoms;  of  these  34  died,  or  about  3.5  per  cent.  ir*Iight  delirium,  excite- 
ment of  l(iw  grade,  lasting  for  only  a  sht>rt  time  or  app<'aring  only  during  the  night,  occurred  in  191  cases,  of  which  38,  or  V.i.'J  per  cent,  died  ;  well- 
marked  delirium  occurred  iu  176  cases,  of  which  90,  or  54  per  cent,  died ;  stupor  and  coma  were  present  in  53  cases,  of  which  30,  or  70  per  cent  died. 

f  MuKcnisox,  p.  534. 

I  "Ten  of  eighteen  patients,  i.  c,  more  than  one-half,  or  in  the  proportion  of  55.5  per  cent,  of  those  who  were  delirious  after  they  entered  the 
hospital,  and  of  whom  notes  on  the  point  were  made,  left  their  beds  to  wander  about  the  wani." — Jex.vhr,  p.  22.  Dr.  Ukkvks  also,  p.  38,  refers  to  the 
occurrence  of  violent  delirium:  "When  the  delirium  is  violent  it  usually  requires  coTistaut  restniint  to  keeji  the  luitieiit  in  bed.  He  cries,  laughs  and 
makes  u.se  sometimes  of  the  nnjst  obscene  languagi-.  .\t  other  times  he  seems  in  a  fit  of  anger,  and  in  some  inuiginary  encounter  strikes  at  tin;  bed- 
posts, the  wall  or  at  the  attendants  with  all  his  strength;  his  cons<.'iousness  being  end)arrassed  'by  false  presentations,  illusions,  phantasms — a  couditiiui 
in  which  he  is  haunted  by  spectra  analogous  to  those  visual  and  auditory  sensations  which  arise  in  connection  with  disease  in  the  optic  uv  acoustic 
nerve;  a  state  iu  which  the  centre  of  consciousness,  abnormally  excited,  forges  subjectively  all  numner  of  images  of  incident  and  circninstance,  with  a 
scdf-asenrance  of  their  objective  reality.' — Himous  General  Piilholinjif,  p.  1,53.  .\  very  common  imiiression  with  such  patients  is  that  they  are  absent 
from  home  and  surrounded  by  persons  who  take  jiarticular  delight  iu  doing  them  an  injury  tu  both  persim  and  property;  and  harassed  by  these  impres- 
sions, they  leap  out  of  bed  and,  if  not  at  once  arrested,  make  for  the  door,  or  in  the  attempt  fall  exhausted  upon  the  floor." 

gB.VRTLETT,  p.  CO.  ll  Louis,  t.  II,  p.  150. 


THE    CONTINUED    h'KVKllS.  291 

icul  liistciiy  of  tlic  disease  duriiiii-  tin.'  w;n\  Tlie  patient  was  raivly  noisy,  l»ut  lay  nnitter- 
ino-  ill  a  low  tone;  when  roiiscJ  Inr  the  adniinistration  of  footl  or  nietliciiie,  he  took  without 
ol)jeetion  whatever  was  presented  to  liiin  and  sank  back  into  kis  former  condition.  Active 
delirium  was  exeeedinii;lv  rare,  tlie  only  instance  in  tlie  i~>eminary  series  beinc  case  38  in 
whicli  it  was  associatLM.l  with  <lilatoil  pupils  and  temporal  lu-atlaclio. 

TiiK  DHJKSTIVE  8YSTKM.— .4noi*ei*;iV«  was  a  constant  symptom  of  tlir  ininuiry  fever  It  -was  manifested 
from  the  ocemrenee  of  the  cliill  of  ousel  or  aecompauieil  the  hel)etn(U'.,  hea(hielie  ami  jiams  in  tlie  limits  which  marVc*! 
the  (leparture  from  the  state  of  health.  Thirst  was  also  common,  hut  it  did  not  attain  its  uia\imnm  nntil  ahont 
the  erupt  ive  ]>eriod  in  cases  which  ran  a  c(nirse  unohscured  h\  the  intensity  of  the  corehral  symptoms,  GtiHtviC 
ivvitiihility  was  rarely  noted  among  the  earlier  nianifestatictns  <tf  the  diMcaHe  ;  it  occurred  only  in  the  two  cases, 
9  and  17,  and  had  no  manifest  intluenco  on  their  luogress.*  In  case  25  it  was  noted  at  the  acme,  and  in  39  nausea 
was  associated  with  the  intercurrence  of  jinennKUiia.  When  vomit  injj;  oecurre<l  at  a  later  jteriod  it  was  ominous  of 
(hm^^erons  inllammatory  conditions  in  the  ahdominal  cavity,  altliitn^rh  in  the  only  case,  LM,  in  which  it  was  noted  as 
havinj;  atfected  the  patient  late  in  the  history  of  the  attack,  it  did  not  pcissess  this  sinister  nu'aning.  In  cases  19,  32 
and  T2iS  of  the  j}o.st-mortvm  records  vomiting  was  associated  with  in'rforation  of  the  intestine,  and  in  213  with  gan- 
grenous conditions  in  the  ahdominal  cavity.  It  was  also  tioted  at  a  late  period  in  If)")  and  l(»t>;  in  2S0  it  occurred 
earlier,  hut  persisted  to  tlie  end.     Nausea  in  150  was  an  accompaniment  of  the  onset  of  jioritonitis. 

In  only  three  of  the  Seminary  cases,  15,  32  and  50,  was  the  breath  mentioned  as  having  been  otfensive  during 
the  i>rogress  of  the  fever. 

The  tongue  was  at  first  moist,  coated  at  tlie  base  with  a  white,  gray  or  yellow  tiir,  and 
with  the  margins  and  tip  of  an  unnaturally  red -color.  Gradually  the  basi?  and  centre  lost 
their  moisture  and  became  brown  in  color  and  rough,  the  edges  continuing  as  before. 
Sordes  gathered  on  the  teeth,  lips  and  tongue,  and  were  generally  regarded  as  a-n  exponent 
of  the  typhoid  eonditioUj  in  view  of  the  great  prostration,  muttering  delirium  and  semi- 
unconsciousness  wliich  W(M'e  usually  present  with  these  accumulations.  The  dry,  brown 
tongue  became  cracked,  and  blood  which  oozed  from  its  tissures  added  to  the  mass  of  sordes. 
The  patient  when  roused  for  the  moment  seldom  expressed  a  desire  for  food  or  drink,  but 
swallowed,  although  sometimes  with  difficulty,  whatever  was  placed  in  his  moutli.  Later  in 
the  attack  the  tongue  lost  its  dark  fur,  becoming  red  and  glossy  and  afterwards  moist,  or  it 
cleaned  gradually,  leaving  brown  or  yellowish  patches  at  the  base  or  on  each  side  of  the 
mesial  line  far  into  the  period  of  convalescence.f  When  cerebral  symptoms  were  not 
strongly  developed  tlie  patient  sometimes  showed  a  desire  for  food  notwithstanding  the  dry, 

*jArK.si>N,  in  his  analysis  of  303  cases,  foiuul  iiauwa  ami  voinitiiit;  tu  liv  rR-tiuciit  syiui»toins,  particuhirly  at  the  (*omni(*nc**inciit  ef  the  fcvor, — p. 
38.  Dr.  FiJNT,  on  the  contrary,  considorfil  that  diirinji  tho  febrile  can-cr  nausea  ami  vumitingare  nut  only  absent  in  the  nmjurity  of  eases,  hut  ure 
juimpiirtant  as  symptoms,  occurring  at  irregular  ])eri(j(ls,  seldom  recurring  or  persistnij;  and  poHsessinj;  no  special  significance, — p.  172.  Wool)  (ttiites 
that  tlie  stniuarh  though  often  retentive  is  f^ometinies  irritable. — Vol.  T,  p.  :il«).  Loris  found  that  in  thirty  fatal  cases  twenty  had  nausea,  vomiting  or 
jmins  in  the  epigastrium.  Eacli  of  these  symptoms  reganletl  by  itself  he  coneeived  to  he  of  little  valui'  as  an  indieatioii  of  the  conditi<ui  of  the  stonuudi, 
but  his  nocropsical  oliservations  demonstrated  tliat  the  unicous  membrane  of  the  stomach  was  more  or  less  altered  in  all  the  cases  (five)  in  which  epigas- 
tric pain  was  associated  with  vomiting  of  bile, — t.  II.  \).  4r).  Mcrchison  was  imiined  to  regard  vomiting  iit  the  commencement  of  the  attack  as  a 
fa\'onible  symptom,  but  cites  Pkacock,  L-niri/^  lS(Vj.  Vdl,  f,  p.  H",  as  expn-ssing  an  opposite  ()piuioii.  Wilson  siys  that  nausea  and  vomiting  o4<-nr 
in  the  early  stages  of  a  small  pro]tcu"tion  of  the  cases,  and  that  so  far  as  his  own  observation  goi-s,  early  vomiting  has  been  foltnwed  by  the  severest  forma 
of  the  disease, — p.  171.  All  antliorities  agree  as  to  the  generally  th-adly  sigiiitication  of  voiuititig  in  the  later  stiiges  when  asstwiati'd  with  other  symptoms 
indicative  of  peritonitis  or  perforation. 

f  In  Jackson's  cases  the  tongue  was  characterized  as  dry,  dark  or  denuded, — p.  37.  Uartlktt  says  that  in  a  certain  proportion  of  cases,  severe  as 
well  as  miUl,  it  is  but  slightl,v  altered  in  api«'araTice  ;  even  in  fatal  cases,  terminating  4'arly,  it  may  be  merely  somewliat  dry  and  coated.  In  mild  cases 
it  is  often  almost  natural  in  appearance  or  covered  only  witli  a  light  y(dlowish  coat,  while  iu  others  of  a  similar  grade  of  st^verity  it  is  smooth,  nunl- 
erately  red  and  moist  with  a  tenacious  adhesive  matter  which  is  common  in  the  severe  forms  iis  well  us  in  the  mild.  Tn  grave  or  protracted  cases  it 
gradually  In'comes  dry  and  brown  along  its  middle  and  red  at  its  tip  ami  edges;  later  it  becomes  dark  over  its  whole  surface, — sometitues  nearly  black, — 
glazed,  stiff  and  crossed  by  cracks  and  fissures.  Tin*  dry  eriist  [H-els  nff  iu  flakes  and  imtches,  leaving  the  surface  red  and  shining;  soniethnes  there  is 
a  whitish  aphthous  exudation  on  the  mncinis  coating  of  the  tongiu-  and  nmuth  ;  at  other  times,  late  in  the  diwase,  the  tongue  is  morbidly  re<l,  some- 
times sw(d!eii.  jiainfiil  and  tender  and  occasioTially  ulcerated, — p.  7'i.  According  to  Wotm,  the  tongue,  frcun  being  nmlst  and  claTumy,  often  bec(jmes  quite 
dry,  assumes  a  brown  color  and  is  at  times  gashed  and  sore.  lie  regards  its  condition  in  the  hiter  stages  as  an  element  of  prognosis  :  A  favonible  termina- 
tion is  indicated  by  the  tongue  becoming  moist  and  clean  ;  but  in  other  instances,  esperially  in  severe  and  protrarted  cases,  **  instead  of  cleaning  gradually 
from  the  edges  it  thiows  (^iff  its  fur  in  fiakes,  generally  at  first  fri>in  the  centre  or  towards  the  base,  leaving  the  surface  snn^oth,  red  and  somewhat 
shining,  as  if  the  papillary  structure  had  been  partially  destroyed.  This  state  of  the  tongue  is  sometimes  preceiled  by  soreness  of  the  fauces ;  and  tho 
velum  iiendnlum  and  half  arches  will,  if  examined,  be  found  covered  with  an  exuchition  which  they  are  tieginning  to  i)art  with.  This  is  usually  a  sign 
(if  an  approaching  amelioration  of  the  symptoms.  If  the  tongue  when  thus  cleaned  renuiin  moist,  convalescence  may  lie  pretty  confidently  exi«'cteil, 
though  it  is  always  tedious.  Tti  some  instances  ttie  tongue  coats  itself  over  again,  and  again  becomes  ch'an  ;  and  tills  change  may  take  place  nmre  than 
once.  Occasionally,  ti>o,  an  aphthous  exuflatioTi  ainn-ars  upon  the  surface  ;  but  still,  if  the  moisture  i-ontinue,  the  prognosis  is  ultimately  faviunble.  If, 
however,  at  any  time  during  the  above  cleainng  process,  or  e\  en  alter  it  has  been  conii)leted,  the  tongue  should  iK'come  permanently  dry  the  symptom.t 
are  again  aggravated  and  the  patient  again  thrown  into  danger,'" — Vol.  I,  p.  :117. 


292  SYMT'ToMATOLOdY    OF 

hrown  ;ind  fi,s.sui'c<l  coiKlitioii  uf  ilic  tuiigiir:  In  ciiKO  4'>  of  Uic  Seminary  Hcri<;K  tlie  apjK'titt.' 
was  good  although  llio  tooth  w(;i'c  covered  with  sordcs;  and  in  48  it  iy  said  to  have  been 
retained  until  the  day  of  death. 

Ill  forty-eight  of  the  Soniiiuiry  eases  in  wliic^h  tlie  eoiiilition  of  tlie  TotlfJUe  was  recorded  during  the  progress 
of  the  fever,  it  was  red  at  the  tij)  and  edges  and  variously  coated  l>r<iwii,  gray,  yellow  or  white  on  the  dorsum  in  thirty- 
two  cases.  Indeed  it  may  lie  said  that  tliese  characteristics  were  present  in  thirty-four  cases,  if  the  descri))tion  given 
in  ease  3,  "siuootli,  fissured,  red,  <lry,  quite  clean  anteriorly,  but  with  a  brown  fur  jiosteriorly,"  and  that  in  22,  "red 
and  slightly  coated  yellowish-white,"  \w.  accejited  as  c(|uivalent  to  red  at  the  tip  and  edijcx*  Of  the  remaining  cases 
the  tongue  was  dry,  brown  and  fissured  in  10,  19  and  24;  red,  dry  and  glossy  in  6,  7  and  10;  smooth,  gh)ssy  an<l  dry 
in  Ki;  ludwn  in  14  and  50;  moist  and  coated  in  17  and  II;  dry  and  coated  in  39;  dry,  red  and  with  enlarged  papilhe 
in  5;  and  yellowish-white  wlu'ii  first  noted,  and  afterwards  white  in  2. 

Ill  two  cases,  4  and  18  of  the  thirty-four  in  wliich  what  may  be  called  the  characteristic  tongue  of  typhoid  was 
present,  it  is  mentioned  as  having  been  at  one  period  flabby.  In  the  first  of  these  the  early  apiiearauco  of  moisture 
on  the  skin,  and  the  benefit  following  the  administration  of  quinine,  suggest  the  possibility  of  a  malarial  complica- 
tion ;  but  in  the  other  tlie  tlabbiuess  of  the  tongue  was  unaccompanied  by  other  suggestive  symptoms. 

The  tongue  when  protruded  in  the  earlier  stages  of  the  disease  was  often  tremulous,  iiarticipating  in  the 
debility  w  hicb  affected  the  muscular  system.  In  the  later  stages  it  was  protruded  with  difficulty,  and  the  mouth 
was  frequently  coated  with  a  tenacious  glutinous  mucus. 

Sorties  gathered  on  thi^  teeth  and  lips  of  twenty-one  of  the  fifty-one  cases,  and  five  of  tliese  had  a  fatal 
termination.  Five  of  the  thirty  cases  wliich  did  not  jiresent  these  acciimiilatious  were  likewise  fatal:  41,  killed  in 
his  delirium ;  42,  died  of  pulmonary  congestion :  47,  from  a  recrudescence  of  the  diarrlioeal  affection ;  51,  from  exhaus- 
tion, and  46,  from  some  unstated  conditions  several  months  after  the  primary  attack. 

From  these  facts  it  may  be  inferred  that  although  sordes  and  the  generally  accompany- 
ing dry,  dark  tongue  were  symptoms  of  great  gravity,  the  disease  was  nearly  as  prone  to 
end  fatally  in  their  absence  as  in  their  presence. 

The  condition  of  the  mouth  and  tongue  was  alone  sufficient  to  account,  in  many  cases, 
for  the  dysphagia  or  disinclination  to  swallow  which  was  sometimes  manifested;  but  owing 
to  the  diflficulty  of  examining  the  throat  in  patients  laboring  under  typhoid  prostration,  it  is 
probable  that  inflammation  and  ulceration  of  the  fauces  and  pharynx  were  more  frequently 
present  than  appears  from  the  records. f  Dysphagia  in  case  40  was  due  to  pharyngeal  inflam- 
mation ;  but  in  other  instances,  as  in  197  of  the  post-mortem  cases,  it  must  be  attributed 
mainly  to  the  deep  stupor  in  which  the  patient  was  plunged. 

Diarrhoea  was  present  at  some  period  in  the  progress  of  most  of  the  cases,  varying  from 
a  slight  relaxation  of  the  bowels  to  an  attack  giving  six,  eight  or  more  stools  daily.  Occa- 
sionally the  intestinal  affection  was  manifested  bv  a  want  of  consistence  of  the  passages 
rather  than  by  their  frequency.  The  discharges  were  usually  thin,  small  and  yellowish, 
sometimes  watery,  often  fetid,  and  generally  painless. J 

*  The  roeognitinn  of  this  condition  of  tlio  tongue  as  chiirartoristic  of  typhoid  fover  has  the  autliority  of  Sir  W.  Jenneh,  wiio  says  tliat :  "The 
small  dry  tongue  with  rt-d  tip  and  edges,  smooth,  pale  Itrowiiish-yellow  fur,  and  lissnred — the  yiirfaee  seen  between  the  fissures  being  of  a  deep  red — may 
he  eousidered  differentially  as  a  diagnostic  sign  of  tyjilioid  fever." — Monthly  JoKniid  of  Mfd.  iirifiire^  Edinb.,  Vol.  X,  IS-W,  p.  ;ilu.  "I  have  observed, 
indeed  have  learned  to  regard  it  as  almost  characteristic,  that  the  tongue  in  typhoid  fever  shows  at  the  tip  a  wedge  of  reddish  or  brownish  surface  free 
from  coat." — .T.  M.  D.\Cokt.v  in  Tnim,  O'llri/r  /'A^/.v/c/.o;.-*,  I'hila.,  1877,  |i.  104. 

f  Jackson  found  a  difficulty  in  deglutition  more  or  less  strongly  marked  in  21  of  his  30.3  cases,  and  of  these  four  were  fatal.  lie  considered  that 
were  he  to  count  only  those  cases  in  which  the  dysphagia  was  very  great  this  symptom  would  be  an  indication  of  nnich  danger, — p.  3H.  Of  thirty-tw() 
grave  but  not  fatal  cases  in  which  Lons  examined  the  mouth  and  fauces  with  care,  there  was  inflammatory  redness  in  twenty-one  ;  the  tonsils  were 
swollen  in  three  of  these  cases,  the  velum  in  two,  the  jiharynx  to  some  extent  in  one  ;  the  roof  of  the  palate  was  in  one  instance  covered  with  a  number  of 
whitish  pellicles  which  were  easily  sejiarated  from  it;  ulceration  was  present  in  three  ca.ses,  the  pillars  of  the  fauces  being  affected  in  two  and  the  lower 
Up  in  the  third, — t.  II,  p.  DO.  And  in  connection  with  these  signs  of  inflammation  most  of  the  patients  complained  of  pain,  pricking  .sensations,  dryness 
and  more  or  less  difficulty  in  swallowing.  But  among  his  fatal  cases  there  were  several  in  which  the  pharynx  and  (Kso]ihagus  were  more  or  less 
seriously  affected  with  no  symptom  to  indicate  their  altered  condition.  In  explaining  this  anomaly  by  the  presence  of  delirium,  he  took  occaiiion  to 
remark  that  an  ol)stiuate  refusa'  to  drink  on  the  part  of  a  delirious  jiatient  may  be  regarded  as  an  index  of  the  state  of  the  throat  anil  gi'tierally  of  the 
organs  of  deglutition, — t.  II,  p.  I:i0. 

J*'Tlie  stools  may  ^e  only  one  or  two  daily,  or  more  fre^pient,  up  to  ten,  twelve,  or  more.  They  are  geucTally  ycdlowish  or  brownish,  and 
api»arently  healthy  except  in  ci)n'-'stence.  This  is  one  of  the  remarkable  features  of  the  disease.  While  in  other  severe  fevers  the  discliarges  ari>  almost 
always  greatly  altered,  in  this  they  often  remain  nearly  natural,  with  the  exception  alluiied  to,  throughout  the  complaint." — Wood,  Vol.  I,  p.  'M'.K 
B.iUTLETT  comimres  the  liquid,  turbid  and  yellowish  stools  to  new  cider ;  but  says  that  in  a  considerable  number  of  casej  they  are  of  a  dark-brown  color, 
fetid  and  offensive, — }).  75.  Muechison  represents  the  stools  as  liquid  «nd  of  the  color  of  yellow  ochre,  offensive  and  often  ammoniacal  in  odor  and 
alkaline  in  reaction,—^:.  524.  Watson  characterizes  them  as  somewhat  like  jK-a-soup, — p.  10il7.  Iiebeiimeister  says  :  "The  stools  are  thick  or  watery, 
light-brown  or  yellow,  often  like  pea-soup  ;  after  standing  they  separate  into  two  layers  ;  the  upper  is  a  turbid  brownish  fluid,  the  lower  is  a  brownish 
fiocculent  mass:  the  reaction  of  the  fluid  is  alkaline  ;  it  contains  little  albumen.  In  the  sediment  we  find  fragments  of  fowl,  detritus,  mucous  corpuscles, 
fungous  spores,  accidental  substances,  often  crystals  of  trijilc  phosphate," — p.  92. 


THE    CO^'Tr^-UED    FEVERS. 


29.'^ 


Oraitthi"'  cases  33  ami  S.").  Ilioii'  are  (uity-iiine  eases  in  the  f^eminaiy  leeiirds  in  whicli  the  condition  of  tlie 
liowels  was  stated  from  day  to  day.  In  torty-live  of  tliese  llie  diarrlio'al  tendency  was  more  or  less  marked:  never- 
theless in  nine  of  them  at  some  jieriod  of  their  histoi'y  it  was  deemed  advisahle  hy  the  medical  attendants  to  adopt 
some  means  to  ett'ect  a  movement  of  the  howels:  In  two.  Jill  anil  Iti,  enemata  of  soajisuds  were  employed  with 
the  intent  of  relievinjj;  abdominal  pain  and  distention  associated  with  eons|i])ation  in  the  one  case  and  a  ([niescent 
eonilition  of  the  howels  in  the  other:  in  the  former  no  recorded  etfect  was  ])iddnci'd,  and  diarrloea  did  not  occur 
until  several  days  later:  in  the  latter  the  enema  appeared  to  determine  a  <dnditioii  of  relaxation.  In  30  and  10 
castor  oil  was  administered  withont  prodticinj;  any  over-active  etVect :  luit  in  ti  its  exhibition  was  followed  liy  nmhil 
ical  i)ain  and  a  necessity  for  the  administration  of  acetate  of  lead  and  opium.  In  3X  and  39  calomel  and  .jalap  wore 
employed  without  apparent  harm  to  the  intestinal  tract.  In  il  and  13  Idue-pill  and  E])Som  salt  were  administered,  hut 
the  induced  action  did  not  persist.  Of  the  four  eases  which  were  not  characterized  hy  marked  diarrlueal  tendencies 
the  howels  are  said  to  have  been  regular  in  one,  the  mild  febrile  attack,  2,  in  which  castor  oil  was  j;ivcn  towards 
the  conclusion  of  the  case;  in  two  cases,  8  and  lo,  the,  bowels  were  quiet  and  <'alomel  and  .jalaj)  did  not  cattfc  undue 
action;  in  the  fourth  of  these  cases,  29,  there  was  iu)t  able  constipation,  no  passaj;e  having  been  procured  during  the 
stay  of  th(!  patient  in  hospital  except  hy  the  use  of  castor  oil. 

It  is  somewlitit  difficult  to  comjwro  tlic  relative  frequency  of  diarrlioeii  in  tv}ilioid  c;ises 
re])orted  by  different  observers  when  numerical  statements  oidy  are  made  the  basis  of  the 
comi)arisoii.  This  appears  due  to  a  bias  given  to  the  clinical  records  by  the  ptithological 
knowledge  of  the  reporter.  The  recognition  of  an  intestinal  lesion  as  the  iinatoinical 
essential  of  the  disease  and  the  connection  of  diarrlufa  with  an  ulcerated  condition  of  the 
intestinal  mucous  membrane  have  [irobably  led  many  physicians  to  regard  and  report  as 
diarrhcxia  in  typhoid  fever  that  whicli  would  not  have  been  recognized  by  so  formidable  a  title 
had  it  occurred  in  the  course  of  a  pneumonia  or  other  acute  disease.  Laxness  of  the  bowels, 
or  even  a  tendency  to  relaxation,  manifested  by  a  diminished  consistence  of  passages  of 
natural  frequency,  may  by  some  have  been  considered  as  establishing  the  diarrhoeal  condi- 
tion. To  draw  conclusions  from  statements  regarding  the  frequency  of  diarrhoea  it  is  need- 
ful to  know  precisely  to  what  conditions  of  the  bowels  the  term  was  applied.  It  is  clear 
that  Louis  recognized  one  passage  daily  as  a  typhoid  diarrhoea;  he  graded  this  symptom  as 
fort,  modere  and  faible,  and  the  last  included  cases  that  might  not  by  every  one  be  considered 
diarrhoBal.* 

Nevertheless,  in  view  of  the  acknowledged  absence  of  diarrhoea  in  a  notable  propor- 
tion of  typhoid  cases  observed  in  civil  practice,  there  appears  no  room  to  doubt  that  the 
cases  which  occurred  among  our  soldiers  dui'ing  the  war,  as  illustrated  by  those  preserved 
in  the  records  of  the  Seminary  hospital,  were  characterized  as  a  whole  by  the  prevalence  of 
a  more  severe  and  protracted  diarrhoea  than  is  usually  associated  with  the  disease.f 

*  Louis's  t;tatistics  bearing  on  tlio  frequency  and  severity  of  diarrhoea  in  typhoid  fever  are  a«  follows :  Of  120  ca-ses  iliarrlioea  w.-w  present  in  all 
hut  two.  Of  ;J2  fatal  cases  an  active  diarrlnca  of  eight  tu  ten  or  more  stools  in  the  twenty-four  hours  was  pri'sent  in  18 ;  a  niodemte  iliarrhcea  of  from 
four  to  six  stools  daily  in  7  ;  and  a  mild  diarrhoea  of  one  or  two  stools  daily,  r.irely  more,  also  in  7.  In  o7  severe  but  not  fatal  cases  t::o  diarrlio-a 
was  violent  in  14  jMitients  who  had  from  eight  to  twenty  stools  daily;  les>i  severe  In  22  cases  with  two  to  four  stools  daily;  and  nn«liT.ite  in  21  t»tliers  in 
■which  the  number  of  the  stools  is  not  indicated.  The  diarrluea  in  :{l  mild  ca-st's  was  less  inten.se  and  of  shorter  duration  than  in  those  already 
stated;  it  was  considerable  in  4  cases,  absent  in  2,  while  in  the  remaining  2.'J  the  degree  of  sfiverity  is  not  stated  in  direct  terms,  but  the  iircstnup- 
tioii  i.s  that  it  did  not  exceed  one  or  two  stools  daily, — t.  IT,  pp.  17,  2:t  and  2.5.  H.\i.k,  in  his  aiuilysis  of  the  oises  of  the  Miissachusett.s  Genenil  hosjiitil, 
concluded — p.  22:i — that  the  princiiial  difference  between  the  lyi)hoiil  fever  of  Nc^w  Kngland  and  that  of  Paris,  as  delineated  by  Louis,  was  the  greater 
frequency  of  diarrhoea  in  the  latter.  In  his  hospital  cases  he  found  iliarrluea  in  ni7  of  2'.i7  ca^e.s  or  in  ,'i)i  percent.;  and  in  1H7  ciuscs  of  which  he  had 
the  liistories  in  detiiil  the  proportion  wa.s  still  les.s,  ttfi  ciuses  or  40  per  cent.  Ibit  lie  fiuiud  a  similar  tlltference  in  regard  to  the  prevali-nce  of  iliarrlnea  in 
other  acute  diseases  according  as  they  were  recorded  in  31as.sachns<Uts  or  Paris  ;  Lours  reportetl  til  cases  of  iliarrhiea  in  il'.i  of  acute  diseiLse  other  than 
tyi)boid  fever,  which  is  nearly  :tO  per  cent.,  while  in  150  cases  of  similar  dis»^a.se  in  New  Kngland,  diarrluea  was  present  in  only  IS  cases,  or  1 1  i>er  cent. 
From  these  facts  he  concluded  that  the  more  frequent  (K-currence  of  diarrluea  iu  t\w  fever  of  Paris  was  not  to  Im>  attributed  to  any  ih-culiarity  in  tho 
characti'ristics  of  the  disease  itself  as  comi)ared  with  the  typhoid  of  New  Englantl,  but  to  some  more  general  cause  affecting  other  acute  diseases  in  all 
efuml  proportion.  It  is  possible  that  the  more  general  cause  may  have  been,  to  some  extent  at  least,  a  want  of  precision  in  the  application  of  the  term 
diarrhcea. 

t  .Mu:ii'illS0N  considers  diarrha'a  to  lie  absent  iu  fully  one-fifth  of  the  cases,— p.  .524.  See  also  the  pri'ceding  note  giving  the  observations  of  Louis 
aiul  II.M.F,.  In  Flint's  Ch'iiUaJ  llf^mrtu  on  Cimlmtu'tl  Ftrer  he  states  that  diarrlne.-i  more  or  less  iu  degree  or  duration  Wiw  jirest'tit  in  12  of  hi  ca.ses  of 
typhoid  fever,  in  7  of  which  it  was  mild  or  slight,  in  1  severe  and  in  4  subst-quent  to  the  opemtion  of  cathartics, — p.  80 ;  in  0  of  18  cji-ses  and  in  14  of  29 
eases, — p.  173 ;  and  in  l:i  of  14  cases,  in  all  of  which  it  was  mild  and  eiisily  restrained  by  o]iiates, — p.  31t'i.  With  few  exceptions,  probably  not  more  than 
three  or  four,  no  cathartic  or  laxative  medicine  was  ailministered  in  the  cases  analyzed  by  Vr.  Flint,  consequently  the  conilitiiui  of  tlie  bowels  as  respects 
frequency  of  the  dejections  and  other  symptoms  were  such  as  iMdong  to  the  disea.se  iininiluenced  by  medical  interference.  The  fa<"ts  contained  in  tho 
histories  of  some  of  his  ca.ses  he  considers  to  be  of  int^^rest  and  importance,  and  IwHi'ves  that  they  will  be  a  surju'lse  to  some  of  his  readi-rs  as  showing 
that  oftentimes  instead  of  diarrhcea  a  slate  of  absolute  constipation  was  present.  He  gives  several  c!i.ses  iu  illustration,  of  which  the  following  is  quttted 
aa  a  specimen  :  "t'twe3.  In  this  case  the  bowels  had  not  moved  bu-  //o'-'' days  prim- lo  adniissii>n.     They  remained  tpiiescent  for /*(■"  days  after  luinii.ssion 


294  SYMPTOMATOLOGY    OF 

In  general  tciMns,  the  gravity  of  the  afl'eetion  was  |iroportioned  to  tlie  severity  of  tlie 
diarrlicea.'^'  In  mild  cases  the  diarrhoeal  attack  was  slight;  in  severe  cases  it  was  aggra- 
vated, and  deatli  in  many  instances  was  precipitated  by  its  violence.  The  frequent  occur- 
rence of  involuntary  passages  shows  that  an  implication  of  the  cerebral  system  did  not 
interfere  with  this  manifestation  of  the  morbid  condition  of  the  intestinal  tract.  But  there 
were  many  exceptional  cases  in  which,  with  moderate  diarrhea,  perforation  of  the  intestinal 
tunics  took  place  and  deatli  resulted  from  the  escape  of  fsecal  matters  into  the  peritoneal 
cavity.  The  subject  of  perforation  will  be  submitted  to  better  advantage  in  connection  witli 
the  jwst-mortem  records.  Cases  also  proved  fatal  from  the  gravity  of  pulmonary  lesions 
without  being  of  necessity  associated  with  an  aggravated  diarrhoea. 

Hemorrhage  from  tlie  boivels  occasionally  added  to  the  exhaustion  consequent  on  the 
diarrhoea  and  prosti'ation  due  to  the  specific  action  of  the  fever-poison.  In  case  28  of  the 
Seminary  series  the  bleeding  was  profuse,  and  occurred  about  the  end  of  the  third  week,  no 
doubt  from  an  invasion  of  the  vascular  walls  by  tlie  ulcerative  process;  the  case  terminated 
favorably.  It  is  probable  that  bleeding  in  small  quantity,  dependent  on  a  congested  state 
of  the  intestinal  mucous  membrane,  occurred  in  some  instances  at  an  early  date  without 
exercising  any  marked  influence  on  the  ^^rogress  of  the  disease ;  but  it  is  certain  that  the 
profuse  hemorrhages  of  a  later  period  were  symptomatic  of  grave,  immediate  and  possible 
dangers.  Occasionally  severe  hemorrhage  occurred  in  cases  which  were  otherwise  free  from 
alarming  symptoms;  of  this  Brigade  Surgeon  Geoege  H.  Lyman  has  furnished  an  instance. f 
Fatal  exhaustion  sometimes  followed  the  loss  of  blood,  as  in  case  27  of  the  j^ost-mortem 
records.  But  if  the  patient  rallied  from  the  loss,  the  possibility  of  a  fatal  recurrence  or  of 
peritonitis  with  or  without  perforation,  as  suggested  by  the  depth  of  tissue  necessarily 
involved  in  the  ulcerative  process  before  a  hemorrhage  of  this  character  could  take  place, 
was  such  as  to  occasion  the  most  serious  forebodings.  J  It  is  probable  also  that  fatal  exhaus- 
tion was  sometimes  the  result  of  hemorrhage  which  did  not  manifest  its  existence  by  the 

and  moTPtl  apontanoously  on  the  Ihird  day,  i.  c,  on  the  sixth  day  after  tho  last  iireceding  movenicMit.  On  the  day  following  another  dejection  occurred, 
which  was  moulded  and  perfectly  natural  in  ap|iearauce— a  phenomenon  which  is  not  likely  to  fall  under  the  ubserTatiou  of  practitioners  who  are 
accustomed  to  administer  catliartics  daily,  or  every  other  clay,  during  the  progress  of  the  iliseasel"— p.  17."i. 

*  MuRcnisoN  is  very  positive  on  this  point.  He  says,  p.  :yH  :  "  Twelve  years  ago  I  found  that  in  ;i-4  cases,  whore  the  diarrhoea  from  its  severity  or 
duration  was  noted  as  excessive,  1(1  dieil ;  hut  that  only  Id  died  lait  of  an  cases  in  which  the  diarrhmi  was  moderate  or  slight.  Since  then  I  have  had 
un.lir  my  care  more  than  two  thi>usand  ca.ses  of  enteric  fever,  and  no  fact  apjiears  to  me  to  he  better  established  than  that  the  severity  and  danger  of  this 
disease  are  in  direct  laoportiou  to  the  intensity  of  the  diarrh.ea."  Natfiax  Sjiitu  in  W■>^,  writing  of  the  fever  as  it  prevailed  in  Nevi-  England,  expressed 
a  similar  opinion  :  "The  danger  of  the  disease  is  in  proportion  to  the  violence  of  the  diarrhiea  ;  when  the  patient  has  not  more  than  four  or  five  liquid 
stools  in  the  twenty-four  hours  it  is  not  alarming,  as  it  does  not  seem  to  weaken  him  much,  but  if  they  exceed  that  number  serious  consequences  may 
Iw  ajiprehended," — p.  ;i7. 

fSee  his  letter  to  the  Boslnn  Med.  iniil  Stirg.  Jimnial,  Vol.  LXV,  18fi2,  p.  :i8n :  "One  case  of  continued  fever  so  mild  in  its  type  as  to  call  feu-  little  or 
no  treatment  was  complicated  with  intestinal  hemorrhage  to  an  alarming  degree." 

t  Hemorrhage  from  the  bowels  (x-curred  in  til  of  .Iacksox's  :ilO  cases,  and  of  these  21)  terminated  favorably  while  11  died.  "  In  some  instances 
the  hemorrhage  was  followed  by  ridief,  and  in  a  few  by  well  marked  and  permanent  relief.  But  in  nuist  there  was  great  weakness  and  sense  of  exhaustion 
in  consequence  of  it,"— p.  39.  Notwithtanding  his  statennuit  as  to  the  relief  occasionally  obhiined,  this  author's  observations  show  distinctly  the 
increased  danger  in  cases  attended  with  hemorrhage,  for  while  the  gcuenil  death-rate  based  on  his,;i03  observations  was  13.8IJ  jier  cent.,  the"  rate 
among  the  hemorrhagic  cases  was  35.r)  per  cent.  Hemorrhage  amcjunting  to  over  six  ounces  occurred  in  ,''i8  of  1,504  cases  under  Murckison'r  care,  or  in 
3.77  per  cent.  In  18  of  CO  hemorrhagic  cases  the  antecedent  symptoms  were  mild,  and  in  8,  of  which  6  were  fiital,  the  bowels  up  to  the  occurrence  of  the 
hemorrhage  had  been  constiimted.  Of  the  60  C8.ses  the  bleeding  commenced  towards  the  close  of  the  second  week  in  8;  during  tlie  third  week  in  28; 
during  the  f.)urth  in  17;  during  the  fifth  in  1;  during  the  sixth  in  3;  during  the  seventh  in  1,  an.l  during  the  eighth  in  1,  while  in  1  case  the  date  of  its 
occurrence  was  not  reior,led.  In  three  cases  where  it  took  place  on  the  sixteenth,  eighteentli  and  nineteenth  days,  it  recurred  on  the  forty-ninth,  thirty- 
m-imd  and  forty-foiirth  days.  This  author  never  oliserve,!  benefit  from  its  ..ccurrenie,  but  on  the  contrary  lias  frequently  seen  iKitients  die  unexi.c-.'t- 
edly  l.y  syncoix.  a  few  hours  after  a  copimis  bleeding.  He  therefore  agrees  w  itii  BHET.isxEAr,  Cuomki.,  I.otis,  .If.xnf.r,  Hei.i.  and  othi'rs  in  regarding  it 
as  a  .laugerous  symi.tom,  although  he  cites  somi-  auth<.rs  wh,.  taught  otherwise:  Hravks,  in  his  fli„ical  Uri«ny,  Dublin,  1848,  Vol.  1,  p.  2(1(1,  .-is  speaking 
of  c.Ttain  eases  in  which  the  .H.urreiiee  ,.f  hemorriiage  was  thought  to  be  prwluctiv.-  of  marked  benefit;  Kennkuv,  aiiutmr.jh  Med.  Jour  \KW  p  ■'•'(; 
as  of  a  similar  opinion,  and  TROisSEAf,  rlwi^.e  Medicale,  Paris,  180.%  1. 1,  p.  22.5,  as  urging  that  it  is  a  less  dangerous  symptom  than  is  generallv  tlionght, 
inasnnich  as  in  seven  years  he  had  known  only  three  cases  to  prove  fatal,-pp.  52.5-29.  LiEriEKjiEiSTER,  although  failing  to  concur  with  (Juaves  an,l 
TROfsSEAV  a«  to  the  favorable  import  of  liemorrhage  from  the  bowels  in  this  fever,  does  not  on  the  other  hand  regard  it  as  having  so  dangerous  a  signifl- 
cance  as  was  formerly  thought.  His  mortality  statistics  agree  with  those  of  .Iacksox  given  above  :  38.(1  per  cent,  of  his  hemorrhagic  cases  died,  while 
tho  general  rate  was  only  11.(1  per  cent.  Nevertheless  he  points  out  that  a  patient  seldom  dies  as  the  direct  result  of  hemorrhage  or  during  tho  collapse 
that  imniediat.dy  follows  it,  and  he  considers  the  statistics  inconclusive,  since  bleeding  occurs  most  frequently  among  the  gravest  cases  in  which  tln^ 
mortality  without  hemorrhage  would  still  be  highest.  He  concludes,  therefore,  that  "  while  int..stiiial  hemorrhage  must  be  regarded  on  the  whole  as 
affecting  the  prognosis  uiifuv..nil)ly,  vt  ea.h  individual  i  ase  must  bejudge.l  on  its  own  merits,-— p.  149. 


THE    CONTINUED    FEVERS,  295 

presence  of  blooil  in  the  stool.s/^=  Although  no  cHnical  history  is  recorded  in  case  176  of 
t!ie  post-morteni  series,  the  possiltiHty  of  tlie  occurrence  of  death  witliout  external  man- 
ifestations of  erosion  of  the  intestinal  vessels,  other  than  those  involved  in  the  sujiervention 
of  sudden  collapse,f  is  strongly  suggested  hy  the  condition  of  the  colon,  which  was  found 
filled  with  blood  for  eighteen  inches  of  its  length. 

Diarrhoea  occurring  during  the  course  of  the  primary  fever  was  associated  with  heat  and 
dryness  of  skin,  and  in  mild  cases  its  subsidence  was  concomitant  with  the  decline  of  the 
pyrexia.  Moreover,  when  it  persisted  at  a  later  period  along  with  a  persistence  of  the  febrile 
action  in  more  dangerous  cases,  its  abatement  or  absolute  cessation  was  often  coincident  with 
the  appearance  of  moisture  on  the  skin  and  especially  of  free  perspirations.  Thus  in  eleven 
of  the  Seminary  cases  a  moist  condition  of  the  skin  was  followed  by  more  or  less  quiescence 
of  the  bowels,  and  in  one,  49,  tlie  recurrence  of  acute  diarrhoea  was  associated  with  sup- 
pressed perspirations  and  increased  lieat  of  skin.  On  the  other  hand,  in  five  instances,  16, 
27,  34,  46  and  47,  looseness  of  the  bowels  persisted  notwithstanding  the  occurrence  of  per- 
spirations; in  tw^o,  14  and  37,  it  followed  their  appearance,  and  in  one,  26,  it  abated  with 
diminution  of  tlie  febrile  heat  some  days  before  the  skin  became  moist.J 

Although  diarrhoeal  stools  were  usually  passed  without  pain,  the  patient  generally 
suffered  from  pain  or  tenderness  in  the  abdomen  at  some  period  of  the  disease.  In  many 
instances  the  tenderness  was  limited  to  the  situation  of  the  ileo-colic  junction,  and  although 
in  others  the  suffering  was  not  thus  localized,  it  was  nevertheless  more  acutely  felt  in  that 
region  than  in  other  parts  of  the  abdominal  cavity.  It  was  frequently  associated  with 
tympanitic  distention  and  gurgling  on  pressure. §  These  symptoms  usually  accompanied 
the  diarrhcjea,  sometimes  preceded  it,  and  often  persisted  after  its  subsidence. 

Tenderness  was  inescnt  in  thirty-iiine  of  the  forty-nine  Semin.ary  cases,  tympaniten  in  twenty 
eiglit  and  ffurfflinff  in  nineteen. 

Tenderness  was  recorded  as  having  affected  the  al)donien  generally  in  eighteen  of  the  thirty-nine  cases,  but 
in  ten  of  tlicse  ccitaiii  regions  were,  in  addition,  siiecifiiMlIy  indicated  as  the  seat  of  sufiering;  in  time  the  riglit 
iliac  region  was  )  particularized,  in  tiro  tlie  right  iliac  and  umbilical  and  in  fin:  both  iliac  regions, — one  of  these  having 
the  umbilical  and  another  the  hyjiogastrie  region  also  airected.  The  right  iliac  region  was  mentioned  alone  as  the 
site  of  tenderness  in  fifteen  cases,  and  in  association  with  other  regions,  in  addition  to  the  cases  just  mentioned  in 
connection  with  general  abdominal  tenderness,  three  times — with  the  umbilical  once,  the  left  iliac  once  and  the 
hypogastric  and  umbilical  regions  once.  The  last-mentioned  region  was  principally  affected  in  one  case,  6,  in  wluch 
the  tenderness  was  jirobably  due  to  castor  oil  administered;  pain  in  the  epigastrium  was  reported  in  one  case,  17,  in 
which  the  onset  of  the  disease  was  characterized  by  the  presence  of  nausea;  lastly,  in  one  case,  18,  tenderness  was 
associated  at  different  times  with  different  regions,  as  the  left  iliac,  epigastric  and  umbilical,  the  track  of  the  colon, 
and  on  one  occasion  the  right  side. 

In  these  thirty-nine  cases  of  abdominal  tenderness  the  general  surface  is  mentioned  eighteen  times,  tlie  right 
iliac  region  twenty-eight  times,  the  left  iliac  seven  times,  the  umbilical  seven  times,  the  epigastric  three  times  and 
the  hypogastric  once. 

*  MuRcnisoN  has  known  profuse  bleeding  to  take  place  into  the  bowels  and  the  patient  die  before  any  blood  had  been  voided, — p.  F^'ZCt. 

f  *'In  any  case  of  intestinal  hemorrhage  the  temiierature  suddenly  falls  sometimes  below  the  normal  standard,  but  it  speedily  regains  its  former 
height  or  rises  beyond  it." — Mcrchisox,  p. 526.  "If  severe  heniorrhagea  supervene  in  the  cttnrse  of  ab<loniiiia!  tyithus,  iiartieularly  heniorrbajres  from 
the  bowels,  a  considenible  fall  of  temiM?rature  may  be  met  with,  even  to  below  normal;  but  the  temperature  usually  rises  again  speedit}'  to  the  previous 
heights,  or  even  above  them." — C.  A.  Wuxderlich,  Oh  the  Tetiqifrutiire  in  i>we((-sefi,  New  Sydenham  StK'iety,  London,  1800,  p.  :il3. 

tSee  notes  on  pp.  2S;i  and  284,  )*Hj)ra,  indicating  the  greater  frerpiency  cjf  iwrspirations  throughout  the  attack  of  typhoid  fever  in  the  disease  as 
described  by  the  authorities  than  in  the  ea.scs  depicted  by  our  medical  ofticers  during  the  war,  and  the  opiniuu  that  such  perspinitions  have  no  favonible 
intluiuice  on  the  progress  of  the  di-sease.  Speaking  di-iinitely  as  to  a  possible  relationship  between  iwrspiratiou  and  diarrhtea  Loris  siiys,  t.  II,  p.  2ti(i, 
that  in  grave  ca.ses  which  recovered  the  skin  was  ordinarily  dry  during  the  day  ami  a  iiart  of  the  night,  while  during  the  remainder  of  the  night  there 
was  nearly  always  sweats  which  were  no  nujre  inlluenced  by  the  diarrho-a  and  bail  no  more  intlnence  on  it  than  in  the  fatal  cases ;  and  he  bad  already 
slmwu  that  tliree-fourths  of  the  latter  had  lieen  affected  with  copious  perspirations.  He  also  mentions — p.  207 — the  case  of  a  patient  witli  obstiuato 
diarrh<»-a  in  whom  the  perspirations  lasted  for  eighteen  days. 

^(iurgling,  as  elicited  by  pressure  with  the  hand  <m  the  lower  part  of  the  alsiomen  and  especially  in  the  right  iliac  region,  was  regarded  by 
CnoMEl,  as  of  diagnostic  importance.  In  his  experience  it  was  a.^  rare  in  other  iliseases  as  it  was  etimmon  in  typhoid  fever, — t.  I,  p.  12.  H.MtTl.ETT 
rousidered  it  a  diagnostic  element, — p.  78.  Ref.ves  found  it  a  constant  accunii>animent  of  enteric  f(;ver, — p.  20.  MrnciliaoN  noted  it  in  :J1  of  44  cases, 
but  sub.sequent  experience  sjitisfied  him  that  it  is  absent  in  a  larger  proportioti  nf  cases  than  is  indicated  by  these  figures, — ]>.  ."i2:i.  Wilson  consiilers 
that  this  symptom,  when  associated  with  tenderness,  has  an  undoubted  diagnostie  valm-,  but  as  it  occurs  sd  constantly  in  other  atfectiuns  attended  with 
diurrbeea  it  cannot  be  looked  upon  as  a  characteristic  phenomenon  of  enteric  fever, — p.  174. 


296  sYMPTfnrATor.ofiY  of 

Teiidc.nit^sM,  iiltliouf^li  iisiiiilly  not  a  somcr  of  iiiiii-li  com  plaint .  wiis  s<nnetiiiios  very  acute;  in  10  it  was  recorded 
as  exquisite,  and  in  liO  the  jiatieut  olijceted  to  havinj;  the  alidomen  touched. 

In  tlireo  ol'  tlie  four  cases  which  were  free  from  diarrhu'al  tendencies  there  was  nevertheless  some  tenderness 
of  the  abdomen.  Amonj;  these  is  included  ea.se  29,  in  whi(di  the  bowels  were  moved  by  the  action  of  castor  oil;  the 
only  case  which  presented  no  cliuioal  sign  of  an  enteric  lesion  was  tire  mild  and  ai>i)areutly  unsiiecific  attack  recorded 
as  case  2. 

Of  the  ten  cases  in  whicli  there  is  no  record  of  abdominal  tenderness, /o«r,  2,  4,  12  and  11,  were  of  a  mild  tyi>e. 
In  one,  31,  which  was  more  severe,  tht^  prcKcnce  of  tympanites  on  the  record  suggests  that  the  absence  of  tenderness 
may  have  been  due  to  an  omission  on  the  part  of  the  recorder.  A  similar  remark  is  applicable  to  the  tlirce  fatal  cases, 
41,  45  and  51.  In  one  case,  39,  the  gravity  of  the  atfection  was  dependent  on  chest  comi)lications,  and  in  one,  41,  the 
record  was  cut  short  by  the  accidental  death  of  the  patient. 

Distention  of  tlie  abdomen  was  usually  present  in  severe  cases  and  absent  in  those  of 
a  mild  type.*  Generally  it  was  associated  with  diarrhoea  and  abdominal  tenderness.  It 
was,  however,  sometimes  present  in  the  absence  of  decided  diarrlicea,  as  in  46,  in  whicli 
an  enema  was  given  for  its  relief.  In  four  cases  specified  in  tlie  last  paragraph  tympanites 
appears  on  the  records,  while  tenderness  is  not  mentioned;  but  in  some  of  the  cases  it  is 
stated  that  although  the  abdomen  was  tympanitic  there  was  no  tenderness:  In  case  12  it 
does  not  tippear  that  the  abdomen  was  at  any  time  tender,  and  at  one  period  in  the  history 
of  26  there  was  much  tympanites,  but  no  tenderness  until  some  time  later  when  the  right 
iliac  region  became  acutely  affected.  On  the  other  hand,  in  10,  with  much  tenderness  the 
abdomen  was  reported  as  scaphoid,  a  term  ambiguous  in  this  connection,  but  probably  used 
to  indicate  a  concavity  of  the  surface;  but  in  48  there  is  no  uncertainty  as  to  the  condition. — 
the  abdomen  became  flat  shortly  before  death. 

The  frequency  with  wliich  tympanites  was  present  in  fatal  cases  may  be  seen  by  a 
reference  to  the  post-7no7^tem  records.  In  case  19  of  this  series,  the  only  instance  in  whicli 
raeteorism  is  stated  as  7iot  present,  hardness  and  tenderness  of  the  abdomen  were  associated 
with  symptoms  of  intestinal  perforation.  Pain  and  tenderness  in  cases  fatal  by  peritonitis, 
with  or  without  perforation,  were  usually  extreme,  but  not  always  confined  to  the  anterior 
aspect  of  the  abdomen;  in  249,  the  pain,  whicli  was  so  exquisite  as  to  occasion  loud  outcries, 
was  referred  to  the  back. 

In  connection  with  the  symptoms  referable  to  the  abdomen  it  may  be  mentioned  that 
in  no  case  do  the  clinical  records  refer  to  enlargement  of  the  spleen  as  a  characteristic  of 
this  fever.  That  it  existed  is  certain ;  necroscopic  observations  leave  no  doubt  of  tlie  fact, 
but  the  attention  of  our  medical  officers  does  not  appear  to  have  been  given  to  its  detection 
during  life.f 

*IIale  recognized  meteorisni  in  130  of  107  cases;  in  43  it  was  not  pregont,  and  in  24  his  records  did  not  sliow  whether  it  was  present  or  absent, — p. 
190.  MuKCHlsoN  found  the  distention  j^reutest  in  the  gravest  cases ;  it  was  iire.st:nt  in  20  of  21  fatal  caises ;  of  17  in  which  it  was  extreme,  death  iK'Curred 
in  7,  wliile  of  ti2  in  wliich  it  was  nnxlerate  or  slight  only  14  dieil,  and  of  21  in  which  it  was  absent  none  died, — p.  522.  Jf.n.neh  pointc<l  out  that  the 
"convexity  is  from  side  to  side  .and  not  from  aixiv('  downward.  The  jiatient  is  never  pot-bellied  but  tiib-shapeil,  the  cause  probably  being  that  the  flatus 
(K'cupies  the  colon,  asceinling,  desc<'nding  and  transverse," — Mnithhj  Jfinr.  MeiL  Scienv,  Edinburgh,  Vol.  IX,  184?>,  p.  820, 

f  Since  TiOurs  tirst  called  attention  to  enlargement  of  the  spli-c-u  in  cases  ehanicterized  by  tumefaction  and  ulceration  of  the  patches  of  Peycr  thi.s 
condition  of  the  organ  has  assumed  an  increased  importance  in  the  opinion  of  tins  profession,  l>eing  generally  reganled  as  one  of  tlie  most  constant  and 
characteristic  symptoms  of  ty]»hoiii  fever,  J,\ckson  in  1838  wrote  that :  ''  Knlargenient  of  the  sideeli  was  discovered  in  various  cases  ;  some  before  we  were 
aware  of  M,  Locia's  ob.servations  on  this  point,  and  many  more  after.  But  it  was  not  a  matter  so  carefully  attended  to,  in  (^'ery  case,  as  to  give;  value  to 
our  observations," — p.  57.  The  tniietied  spleen  was  felt  during  life  in  lit  of  Knocu  II,\lk's  cases,  not  felt  in  21  and  not  noted  on  the  reconi  in  1.57  cases. 
He  sjiys :  "Enlargement  of  the  sphn-n,  as  perceptible  during  life,  is  not  of  nuicli  value  as  a  pathognomonic  sign.  This  organ  is  occasionally  felt  below 
tlie  ribs,  or  by  pressing  the  fingers  under  the  cartilages  during  a  full  inspiration  ;  but  in  many  cases  it  cannot  bi*  perceived  even  where  examination  after 
death  shows  it  to  i«i  much  enlarged,  A  careful  percussion  wouM  aid  in  liiscovering  it.  Hut  since  there  is  much  uncertainty  in  regard  to  the  enlarge- 
na-nt  itself,  as  a  constant  occurrence,  and  some  difficulty  in  ascertaining  it  when  it  does  occur,  we  can  attach  very  litth^  iniiKtrtance  to  it  in  diagnosis," — p. 
r.K»,  Jlut  although  these  observei-s  thus  hing  ago  culled  attention  to  the  enlai'ged  spleen  us  a  symitton]  and  aid  to  diagnosis  in  typhoid  cases,  tin' 
changes  in  tin!  organ  were  mentioned  l)y  B.\rtlktt,  Woon  and  Dickson  only  as  r,f  pmi-mortinn  interest,  and  to  this  is  probably  due  the  failure  of  our 
meilical  officers  during  the  war  to  note  splenic  enlargement  in  their  clinical  records.  MrRclllsox  says  the  spleen  is  riften  much  enlarged  and  c-an  be 
felt  through  the  alxloudnal  w^all, — p,  .523 ;  and  Likhkhmkister,  tliat  the  enlargement  begins  early,  and  can  usually  be  demonstrated  after  the  iniddlc  of 
the  fii-st  week,  increasing  in  tlie  second  week,  diminishing  in  the  fourth  week,  and  at  the  height  of  tlie  distsast!  ntachiug  to  double  or  treble  its  normal 
size, — p,  104.  CllRiSTl.vN  Bav.mlER — Can  the  Mildest  Forttts  of  Eitttn-ic  fri-rr  he  itiMltmjuixhed  frnm  aeiite  Febrile  hitt  n'm-tfpecijic  tiuuftru-eiUerw  Ctttarrk  t — hahUu 
Journal  Med.  KtejiccK,  Vol,  10,  1H80,  ji,  384 — answers  Iiis  (piery  in  the  aflfirmative  by  the  statement  tliat  a  decided  enlargement  of  the  sjileeli  existing  from 
the  iH'gimiiag  of  tbi!  attack  clearly  points  to  the  infectious  nature  of  a  given  disease.  His  experience  le.ads  him  to  doubt  the  existence  of  a  "gastric 
fever,"  /.  ♦',,  a  catairb  *,f  (he  mucous  membrane  of  the  stomach,  or  |K'rliai»s  ul^n  <.l'  the  small  intestine,  accoiii|Ktnied  by  pyrexia  of  a  week's  duration  or 


THE    CONTTNUKI)    FEVERS.  297 

('iiKsrSYMl'TOMsaii-iiiL-iithiiR-il  in  thiity-oiieot' tUo  lifty-oiie  S<-iiiiiiary  cases.*  Broiicliial  eougli  was  frciiuently 
an  I'uily  syniptdni  of  the  attack:  suiiictinics  dry,  at  otlier  times  att.'iuled  witli  IVotliy  expectoration,  it  nsnally  con- 
tinned  to  the  end  of  the  fever,  and  in  occasional  instances,  as  in  :i.",.  persisted  for  some  time  h)nj;er.  lint  in  many 
cases  it  was  not  dcvehipcd  until  towards  the  end  of  the  primary  fe\  cr. 

In  al»nit  two-thirds  of  the  thirty-one  cases  the  con^'h  was  slifjht  and  did  not  add  mndi  to  the  sulVerinfrs  of  the 
patient.  In  twe]\e  cases  the  cliest  symptoms  were  severe:  In  ."v  and  11  tliere  was  marked  l)roiudiitis ;  in  J8  conjrli, 
wliich  was  ]iresent  from  the  l.e;;innin,u,  became  associate<l  at  a  later  period  with  siliilant  rales  and  hnrried  respira- 
tion ;  in  :«l  it  was  tronhlesoine  from  the  first,  and  prevented  sleeii  at  a  later  sta>;e;  in  15  also  sleep  was  i.revented, 
:ind  the  hiiif;  comi)lication  certainly  caused  death;  in  3G  and  Ki  there  was  consolidation  of  the  lower  lobes  of  the 
liiiifrs  and  bronchitic  sonnds  In  the  njiper  lo)>es;  in  1:3  death  occurred  from  piihnonary  congestion :  in  50  pleuritic 
sij;us  and  hnrried  respiration  were  noted,  and  in  51  pain  in  the  chest  and  increased  fre<|ncncy  of  the  respiratory 
movements;  in  ;i?<  the  cough  was  slight  at  first,  but  the  patient  from  the  twenty-fifth  to  the  thirty-second  day  labored 
under  a  pnenmonitic  attack,  manifested  liy  jiain  in  the  chest,  hurried  respirati<in  and  rusty  sputa,  and  as.sociated 
with  a  recurrence  of  febrile  delirium  :  lastly,  in  40,  one  of  the  few  cases  in  which  the  chest  syni].toms  were  of  a  serious 
character  during  the  early  stages  of  the  disease,  an  attack  of  pneumonia  lueceded  the  typhoid  onset. 

It  is  to  be  observed,  however,  with  regtvrd  to  the  occunviiee  of  blood-strt>;iked  sputa, 
tliat  tkis  in  some  instances  was  not  a  symptom  of  an  engorged  or  eroded  condition  of  the 
puhnonary  membrane  or  tissues,  but  was  considered  an  accidental  result  of  a  trivial  epistaxis.f 

Bronchial  cough  was  sometimes  associated  with  hoarseness,  indicating  the  i)articipation 
of  the  laryngeal  mucous  membrane  in  the  inflammatory  processes.  Pod-vwrtem  observa- 
tions showed  in  so  many  instances  the  presence  of  ulceration  of  this  ineinbrane  that  inflam- 
matory redness  in  the  fauces  during  life  must  be  regarded  as  strongly  suggestive  of  the 
existence  of  more  extensive  and  dangerous  lesions. J  The  voice  generally  became  low-toned 
or  whispering,  symptomatic  of  general  prostration,  and  in  the  later  stages  of  fattd  cases  the 
power  of  articulation  became  lost. 

In  a  large  number  of  such  of  the  post-mortem  records  as  enumerate  more  or  less  of  the 
symptoms,  cough  is  found  to  have  been  present  with  accelerated  or  difficult  respiration  and 
pain  in  the  chest.  Generally  this  affection  of  the  respiration  was  due  to  congestive  or  nneu- 
monitic  processes,  although  in  many  cases  the  breathing  was  hurried  during  the  first  stages 
of  the  disease  as  a  result  of  the  general  febrile  condition;  but  the  clinical  records  do  not 
set  forth  with  sufficient  precision  the  condition  of  the  lungs  in  these  cases.  The  fatality  of 
this  fever  among  our  troops  as  compared  with  that  of  the  same  disease  in  the  experience  of 
civil  practitioners,  together  with,  as  will  be  seen  hereafter,§  the  great  frequency  of  lung 
complications  in  the  fatal  cases,  gives  definite  testimony  as  to  the  greater  frequency  and 
severity  of  such  complications  among  the  typhoid  cases  of  the  war. 

Other  Clinical  Features. — Micttiritiotl  was  frequently  involuntary.  Sometimes  the  urine  was  passed 
with  difficulty,  as  in  12,  28  and  35;  in  the  first  of  these  dysuria  during  the  fourth  week  was  accompanied  with  pain 
and  the  passage  of  blood  from  the  Tjladder,  and  in  the  second  the  use  of  the  catheter  was  re((uired  to  alleviate 
hypogastric  distress.  But  pain  and  swelling  in  the  hypogastrium  were  not  always  indicative  of  retention  of  urine, 
as  may  be  seen  in  ease  244  of  the  ponl-mortem  records,  in  which  an  abdominal  abscess  was  the  cause  of  these  symptoms. 
It  may  1)6  observed,  however,  that  this  case  is  not  recognizable  from  the  record  a.s  one  of  typhoid  fever. 

The  urine  was  scanty  and  high-colored  dtiring  the  primary  fever,  but  its  characters  at  a  later  dat(>  were  seldom 
specified.     In  the  Seminary  case,  28,  the  liquid  removed  had  a  strongly  alkaline  reaction  and  contained  blood, 


more  anil  t)y  goncral  febrile  symptoms.  He  must  therefore  liave  met  with  few  cases  in  which  percussion  failtMl  to  outline  .an  enlarged  ppleen.  Never- 
theless, LiKBERMKisTER  obseFves  that  eularj<ement  is  sometimes  absent,  esiwicially  in  old  i)ersons,  in  whom  the  anomaly  is  exjilained  !iy  a  tliiekenin"  of 
the  capsule  or  stroma  of  the  orfran,  or  by  the  possession  of  a  sjileen  smaller  than  the  normal  bi'fore  the  commeneentent  of  the  diseas*- ;  and  he  cites  Hoff- 
mann a*  having  stated  that  the  essential  changes  can  be,  and  usually  are,  present,  although  the  spleen  is  not  strikingly  enlarged. 

*In  Loris's  e.vperienci!  cough  was  present  in  oil  of  07  subjects  who  had  severe  attacks  of  the  f.'ver,  lint  it  was  generally  so  slight  and  infie,ini-nt, 

that  its  existence  would  not  have  1 n  reconleil  had  he  made  note  only  of  that  which  came  under  his  |«'rsoual   observatiim ;  and  it  W!ls  but  little  less 

fr-eqnent  in  the  cases  wliiclrwcre  mildly  atfected,— t.  II,  p.  2H;J. 

t  L.urs  indicates  Mood-tinged  sjaita  as  dne  .Mcasionally  to  ejiistaxis,— t.  II,  p.  ■J.t^W.  Ki.int  also  nides— p.  I'.l'.l— that  ■■in  three  iiises  sputa  ex|M>ito- 
rated  were  observed  to  be  streaked  witli  blood,  which  miiy  have  been  derived  from  the  iK>sterior  nares,  but  this  is  not  certain.'' 

I  W.  W.  Keex— 0«  the  Surijiml  complk'aiwm  and  t^equeltt  of  Hit'  Cntttinlied  Fei-fru,  AVashington,  Smithsonian  Institntttni,  IsTT — regards  hiKirscness 
and  sometimes  complete  aphonia,  followed  by  jiaroxysms  of  ilyspnu-a,  especially  at  night,  as  the  symptoms  of  laryngeal  implication,  lint  even  tie-  tii-st 
paroxysm  may  be  sudden,  unexjiecteii  and  fatal,  i>articularly  in  supni-glottic  oedema.  He  shows  laryngeal  disea.si'  to  Iw  a  tans.'  of  dysphagia,  which  is 
present  in  cricoid  anil  arytenoid  necroses;  for  in  sixteen  such  cases  the  pharynx  was  normal  in  ten  and  inflamed  in  only  six  cn.scs,— pp.  ■>.",,  •.>il. 

i  See  iii/m,  p.  4311. 

Med.  Hi.st.,  1't.  111—38 


298  ^iYMPTOMATOLOGY    OP 

iiiucuH,  piiH,  cpitlieliiil  scalrs  anil  excess  of  vli'isiiliates ;  in  50  it  was  acid  and  allinniinous,  and  in  :-!8  albnniinons  dmini; 
t,Iio  later  stat;cs,  when  pnciiiiionia  was  iiresent,  l)ut  noi-nial  clicMiically  and  niicroscoiiicall.v  earlier  in  tlie  attack.* 

Diminished  secrotiou  of  uriiii\  k<j  i'rofjiitMitlv  roportcJ  in  tho  oarly  period  of  the  diseas(^ 
\v;is  ol'ton  followed  by  delirium  or  stupor,  but  it  does  not  appear  that  any  causal  relation- 
sliip  existed  between  these  phenomena;  tlie  urine  was  scanty  in  many  cases  that  wore  not 
characterized  by  jn-ominent  head  symptoms. 

The  parotid  f/lnntls  laecame  aftected  in  two  of  the  Seminary  cases,  44  and  50,  and  in  several  of  those 
detailed  in  the  j>ys(-«ior((!m  records. t 

Tiie  inflammatory  action  was  rapid  in  its  progress  to  suppuration  and  disintegration 
of  the  glands.  As  this  complication  is  not  mentioned  in  any  of  the  recoveries  its  presence 
must  be  regarded  as  significant  of  extreme  gravity;  moreover,  as  it  is  generally  accounted 
a  rare  complication  of  ty})]ioid  fevei',  the  f'requenc}'  <jf  its  appearance  among  our  cases  duiint'' 
the  war  must  be  received  as  distinguishing  them  from  the  typhoid  of  civil  life. J 

Itetl-Hores  were  developed  on  the  parts  subjected  to  continued  pressure  in  cases  24, 28  and  36  treated  in  tho 
Seminary  hospital,  and  in  several  of  t\iG poxt-morUm  series. 

JPnins  in  the  lowev  eccfremities  were  reported  in  four  of  tho  cases  as  having  added  much  to  tho 
Hufferinj;s  of  the  patients  at  an  advanced  stage  of  the  disease:  In  the  feet,  on  the  subsidence  of  the  primary  fever 
in  32;  in  tho  legs  for  a  few  days  during  convalescence  in  33;  in  the  heels  and  legs  about  the  beginning  of  the  fourth 
week  in  28,  and  in  the  logs,  which  were  greatly  emaciated,  late  iu  the  progress  of  tho  fatal  attack,  40.  But  as  these 
manifestations  belong  to  tho  sequche  of  the  disease  rather  than  to  the  primary  attack  or  its  complications,  they  will 
lie  referred  to  hereafter  in  their  aiipropriate  connection. § 

JiELAPSES. — It  need  hardly  be  pointed  out  at  this  stage  of  the  analysis  that  the  febrile 
cases  under  examination  seldom  ran  a  regular  course  from  their  accession  to  the  establish- 
ment of  convalescence.  On  the  contrary  diarrhoea  and  painful  raeteorism  were  prone  to 
recur  after  they  had  apparently  subsided  or  been  controlled  by  medicine,  and  latent  lung  affec- 
tions were  liable  to  become  suddenly  aggravated  to  a  dangerous  intensity.  Coincident  with 
these  recrudescences  delirium  might  return,  the  skin  acquire  a  greater  heat  and  fresh  crops 
of  the  rose-colored  eruption  make  their  appearance.  The  duration  of  the  attack  was  thus 
in  many  instances  either  prolonged  or  brought  to  a  speedy  and  fatal  termination. 

*  .^ccoriliiiK  ti>  MrRcllisiiN  tho  lirino  is  sciinty,  Iiij^li  colored  and  ;u-iil,  its  KiMn-ifio  gravity  102;5  to  10;JO  during  tho  first  two  week;*,  hut  afterwards, 
and  es|K'cialIy  during  convalesci'nci',  it  is  coi)ions,  jiali',  IVfldy  acid  or  oven  alicaliiio  and  of  low  sinicitio  gravity.  He  lias  known  it  as  low  as  l(H)n  or 
10(i;l, — p.  .VA).  Tlio  anionnt  of  tirou  oxcroted  during  tlio  folirilo  jioriotl  is  in  excess  of  the  normal.  Pakkks  gives  the  increase  at  one-fiftli  or  a  total  daily 
excretion  of  480  grains  in.-.tead  nr4lto  ;  but  it  is  ix-casionally  greatly  in  excess  of  tliis  amount,  VoijEL  having  in  one  instance  found  12(J0  grains  audPAitKES 
880  grains.  An  alti'red  condition  of  the  kidney,  as  shown  hy  tho  preseiu:e  of  albumen  and  tube-casts  iu  the  urini',  may  prevent  the  elimiuation  of  iiroa 
and  induett  symptoms  of  uraimie  poisoning,  a  result  which  may  also  bo  due  to  reabsorptiiui.  Mt'Eteuisox  found  iu  several  iustancos  that  the  quantity  of 
urea  diminisliotl  (ui  the  advent  of  een't»ral  symptoms  and  ilU'roasod  mi  thoir  cessation.  In  one  <-ase  tlie  (juantity,  which  was  'i^ii  grains  wlion  tho  patient 
■was  delirious  and  uiieonsfious,  rose  to  ;n'4  grains  when  the  delirium  abated  and  ciuisciousness  returned;  in  another  the  ijujintity  which  at  first  was 
422  grains,  fell  to  .'i,'»2  on  the  appearance  of  delirium  and  stupor,  and  rose  to  4fH)  when  these  symptoms  ceased.  During  tho  attack  uric  acid  is  increased 
and  clilorido  of  siHliuni  diuiiuished.  This  author  holds  that  albuuiinous  uriue  coincides  with  the  occurrence  of  coreliral  symptoms.  Ho  sums  up  the 
observations  of  Pakkks,  ISrattlku,  BKcyl'KHEL  and  others,  and  finds  that  albumen  was  present  in  tho  uriue  of  157  of  54iJ  cases  of  ty[)hoid  fever,  or  in  28.G 
jior  cent,  of  tho  cases, — pp.  .'»31-5:'2. 

t  See  iii/rn,  p.  420. 

J  Parotid  swellings  and  suppuration  are  more  frequently  a.ssociated  with  typhus  than  typhoid  fever.  Of  certain  cases  studied  by  W.  W.  Keen, 
typlius  was  the  preceding  feviu'  iu  :ir)2  and  typhoid  in  only  2t>, — j).  53.  Murchison  mot  witli  six  cases  of  parotid  bubo,  which  he  regards  as  a  rare  conijdi- 
catiou  of  typhoid  fever,  citing  Loris,  i'homei,  and  Gairdser  as  each  reporting  but  one  case  ;  two  of  his  six  eases  died, — p.  .^8:J.  Sujipunitive  jiarotitis  was^ 
however,  more  frequent  and  less  fatal  in  Hoefmasn's  exiR'rience  at  Bj\slo.  Of  l,f)00  cases  of  typhoid  fever  tlio  parotids  iiocame  inflanied  in  19 ;  iu  10  of 
the  cases  tho  inllaniinatiou  eudeil  in  suppuration,  and  of  those  only  7  proved  fatal  ;  the  right  side  was  afToctod  in  i)  instances,  the  loft  in  fi,  and  both  sides 
in  4, — p.  178.  Correspondingly  iu  this  country,  while  Hai.e  and  Reeves  make  no  mention  of  fsirotitis  as  a  complication  of  their  cases,  Avstin  Flint 
n-i-onls  :t  ca.sos  of  pamtiil  intlaniniatiou  in  7:1  of  fever.  In  his  first  series  tho  parotid  was  inflamed  twice  in  :iO  cases ;  in  liis  tiiird  series  once  in  14  cases, 
while  in  liis  si'cond  series  of  2'.l  cases  this  complication  was  not  present.  Couimenting  on  tliese  dissimila.r  results  iu  his  first  and  second  series  of  cases, 
Dr.  Flint  iioiuts  out  that  "inirotitis  is  not  to  bo  regarded  as  an  intrinsic  element  of  the  disease,  but  one  of  the  events  which  are  duo  to  cortiiin  special 
feudencioa  ineiilent  to  the  disease  at  particular  times  or  platn-s — tendencies  tlie  nature  of  which  are  not  susceptible  of  explanation  with  our  pri'sent  knowl- 
odgo  of  the  pathology  of  fever."' — p.  171.  In  his  first  case  tho  rigiit  jiarotid  became  afTected  on  the  tenth  day  of  the  .attack  and  tho  left  on  the  following 
day.  Tho  large  liviii-red,  lender  and  imiiiful  swelling  immediattdy  proceeded  to  suppuration.  There  was  no  diarrlooa  iu  this  case,  and  but  slight  delirium 
and  iniHlonito  soinuoloney.  The  patient  .sat  up  on  the  twenty-eighth  day,  and  on  the  thirty-second,  wdion  the  last  entry  was  made  in  the  record,  thi'ro 
was  still  some  distdiargo  from  the  absi-oss.  In  the  socoud  cast?  the  right  parotid  began  to  swell  on  tlio  seventh  day.  This  case  was  char.ieterized  by  luitd 
diarrlooa,  tenderness,  nieteorism,  jklssIvo  delirium  and  somnolency  eventuating  in  coma,  the  patient  dying  lui  tho  uintii  day  wliilo  tile  [uirotid  continued 
enlarged  and  resisting  to  the  touch.  In  tho  third  case  the  right  jiarotid  hecunie  affected  at  the  iM'ricdl  of  convalosci?nce  and  itrocoedod  to  supimration  ; 
tho  patient  recovered.  Dr.  .Jackson  noted  f(uir  casoB,  of  which  one  was  fatal,  iu  .30:j  of  typhoid  fever ;  Huppuratiuu  took  jdace  in  but  one  of  the  cases,  the 
issue  in  this  instance  being  favorable,— p.  57. 

J. See  i«//-ii,  p.  :!09. 


THE    CONTINUED    KEVKRS.  299 

But  oases  which  with  accuracy  might  bo  calloil  relapses  were  not  comraon.*  Possibly 
SOUK?  which  ran  a  leiigthciRMl  course  may  liave  been  instances  of  w'hat  Ikvink  lias  calleJ 
intercuri'iMit  rehi])se,f  but  this  appears  to  bo  a  nce<lless  refinement  in  clinii'al  study  Itascd 
upr.u  tlir  ussumjition  ot"  a  regularity  in  tlie  progre^s  of  the  disease  which  is  not  fouiul  in 
nature.  \'^iewing  a  rdapsc  as  a  return  of  the  fever  witli  all  the  symptoms  of  the  primary 
attack  sometime  after  the  recognized  establishmeni  (►f  convalescence,  the  Seminarv  n^'ords 

*  MriiciiisuN  rci-urds  i^n  niai)><>  in  ■^..'■••A  ,m>.>  ..f  tyiihoiii  ffu-r  in  the  \\:iy<U  <•(  t\\r  Li'iuinii  Kcvt-r  liur*pitiil,  «r  in  :i  \»i  <riit.  nf  tin-  caws;  lie  liti-s 
CrRiRsiNiiKR  jiH  liJiviiig  iiiitt'il  tlii'iii  ill  T.  [n-r  '  iiit.  of  4ii:l  r.iM-.-  at  /iirirli,  llrM.w  in  s  ji.t  ctiit.  ol'  MS  at  I.i-ip/i^,  iiiul  Mai'I.ahan  in  Ki  lasi'i*  nr  jiIkivi'  H)  [kt 

crtil.  iif  ijN  riiscs  at  l>uinli'r.     It  .-fiiii-.  cliai'  tiMtii  llir-i'  vat  \  iii^  iH'ncutit^cfi  tliiit  rt'la|i>"s  arr  nt*  iiiur.'  tVi'ipii'iit  uri-iirri-n.r  Jti  xni piili'inii's  tliiiii  in 

c.tliiTs.  .Iaiksiin  callfil  atti'iitiuii  in  this  .niintry  t"  ttii'  p<i>siliility  of  n-Iapsr  in  tyjihoid  :  "An  ■iii.r  in  tlict  uml  n-Ljiintii  is  I'l'lm  rulluwi'd  hy  a  new 
train  uf  symptoiiiH  Hl'tcr  cuiivalfscfncc  fmin  tlii.--  <li><a>c  ;  and  tln-sr  apiKar  tu  nir  to  Im-  swrli  as  h.-liHij;  to  thin  IV'ViT.  It  i.s,  howcvt-r,  true  that  tlicy  aro 
not  always  no  Ktronjily  cliarartiTlstic  as  to  l.a\''  ii.>  doiiM  ..n  th«-  Mil.J.it.  W.  h.iw.v.r.  tht-y  aiv  raii-fnlly  noted,  thi'y  will  not  In-  found  to  airoril  with 
any  uthcr  disease.  1  hopo  hy  tln'sr  n-niarks  to  call  sindi  exact  attmtiun  to  thr  stihjnt  as  may  dtriih-  this  point  hi-rcaftcr,"— p.  (11.  Hut  he  K'vt'S  only 
oiH^  case  to  point  liis  rrrnaiks.  Dr.  Flint's  fxpcrii'iu-c  was  of  ■;n'at«'r  int»'ir>t.  In  Ins  tirst  si-rifs  ipf  tliirly  casi-s  lln-ri'  was  no  iclapsi-,  and  as,  up  to  that 
time-,  In-  had  ni'ViT  witiu-sscd  wliat  nii<;lit  property  !»•  railed  a  ndapse  after  the  <-areer  of  rontiiuied  fever  was  ended,  he  was  Hiirjirised  at  the  statements 
niaile  hy  sonu'  w  riters  on  the  snhjei  t.  I!ut  in  tin'  second  series  of  eases  "  my  attention  was  fiei|uintly  ealleii  to  the  fact  that  ihirin^  ri)nvaleMenee,  and 
after  patients  had  so  far  recovered  as  to  sit  up,  and  even  walk  ahout  the  ward,  they  were  attai-ked  with  fehrile  nn)venn'nt,  sometimes  preceded  hy  a  chill 
aceonijKinied  hy  anorexia,  delirium,  etc.,  tlu'se  symplnins  continnint;  ftir severii!  days,  when  they  aj;ain  hej;an  to  convah'S4-c.  In  sotni'  instantes  I  was  dis- 
pos<'d  to  attrihnte  this  recurrence  (»f  fever  to  imprudence  in  diet,  exposure  to  cold  or  over  exertion,  hut  it  appeared  to  ik-cuf  when  no  such  cause  could  he 
assij;;neil ;  and  as  respects  the  management  of  convah-Hcenci",  tlie  [Kitients  liad  the  heiietU  of  the  sann-  precautions  and  caii'  as  those  whose  histories  were 
emhnici'il  in  the  first  ctdlection,  and  in  the  latter  this  seqnence  of  the  disease  did  not  occur  in  a  siri{r](.  iuHtance.  Moreover,  th4>  fehrile  nniveiuent  un<I 
assm-iated  symptoms  were  out  of  proportion  to  those  which  mifiht  he  expectinl  to  ftillow  the  impriidencert  Just  meuthuied.  The  imtients  in  fact  apiM-areil 
to  [KISS  through  a  second  feiu'lh-  career  of  slmrt  dnnitiou," — ji.  ■224.  Nine  4ases  of  relapse  occurred  in  this  series  of  twenty-nine  typhoiil  case«.  In  Iiik 
third  seru's,  endu-iicing  fourteen  cases,  relapse  occurred  in  hut  a  single  instance.  AIai'Lauan's  experience  runs  pnmllel  tti  that  of  Dr.  Flint.  Tlte  VA 
ridapKes  in  his  128  cas<'s  occurred  within  a  perliMl  of  two  yeats,  and  nmst  of  them  during  <ine  outhn'iik  of  the  disease  siireaiiing  over  a  perio<I  of  fifteen 
nioiitlis, — Kdiuh.  Mi'if,  Ji)nr.,  .\pril,  1H71,  p.  MTS.  The  large  percentages  mentioned  at  the  i-oTnrnencenn'ut  iif  thiij  note  jire  therefore  not  of  general  ajipli- 
catiun.  Concerning  relaiwi-s  MuitcuL'^oN  states  that  after  a  convalescence  of  ten  or  twelvt;  (hiys  there  is  a  recurrence  of  the  tmin  of  wyniptonis  wliich  tin* 
patient  experieuceil  on  tlie  tirst  attack.  Init  their  course  is  usually  more  rapid.  In  tilty-tliree  cases— p.  Ti.Vi— the  mean  duration  of  the  primary  attack 
was  27  days,  the  extrcMiies  hejng  14  ami  4(1  days,  the  mean  and  extrenn-s  of  the  intermission  11.7(1,  ;t  and  2'"  (lays,  and  of  the  relapse  Hi,4,  7  anil  :tn  days. 
Thi^  relapse  is  nnlder  than  the  tirst  attack  ;  hut  ill  oni*-lliird  of  his  cases  the  symptoms  of  the  fornH-r  wi^re  of  great  severity,  and  deatli  iK'ciirred  in  seven 
of  tlio  cases.  Rose-spots  appear  on  the  thinl.  fouitli  or  tifth  day.  and  MiitcmsoN  hases  tlie  diagnosis  on  the  presence  of  this  eruption  and  the  atwence 
of  any  local  inflammation  to  acccaint  for  the  ]iyrexia.  Skuiin  doe;^  not  dfsciihe  the  therniometiic  conrsi-  of  ndapse,  hut  leads  ns  to  infer  that  it  is  similar 
to  that  of  the  priniarv  attack  hy  indicating  tlie  temperature  euive  of  tin-  first  few  days  as  pathognomonic  of  tyjihoid  processes, — p.  124.  I^ater  author- 
ities descrihe  a  diflerenci-  hetweeu  tile  accession  of  the  in'iniary  fever  and  that  of  the  relapse :  Ikvink  (see  next  note)  consideix  the  teinpenitnre  curve 
diagnostic  :  "  It  is  asserted,"  he  says,  "liy  all  autliorities  that  the  teniiierature  of  relapse  rises  to  its  highest  level  more  quickly  than  in  the  primary  dis- 
ease ;  an<l  this  is  true,  hut  it  would  he  nu»re  correct  (judging  hy  the  instrtiiciw  given)  to  s;iy  that  there  are  not  in  relapse  the  typical  evening  exaccrhations 
and  morning  n-niissioTis  met  with  for  the  tirst  few  days  in  the  oi-dimiry  fever.  The  rise  in  relapse  in  tlie  gri'at  majority  of  cases  is  to  the  lifth  day  all 
hut  uninterrupted,  and  where  great  interriiittioiis  occur,  there  are  accidents  onongli  t<i  account  for  tln-in.  The  maximum  evening  temperature  is 
reached  hy  tlie  tifth  day,  as  (U'tnirs  in  primary  typhoitl ;" — In-re  the  author,  recognizing  that  the  experience  of  most  observers  indicates  the  third  day  iih 
that  of  highest  temiM-rature,  invites  attention  to  his  own  cliarts  in  support  of  his  statements,  after  which  h^'  continues:  "Hut  afterwards  the  curve  pre- 
sents a  decided  contnist  to  that  of  tlie  hitter,  in  which  to  the  twelfth  day  the  fever  remains  high,  though  with  a  maximum  si-arctdy  so  Iiigh  as  in  the 
fourth  to  sixth  days.  *  *  *  The  second  stage  in  relapse,  as  compan-d  with  that  td'  the  primary  attack,  is  cut  short ;  and  the  siune  is  true  of  the  thin! 
stage.  In  ndapse  tliis  stage  is  marked  hy  decided  fall  of  the  tempeniturc  to  tin-  normal,  and  there  is  no  /ninth  vcrk  in  which  deep  curves  prove  the  end 
of  ordinary  attacks  tif  primary  typlutid.  The  absence  of  those  exacerbations  and  remissions  met  with  at  the  end  of  typhoid  fever.  In  the  caws  of  relapsi', 
was  striking:  but  in  many  diarts  of  mild  (primary)  typhoid  which  are  given  by  several  authorities  this  absence  is  met  with,"— pp.  i:il-l;i4.  In  fact  thirt 
author  represents  the  temperature  curve  of  a  relai)se  as  ditlering  from  w  hat  is  considered  the  tyjiical  curve  of  tyi»hoid  fever  only  by  a  lessened  dev»dop- 
nient  of  the  diiirua!  oscillations  during  the  periods  of  accession  ami  ileclinatiou,  and  by  a  shorh-r  duration  of  the  fastigium.  This  Is  well ;  but  the  cune 
of  mihl  cases  of  typhoid  fever  being  very  similar  to  that  of  relapst',  he  tloew  not  hesitate  to  suggest  that  many  of  the  ca^es  reganle<i  as  mild  typlndd 
attacks  are  in  reality  relajwes  in  patients  hy  whom  the  primary  fever  has  Ik'cu  disregarded.  Here  the  argument  appears  to  1h'  pushi-d  to  the  extrenu'. 
According  to  Da  Costa — Jtemnrkn  on  Hel/^ses  in  Tijphui-}  Ferer — Trans.  Cnl.  I'lif/sicianf,  IMiila.,  1H77,  the  relajise  generally  comes  on  in  tlie  second  or  third 
Wir4'k  of  assured  convalescence,  and  in  the  second  oftener  than  tlie  third.  Abruptly  ami  almost  without  warning  the  iKitient  |«isses  from  com|iJinitlvo 
)iealt)i  into  a  decided  febrile  condition.  The  eruption  comes  on  earlier  tliau  in  the  primary  attack,  generally  about  the  fourth  day,  and  is  as  a  nilo 
Koniewhiit  coarser  and  redder.  It  does  not  disa^ipear  so  readily  mi  jn-essure,  and  tlie  first  eruided  spots  are  more  likely  to  last  until  the  whole  rash  fath^H. 
His  ilescriptiou  of  the  temiH-rature  curve  does  nut  agree  with  tlmt  given  hiter  by  Tuvine:  "I'nlike  the  graduated  ascemiing  course  until  the  evening  of 
tlie  fourth  or  fifth  day,  which  is  the  rule  in  ordinary  inst-mces  of  typhoid  fever,  the  tenii)erature  bounds  within  twenty-four  lupurs  to  a  decidi'd  fever  teiu- 
IK'nitnre,  remits  1  to  U°  tlie  next  morning,  anil  by  the  evening  of  the  second  day  is  »  degree  or  more  higher  than  on  the  tirst  day,  the  thernmmeter  very 
commonly  marking  lli4°  degrees.  Then  for  from  live  to  seven  days,  according  to  the  severity  <if  the  attack,  the  evening  tigures  read  about  the  sjime  ;  and 
a  morning  remission  of  ahout  1^,  or  somewhat  more,  hapiH'iis,  very  similar  to  what  we  observe  in  the  tirst  attack  aft-'r  the  initial  iMTiod  lias|«issed,  Sub- 
se)piently  irf-cur  the  same  more  marked  morning  remissions  and  less  severe  evening  exacerbations,  until  the  temperature  in  a  zig-ziig  manner  apprtwiclies 
to  the  normal  that  we  (.ibserve  during  typical  cases  of  the  typhoid  attack.  Yet,  as  here,  until  convalescence  is  established,  lo«al  complications  arrest  or 
reverse  the  daily  ilescent.  Neither  do  we  always  iind  during  the  heiglit  of  the  relapse  that  the  temiK-'ratiire  is  as  regular  as  desiribed.  It  may  sink 
almost  continuously  for  the  first  three  days  after  it  has  reacheil  the  height  occasioned  hy  the  returning  fevt-r,  and  then  for  three  oi'  four  days  more 
gradually  ascend  without  any  morning  remission,  yet  subsequently,  as  defervescence  sets  in,  show  the  cliaracteristic  zig-zjig  d4*cHne  alluded  tti,"— P-  l"3. 
He  invites  attention  to  the  interference  with  the  growth  of  the  nails  in  typhoid  fever  and  typhoid  relapse,  pointing  out  that  "with  the  relaiw<'  of 
typhoid  fever  the  second  ridge  of  the  altered  nail  growtli  comes  to  tidl  us  liow  completely  in  every  resp<'ct  the  fever  luvs  been  reproduced;  and  tlie  tirst 
ridge  may  in  oltscure  cases  give  us  the  true  meaning  of  doubtful  symptoms,  and  prov(!  conclusive  of  the  diagnosis.'"  A  year  after  this  paper  was  read  Dr. 
Da  (.'osta,  in  a  ('Uniml  LfiUu-e  :m  Ri-hqiaes  in  Ttjphoid  hWtr,  Philmiflphiit  Mtd.  TinifK^  Vol.  VIII,  1«77-M,  p.  4^j;i,  is  reported  as  having  stated  that  it  is  tho 
rule  for  the  eruption  to  reappear  almost  coincidently  with  the  first  symjitoms  of  relapse.  In  the  case  whicli  fonned  tlie  basis  of  his  remarks  convales- 
cence from  the  primary  attack  t)ccurred  at  the  end  of  the  thinl  week,  and  a  few  days  later  the  temperature  was  at  the  normal.  Two  wei'ks  afterwards, 
the  patient  being  so  far  recovered  in  the  mean  time  as  to  be  alh)wed  to  dress  and  leave  tlie  ward,  ate  very  largely  of  chicken  and  boiled  potatoes.  This 
was  followed  immediately  hy  alMlominal  imin ;  the  temiKjrature  ran  up  to  105  and  the  rose-iush  reappeared  within  twenty-fuur  hours:  at  the  end  of  the 
fifth  day  the  temjwrature  "as  again  <leclining. 

t  HthipAt'  uj  Tt/pltoitl  fWvr,  i.y  .1.  I*.  Ikvine,  London,  1880. 


300  SYMPTOMATOLOGY    OP 

are  found  fo  present  but  two  illustrative  cases,  48  and  49,  while  the  post-inortem  series 
furnishes  but  one  case,  32.  In  neither  of  the  former  is  the  history  of  the  primary  attack 
given  in  detail;  but  in  the  latter,  the  patient,  who  remained  under  the  observation  of  the 
reeonler  li'diii  lirst  to  last,  was  considered  convalescent  on  the  thirtieth  <lay;  twenty-five 
days  later  he  was  seized  with  symptoms  of  typhoid  fever  which  soon  became  characteristic, 
deatii  ultimatelv  taking  place  from  chest  complications. 

The  foregoing  analysis  of  the  cases  set  aside  as  illustrations  of  pure  typhoid,  by  weed- 
ing from  the  continued  fevers  of  the  Seminary  hospital  such  as  appeared  to  present  definite 
indications  of  a  malarial  element,  has  determined  the  existence  of  certain  difierences  between 
the  typ)hoid  fever  which  aflPected  our  troops  and  that  recorded  by  writers  of  large  experience 
as  prevalent  among  the  civil  population  of  this  and  other  countries.  These  may  be  sum- 
marized as  follows: 

The  nlative  infrequinvy — 
Ist.  Of  nausea  aud  vomiting  at  an  early  period; 

2(1.    Of  a  moist  skin  dnriuR  tlie  oontiniianco  of  tlio  primary  fever;  and 
lid.    ( )f  the  pulse  dining  tlie  same  period. 

The  ijriater  priivuh'ticr — 

1st.  Of  diarrlura  during  the  whole  of  the  attack; 

2d.    Of  dangeious  congestions  of  the  lungs  and  grave  broncho-pneumonic  complications; 

3d.    Of  ataxo-adynamic  delirium; 

4th.  Of  dusky  spots  and  ecchymotic  patches,  simulating  typhus  maouhe;  aud 

5tli.  Of  suppurative  destruction  of  the  parotid  glands. 

But  these  differences  will  be  discussed  to  better  advantage  after  the  symptoms  of 
modified  typhoid  have  been  considered. 

m.— MODIFIED  TYPHOID  FEVER. 

Instead  of  illustrating  typho-malarial  fever  by  febrile  cases  recorded  under  that  heading, 
the  writei-  lias  been  constrained  in  the  first  instance  to  determine  what  ought  theoretically 
to  be  the  probable  symptoms  of  a  typho-malarial  fever,  and,  thereafter  to  collect  appropriate 
illustrations  from  the  records  of  tlie  camp  fevers,  whether  registered  as  typhoid,  typho- 
malarial  or  remittent.  This  mode  of  procedure  exposes  its  results  to  the  criticism  that 
the  fevers  submitted  as  typho-malarial  in  this  report  are  not  such  as  were  called  by  that 
name  by  the  medical  officers  in  attendance  on  the  cases,  but  merely  such  as  the  mental 
bias  of  the  editor  has  led  him  to  assign  to  that  class.  Undoubtidly  the  first  half  of  this 
criticism  is  well  taken,  for  the  cases  presented  are  seldom  those  wliicli  were  regarded 
as  typho-malarial  in  our  camps  and  hospitals.  The  nature  of  the  reported  cases  of  typho- 
malarial  fever  will  be  investigated  hereafter.*  But  with  regard  to  the  latter  half  of  the 
criticism,  certain  considerations  already  suggestedf  indicate  that  the  method  adopted,  while 
the  best  available  for  determining  the  characteristics  of  the  fevers  which  should  have 
been  reported  as  tyjiho-malarial  in  accordance  with  Dr.  AVoodward's  views,  is  susceptible 
of  yi(dding  as  accurate  and  trustworthy  results  as  can  be  obtained  in  a  medical  inquiry 
concerning  the  consequences  of  unknown  causes;  and  this  is  the  more  gratifying  inasmuch 
as  not  on]v  are  the  characteristics  of  a  so-called  typho-malarial  fever  a  subject  of  uncertainty 
and  corresponding  interest  at  the  present  time,  but  the  more  important  question  of  the 
relationship  between  the  morbid  causes  of  malarial  phenomena  and  febrile  conditions  attended 
with  a  specific  intestinal  lesion  are  necessarily  to  a  large  extent  involved  in  the  discussion. 

*tiifni,  II.  .■i72.  ^tiiipra,  11.27:1-5. 


Onsk'I". — Till' aix'cssiun  of  llie  frvcr  in  casi's  jn'opcrlv  tvplio-inalarial  was  not  graihial 
and  pi'OLi'ressive  as  in  nninoditieil  tvjilioid,  but  was  niarkdl  liv  ilistinct  remissions  or  even 
interiinssidns  in  tliosr  having  tlie  iVbrilc  action  ot'  tiic  tv|>liui(I  jioison  preceded  by  a  malarial 
attack.  Perspirations  or  a  moist  skin  t'ormed  iw)  part  of  the  clinical  record  of  typhoid  until 
defervi^scence  was  in  progress;  but  in  cases  complicated  by  the  presence  of  malarial  fever 
the  skin  was  at  times  hot,  dry  and  I'ough,  and  at  other  times  soft,  moist  or  perspiring.  In 
some  the  remissions  seemed  but  an  exair^crat-ion  of  those  which  the  thermometer  alwavs, 
and  the  general  symptoms  frequentlv,  indicate  as  occurring  daily  in  the  progress  of  typhoid; 
Ijut  in  others  paroxvsmal  activitv  was  developed  at  an  unusual  hour,  as  at  noon-time  on 
alternate  days,  or,  if  occuri'ing  at  irregular  intervals,  it  was  unaccompanied  by  local  condi- 
tions to  which  the  sudden  access  of  fever  might  1)0  attributed.  Assuming  the  alleviation 
or  abatement  of  these  paroxysmal  features  by  a  free  use  of  (piinine,  the  I'ebrile  action  per- 
sisted and  was  associated  with  many  of  the  symptoms  peculiar  to  typhoiil  fever,  moditicd 
in  many  instances  by  that  deteriorated  state  of  the  blood  which  has  been  seen  to  be  one  of 
the  formidable  causes  of  danger  to  life  in  malarial  cases.  Death  from  sudden  cerebral  or 
pulmonary  congestion  as  in  pernicious  malarial  attacks,  not  unfrequently  cut  short  the  course 
of  the  fever  at  a  period  when  unmodified  typhoid  rarely  proved  fatal.  Rut  in  the  absence 
of  such  fulminant  demonstrations,  defervescence  began  about  the  end  of  the  second  week, 
usually  with  exaggerated  remissions  and  profuse  perspirations,  or  the  case  was  prolonged  by 
intestinal,  pulmonarv  or  other  visceral  troubles,  at  any  period  of  which  paroxysmal  manifesta- 
tions were  {.irone  to  recur. 

Of  the  sixty-four  cases  of  moclifled  typhoid  treateil  in  the  Seminary  hospital,  the  fel)rile  eondition  was  devel- 
oped, so  fiir  as  is  shown  hy  tlie  records,  without  initiatory  chills  in  nineteen,  but  in  live  of  these  the  continued  ty])o 
was  assumed  hy  cases  which  at  their  connnencenient  were  regarded  as  remittents.  Of  the  reniaiiiing  forty-live  cases 
the  continued  fever  was  said  to  be  sequent  to  the  chills  of  aguish  attacks  in  scri'iitii'ii;  it  was  preceded  by  chills, 
fever  and  perspirations  in  eight  and  by  chills  in  nineteen;  in  one  case,  70,  there  was  a  chill  on  the  eighth  day  of  the 
increasing  indisposition.  From  the  terms  of  the  record  or  from  the  context  it  appears  that  in  most  of  these  cases 
the  chills  recurred  on  several  occasions  before  tlie  febrile  condition  reached  its  acme;  but  in  5ii,  Gli,  07,  74,  93  and 
111  it  is  definitely  stated  that  a  single  chiO  preceded  the  feiirile  attack. 

Five  of  the  nineteen  cases  that  were  not  characterized  by  chills,  and  twelve  of  the 
fortv-five  that  showed  more  or  less  evidence  of  a  paroxysmal  type  in  the  early  period,  proved 
fatal.  These  results  manifest,  so  far  as  the  small  number  of  cases  will  permit,  that  typhoid 
fever  was  deprived  of  none  of  its  dangers  by  the  concurrent  action  of  the  malarial  poison. 

The  malarial  character  of  these  typho-malarial  cases  is  sustained  in  most  instances  by 
other  evidence  than  their  paroxysmal  onset.  Chills  are  insufficient  to  establish  the  malarial 
presence,  since  they  have  been  developed  in  cases  of  apparently  unmodified  typhoid.  Con- 
cernino-  these,  however,  it  may  not  be  out  of  place  to  inquire  whether  malarial  possibilities 
have  been  excluded  from  their  causation.  The  typhoid  and  malarial  influences  are  so  closely 
allied  that  it  is  often  impossible  to  say  of  a  symptom  which  seems  common  to  both  that  it 
is  due  to  one  and  not  to  the  other;  but  recurring  chills,  especially  when  followed  by  heat 
'and  perspirations,  are  so  essentially  manifestations  of  the  malarial  poison  that  when  they 
occur  with  regularity  as  a  prominent  feature  of  the  clinical  picture  the  probable  presence  of 
that  poison  is  strongly  suggested.* 

Pulse. In  one  of  the  sixty-four  cases  the  rate  of  the  pulse  was  not  recorded,  and  in  three  it  was  character- 
ized as  rapid,  but  the  number  of  beats  was  not  stated.  In  forty-two  of  the  remaining  sixty  the  rate  did  not 
exceed  100,  except  on  the  occurrence  of  pulmonary  or  peritoneal  inflammation  or  in  the  onward  progress  of  fatal 
exhaustion,  as  in  85,  86,  93, 98  and  99.     In  eleven  of  these  cases  its  quality  was  not  reported;  in  one  it  was  considered 

*  Louis  froqiiputly  observed  recurring  chills  in  the  early  period  of  his  typhoid  cases,— t.  II,  p.  259;  is  his  forty-fourth  observation  aguish  parox- 
ysms recurre<l  for  many  days.    See  also  svpra,  note  *  p.  284. 


302  SVMl'loMA  liM.OiiV    OK 

thready,  in  six  \\o;i\<.  or  foclilr,  in  Hirer  (|iiii'l<,  in  '"■"  of  l;iir  strciifitli.  in  Jh-r  stnni};,  in  fi>ur  ()ui<ls  iliid  stniiiy,  in 
fire  slionj;  and  I'nll,  In  »«c  (jiiick  ami  riill,  in  Inn  lull,  in  "m  strcmi;'  and  lirui  ami  in  niii-  ijuick,  full  and  tirni.  In 
the  f<-liril<'  cases  already  iircsciitfd  as  cxainiilcs  of  ]irol)alily  ]inrc  lyplioid,  fiilni'ss  andslrcnjftli  were  iinalitie.s  rarely 
I'onnd  in  llie  inilso,  but  tlii^  sthenic  character  of  I  lie  arterial  excitement  in  thosi^  now  under  consideration  is  very  llota- 
hleand  a]>i)ears  to  have  heen  connected  with  the  existence  of  the  malarial  element.  In  Tit  the  ])nlse,  .seemingly  under 
the  inllnenc('  of  (|uinine.  fell  dnriiiLj  the  tiist  week  from  !I5  to  70  and  two  days  later  to  15,  while  the  typhoid  (■lenient 
wa.s  manifested  l>y  tlu^  aiipiM ranee  of  ihe  spi'citic  i'ni]it  ion  :  in  !ll  also  the  ]mlse-rat<'  fell  nnih'r  tlie  iiillneiice  of  c|uiniiie. 
and  ill  \(i'J,  allhoiij;h  the  rate  diiiinsj;  Ihe  initialory  iiaroxysiiis  was  not  slated,  it  is  evident  from  the  liistory  that  it 
must  have  heen  hij^her  than  later,  when  Ihe  rose-spols  were  almost  the  only  iiidiealioii  of  tlie  presence  of  typlnnd 
fever.  !^treiij;th  of.pulse  is  also  recorded  In  many  of  the  ca.ses  m  which  its  rate  exceeded  IIIU  diirinn'  Ihe  ]iriinarv 
fever:  and  in  these  the  stlieni<-  ch.aracter  seems  to  have  heen  definitely  associated  with  paroxysmal  manifestation.s. 
In  the  on.set  of  thi^  relapse,  ill,  thi^  iiui.se  was  120,  full  and  stroiij;';  in  95  it  was  rapiil,  full  and  hoiindinj;  iu  the  tliir<l 
week  notwithstandiii};  the  occnrrciice  of  pcrsjiirations  :  in  the  mtcrjstinf;  ca.se,  105,  the  pulse  exceeded  100  durin}^ 
the  iiaroxysmal  ]ieriod  of  the  attack,  fell  below  that  rate  during  the  accession  of  the  continued  fever  and  rose  to 
110  at  its  acme;  in  llil  a  high  rate  ccdncided  with  remis.sions  and  a  lower  rate  with  the  progress  of  tin-  continued 
fever  until  its  termination  in  fatal  iieritonitis;  in  101  and  110,  also,  the  rate  was  higher  during  the  early  period  when 
the  f(d)rile  action  remitted  than  later  when  it  was  continued,  and  in  li;i  and  111  rapidity  of  pulse  was  associated  with 
paroxysmal  symptoms. 

From  these  observations  it  nmy  be  concluded  that  although  the  pulse  was  not  in  general 
more  rapid  in  these  cases  than  in  those  of  pure  tyt)lioid,  it  was  fuller,  stronger,  quicker  and 
firmer  in  proportion  to  the  activity  of  the  paroxysmal  element. 

The  febrile  disturbance  was  accompanied  in  its  onset  by  headache,  pain  in  the  limbs 
and  back,  lassitude,  anorexia  ;ind  thii'st.  In  a  few  exceptional  instances  the  a})petite  was 
not  much  impaired  :  thus  in  89  it  was  good  notwithstanding  the  brown  itnd  thickly  coated 
condition  of  the  tongue  and  the  bad  taste  conveyed  by  the  abnormal  secretions  of  the  mouth, 
and  in  some  mild  cases,  as  109,  it  was  recorded  as  fair  throughout  the  attack. 

In  most  of  the  cases  the  eyes  were  injected  and  the  cheeks  flushed  during  the  period 
of  accession ;  in  a  few  instances,  as  in  case  100,  one  side  of  the  face  was  more  deeply  suf- 
fused than  the  other.  Later  in  the  disease,  and  corresponding  with  the  development  of 
cerebral  manifestations,  the  eyes  became  dull,  and  at  a  later  stage,  when  the  patient  fortu- 
nately emerged  from  the  ty[)hoid  narcosis,  they  were  usually  clear  and  bright  but  sunken, 
the  features  [lale  and  the  skin  cool. 

EpiHtn.l'ilt  was  noted  in  twenty  of  the  sixty-four  cases.  In  ten  of  tliese  it  was  an  early  symptom,  occurring 
l)efore  the  .appearance  of  tlu^  ro.se-eolored  s|iots;  in  six  it  took  place  when  the  fever  was  at  its  height;  in  71  and  SI 
it  apjieared  late  in  the  attack,  and  in  !K)  when  profuse  ]i(.'rs|iii'ations  and  vihices  were  foreshadowing  the  end;  in  (! 
it  was  of  frequent  occurrence  for  a  month  Ix-fore  the  febrile  onset,  recurring  many  times  during  its  progress. 

It  does  not  appear  tluvt  any  evil  eifect  was  attributed  to  the  loss  of  blood,  even  iu 
those  cases  in  which  it  was  a  specially  marked  sym]")tom;  nor  can  any  notable  benefit  be 
associated  with  its  recurrence:  In  67  epistaxis  was  followed  by  the  development  of  cerebral 
symptoms;  in  69  its  return  on  alternate  days  coincided  with  febrile  exacerbations. 

Epistaxis  occurred  piM'haps  with  more  frequency,  if  its  recurrences  are  considered,  in 
tliese  cases  than  in  those  of  unmodified  fever.  Prom  its  appearance  during  the  accession 
or  continuance  of  febrile  action,  paroxysmal  or  continued,  it  would  seem  dtic  in  part  at  least 
to  circulatory  excitement;  and  since  this,  as  manifested  by  fulness  and  strength  of  pulse,  was 
greater  in  the  typho-malarial  cases,  the  greater  frequency  of  its  occurrence  among  them  may 
be  understood.  Its  paroxvsmal  tendency  was  chiefly  manifested  at  a  later  period  when, 
coincident  with  vibiccs  or  other  signs  of  alteration  of  the  blood,  it  occurred  on  alternate 
days  in  conjunction  with  the  lieat,  dryness  of  skin,  headache  and  linging  in  the  ears  which 
betokened  the  intermittent  attack. 

Thpj  Skin,  during  the  continuance  of  paroxysmal  phenomena,  was  alternately  dry  and 
moist,  but  when  the  febrile  action  assumed  a  continued  type  moisture  ceased  to  appear. 
Occasionally  dt.'l'c'j'vesceiice,  as  in  unmodified  typhoid,  was  accompanied  with  free  peropira- 


THE    CO^TlJsUKU    bKVKKS.  303 

tion.     i^ii(l(inuna  wore  frequently  observed,  Lut  no  herpetic  eruptions  were  noted  in  tlio 

Houiiiiary  cases. 

TIk'  rose-colored  eruiition  was  ab.scut,  not  sfon,  or  not  stated  as  havinj;  l)oen  seon,  in  twrnty-onc  of 
the  sixty-four  cases.  In  three  of  tlie  twenty-one  there  apjieared  an  erniition  tlie  eharaeters  of  wliieli  are  unsiieeilied ; 
in  !>5  this  i)rol)ably  consisted  of  tlie  typhoid  lenticular  spots,  and  in  !'8  of  the  scarlet  rash  which  sonu'tinu's  accom- 
panies them,  but  its  site  on  the  genitals  in  (U  throws  doubt  upon  its  nature.  Nine  of  the  cases  failed  to  conu_>  uniler 
observation  until  after  the  end  of  the  second  week.  Nevertheless,  an  ecjual  number,  cases  tiO,  H'A,  K>,  HX,  '.111,  101,  101, 
117  and  122,  were  admitted  early  enough  to  have  shown  the  eruption  had  it  been  jiresent.  J'irc  of  these,  however, 
813,  85,  101,  117  and  122.  had  the  malarial  symptoms  .strongly  developed.  Indeed,  the  absence  of  rose-colored  sjiots 
in  these  cases  renders  the  diagnosis  of  tyi>hoid  fever  somewhat  doulitful,  since  it  cannot  be  established  that  the 
existence  of  malarial  paroxysms  interfered  with  their  dovelopnu'nt,  for  cases  102  and  105  presented  the  rose-rasli 
although  the  typhoid  attack  was  mild  in  comparison  with  the  f<'brile  paroxysms  w  hich  were  its  prelude.  If  these 
five  cases  be  excluded  from  consideration  there  reuniin  but  Jour  in  which  the  existence  of  the  rose-eoloriMl  eruption 
is  uudet(<rniined, — 60,  a  light  febrile  attack,  the  history  of  which  is  not  given  with  sullicient  detail;  !l!l,  in  which 
typhoid  iever  apjiears  to  have  been  developed  on  the  tenth  day  aftcu-  admission  with  intermittent  jiaroxysms;  101, 
in  which  the  ]iatient  was  admitted  on  the  fifth  day  of  an  intermittent  attack,  and  88,  the  record  of  which  was  begun 
on  the  ninth  day  of  the  disease. 

Rose-colored  Ki)ots  in  the  forty-threo  cases  in  which  they  are  mentioned  as  having  l)een  present  ai)peared  usually 
during  the  second  week  of  the  typhoid  attack;  but  by  dating  the  onset  of  that  attack  from  the  connuencement  of 
febrile  symptoms  their  appearance  was  in  many  cases  delayed  beyond  this  period.  In  cases  108,  lOil  and  110  they 
were  noticed  on  the  seventeenth,  eighteenth  and  twenty-fifth  days  res])ectivcly,  counting  from  the  conuuenccMU'ut 
of  the  remittent  attack.  As  in  jinre  typhoid  they  were  occasionally  few  in  number,  case  115  for  instance  presenting 
only  two  spots,  while  in  other  cases  they  were  ])rofuse  and  occurred  in  successive  crops:  In  7,)  they  eruiited  from 
the  tenth  to  the  thirtieth  day  and  in  75  from  the  tenth  to  the  thirty-sixth  day. 

But  their  appearance  was  not  in  every  instance  that  which  is  usually  accepted  as  characteristic  of  ty]du)id  fever. 
There  were  noted  in  the  tyi)hoid  series  exceptioiuil  cases  in  which  the  spots  were  of  a  ilarker  color  and  did  not  dis- 
appear on  pressure.  Such  instances  were  of  more  frequent  occurrence  when  the  typhoid  fever  was  a)iparently  com- 
plicated by  a  nuilarial  element.  In  case  62  tlieir  appearance  on  the  tenth  day  was  followed  by  an  erupt  ion  of  a  darker 
color  on  the  fourteenth;  in  100,  rose-spots  apiieared  on  the  eleventh  and  fifteenth  (lays,  and  were  followed  two  days 
later  by  a  few  dark-red  spots  which  were  im)>erceptible  to  the  toucli  and  disaiijicared  under  ]>ressure;  in  lOS,  also, 
rose-spots  on  the  fourteenth  day  were  followed  by  dark-red  s])ots  on  the  sixteeutli.  and  it  is  interesting  to  remark  that 
in  both  of  these  cases  the  skin  was  jaundiced;  in  the  fatal  relajise,  ill,  the  rose-colored  eruption  was  ]ireccded  by  a 
few  spots  of  a  dark-red  color  which  did  not  disa))pear  on  pressure;  late  in  the  progress  of  !);3  tlu-re  occurred  an  erup- 
tion of  dark,  almost  black,  sliglitly  elevated  spots  somewhat  larger  than  split  ])eas,  some  of  which  afterwards  becauio 
of  a  light  yellow  color  from  purulent  accunmlations;  in  case  82  there  is  said  to  have  l>een,  in  addition  to  the  rose- 
spots,  a  profuse  eruption  the  characters  of  which  were  not  recorded;  in  83  souui  pustules  appeared  on  the  abdomen 
about  the  eighteenth  day. 

The  eruption  was  seldom  mentioned  in  the  <lefective  clinical  histories  atta(died  to  the  posl-morhm  records;  and 
the  acknowledgment  of  its  presence  in  the  few  exce])tional  instances  apjtears  to  have  been  dictated  by  its  peculiar 
characteristics  lather  than  by  its  mere  presence.  Thus  in  case  115  two  or  three  ro.se-rcd  spots  of  doubtful  character 
were  observed;  in  1)7  a  red  papular  eruption  aj>peared  about  the  <uid  of  the  third  week;  in  51  and  8»i  rose-spots 
erupted,  which  in  the  latter  case  became  subse(jueutly  of  a  dusky  crimson  color  and  uuati'ected  by  pressure. 

Kose-colored  spots  usually  appeared  on  tlie  chest  and  abdomen;  but  in  two  cases,  70  and  74  of  the  Seminary 
series,  they  were  found  as  well  on  the  forehead  and  face.* 

It  is  seen  from  this  analysis  that  the  rose-colored  ei-uption  was  not  observed  in  so 
large  a  proportion  of  modified  as  of  unmodified  typhoid  cases;  but  the  conclusion  is  by  no 
means  warranted  that  the  rash  was  more  frequently  absent  in  the  one  class  of  cases  tlian 
in  the  otiier.  The  date  of  onset  of  typhoid  fever  in  a  patient  presenting  malarial  symptoms 
was  often  involved  in  obscurity.  Cases  have  been  instanced  in  whicli  the  rose-colored  spots 
appeared  for  the  first  time  at  a  late  date,' if  the  initiatory  malarial  ])aroxysms  were  regarded 
as  the  period  of  onset.  Cases  have  also  been  presented  in  which  the  malarial  element 
obscured  the  symptoms  of  a  mild  typhoid  affection,  the  existence  of  which  was  manifested 
duriny  the  second  week  by  its  specific  eruption.  It  may  therefore  be  assumed  that  in  some 
instances,  as  in  99  of  the  post-mortem  series,  a  mild  typhoid  may  have  existed  for  many 
days  in  patients  subject  to  ill  health  from  the  malarial  influence  without  exciting  an  appre- 
hension that  there  was  anything  unusual  the  matter,  and  that  these  men  would  date  their 
disease  from  some  subsequent  well-marked  paroxysm.     In  such  instances  the  eruption,  if 


*  In  8  of  98  cases  of  typhoid  Mcbchisos  noted  the  spots  as  present  on  tlic  arms  and  legs,  and  iu  one  case  on  the  face,— p.  511. 


304  .SYMrroMATuLudY    OK 

incoiispii'iKnis  uiiil  nf  short,  ilui-atinii,  miu-lit:  I'scajii,'  ohsci'vatidii.  ami  tlu;  ciisos,  owing  to  an 
iiK-onx'ct  ihitc  <>(  (Misi'l.  wmiM  l>i'  ivgai'dnl  as  luvving  pri'Sfiilrd  iiu  eruption  altliuugli  uinl(.'i' 
observation  at  tlie  time  wlieii  it  usually  niaile  its  a])])earanec.  Again,  since  in  many  cases 
the  disease  was  regarded  as  remittent  lever,  it  is  fair  to  suppose  that  in  some  of  these  the 
specific  erupli(jn  was  not  discovered  because  it  was  not  looked  for  until  lato  in  the  attack, 
when  the  f(^\-ei'  had  assunie(l  a  continued  type  and  the  prostration,  diarrhoea  and  accom- 
panying tenderness  of  the  bowels  suggested  the  presence  of  typhoid.  The  febrile  condition 
lasted  in  the  Seminary  hospital  case  110  for  twenty-'Hve  days  before  the  rose-spots  made 
their  aj>[)earance.  Physicians  in  similar  instances  of  prolonged  febrile  action  may  have 
accepted  the  absence  of  the  spots  and  have  ceased  to  look  for  them,  altliough  tlicir  ]iresence 
miirht  have  been  demonstrated  at  a  later  period.  Under  such  circumstances  failure  to 
observe  the  eruption  does  not  imply  its  non-existence. 

Moreover,  as  has  b(>en  indicated  in  the  presentation  of  the  records  of  the  19th  Mass. 
Vols.,  and  as  will  be  shown  more  definitely  liereafter,'-'  then.'  is  little  doidjt  that  many  cases 
reported  as  typho-malarial  were  due  solely  to  the  action  of  the  malarial  poison.  The  failure 
of  a  close  scrutiny  to  observe  the  rash  in  such  cases  may  have  led  to  the  opinion  that  its 
absence  was  common  in  cases  of  modified  typhoid.  However  this  may  be,  the  typho- 
malarial  series  of  the  Seminary  hospital  presented  in  so  many  instances  a  characteristic  or 
modified  eru|)tion  as  to  render  it  highly  probable  that  when  typhoid  was  present  it  was  man- 
ifested by  the  rash  as  frequentlv  in  the  presence  as  in  the  absence  of  malarial  complications. 

The  occurrence  of  8U(ltttnitl€l  aiipcars  frequently  on  the  records;  in  case  6  of  the  27th  tJouneeticut  tlie 
miliary  vesicles  coalesced  into  hulhe  containing  a  turhid  yellowish-white  liquid,  and  in  9  they  were  developed  on  the 
site  of  existing  rose-colored  spots. 

Petechial  and  ecchytnotic  patches. — Petechial  spots  were  found  in  two  of  the  Seminary  cases, 
77  and  US,  hotli  of  which  recovered,  and  larger  patclies  of  an  ecchyniotio  appearance  in  the  seven  cases,  68,  (>9,  7H,  7-1, 
00,  !(S  and  101.  I'sually  these  lilotclies  were  contined  to  the  chest  and  abdomen,  but  in  the  last-mentioned  case  they 
covered  thi!  whole  body  (except  the  face  and  lu'ck.  In  (18,  <iO,  7;i  and  71  they  api)eare(l  about  tlie  close  of  the  third 
week;  these  cases  recovered,  but  the  others  were  fatal.  Ecchynu>sed  spots  appeared  on  the  abdomen  in  case  4  of  the 
records  of  the  27th  Connecticut,  and  spots  like  small  blood  blisters  on  the  limljs  and  trunk  in  case  (i. 

It  will  be  observed  that  these  facts  do  not  demonstrate  a  greater  freijuency  of  hemor- 
rhagic exudations  in  this  series  of  cases  than  was  found  in  that  which  has  been  submitted  as 
representative  of  unmodified  ty|>hoid. 

Erg/ftiltelns  ap))eare(l  as  a  com])lication  in  several  of  the  cases,  as  in  92  of  the  Seminary  series  and  in  71  and 
77  of  the  poxl-iiKirtiiii  records;  the  ear  and  side  of  the  face  seemed  to  be  its  favorite  site,  lu  the  first-mentioned  case 
it  was  associated  with  intiammation  of  the  parotid  and  became  gangrenous  in  its  progress. 

Betl-SOfen  are  recorded  in  case  113  as  having  occurred  at  a  late  period,  but  the  circulation  at  this  time  for- 
tunately became  improved  and  the  patient  was  soon  able  to  walk.  They  were  found  also  in  101  of  t\\e pont-mortem  series 
at  the  end  of  the  third  week,  over  the  sacrum,  trochanters  and  angles  of  the  ribs  of  the  right  side. 

In  case  8i),  during  the  height  of  the  fever,  when  tlie  rose-rash  was  erupting  and  the  patient  muttering  in  his 
sleep,  a  fteculifir  odor  was  rejKjrted  as  emanating  from  his  body.  In  case  li  of  the  records  of  the  27th  Connect- 
icut, an  odor  like  that  from  spoiled  meat  was  perceived  about  the  person  of  the  patient  shortly  before  the  occurrence 
of  the  fatal  event :  he  was  much  emaciated  and  suffered  from  bed-sores. 

Ceukhhai.  Sy.mptdm.s. — In  the  sixty-four  cases  of  the  .Seminary  hospital  series  headache  was  reported  fifty-two 
times,  wakefulness  eleven  times,  drowsiness  eleven  times,  more  or  less  of  dulness  or  stupor  tliirty-one  times,  dizzi- 
ness seventeen  times,  ringing  in  the  ears  twenty-six  times,  deafness  twenty  and  delirium  twenty-four  t'liies. 

Itelirillin  occurred  in  thirteen  of  the  seventeen  fatal  cases  and  in  twelve  of  the  forty-seven  recoveries.  Of 
the  four  mortal  cases  in  which  <lclirinm  was  unrecorded,  one,  85,  had  the  malarial  symptoms  strongly  developed,  death 
beiug  iirece<led  by  stupor;  UK  was  fatal  by  peritunitis ;  the  two  other  cases,  9-1  and  111,  were  not  rendered  in  full 
towards  their  close.  Among  the  forty  cases  in  which  delirium  was  absent  or  not  stated  as  present,  headache  was 
reported  thirty-two  times,  wakefulness  six  times,  drowsiness  seven  times,  more  or  less  of  stupor  sixteen  tinuvs,  dizzi- 
ness ten  times,  ringing  in  the  ears  sixteen  times  and  deafness  seven  times.  .\h  the  patients  in  many  instances  were 
not  received  until  the  disease  had  ma<le  much  progress,  it  is  not  surprising  that  in  twelve  cases  there  is  no  evidence 
that  headache  constituted  one  of  the  symptoms  of  the  attack.     In  two  ca.se8,  102  and  106,  neither  headache  nor  any 

*  Lijrx,  iJUgo  375. 


TIIK    •wXTINfl-li     KKVKKS. 


:iOo 


ritlici  syiiiiitiiiii  vcfcnililc  In  ihc  iiti'IumI  systi-m  n]i)ii-:ii^  I'li  iln'  iiiciiii,  uliili'  in  TH,  H'T  and  IL'O  lit'iulaclif  aldiii':  in 
.'i;i.  '.i|  :iii(l  1  l.'i  wukcliiliioN  :  in  117  licacl:i(lic  ami  \v  aUilii  Im  >> :  in  tio  lii'Milarlic  anil  ilrowsiiicsK;  in  7!{  lii-ailai-lif  anil 
lUzziucss:  in  7."i  ami  7s  In'adai-lir  anil  tiuniin>.  ami  in  ^1'.  lul.  li'lt  ami  IL'I  lirailaihc.  linnilu^  and  di/zincss  tornu'd 
lespcctivi'ly  tin-  indications  dC  thr  I'liclnal  inipiical  inn.  In  I  u  o  insiami-^,  mi  ami  si.  t  In-  jial  ii-nis  wnc  in  a  MMni-iMini- 
atiisc  cumlitiim,  wliicli  \\  as  assm-iaud  in  I  lie  lal  Irr  rasi-  \s  ii  li  sjiasmodic-  cniii  lacl  inns  id'  nnnsual  si  ri'nj_'lli  atVi'i'tin^; 
thi-  niUM-lrs  nf  the  fan-  and  i-xl  rruiil  ii-s.  This  stnpni'  did  iini  ahriiiali-  w  illi  llir  ln»  drlirinni  so  cninninn  in  nnnind- 
ilii'd  lyidinid  I'rviT.  Init  li-l't  lliv  patirnts  vi-iy  iltal'  in  Imih  lasis.and  u  itli  sli^hl  dilii  inni  and  lu'adarlir  in  t  In'  latlrr. 
I'lir  jio'tl-iiiiirti  IK  I'ccniil  of  fasc  L'!i7  coniiiaics  tlir  cons  ulsi\r  n\  i!rliinj;s  of  tlir  nuisidis  of  I  lir  pal  irni  lo  t  lif  spasmodic 
ni(ivfniciits  yiioduced  by  nuidfrato  shocd-;s  fiuni  a  f;alvauic  lialli'iy. 

Instrad  of  dilatatiim  id'  tii<'  luijiil,  which  was  vcconU'd  in  sr\  rial  of  ihr  typlmiil  rasrs.  I  he  lypho-nnilarial  sfiicM 
of  the  Seminary  hos]iital  jiiesents  two  cases,  itt)  and  !•".  id'  COHfl'fK'feti  fUtpil.  In  one  the  eontiai-tioii  waM 
assoeiati'd  with  delifiuin  i)iecedinf;  the  ad\cnt  ot  let  lial  st  npnr.  and  in  1  lie  ol  her  wit  li  a  stale  nf  conni  vijjil  wliieli  ended 
fatally.  The  [mpils  were  also  contracted  in  Sli  id'  the  iiost-iiiniti  ni  rrennls  diuinj;  the  stupor  which  was  the  harbinger 
of  death  ;  nevertheless,  in  case  IL!  nf  the  re;;!  mental  recnid  nf  the  l;i|  h  Mass.  tlie  pupils  were  (disi'ived  to  be  dilated. 

Delirium  was  generally  of  the  ])assive  (diaracti'r  observed  in  nnmodilied  ly])hnid,  bill  there  appeared  to  be  a 
greater  tendency  to  la]i8e  into  tlie  cnmatose  static  tlian  was  foiu.d  in  cases  of  that  fever.  In  some  instances,  how- 
ever, the  |)ar(>.\yKnuil  exacerbatinns  were  aceoni]iaiiied  by  more  active  cerebral  nianifeslations;  in'.M  of  the  Seminary 
series  tlierc  was  what  the  record  calls  w  alkinu;  delirium,  and  the  ])atient  afterwards  raved  and  showed  much  strenglli ; 
in  (iof  tlie  27th  (;onn.  the  delirinin  was  at  lirst  vndent,  then  sullen  and  afterwards  id'a.jocose  character.  Coma  wa8 
indeed  not  nnfreiiiieiitl.v  l>receded  by  continued  insomnia,  .jactitaticni  and  active  delirium,  as  in  o^  and  111  of  thu 
liiixt-miirlfin  records,  or  by  intense  headache,  as  in  St!  and  !U  of  the  same  series.  In  5()  delirium  and  coma  were  appar- 
ently connected  with  inllaniniatory  iirocesscs  In  the  middle  ear. 

Death  at  an  early  ])eriod  was  usually  due  In  coma,  as  in  111  of  the  jiiixl-niortciii  records,  which  terminated  on 
the  ninth  day,  and  in  i»l  of  the  same  series,  whieli  ended  on  the  tliirteenth  day,  although  in  V2'2  of  the  Senunar.v 
oases  the  i)atient  is  stated  to  have  lieen  deliiioiis  when  death  took  places  on  the  idglith  day. 

FJ.ffrente,  prOHtrntian  and  mnscitlav  debitifff,  manifested  bytlu^  position  of  the  i)aticnt  in 
bed,  the  tremulous  tongue,  occasional  falling  of  the  lowi'r.jaw  and  subsultiis  tendiniim  were  as  frei|iieiitl.v  noted  in 
these  cases  as  iu  those  of  the  ty|)h()id  series.  Occasionally,  as  in  casi^  (i  of  the  record  of  the  27th  Conn.,  the  patient 
recovered  his  intelligence  while  in  this  state  of  extreme  <lcl)ility. 

The  Seminary  i-ecords  show  tliatdelii'ium,  iiUliuUiih  of  less  iVcquciit  occurrence  in  typlio- 
iiuilarial  cases,  was  of  much  more  serious  import  than  in  cases  of  pure  typhoid.  Delirium 
was  present  in  twentv-one  of  forty-one  favorable  cases  of  typhoid  and  in  only  twelve  of 
forty-seven  recoveries  from  typho-malarial  fever;  hut  although  only  eight  of  twenty-nine 
cases  of  tyi^hoid  delirium  resulted  fatally,  no  less  than  thirteen  of  twenty-four  cases  of  typho- 
inaUirial  delirium  had  an  unfavorable  termination.  These  figures  give  expression  to  an 
increased  gravity  with  which  the  malarial  complication  endowed  the  tyfihoid  disease.  It 
cannot  be  allowed  tJiat  the  existence  of  intermittent  or  remittent  fever  tended  to  repress  the 
dev(dopment  of  the  cerebral  symptoms  of  typhoid,  since  malarial  fevers  are  themselves 
associated  at  times  with  delirium.  Hence  it  may  be  inferred  that  the  increased  mortality 
in  typho-malarial  cases  presenting  delirium,  as  compared  with  typhoid  cases  having  similar 
cerebral  manifestations,  was  due  to  the  coincidence  of  malarial  disease. 

The  Dige.'^tivk  .Systkm. —  Votnithlf/  was  noted  in  twenty-six  of  the  sixty-four  cases  and  nmisen 
without  vomiting  in  four  cases.  In  UlS,  lit  and  122  thi"  nausea  occurred  early  in  the  attack,  but  in  St!  the  fever 
was  at  its  height  when  the  patient  became  thus  aft'ceted.  In  thirteen  of  the  twenty-six  cases  the  vo'miting  was 
reeordcn  during  the  early  j)eriod  f  the  attack:  four  of  these,  90,  it2,  !•.">  and  lit!,  were  fatal,  but  it  does  not  ai>pearthat 
the  vomiting  had  any  piognostio  value,  for  recovery  took  place  in  sonu^  of  the  cases  in  which  it  was  a  troublesome 
symptom,  as  in  79,  in  which  it  continncd  for  several  days,  and  in  82,  in  which  it  ])ersisti'd  for  two  weeks,  ceasing  only 
on  the  occurrence  of  epistaxis  and  perspirations.  In  98,  101,  107,  110  irritabilitv  of  the  stoiiuich  corresponded  in 
time  with  the  full  develoiiincnt  of  the  febrile  condition,  and  in  88  it  followed  the  administration  of  (luinine;  one  of 
these,  98,  was  fatal.  The  vomiting  which  occurred  at  a  late  period  in  (W.  7")  and  80  was  not  a  sign  of  evil  omen, 
hut  in  84,  85,  89,  91  and  97  it  was  connected  with  fatal  ]>eritnnitiH  or  collapse. 

Xausea  and  vomiting  were  of  corresjiondingly  freiiuent  occurrence  in  flie  ea.ses  embraced  in  the  iKint-inortrm 
records.  In  a  few  instances  gastric  irritability  was  unusually  distressing  and  ])ersistcnt :  In  llti  nourishment  had 
to  be  introduced  by  enemata;  in  95  vomiting  was  associated  with  severe  epigastric  pain  and  inllammatory  processes 
ill  the  gall-bladder;  in  280  it  occurred  early  and  persisted  to  the  end. 

More  or  less  of  Jattntlice  was  observed  in  seven  of  the  Seminary  <ases :    The  jiatient's  face  was  slightly 
tinged  in  67  and  the  skin  and  con.junctivie  in  121,  at  the  close  of  a  mild  fidirile  attack ;  in  81  and  100  the  eyes  and 
skin  were  yellowish,  this  condition  having  been  associated  with  epigastric  )>ain:  in  lO.S  .jaundice  followed  the  exhi- 
bition of  calomel  and  .jalap:  it  occu^reij  t.lso  in  112,  in  which  remittent  and  typhoid  fevers  coincided,  and  iu  118, 
Med.  HIST.,  Pt.  HI— 39 


30() 


'YMl'Tu.MA'IOl.OilV    OK 


during  tlie  activity  of  a  rciiiittciit  wliicli  was  fdllowcil  liy  a  tyiilmicl  iitt:ick.  In  addition  to  tlieso  tliero  was  some 
derangement  of  tlie  livin-  in  105  ihiiinj;  its  iiaioxysiiuil  [lerioil.  Only  one  of  these  eases,  81,  was  fatal.  Jaundice 
appeared  freouently  among  tlie  symptoms  of  tlie  jiiiil-iiiorh'm  series;  it  was  seen  in  54,  6"),  81,  95,  SiCi,  il7,  98,  100  and 
111,  and  in  these,  as  in  those  already  instanced,  the  coloration  of  the  skin,  conjunctival  and  urine  occurred  generally 
in  the  early  period,  hut  sometimes  towards  the  end  of  the  attack. 

The  greater  IVoqui'iiry  of  iKUisea.  vdiniting  and  jauiidicc  in  these  cases  must  be  regarded 
as  symptomatic  of  the  action  of  thi;  mahiriiil  poison,  since  such  symptoms  are  usual  in  the 
paroxysmal  fevers,  while,  as  has  been  seen,  tliey  are  so  often  tdjsent  in  typhoid  that  it  is 
impossible  to  consider  them  essential  features  of  its  clinical  picture. 

The  tongue  was  more  lieavily  coated  with  a  white,  yellow  or  grayish  fur,  especially 
towards  the  base,  than  in  unmodified  ty])hoid.  Later,  as  it  became  dark  in  color  it  lost 
its  moisture,  but  it  did  not  remain  dry  and  brown  during  (he  height  of  the  febrile  manifes- 
tation with  such  persistency  as  in  pure  typhoid.  It  varied  in  its  conditicju  fnjin  day  to 
day,  being  sometimes  more  or  less  moist,  and  at  other  times  dry  or  coated  with  tenacious 
mucus;  but  at  some  period  of  the  disease  the  red  tip  tiinl  edges,  so  frequently  recorded  in 
the  unmodified  fever,  were  also  seen  in  the  typho-malarial  cases.  Before  the  accession  or 
subsequent  to  the  disapiieai-ance  of  typhoid  symptoms  the  tongae  was  often  pale,  flabby 
and  coated  as  in  malarial  attacks,  and  occasionally  this  flabbiness  persisted  during  the  con- 
tinuance of  pathognomonic  symptoms  of  tyj^hoid.  Tn  ftivorable  cases  the  fur  sometimes 
cleaned  off  in  patches,  but  more  generally  a  white  or  yidlow  coating  was  observed  far  into 
the  period  of  convalescence. 

In  t>cent;/-two  of  the  sixty-four  cases  the  foilfflte  at  some  period  of  the  disease  was  recorded  as  red  at 
the  tip  and  edges,  this  characteristic  heing  frequently  rioted  when  the  rose-colored  eruption  was  visible  on  the  chest 
and  ahdomen;  seven  of  these  were  fatal,  84,  89,  90,  '.)2,  91.  99  and  122.  The  red  tip  and  edges  appeared  also  in  fonr- 
teeii  cases,  in  which  the  tongue  was  characterized  as  llahliy  or  i)ale  an<l  tlahhy — (i9,  70,  74,  75,  80,  81,  8;{,  85,  98,  100, 
109,  111,  112  and  118;  throe  of  these,  85,  98  and  111,  did  not  recover.  In  tin  other  cases  liabbiness  was  specially 
noted:  In  59,  (52  and  121  the  tongue  was  tlahby  and  slightly  coated;  in  (55  yellow-patched  and  afterwards  white  and 
flal)by;  in  67  dry,  red,  white-coated  an<l  flabby;  in  77(lry  and  brown,  with  subsequent  flabbiness  and  prominent  papilla', ; 
in  79  red,  glossy  and  dry,  becoming  aft(M-wards  moist  iind  flabby ;  in  82  white  or  yellow-coated,  and  afterwards  flabby; 
in  lOti  pale,  flabby  and  coated  yellowish-brown  in  the  (teiitre,  and  in  9.)  pale  and  flabliy.  As  none  of  these  jiroved 
fatal  except  the  last,  it  would  seem  that  danger  diminished  with  the  distinct  api)reciation  of  the  characteristics 
of  the  malarial  tongue  as  distinguished  from  those  of  the  typhoid  tongue.  In  the  remaining  eiijhteai  cases  the 
tongue  was  characterized  as  follows:  Coated  at  the  liase,  l)ut  cleaner  at  the  tip  and  edges  in  102  and  108;  dry, 
rough  and  coated,  but  cleaner  and  nujist  at  the  edges  in  1 14  ;  coated  in  the  centre,  but  with  the  edges  moist  in  105  and 
119;  white-coated  and  moist  in  95;  heavily  coated  in  1115;  yellow-furred  and  fissured  in  115;  yellowish  in  64;  dry 
and  brown  in  104  ;  brown  and  fissured  in  107;  dry,  brown  and  fissured  in  91  and  96;  dry,  brown  and  coated  in  66  and 
97;  brown,  8nhse()uently  becoming  white  in  86;  red,  dry  and  fissured  in  71;  red  and  clean  in  73.  Six  of  these  cases 
were  fatal,  viz:  91,  95,  96,  97,  104  and  119. 

Notwithstanding  the  oftentimes  foul  condition  of  the  tongue  the  hrenth  is  said  to  have  been  oftensive  in  but 
two  cases,  100  and  113;  in  the  latter  it  was  referred  to  the  existence  of  oza/na. 

The  lips,  teeth  and  gums  were  covered  with  sOfdes  in  ten  of  the  seventeen  fatal  cases,  and  in  eleven  of  the 
forty-seven  which  resulted  favorably',  so  far  as  the  record  follows  up  their  history.  Of  the  seven  mortal  cases  in 
which  the  mouth  was  not  reported  as  having  been  in  this  foul  state,  death  occurred  at  an  early  date  in  one,  122 ;  in 
two,  84  and  85,  the  fatal  result  was  due  to  peritonitis, — in  the  former  the  patient's  condition  towards  the  close  sug- 
gests that  sordes  may  have  been  present  thcnigh  unrecorded;  in  92  death  was  precii>itated  by  gangrenous  erysipelas 
and  in  99  by  pulmonary  complications;  in  94  and  95  the  reccjrd  slurs  the  details  of  the  last  stages  of  the  malady. 

The  condition  of  the  ntoufh,  throat  and  IfiryilOC'  in  these  cases  was  sometimes,  as  in  pure  typhoid, 
such  as  to  occasion  more  or  less  dysphagia  and  alteration  of  voice.  The  mouth  and  throat  were  covered  with 
aphthous  spots  in  88;  the  larynx  was  probably  congested  in  77  and  81,  as  it  certainly  was  in  93;  in  87,  however, 
aphonia  appears  to  have  been  due  to  prostration,  and  although  in  96  and  114  dysphagia  must  be  attributed  to  cere- 
bral implication,  it  was  in  the  earlier  stages  of  the  latter  case  probably  a  result  of  local  inflammatory  processes. 

Diui'i'hiKfl  or  relaxation  of  the  bowels  was  present  in  perhaps  the  whole  of  the  sixty-four  cases  of  the 
Seminary  series  that  have  been  submitted  as  illustrations  of  the  coincidence  of  the  tyjihoid  and  malarial  ]K)isons  in 
the  same  subject.  As  in  the  unmodified  cases,  it  was  sometimes  an  early  symptom,  whihs  at  other  times  it  was  not 
developed  until  late  in  the  attack;  it  lasted  for  !i  few  days  in  some  cases,  while  in  others  it  not  only  continued 
throughout  the  fever,  but  was  prolonged  into  the  period  of  convalescence.  It  varied  in  intensity  from  an  aggravated 
and  exhausting  flux  to  a  slight  relaxation  manifested  rather  by  lessened  consistence  than  freciuency  of  the  passages. 
The  stools  were  thin,  yellowish,  watery  and  often  fetid.  I'sually  they  were  passed  without  pain,  notwithstanding 
the  exietence  of  abdominal  tenderness;  as  an  exceptional  instance,  tormina  was  recorded  in  case  87. 


THE    ('ONTI-NTKI)    FKVKRS.  3f»7 

Diairlicra  was  assooiateil  with  JtciHOi'l'/iaf/C  friMii  tlu'  hoivels  in  Illicit  dl'  tin-  cast's.  85,  !I2  ami  it3,  all  of 

winch  were  I'aliil.  ihmijjh  not  as  a  diicct  coiiscinu-iu  c  nl'  ilic  lu>s  nl'  hlood:  ncvcitlii'lcss,  its  occurrence  ])rohalily 
hastened  the  fatal  event,  for  in  X.">  the  Moody  stools  were  reiiorled  as  liii\  ini;  c:nised  iinicli  depression,  lieuiorrhafic 
from  the  bowels  forms  part  of  tlie  record  iii  case  lUii  id'  the  iiu.-<t-iiinrli  in  siiii>. 

As  in  the  tyiihoid  cases,  several  instances  oiiuirid  in  which  tlu'  dinrrlKcal  Ien<lency  was  not  stron<;ly  enii)ha- 
sized:  There  was  jio  diarrluea  in  (i>!  dnrinj;  the  stay  id'  the  iiaticnt  in  hosjiiial.  Imt  as  tin'  iiiti'stinal  lesion  was  marked 
liy  tenderness  and  f^^iirijling.  it  is  )irohalile  that  diariho'a  may  have  heeii  a  synijiiom  diirinji  the  two  weeks  of  sickness 
wliicli  precedeil  his  admission.  In  111'  the  jiaroxysmal  iieiio<l  was  characici  i/ed  hy  diarrlicea,  hut  diirinjj  the  ]>ro- 
ffress  of  the  ty])hoid  fever  the  limvcls  were  comiiaratividy  ipiiet.  In  iHialso  the  howels  weri^  (|niot,  hut  there  was 
much  tympanites.  In  some  cases  the  use  of  su(di  pnrfj;atives  as  <'alomcl  and  jalaj).  Idue  ])ill.  com]ioiind  cathartic 
l)ills.  Kpsom  salt  or  castor  oil  shows  that  at  the  time  of  their  administration  the  howtds  wen-  not  loose.  In  (i:2.(i:i.  li" 
and  lOX  these  cathartics  did  not  luodnce  undue  effects,  hut  in  ill  and  lOU  intestinal  symptoms  were  develo])ed  or 
a<rgra\ated  after  their  administration.  In  To,  which  was  characteri/ed  hy  diarrhcea  al  first  hnt  not  tliroufihont  its 
progress,  purgative  medicines  did  not  intensify  the  diarrhccal  tendency,  while  in  Til.  in  which  the  conditions  ap|>eared 
to  he  similar,  full  doses  of  K|isom  salt  <'aused  frc([Ucnt  stools  and  iliac  ti'iidcrni'ss.  Lastly,  in  71',  with  constipation 
present  and  some  tenderness  (jf  tlu^  howels,  the  cathartics  adminislcre<l  wcr<'  ncd  |irodnctive  of  nndesirahle  effects 
until  the  twenty-first  day  of  tin'  disease,  when  vioh'nt  action  was  set  up.  In  some  lascs  sniMMilted  from  rejjimental 
records  the  howids  are  said  to  have  hm'U  const ijiated,  as  in  2, 'A,  1,  (!  and  it  of  the  l!Mh  Mass.  and  ."i  ami  S  of  the  L'Tth 
Coiin.;  in  two  of  these,  S  and  '•,  laxative  and  even  powerful  cathartic  doses  iiroduecd  hut  little  etfe<',t. 

IJiarrhcea  ap]>earB  with  ei|ual  fre(|uency  in  the  clinical  histories  whicdi  precede  thi'  juixt-niortcm  records.  In  54 
and  IKi  there  was  a  recrMdescenee  of  the  diarrhnal  affection.  A  few  of  these  fr.igmcntary  liistorii's  report  constil>a- 
tion  as  the  characteristic  conilition  of  the  howcds  during  the  attack.  Thus  in  !I5  Mii're  was  constipation  dtiring  the 
initiatory  paroxysmal  fever  and  durinj;  ten  days  of  jaundice  which  followed  it,  nor  did  diarrlm'a  sot  in  when  ady- 
namic symptoms  were  suhseiiuently  d<'veloi>ed.  In  2(>8,  also,  const  ijiat  ion  was  present,  hnt  in  this  instance  there  was 
cerebral  di.sease  snfflcient  to  acccumt  for  most  of  the  recorded  8ym]if  oms.  The  bowids  were  slugfiish  in  52,  a  ease  cliar- 
acteiizcd  by  its  frequent  and  copious  i)ers|)irations.  Constipation  is  uientione<l  also  in  the  records  of  Xti  and  111:  and 
diarrlnea  was  certainly  absent  from  the  history  of  llti,  in  which,  jii  account  of  the  condition  of  the  stomach,  nutrient 
enemata  were  lar;;cly  employed. 

Sometimes,  as  in  unmodified  tyi)hoid,  duirrhiea  ceased  on  tlie  oceurrenc  ■,  of  perspiration  at  the  period  of  defer- 
vescence. Such  cases  as  72,80  and  113  are  sugfjestive  of  a  connection  between  the  cessation  of  the  flux  and  the 
increased  action  of  the  skiu,  and  in  til  and  ;I0  this  suggestion  is  strengthened  by  alternations  of  hot  skin  with  diar- 
rhiea  and  free  piMspirations  with  (jniescent  bowels;  but  it  is  doubtful  if  these  bore  to  each  other  any  closer  relatioii- 
shij)  than  that  of  association  as  results  of  the  same  cause. 

JIt'feoristn,  nbtloniinal  ittliti  and  teitderneKS. — of  the  sixty-four  cases  of  the  Seminary  series 
pain,  tenderness  anil  tymi)anites  of  the  ahdoinen  were  mentioned  in  all  exce|)t  the  three  mild  ca.ses,  (it),  102  and  lit!, 
the  markedly  malarial  ca,se,  121,  and  the  rajtidly  fatal  i>aioxysmal  case,  122.  I'ain  or  tenderiu'ss  was  recorded  with 
tym]ianitcs  in  thirty  eiglit  cases  and  without  tym]ianites  in  twenty,  while  in  but  one  case,  117,  was  tymiianites 
noted  without  coincident  pain  or  tenderness.  The  meteorized  condition  of  the  abdomen  was  generally  proportioned 
to  the  gravity  of  the  attack,  but  in  99,  in  which  the  fatal  result  was  due  to  pneumonic  complications,  the  abdomen, 
which  at  times  had  been  tympanitic,  became  soft  towards  the  end. 

In  thirty-one  cases  the  abdomen  generally  was  assigned  as  the  seat  of  the  fciiiierness,  liut  in  twenty-five  of 
these  one  or  more  localities  were  indicated  as  particularly  affected:  In  ween  the  right  iliac,  in  «nc  the  iliac,  in  tivo 
both  iliac  regions  and  in  ohc  tlie  right  side;  in  iiuf  the  right  iliac  and  ejiigastric,  and  in  one  the  right  iliac,  ejiigastric 
and  nmbilical  regions;  in  tu-dec  the  umbilical  with,  in  four  of  these,  the  right  iliac,  in  one  the  left  iliac,  and  in  five 
both  iliac  regions,  one  of  the  last  having  the  hypogastric  also  affected  and  another  the  hepatic  and  epigastric  regions. 
In  the  cases  in  which  the  abdomen  was  not  mentioned  in  general  terms  the  localities  were  specified  as  follows:  In 
fourteen  the  right  iliac  region  with,  in  two  of  these,  the  umbilical,  in  one  the  epigastric,  in  one  the  umbilical  and 
epigastric,  in  one  the  hepatic  and  in  one  the  hypogastric;  in  nix  the  left  iliac  region  with,  in  three  of  these,  the 
nmbilical  also,  and  in  one  the  umbilical  and  epigastric;  in /ohc  both  iliac  regions  with,  in  one  of  the.se,  the  umbilical, 
in  two  the  epigastric  and  in  one  the  epigastric  and  umbilical;  lastly,  in  three  the  umbilical  with,  in  one  of  these,  the 
iliac,  side  not  stated,  and  in  one  the  iliac  and  hypogastric.  Thus,  in  the  sixty-four  cases  the  abdomen  was  mentioned 
in  thirty-one  cases,  the  right  iliac  region  in  thiity-eight,  the  nmbilical  in  twenty-live,  the  left  iliac  in  eighteen,  the 
iliac  in  three,  the  epigastric  in  nine,  the  hypogastric  in  three  and  the  hepatic  region  in  two  cases. 

Hypogastric  pain  was  connected  in  107  and  119  with  retention  of  urine;  in  84  it  was  probably  due  to  the  con- 
dition of  the  bladder  in  the  early  period  and  to  peritonitis  at  a  later  date.  In  some  of  the  pont-mortrm  records  also, 
as  in  cases  82  and  83,  it  was  associated  witii  peritoneal  inflamnuition.  Ejjigastric  pain  was  connected  in  some 
instances,  as  84  and  100,  with  jaundice;  in  others,  as  85,  101  and  105,  with  irritability  of  the  stomach;  in  78  the 
morbid  feiding  experienced  in  this  region  was  not  tenderness  but  a  burning  sensation. 

twtli'fflitlff  was  freiiuently  observed  in  connection  with  abdominal  tenderness  and  distention. 

Splenic  enlai'ffenient  was  not  noted  during  life  in  any  of  these  cases,  an  omission  probably  due  to 
the  cause  suggested  when  referring  to  this  as  a  symptom  of  typhoid. 

CliKST  COMPLICATIOXS. — Votlfflt.  was  present  in  thirty-two  of  the  sixty-four  cases.  Generally  it  was  slight 
and  yielded  a  frothy  mucous  expectoration;  but  in  some  cases,  as  78,  86  and  101,  it  was  associated  with  pain  in  the 
chest,  and  in  others,  as  87,  90  and  93,  with  definite  pneumonitic  signs.  The  expectoration  was  blood-streaked  in  87 
and  105  and  purulent  and  blood-streaked  in  80;  in  114  blood  in  the  sputa  was  referred  to  a  couctirrent  epistaxis. 


308  SY.M1'T(JMA  roi.OGY    OF 

Occasionally,  as  in  118,  inu«)UB  and  siliilimt  i-rilcs  wcic  lirard  altli(iiif;li  I'dujili  i.n  said  to  Ijavf!  been  aliscnt.  The  r€S- 
ftiratiott,  became  accelerated  in  some,  as  in  i)i)  and  infi:  it  was  liiniied  also  in  1(1(1,  in  w  liitli  coufjli  did  not  appear 
as  a  symptom ;  and  in  tlut  fatal  casiis,  !Ki,  iMi  and  StT,  tlii^  liieal  liinj;'  liecaiuc  jjieatly  laliorcd  towarils  tlie  end,  iilthoii};li 
in  the  two  last-mentioned  instances  oilier  syniptonis  id'  i)n('innonic  complication  were  oliscured  l)y  the  intensity  of 
the  stupor.  Amonj;  tin;  cases  in  the  jxtxl-morh  in  records  pulmonary  embarrassment  was  observed  in  some,  as  100; 
pneumonia  in  otln^rs,  as  58  and  it7.  In  05  the  coufrh  was  paroxysmal  and  pr<n-ent(Ml  sleep.  In  115,  which  was  prob- 
ably an  adynamic  malarial  case,  the  chest  att'ection  was  att  ributed  to  exposure  by  throwini;  off  the  bedclothes  <lurinK 
the  niglit.     Accelerated  breathinf;  in  111  was  probably  <liie  in  part  to  ]ilenritic  ctl'iision. 

Other  clinical  kk,\tuukh. — The  urine  was  retained  or  passed  with  dilHcnlty  in  twelve  of  the  sixty-four 
oases;  usually  it  was  scanty  and  hi<5h-colored.  No  special  record  was  made  of  its  ([uantity  or  (juality,  save  in  KM 
and  113,  in  the  latter  of  which  it  was  passed  in  excessive  quantity  notwithstanding  the  concurrence  of  free  perspi- 
rations; in  the  former  it  was  acid  at  first,  afterward  alkaline,  large  in  quantity  and  of  small  specific  gravity.  From 
these  cases  it  does  not  ai)pear  that  retention  or  difficult  micturition  was  cotemporaneous  with  the  development  of 
head  symptoms:  In  65,  73,  7><,  K2  and  K!  the  urinary  trotible  was  noted  early,  but  there  were  no  markiid  cerebral 
manifestations.  In  (i!)  also,  micturition  was  atl'ecled  at  an  early  date,  but  delirium  did  not  supervi-ne  until  after 
a  lapse  of  ten  days.  In  70,  with  dlflicult  niicturiti(Mi  on  the  twelfth  day,  the  only  head  symptom  was  some  mental 
dulness,  which  was  shown  about  six  days  later.  The  uiinary  atiection  occurred  in  the  middle  of  the  second  week 
in  121,  in  the  third  week  in  107,  in  the  fourth  week  in  110,  Imt  in  none  of  these  was  there  any  delirium.  In  the  fatal 
case,  84,  difficult  micturition  was  followed  in  a  t'i;\v  days  by  the  development  of  cerebral  symptoms,  but  as  the  latter 
appeared  and  became  aggravated  the  former  ceased.  In  119,  also  fatal,  headache  and  slight  delirium  accompanied 
a  difficulty  in  retaining  the  urine,  while  the  opposite  condition  of  retention  subsequently  dev<'loped  was  not  thus 
accompanied.  On  the  other  hand,  although  in  many  cases  characterized  by  delirium  and  stupor  theri'  was  an  invol- 
untary or  uncontrolled  passage  of  the  urine,  case  81  is  the  only  instance  in  which  temporary  retention  was  reported 
as  associated  with  the  comato.se  condition.  In  the  pnnt-morlnn  series  of  cases,  although  delirium  followed  dysuria  in 
some,  as  in  65,  in  others,  as  83  an<l  lOti,  there  was  no  association  of  head  symptoms  with  retention  or  dystiria. 

Purotitis. — Swelling  of  the  parotid  appealed  about  the  end  of  the  third  week  in  (59, 112  and  98;  the  termina- 
tion was  favorable  in  the  first-mentioned  case,  but  the  two  others  were  fatal.  In  92  a  gangrenous  inflammation 
spread  over  the  face,  and  death  took  place  four  days  after  the  implication  of  the  parotid  ;  in  98  the  swelling  increased 
so  rapidly  that  in  a  few  days  tli<^  patit^nt  was  unable  to  protrude  his  tongue,  and  in  six  days  death  oceurtcH  with 
vibices  and  aggravated  intestinal  symptoms.     In  the  iiont-iiiorti-m  series  parotid  swelling  was  found  in  53,  65  and  97. 

Piling  iu  the  joints  and  inuscles,  especially  of  the  lower  oxtreinities,  were  noted  at  a  late  period  in 
the  history  of  115  of  the  Seminary  series,  8  of  the  record  of  the  27th  Conn,  and  1,  2,  3,  4  and  12  of  those  belonging  to 
the  19th  Mass.;  in  ease  4  of  the  last-mentioned  series  these  pains  were  so  severe  as  to  cause  loss  of  sleep  and  slight 
delirium,  iwatlff rents  of  a  blistered  surface  was  recorded  in  case  104;  gangrenous  erysipelas  of  the  face  has 
already  been  noted  as  having  been  present  iu  92 ;  gangrene  of  both  feet  occurred  in  5  of  the  records  of  the  27th  Conn, 
and  in  some  of  the  cases  of  the  post-mortem  series.  These  will  be  referred  to  hereafter  in  speaking  of  the  so<iueliB  of 
the  continued  fevers.* 

Relapsks. — The  procrress  of  typlio-inaliirial  cases  was  even  more  irregular  than  that 
of  typhoid  cases,  for  in  addition  to  the  complications  and  recrudescences  to  which  the  typhoid 
element  rendered  them  obnoxious,  their  course  was  liable  to  interrupt  ion  and  prolongation 
by  intercurrent  exacerbations  due  to  their  malarial  el<Mnent.  i^>ut  well  dehned  rt'lapscs  ot' 
the  typhoid  phenomena  were  as  infrequent  as  in  unmodihed  tvj)hoid. 

Relapse  w-as  recorded  in  69  and  91  of  the  Seminary  series  and  in  56  of  the  jxist-mortrm  series.  In  the  first- 
mentioned  case  the  relapse  was  manifested  by  chill,  fever  and  perspiration,  wakefulness,  diarrh(pa,  thirst  and  some 
febrile  heat,  while  the  pulse,  although  strong  and  full,  was  not  accelerated,  beating  only  at  the  rate  of  66  per  minute; 
rose-colored  spots  appeared  on  the  eighth  day,  after  which  defervescence  took  place,  diarrhu'a  subsided  and  the 
appetite  returned.  The  second  case  presents  a  difterent  recjord:  Fever,  diarrlnca,  delirium  and  unconsciousness  were 
at  once  developed;  modified  red  spots  appeared  on  the  third  day,  about  which  time  the  delirium  became  violent; 
this  was  interrupted  by  a  severe  chill  with  the  subse(|uent  establishment  of  the  typhoid  condition,  dui  ing  which,  on 
the  sixth  day,  rose-colored  spots  erupted;  death  occurred  on  the  seventh  day  from  perforation.  In  the  third  case  the 
details  of  neither  the  primary  fever  nor  the  relapse  are  given;  but  it  is  stated  that  during  the  subsidence  of  the 
febrile  action  delirium,  coma  and  death  oconned  in  connection  with  inflammatory  processes  in  the  ear. 

Fatality. — Lastly,  it  is  of  importance  to  point  out  that  the  fatality  of  these  cases  was 
considerably  greater  than  that  of  the  typhoid  series, — in  fact,  their  percentage  of  fatality  was 
greater  than  the  sum  of  the  percentages  of  typhoid  and  malarial  diseases.  Of  fifty-one  Sem- 
inary cases  of  unmodified  typhoid  ten  were  fatal  or  19.6  per  cent.,  while  of  sixty-four  cases 
in  which  this  disease  was  influenced  by  the  coincidence  of  malarial  phenomena  seventeen 
or  26.6  per  cent,  ended  fatally.     These  results  are  consistent  with  medical  experience  in 

*Seo  infra,  page  309. 


TTIK    CONTINUED    FEVERS.  309 

analogous  cases.     No  oiif  will  deny  tliat  wlien  pneumonia  occurs  in  tlie  progress  of  typlioid 
or  malarial  fever  the  patient's  danger  is  correspondingly  enhanced. 

In  summarizing  the  differences  between  the  symptoms  of  the  typhoid  affection  per  se 
and  the  same  disease  as  modified  by  the  intercurrence  of  active  febrile  conditions  usually 
attributed  to  the  malarial  influence,  the  following  points  require  mention  as  generally  char- 
acteristic of  the  latter: 

1.  I'aroxysmal  Invasion  with  persjihations; 

2.  Greater  strengtli  and  fi'e()uency  of  the  pulse  (luring  the  febrile  access; 

3.  Intercurienco  of  febrile  paroxysms  at  any  stage; 

4.  The  paroxysmal  recurrence  of  epistaxis; 

5.  A  doubtful  infre(iueucy  of  the  eru])tion  and  an  undoubted  modification  of  its  characters  in  certain  cases; 

6.  Tlie  pale,  Habby,  nioiHt  and  coated  condition  of  the  tongue; 

7.  The  greater  frequency  of  nausea,  vomiting  and  Jaundice; 

8.  A  more  defined  tendency  to  constipation  in  the  few  cases  not  characterized  by  relaxation  or  positive  diar- 
rhoea, and  the  fre(|Ueiicy  of  abdominal  tenderness  beyond  the  limits  of  the  right  iliac  region,  especially  towards  the 
epigastric  and  left  iliac  regions; 

9.  The  greater  gravity  of  the  cerebral  symptoms  and  the  earlier  period  at  which  death  was,  in  some  instances, 
occasioned  by  malarial  coma; 

10.  A  greater  fatality  or  ratio  of  deaths  to  cases. 

It  appears,  therefore,  that  when  these  cases  as  a  whole  are  compared  with  those  of 
pure  typhoid,  there  are  manifested  certain  clinical  differences  which  were  marked  in  pro- 
portion to  the  activity  of  tlie  malarial  phenomena;  when  the  latter  were  pronounced  there 
was  no  difficulty  in  determining  the  interference  with  the  course  of  the  typhoid  fever,  pro- 
vided the  occurrence  of  the  characteristic  symptoms  of  that  fever  indicated  its  presence. 
But,  as  may  be  seen  in  the  records  of  the  19th  Mass.,  there  were  occasionally  presented 
obscure  cases  in  which  it  was  impossible  to  say  whether  the  sub-continued  fever  which  [)ros- 
trated  the  patient  was  due  solely  or  chiefly  to  one  or  other  of  these  fever-poisons,  since  the 
characteristic  symptoms  of  neither  were  distinctly  marked,  wfiile  well  defined  cases  of  each 
of  these  febrile  conditions  were  occurring  at  the  same  time  in  neighboring  commands  and 
had  occurred  only  a  short  time  before  in  the  regiment  itself. 

Further  inquiry  into  the  nature  of  tlie  typho-malarial  cases  of  the  war  must  be  post- 
poned until  after  tlieir  presentation  from  the  post-mortem  standpoint. 

IV.— TYPHOID  FEVER,  MODIFIED  AND  UNMODIFIED. 

Sequelae. — But  wliether  the  febrile  cases  that  occurred  among  our  troops  were  typhoid 
or  typho-malarial  certain  sequeliB  were  prone  to  follow.  Persistent  debility,  occurring 
alone  or  in  association  with  tubercular  developments  or  some  local  morbid  conditions,  often 
incapacitated  the  soldier  for  further  military  service.  Diarrhoea  was  the  most  frequent  of 
the  engrafted  diseases,  owing  to  the  prevalence  of  its  causes  and  the  condition  of  the  intes- 
tinal lining  in  convalescents  from  fever:  Following  it  in  oi'der  of  frequency  were  inflamma- 
tory processes  in  the  lungs.  Diseased  conditions  of  the  liver,  spleen  or  kidneys  were  also 
found.  Many  of  the  cases  already  submitted  illustrate  these  occasional  consequences  of  the 
febrile  attack,  and  others  of  a  similar  tenor  will  be  found  in  the  post-mortevi  records. 

Perhaps  the  most  interesting  sequel  presented  by  the  records  is  the  pain  in  the  feet  and 
legs  which  constituted  a  prominent  and  distressing  symptom  in  many  of  the  cases.  It 
occurred,  but  not  with  frequency,  in  tfie  Seminary  cases;  it  constituted  a  characteristic  of 
those  treated  by  Surgeons  Dyer  of  the  19th  Mass.  and  Barr  of  the  36th  Ohio,*  and  it  is 
mentioned  in  the  report  of  Surgeon  McLaren's  Board  of  Inquiryf  and  in  several  of  the 

•See  report,  iV«,  p.  327.  t  I"f''<h  P-  365. 


310 


SYMPTOM ATOI.OCY    OF 


cases  taken  fi'oin  tlie  recorils  of  Viuious  general  hospitals.     Occasionally  it  is  noted  in  Sani- 
tary reports,  as  in  the  lolluwing: 

Siiryion  IIakvkv  K.  ISiiown,  Wlh  X  V.  VaJn.,  Camp  Miihaii,  )'((.,  (M>ih<r  HI,  l>i(;i'. — A  number  of  Novero  ('asos  (if 
tj'jihoid  fevov  presiintdl  thi!  inculiarity  that  duriiif,'  com  alesociici^  tliere  was  a  remarkalilc  tcmlerue.ss  of  the  feot  and 
ankles:  the  iiatient  wouid  cry  out  with  a^^ouy  at  the  nun-o  weif;ht  of  the  bedclothes,  and  a  touch  of  the  hand  gavo 
exer\iciating  pain.  I  found  but  little  relief  in  this  distressing  syuiptoni  from  co(ding  lotions  or  poultices;  perhaps 
I  was  more  successful  with  the  use  of  hog's  lard  smeared  over  the  foot  than  with  any  other  ri'uu'dy.  lu  most  of  the 
cases  this  soreness  gradually  disappeared,  liut  loss  of  power  iu  the  feet  remained  fin'  nuiny  weeks,  although  the 
l)atieuts  iu  other  respects  grew  strong  and  well.  In  one  case  large  abscesses  formed  on  the  dorsal  surface  of  the  foot ; 
these  discharged  and  the  foot  got  well. 

Owing  to  tlie  meagre  character  of  tlie  reconls  it  is  difficult  to  appreciate  the  cause  of 
this  pain  in  the  cases  in  which  it  is  mentioned.  In  some  it  was  probahly  duo  to  fatigue 
induced  by  the  first  efforts  of  the  convalescent  to  test  liis  returning  strength.  Muscular  and 
rlieuniatic  pains  may  also  he  ascribed  to  degenerative  changes  arising  from  mal-nutrition, 
the  poverty  or  abnormal  state  of  tlio  blood  being  manifested  by  an  cedeinatous  condition  of 
the  feet  and  ankles  or  by  boils,  subcutaneous  abcesses  or  ecchymoses.  But  the  occurrence 
of  eangrene  in  cases  40-42,  from  the  records  of  various  hospitals,  and  in  six  cases  of  tlte 
post-mo rtaii  series,'-' is  of  importance  in  this  connection.  The  severe  pain  mentioned  as  the 
only  abnormal  phenonteiion  in  some  cases,  as  in  those  of  the  36th  Oliio,  was  associated  wnth 
swelling  in  others,  in  two  of  Burgeon  Kkndall's  cases  with  discoloration,  and  in  certain 
cases  with  ulceration,  supej'flcial  sloughing  and  even  gangrene  necessitating  amputation 
above  the  ankle  joint.  Burgeon  ]iAHK  viewed  the  occurrence  of  this  pain  as  a  favorable  sign 
indicating  the  commencement  of  convalescence,  but  a  larger  experience  showing  its  probable 
connection  with  a  df.'adly  lesion  sup])lies  ground  for  regarding  it  with  much  anxiety. 

Surgeon  J.  II.  Tavi.oi;,  U.  S.  Vols.,  iu  his  report,  April  10,  18(33,  on  the  occurrence  of 
gangrene  of  the  toes  in  the  Third  Army  Corps,  Army  of  the  Potomac,  attributed  this  morbid 
condition  to  exposure  to  cold.  Iu  the  field  hospitals  of  the  corps  he  found  six  cases,  one  of 
which  was  manifestly  a  true  fi'ost-bite.  In  five  the  gangrene  set  iu  during  convalescence 
from  typhoid  fever,  but  in  the  history  of  each  there  was  detected  an  exposure  to  wdtich,  in 
the  debilitated  condition  of  the  patient,  the  local  injury  was  ascribed.  In  one  of  these  cases, 
that  of  Adam  llayerd,  122d  Pa.,  amputation  was  performed  at  the  upper  third  of  botli  legs, 
subsequent  to  separation  of  the  feet,  and  at  the  time  of  Surgeon  Taylor's  enquiry  the  stumps 
were  healed.  Gangrene  in  this  case  set  in  during  the  intensely  cold  weather  that  followed 
the  battle  of  Fredricksburg  and  while  the  patient  was  under  treatment  for  typhoid  fever  in 
the  regimental  hospital.  A  suspicion  that  scurvy  was  e<:)nceriied  in  the  development  of 
these  cases  was  not  sustaiiK.M.l  by  the  results  of  tlte  investigation. 

Iu  the  cases  above  reported  the  disease  has  presented  a  reuuirkable  uniformity  in  its  comnieucinjj  stages  and 
iu  the  ])arts  attacked,  invariably  begiuuiug  at  the  cuds  of  the  toes  and  generally  with  the  greatest  severity  in  the 
little  toes.  I  failed  to  detect  iu  a  single  instance  the  evidence  of  its  liaving  manifested  itself  at  any  point  above  the 
ankle  joint  or  anywhere  except  in  the  parts  inuuediately  involved  as  already  indicated. 

In  every  case  the  constitutional  symptoms  have  been  severe  and  such  as  are  usually  found  iu  nu^rtification 
superveuiug  on  injuries  involving  sudden  loss  of  vitality.  Great  depression  of  the  vital  powers,  rapid  and  feeble 
pulse,  with  cold  sweats  iu  some  instances,  have  marked  the  course  of  the  disease.  It  is  true  that  most  of  the  cases 
were  enfeebled  and  deliilitated  by  typhoid  fever  at  the  time  the  disease  iu  (juestion  manifested  itself,  and  that  a  great 
part  of  the  depression  might  be  due  to  the  primary  disease;  nevertheless  the  change  was  decidedly  nuuked,  particu- 
larly in  the  pulse,  which  became  more  freiiuent  and  irritable.  This  change  took  place  inuuediately  upon  the  accession 
of  tlu;  gangrene  and  not,  apparently,  from  the  gradual  dift'usion  of  any  scorbutic  taint  or  latent  cachexy.  From  the 
absence  iu  every  case  of  general  symptoms  indicating  scurvy  as  the  cause,  and  the  evidence  connecting  the  gangren- 
ous condition  with  exposure  to  cold,  I  am  couipellod  to  assume  the  latter  to  be  the  cause.  It  maybe  alleged  that  in 
two  of  the  cases  the  patients  were  not  exposed  to  a  sutticient  degree  of  cold  to  produce  freezing  at  the  time  the 
disease  manifested  itself — that  they  had  been  iu  division  and  regimental  hospitals  for  some  time  previous,  where  it 

*  Scu  in/r.i,  l>.  432.  , 


TlfE    rONTTNUKD    FEVEKS.  311 

was  not  proliahle  tliat  snoli  ;ui  injury  wimUl  liMiijieii.  lint  l>y  iiutiiii;  IIik  facts  uo  fniil  that  in  ono  ra.i(<  tlic  piitieut 
was  sent  t'roui  ii'jj;inicntal  to  division  liosjiital  on  the  4th  of  Marcli,  anil  tliat  iinniriliatfly  after  hcconiiuf;  warm  in  bed 
ho  was  seized  witli  severe  burning  i>aius  in  tlie  ends  of  his  toes,  and  tliat  the  followinj;  morniuf;  gangrenous  jiatehes 
were  observable.  It  is  reasonable  to  infer  that  this  jiatient  was  frost-bitten  while  iH'ing  eonveyed  from  oim  hospital 
to  another.  The  case  beeonies  iiiiiih  stronger  when  we  remember  the  man's  i'ondition  at  the  tiim',  and  know  that 
such  acei(b^nts  were  of  fre(|nent  oeeiirrenee  during  tln^  Crimean  war,  even  when'  the  tiii-k  were  transferred  to  no 
greater  distance  than  ])robably  intervened  between  the  hos|iitals  in  i|uestion.  The  hi.sloiy  of  the  other  ease  is  very 
similar.  The  patient  had  been  sick  in  division  hus]iital  four  weeks  with  tyjilioid  fever:  he  was  ri'turned  to  his  regi- 
ment January  27,  where  he  renuiined  about  two  weeks,  when  he  was  again  sent  to  di\  ision  hospital.  Within  forty- 
eight  hours  after  liis  re-a<lmissiou  symptoms  of  gangrene  weic  manifested  in  the  ends  of  his  toes.  The  same  inference 
is  deducible  iu  this  case, — that  the  man  was  frost-bitten  while  being  conveyed  fioiu  (Uie  hospital  to  amithcr.  It  will 
be,  remembered  that  hi!  was  in  hospital  lor  six  weeks  i)rior  to  the  attack  of  gangrene:  that  his  diet  had  been  generous 
and  varied;  that  at  the  time  of  his  lirst  admission  and  during  tin'  conjinuance  of  his  stay  no  symiitom  (d'  scurvy 
was  discernible,  Ijut  that  immediately  after  being  removed  from  one  hospital  to  another  mortilicatiiui  set  in. 

In  conclusion  I  will  add  that  it  apjicars  to  me  scarcely  ]i<issibh'  for  scurvy  to  so  atfi'ct  the  systi-m  as  lo  ]iidduce 
ten  gangrenous  si)Ots  each  in  the  end  of  a  toe  without  manifesting  itself  still  further  through  some  one  or  more  of 
its  ordiiuiry  concomitant  syinptiuns. — Sui-<iii>ii  .1,  II.  Tavixiu's  L'ljKiii. 

Blouuliiuii:  of  tlio  foriiea  orcurivJ  iu  case  oW  of  the  rororJs  ol  vai-ioiis  liospitals,''^ 
Bwelling  of  the  parotitis  with  fn'(|ueiit  sup[iui'ation,  wliicli  lias  been  mcutioiKMl  in  coii- 
nection  witli  both  typhoid  and  typlio-malarial  cases,  occurred  as  a  sequel  ov  late  compli- 
cation in  the  cases  43-50  from  various  hospitals.  Rurgoon  ]^)ARii  gives  thi>  only  refci'once 
to  a  similar  condition  of  tlie  submaxillary  glands,  and  j-iM-ords  the  testicles  as  liaving  been 
affected  in  two  instances.  Purulent  deposits  in  other  ]iarts  of  the  boily  ar(!  noted  in  cases 
34-36  of  the  series  last  mentioned  and  in  several  of  i\\Q  poKf-iaorlcm  reeoi'ds.-j- 

Sequehe  involving  impairment  of  nervous  power  are  illustratt^d  in  cases  r)l-61  from 
various  hospitals.  These  cases  do  not  differ  from  those  described  liy  Muiu'iiiso.N, NoTHNAOHL 
and  otliers,  as  occasionally  occurring  after  ordinary  typlioid  iever.  They  consist  of  j)artial 
paralysis  of  various  parts  and  include  one  case,  59,  of  paralysis  agitans,  in  which  the  nvmors 
persisted  notwithstanding  the  return  of  muscular  strength,  one,  (iO,  of  cerebro-spinal  fever, 
with  death  from  coma  on  the  second  day  of  the  attack,  and  one,  61,  of  pai-aplegia  from  spinal 
meningitis,  in  which  a  gradual  improvement  took  place,  so  that  in  about  four  months  the 
patient  was  able  to  make  very  good  use  of  his  legs  and  was  strong  and  liealtliy  in  his  general 
condition.  In  51  the  right  leg  became  (jedematous  and  paralyzed;  the  cedema  disapp(;ared 
in  two  weeks,  but  a  considerable  time  elapsed  before  the  power  of  free  motion  was  restored. 
Jn  52  the  lower  extremities  were  partially  paralyzed,  tlio  result  being  discharge  from  service 
on  account  of  a  slow  and  unsteady  gait;  in  53  paraplegia  was  associtited  with  some  atrophy 
of  the  right  leg,  but  the  patient,  after  a  course  of  crutches  and  canes,  was  eventually  returned 
to  duty;  in  54  there  was  progressive  loss  of  motion  and  sensation  in  the  lower  limbs  until 
a  state  of  almost  complete  paraplegia  was  reached,  after  which  the  patient  iniproved,  but 
was  discharged  at  the  end  of  six  months  as  incapable  of  further  service^;  in  55  hemiplegia 
improved  rapidly,  but  left  the  soldier  unfit  for  duty  owing  to  contraction  of  the  right  leg; 
in  56  there  was  no  improvement  in  a  paralyzed  left  side  at  the  end  of  four  months.  All 
these  cases  occurred  during  convalescence;  in  fact,  in  54  the  patient  is  described  ;is  having 
been  doing  well  for  seven  weeks,  when  he  was  taken  with  the  gradually  increasing  paraple- 
gia. But  in  57  and  58  the  patients  were  prostrate  at  the  time  of  seizure:  In  the  f)rmer 
hemiplegia  occurred  during  the  height  of  a  sequent  pneumonia;  this  man  was  discharged 
after  several  months,  able  to  walk  with  the  aid  of  a  cane  but  with  the  arm  powerless.  In 
the  latter  the  right  arm  and  left  leg  were  paralyzed  during  the  unconsciousness  of  a  late 

*Dr,  Woodward  Bays,  iu  tlie  Becond  part  of  this  work,  p.  501,  that  no  case  of  corueal  ulcer  occurring  in  the  later  stages  offerer  was  brought  to  the 
notice  of  the  Surgeon  General's  Office  during  the  war.    See  also  Case  4©  of  the  porf-mortem  records. 

■f  See  w*/>a,  page  432.  , 


312  SYMl'I'OMATOLOOY    OF 

period  of  a  severe  typlioid  uttaclc;  tlie  case  ended  in  discharge  twelve  montlis  afterwards  on 
account  of  atrophy  of  tlie  leg  and  inability  to  flex  the  foot. 

Relapses. — Besides  the  instances  of  typhoid  relapse  in  the  typhoid  and  typho-mala- 
rial  cases,  48  and  49,  59  and  91  of  the  Seminary  series,  and  32  and  56  of  the  post-ynortcm 
records,  63-65  from  various  liospitals  were  regarded  by  their  medical  attendants  as  cases  ot 
relapse  in  typhoid  fever.  In  6o  the  details  of  tlie  primary  attack  are  not  given;  but  the 
patient  died,  after  passing  hemorrhagic  stools,  on  the  fourth  day  from  tlie  second  access  of 
fever,  typhoid  symptoms  and  rose-colored  spots  having  been  developed  in  the  meantime.  In 
64,  three  weeks  after  the  apparent  establishment  of  convalescence,  the  patient  was  seizeil 
with  severe  diarrhoea,  which  terminated  fatally  in  twenty  days;  but  tliere  is  nothing  on  the 
record  to  show  that  it  was  a  true  relapse.  In  65,  which  ended  favorably,  both  the  initial 
and  sequent  attacks  are  detailed,  but  the  evidence  of  tlie  presence  of  typhoid  is  by  no  means 
convincing. 

Second  attacks. — The  records  of  the  series  from  various  hospitals  furnish  only  two 
cases,  66  and  67,  of  typhoid  attacks  in  men  who  had  suffered  from  the  disease  at  a  previous 
period.  In  one  case  the  second  attack  was  well  defined  and  under  observation,  but 
the  first  rested  on  the  testimony  of  the  patient,  corroborated,  with  some  details,  by  his 
father;  in  the  other  a  clear  history  of  the  anterior  attack  is  furnished,  and  the  second, 
typho-malarial  in  its  character,  is  also  described  with  precision.  The  patient,  in  75  of  the 
Seminary  series,  is  said  to  Lave  suffered  from  typhoid  fever  two  years  before  his  admission 
with  a  pronounced  typho-malarial  attack. 

Extracts  from  reports,  etc. — A  few  papers  on  file  in  the  office  of  the  Surgeon 
General  give  clinical  descriptions  of  the  continued  fevers  which  prevailed  in  our  camps 
and  hospitals.  These  are  herewith  presented.  Abstracts  of  most  of  the  journal  articles 
on  this  subject  are  appended  as  notes.* 

*  .T.  .7.  Levick, — Mnl.  and  Snnj.  liepinii^r,  Phila.,  Vol.  VIII,  IBOi^,  p.  283, — in  a  clinic;il  lecture  on  .six  cases  of  miasmutk-  tyiihuid  fever  from  tlie  seat 
of  war  sumruarizes  the  iiriiicipal  features  of  the  disease.  lu  some  there  luui  heeii  an  iil-Lletined  fortiiiug  stage  tlurinj;  wiiich  the  patients,  altiniugh 
iiiueh  troubleil  with  iliarrlufa,  would  attend  to  their  ordinary  duties;  in  others  the  attack  was  suilden,  coming  on  with  chillini'ss  and  intense  headache, 
Diarrhiea  was  a  con.stant  sj-nijitoni ;  i-hilliness  (_ir  rigors  affected  all  the  patients ;  a  tiushed  face  and  slight  cough,  witli  the  usual  bronchitie  rales,  were 
also  noticed  iTi  every  case.  .\t  the  beginning  there  were  e.xacerbations  and  remissions,  and  in  connectitm  with  the  latti-r  was  found  a  nioistness  of  the 
skin  at  certain  periods  of  the  day,  the  fondiead  being  covered  with  large  drops  of  persjjirjition  ;  but  this  was  in  no  instance  critical, — it  ceased  and 
recurred.  Headache,  i)resent  in  varying  ilegree  in  every  instance,  was  sometimes  described  as  splitting  or  hullTiwi ;  there  was  always  a  sense  of  weight 
and  weariness  iu  the  eyes,  .sevei-e  pain  in  the  back  ctf  the  in-ck  and  between  the  shoulders  rather  than  in  the  loins,  and  restless  aching  in  the  lower 
limbs.  The  tongue  was  more  or  less  furred,  but  not  heavily  coated  nor  ilisposeil  to  dryness  as  in  typhoid  fever  ;  tliirst  was  moderate ;  loss  of  an.ctite 
complete.  The  pulse  in  two  ea.ses  reached  120;  but  witli  these  exceptions  it  was  rarely  above  W,  and  in  one  it  was  as  low  as  60  ;  it  was  soft  although  in 
no  case  alarmingly  feeble.  Epistaxis  was  not  always  jtresent.  The  abdomen  was  more  or  less  itromineut,  but  not  decidedly  tympanitic.  There  was 
none  of  the  mental  dnlness  of  enteric  fever,  so  that  even  in  the  com[)aratively  advanced  stage  of  the  disease  questions  were  answered  intelligently  and 
the  patient  showed  interest  in  what  iKissed  around  him;  in  no  case  was  there  well-marked  delirium.  In  auother  article — Amer,  Jour,  Mtd.  ,ScieHcf,  Vid. 
XLVII,  1804,  p.  404— he  recapitulates  the  stdistance  of  his  former  lecture,  and  adverts  to  the  invariable  presence  of  the  rose-colored  eruption  ami  dis- 
ease of  Peycr's  i>atclies,  the  latter  indicated  by  diarrluea  which  was  either  present  or  readily  induc(-il  by  a  small  dose  of  castor  oil.  .Sanfoed  B.  IIixt, 
.Surgeon  U.  S.  Vols.,  in  a  communication  to  the  Bnffnln  MM.  niiil  Surg.  Jour.,  Vi>I.  II,  ISIVi,  p.  2(12,  describing  the  camp  fever  which  he  observed  in  a  recently 
recruited  New  York  reginn'iit,  says  tli.at  for  a  few  days  the  [Kitients  felt  weary  and  stupid,  had  headaihe  and  pain  in  the  back,  loss  of  appetite  and  fever, — 
skin  hot  and  dry,  pulse  loti  or  more,  tongue  ilry  and  brownish.  Suffering  little  pain,  they  frequently  were  cheerful  throughout,  seeming  rather  lazy 
than  sick.  Diarrhrea  set  in  ;  the  pulse  reache.l  12o,  but  seldom  rose  higher ;  .sordcs  collecte.l  about  the  teeth  and  the  tongue  biranie  <nveked.  After  a  time 
these  symptoms  declined,  the  trmgue  beiiig  the  last  to  n-gain  it-  normal  state.  A  good  appetite  on  a  dry  tcmgne  was  not  uncommon.  Joseph  Kl.mM', 
Act.  Ass't  Surg.,  U.  S.  A.,  in  an  arti.-le  on  T;qthoi,l  hVr.i-  i„  our  MiliJari/  l[o>i,iliil.<,—Mr<!.  timl  liunj.  Reporter,  Philadelphia,  Vol.  IX,  18G2-0:i,  p.  18,— says  that 
a  large  proportion  of  the  fever  cases  admitted  into  the  luwin'tal  in  whicli  he  served  b.jre  a  considerable  resemblance  t(i  ordinary  typhoid.  In  giving  a  brief 
notice  of  the  nnjre  obvi.ius  features  of  the  army  fever,  he  remarks  that  deafness  wa-'  infreipient  and  sliglit;  five  cases  had  the  dull,  hiavy,  stolid  exprc- 
siou  of  countenance  so  often  f.mnd  in  pure  typhoid ;  delirium  was  present  only  in  the  most  unfavorable  ca.se3;  sleeplessness  was  scarcely  comiplaineil 
of.  In  most  cases  there  was  diarrlicea,  the  discharges  being  thin,  yellow  and  more  profuse  jierhaps  than  iu  enteric  fever ;  paiu  on  pressure  was  felt  iu 
the  right  ilia.-  region  and  over  the  alMlomen  genenilly,  but  iu  a  less  degree  than  i-  usual  iu  tyjihoid.  The  rose-colored  eniiition  was  present  in  most 
instances,  sudaniiua  in  but  few.  Couvale.sceuce  was  jriore  rapid,  and  a>  >n„n  as  it  began  the  countenance  acrpiircd  a  brighter  and  more  cheerful  e.xpres- 
.sion;  severe  cases  had  a  li.»tlcss,  in.liffiivnt,  yet  lo.t  -tu|.id  cxpres-iun,  a  dark  mahogany  cidor  of  the  face,  soriles  about  tlie  tei-th  and  a  dry  tongue  disiio.sed 
to  become  aphthous  iu  the  progress  tu  recovery.  Chronic  rheumatism,  ni^vr  complained  of  before,  affected  many,  but  not  until  they  had  in  a  great  measure 
recovered  their  strength.  Most  of  the  patients  came  from  the  region  of  the  .lames  and  Chickahoniiny  rivers  and  were  benefited  by  quinine.  When 
tenderness  of  the  abdomen,  tympauite,  and  acute  diarrhcea  co-existed  with  well-marked  typhoid  symptoms,  oil  of  tunientiuc  was  given,  with  good  nourish- 
ment, wine,  whiskey  or  milk-punch;  warm  rubefacient  cataplasms  over  the  abdomen  afl.irded  great  ridief.  Hexhy  M.  Lyji.ix,  Act.  Ass't  Surg.  V.  S. 
A.,  writingfrom  University  Hospital,  Nashville,  Tonn..  .Viigust  6,  ]8fi2,— .liner.  Med.  TiiiieK,  X.  Y.,  Vol.  V,  p.  10'.),— says  that  typhoid  fever  was  of  fre.|neiit 
occurrence  in  the  spring  of  1862,  and  that  "if  all  the  cases  of  fever  attended  with  rose-colored  spots  upon  the  skin,  diarrhuia,  etc.,  are  to  be  reported  as 


TiiK  rnxTlNUEn  Ki:vKni'.  olo 

nrmnrl-x  mi  the  Tiiph/iir]  F:  m-  of  the  Army  hj  .is.v'f  Surii.  Jos.  R.  Smith.  T.  S.  A.,  SfiniiKifii  hofipitnt,  Georgetnirn,  D. 
C,  .S(j)/.  .i(>,  IM'2. — \N  ;ishhi<^ri]ii  and  its  i-iivirdiis  sfem  to  liiivr  Im-cu  a  fiivoritu  li.iliitMt  (if  iutfiiiiittriit  fcvcv  for  iiiuiiy 
year.s  ]Kist.  In  Cdimiioii,  howov;-!-,  with  many  olluT  iilaocs  in  tliis  cdiiutiy,  tln'  ty|ic  <it"  luovailiiii;  iV-viT  has  been 
steadily  tiiidcifidini;  a  change,  inteniiittt-iits  jriailnally  giving  place  to  reiiiittoiit.s  and  tlu>  latter  iii  tiiiii  to  tyidioid. 
Two  hiiiidied  aud  eighty-eight  cases  of  fever  have  hern  treated  during  the  Jiast  quarter  in  tlu^  Seminary  ho.Hpiial: 
twenty-two  were  intermittent  eases,  one  hnndred  and  thirty-seven  remittent  and  oiie  linndred  and  twenty-nino 
typhoid;  one  of  the  remittent  aud  twenty-three  of  the  tyjihoid  eases  were  fatal. 

Intermittent  and  remittent  cases  presented  no  peculiarities,  and  generally  yielded  promptly  to  the  free  use  of 
ipiinine.  Those  cases,  however,  which  proved  most  ob.-.tinate  assimilated  gradually  to  typhoid,  and  in  a  nnniher 
there  was  donht  as  to  the  diagnosis.  The  cases  of  remittent  fever  diminished  in  frei|iiency  during  tlie  month  ot 
■September,  and  those  of  ty}>hoid  increased  in  a  greater  ratio.  This  was  prolial)ly  owing  not  siinidy  to  a  greati'r 
lirevalence  of  typh<jid,  hut  to  the  fact  that  stringi-ut  orders  were  isstied  prohihiting  the  sending  of  light  eases 
of  disease  from  camp  to  general  hosjiitals;  in  eonsiM|Ueni-e  light  remittents  were  retaiiu'd  for  treatmeul  In  eainp, 
while  those  febrile  cases  that  weri'  more  nn|)romising  in  their  a|ipearance  were  sent  to  the  various  general  hos[)itals. 

Under  the  head  of  ty]>hoi(l  fever  I  include  only  those  which  |neseut<'d  typhoid  syn\ptoms  fioni  their  reeei>- 
tion  into  hospital,  though  .some  of  them,  aeeonling  to  the  history  (ditained  from  the  ]>atieiit8  themselves  or  their 
former  physicians,  evidently  commenced  as  remittents.  According  to  my  own  observation  nearly  half  of  the  cases 
originated  as  remittent  fevers, — at  all  events  they  presented  well-marked  daily  remissions  and  exacerbations.  In 
the  hospitaP,  where  in  such  cases  the  utmost  attention  of  the  attendant  medical  olticerwas  given  and  even  the  whade 
of  a  remission  watched  for,  that  the  great  specificv,  (luiiiine,  might  be  administered,  either  only  a  slight  trace  of  u 
remission  would  be  discovered,  refusing  frankly  to  declare  itself  under  appropriati^  doses  of  (luinine,  or  a  continued 
fever  would  be  at  once  established  with  all  its  usual  and  familiar  symptoms.  Crises  tyi)lioid  ah  oriijinc  wm-v.  usually 
recognized  a.s  such  within  a  very  few  days.  They  began  with  chills  or  sensations  of  chilliness,  heailaehe,  ])ains 
in  the  back  and  aching  limbs,  .'ioon  followed  by  a  rapid  )iulse,  hot  skin  iunl  feelings  of  debility  and  weakness.  Casi's 
of  this  kind  presented  in  general  the  greater  ])art  of  the  following  symptoms:  Chills,  headache,  pains,  feeling  of  pros- 
tration, hebetude,  deafness,  tinnitus  aiirium,  snbsultns  teudiniim,  heat  of  skin,  delirium,  cajiillaiy  congestion,  opis- 
taxis,  accelerated  pulse  and  hemorrhage,  siulaniina,  i)etechia'.  ernjitions,  sweats,  tongue  foul  and  coated  or  dry  and 
harsh,  sordes  on  teeth  and  lips,  nieteorism,  borborygmus,  iliac  or  abdominal  tenderness,  constipation  or  diarrlnea 
with  involuntary  (fvacnatious,  viuuiting  and  gastric  irritability,  perit(uiitis,  reteni  ion  of  urine  aud  apparent  coiiva- 
lesceuce  followed  by  relapse.  The  disease  was  ordinarily  ushered  in  by  a  chill  with  <'(^phalalgia  and  iiaiu  in  the  back 
and  limbs.  AVithin  three  or  four  days,  however,  these  symptoms  almost  entirely  gave  phn'e  to  a  sensation  of  muscu- 
lar weakness.  Htdietiide  was  marked  in  most  of  the  cases.  The  jiatient  could  be  easily  rou.sed  from  a  state  of  stujior 
to  answer  ijnestions:  he  would  jirotrnde  his  tongue  if  asked  to  do  so,  but  would  often  forget  to  draw  it  back.  I'he 
hearing  was  freiiueiiMy  impaired,  although  the  patient  might  not  recognize  his  deafness.  Delirium  was  a  couslani 
symptom;  it  was  rarely  viident,  generally  low,  accompanied  by  muttering  or  talking  and  a  desire  to  leavi^  the  bed 
for  some  senseless  object,  a  desire  which  he  endeavored  to  gratify  whenever  the  attention  of  the  nurse  was  with- 
drawn; but  even  when  delirious  he  could  often  be  roused  to  give  a  sensible  answer.  Tinnitus  auriniu  was  fre- 
<inently  absent,  bnt  subsnltus  tendinnni  and  general  jactitation  were  among  the  constant  symptoms  in  severe. 

frtsi'rt  uf  tyiihniil,  we  niu>t  conchnlo  ttiat  the  disease  is  motiifi(.Ml  in  many  particulars  by  its  intiniatu  rclatiim  with  the  raust's  (if  tlii'  remittent  IViriu  wliif  li 
lias  thns  far  marlied  at  least  nine-tenths  of  the  cases  of  fever  which,  tlnriuix  the  last  three  liimitlis,  h;ive  heirii  plaeeii  ufnler  my  uliservatiun."  The  same 
jiinrnal,  in  its  issue  of  .July  12,  lSti'2,  has  an  eiiitorial  heaihxl  lit'yorU  nf  ll">-pUiih,  wliieli,  in  referring  tn  the  experience  of  the  Ladies'  Home  hospital.  New 
Yiirk  City,  states  that  the  malarial  fever  met  with  there  had  its  symptoms  minf^led  with  those  of  tnn'  typhoid.  Diarrhiea  and  rose-colored  spots  were 
almost  eonstautly  present,  and  thefever  exhiliited  a  marked  disposition  to  exaeerhations  and  sometimes  to  collapse, — patients  presenting  nothiiif;  untoward 
in  their  condition,  and  with  the  mind  perfectly  clear,  would,  in  three  or  four  hours,  aud  oec.'isionally  in  less  time,  bo  found  pulseless,  the  surface  moist 
and  cold  and  death  imminent.  "When  in  this  condition  they  wtiuld  converse  intelligently  aud  express  themselves  well  enough  to  sit  up.  When  asleep 
the  decubitus  was  dorsal  and  the  aiipearauco  of  the  couuteuaneo  that  jieculiar  to  severe  eases  of  typhoid  fever,  but  the  patient  could  readily  be  ronseii, 
aud  when  awakened  showed  no  bewilderment.  In  severe  cases  the  tongue  was  dry  and  disjiosed  to  crack.  Tlieniijietite^'euenilly  was  not  niueh  imiiaired. 
Scorbutus  was  a  frequent  complication,  and  snppuration  of  the  parotid  gland  was  present  in  a  few  instances.  Ikviso  W.  I.von,  House  JMiysieian,  Iti'lh-- 
vue  hospital,  eouinieuting  on  parotitis  as  a  eomjilieation  of  typhus, — Atiifi:  Mfl.  Tones,  ..V.  1'.,  Vol.  VIl  [,  ISOt,  p.  87, — states  that  in  the  sinnmer  of  lsii2 
he  s;iw  in  the  hospital  near  Corinth,  Miss.,  about  one  hundred  and  tlfty  cases  of  typlio-malarial  fever  with  pjirotid  swellings  in  ten  per  cent,  of  the  cases 
aud  on  both  sides  ill  half  of  tlm  niunber  affected.  Suppuration  almost  invariably  took  place  if  the  patient  lived  long  enough.  Tliis  was  reganied  as 
an  unfavorable  complication.  Patients  who  recovered  after  having  been  thus  affecteil  were  slow  in  gaining  strength,  the  disi-liarge  from  the  gland  con- 
tiiiuiug  for  a  long  time.  S.  K.  Towle,  Surgeon  :Unh  Mass.,  in  au  arlitde  Xot'^s  of  Pnuiin'  in  thi'  I'.  .<  .1.  t;e,e  ni}  llnnjnt'il,  ll>il"tt  lii-if'j>;  /,o., —  /ios/ea  .1/.,/. 
mill  ^iii-g.  Joiuiial,  Vol.  LXX,  1SG4,  p.  49, — speaks  of  the  mixed  characters  of  the  fevers  prevalent  in  that  section.  The  renii>sions  in  remittent  fever 
were  less  marked,  aud  often  nearly  disappeared  after  two  or  three  days,  while,  with  the  eontiunanee  of  the  fever,  enteric  rather  than  gastric  symptoms 
became  prominent.  He  holds  that  cases  registered  as  tyjihoid  fever  were  withtuit  donht  of  uiaho'ial  origin.  These  had  not  the  rose-<'olored  eruption, 
aud  on  admission  had  already  lost  the  early  diagnostic  features,  retaining  only  the  prostrated,  low  vitiated,  semi-conscious  <-ondition  of  the  last  stage  of 
severe  typhoid  fever.  The  mortality  was  nuieh  greaterthan  in  pvire  typhoid,  aud  in  tliose  that  eventually  recovered  convalescence  was  slow  and  halting. 
•'  I  ilo  not  rememlK-r  to  have  seen  tliis  season  amongst  those  who  had  spent  last  year  in  this  depai-tment  a  single  ease  of  typh.iitl  fever  sueh  a-s  we  see  in 
New  England,  aud  mo.st  of  the  cases  occurring  amongst  the  newH-omers  after  they  had  lieeu  here  two  nuuiths  were  decidedly  modified  by  the  miasmatic 
Mirrouuding.s.  Indeed,  one  eonld  almost  tidl  how  long  a  .Vew  Kuglaud  fever  patient  h.ad  been  iu  this  section  of  the  eonutry  by  the  type  of  his  disease, 
a  genuine  rase  of  uucomplieated  typhoid  being  strictly  piitliognomonic  of  a  recent  down-east  Yankee.  *  *  During  the  spring  I  saw  at  the  dilTerent 
regimental  hospitals,  by  invitJitiou  of  the  surgeons  of  several  Sav;  Kngland  uine-iuonths  regiinent.s,  a  great  many  .severe  cases  of  typhoid  fever  (then 
•  inite  prevalent  iu  the  new  regiments  here),  aud  although  most  of  them  did  not  exhiiiit  any  remissions,  ami  hence  hail  not  been  thought  eoniplicaled  at 
all  with  malaria,  yet  the  fact  was  indisputable  that  they  did  better  after  the  iutroilin-lioii  into  the  treatuient  of  full  dose;,  of  (piinine  during  the  fn>t 
part  of  the  disease ;  and  iu  cases  in  which  (piinine  had  not  been  given  at  tir>t,  it  often,  though  not  invariably,  was  of  apimreiit  benefit  in  somewhat  small 
doses  iu  the  later  stages."  After  adverting  to  the  various  inlluenees  that  modify  camp  fevers  he  remarks :  *'  Hence  it  follows  that  few  of  the  serious 
cases  of  malarial  disease  one  is  called  upon  to  treat  after  pix  months  service  in  the  army  are  either  siniph',  well-iletiued  or  exactly  described  by  any  of 
the  oltl  terms,  as  intennittent.  remittent  or  tyjihoid,  but  jiartake  in  some  degree  of  the  nature  of  all ;  and  from  the  previous  eurroundings  of  the  putieut 
are  inelineil  to  !-ajiidly  assumi'  a  decided  typhoid  type.'* 

Mkd.  Hist.,  Pr.  111—40 


314  sY>rPTOMA'roT.oi;Y  of 

cases.  Fii  ii^ifji'iivatcd  cases  tlm  nervdiis  systrni  Kcciiicil  (,'utiirly  ]ii(istratiMl  vciy  early  in  the  disease,  the  above- 
(les(tril)e(l  syiii|)toiiis  lieiiij; developed  liy  the  (H'th  or  sixth  day.  Capillary  eou^;estioii  was  well  marked  iii  the  majoi-ity 
of  eases;  the  liiowii  color  of  the  eheeUs,  disappeariiji^  on  pressure  and  hut  slowly  n^uiiiinj;  after  the  removal,  helped 
mueh  to  im])art  tliat  e.\]iression  of  the  connti^naiice  known  a.s  thv  J'dcicn  tijiihoHU.  Kpistaxis  was  of  rather  infretnient 
o'cenrrenee;  in  two  eases,  liowever,  it  was  so  severe  as  to  lieoonie  of  serious  imiioit.  Ilemorrhase  oeenrred  from  no 
other  part  excei>t  the  howels  as  an  effect  of  erosion  of  the  walls  of  a  bloodvessel.  In  every  case  that  I  noticed  the 
l)ulse  was  accelerated  iVom  the  beirinnlnj;  of  the  attack,  rauf^lng  from  about  ilO  to  110,  but  in  many  cases  it  diminished 
in  fre([uency  coincideutly  with  the  disappearance  of  headache  and  jiain  in  the  back  and  limbs,  so  that  after  three  or 
four  days  the  pulse  ranjied  from  N")  to  100  or  a  little  more.  I  have  been  accustomed  to  consider  the  fre(ineucy  of  tlie 
pulse  and  its  strenj^th  or  weakness  as  furnishing  important  profjnostic  indications.  Cases  in  which  the  pulse 
exceeded  li!8  seldom  ended  favorably;  sometimes  in  fatal  cases  it  ranj;ed  for  days  beyond  this  number,  gradually 
running  up  to  110  or  higher,  until,  with  imperceptible  Jiulse,  the  patient  died.  An  unfavorable  result  was  common 
also  in  tliosi!  ca.ses  in  which  there  was  a  want  of  correspondence  between  the  force  of  pulsations  in  different  parts  of 
the  l)ody,  as  indicated  by  tlie  action  of  the  heart  ami  the  beating  of  the  carotids,  the  abdoiiunal  aorta  and  radial 
artery,  sometimes  a  labored  cardiac  action  producing  but  a  weak  arterial  pulsation.  Petechia)  and  vibices  were 
present  in  many  cases,  particularly  on  the  abdomen,  less  fre(|nenf  ly  on  the  chest  and  but  rarely  on  the  limljs.  Sudaniina 
were  of  constant  occurrence,  jirofuse  all  over  the  abdomen,  but  in  no  instance  upon  the  limbs  or  face.  These  sweat- 
vesi(-les  burst  shortly  after  their  appt^a ranee,  and  in  many  cases  reappeaivd  in  a  succession  of  cro])S  during  the  whole 
atta<'k.  Their  presence  or  absence  st^enunl  of  but  little  valiu^  as  an  index  of  mildness  or  severity.  The  typhoid  erup- 
tion was  not  an  invariabh'  symptom.  When  present  it  appeared  usually  during  the  second  week,  chiefly  on  the 
abdomen  and  thorax.  Sometimes  only  two  or  three  s))ots  were  discovered  after  a  careful  exanunation  of  the  sur- 
face, and  in  a  certain  nninl)er  of  cases  no  eruption  whatever  was  observed.  Some  of  these  non-erui>tive  cases 
were  as  severe  as  any,  and  when  fatal  exhibited  no  variation  from  the  ordinary  ^)MS<-«io;to(i  lesions.  The  digestive 
system  early  shared  in  the  morbid  actions  constituting  the  febrile  condition.  From  the  beginning  the  tongue  was 
covered  with  a  white  coating  which  stddom  disappeared  during  the  disease,  or  with  a  black  coat,  the  tip  and  edges 
being  red  and  angry-looking;  it  was  often  moist,  sometimes  tlahhy,and  freciuently  dry  and  harsh,  much  fissured  ami 
covered,  like  the  teeth  and  lips,  with  sordes.  In  fatal  cases  this  state  of  the  tongue  persisted  to  the  end,  but  in 
favorable  cases  it  cleaned  from  the  centre  to  the  edges  or  ricf;  rirxa.  One  of  the  most  encouraging  ap|iearances  pre- 
sented by  the  t<ingue,  noticed  ehielly  about  the  period  of  convalescence,  was  the  assumption  of  a  delicate  film  of 
white  on  the  cleaned  surface.  .Sordes  could  in  general  be  wiped  or  washed  away,  and  attention  to  this  ai)parent]y 
trivial  act  was  productive  of  much  conifoit  to  the  jiatieut.  The  pathological  changes  taking  place  in  the  abdom- 
inal cavity  early  invited  attention  by  their  local  indications.  Tlie  skin,  particularly  that  of  the  abdomen,  was 
apparently  much  raised  in  leuqiiratuic.  this  being  sometimes  so  striking  as  to  constitute  the  caJor  niordax  of  the 
books.  I  noticed  a  very  fre(|U<'iit  connection  of  this  symptom  with  violent  delirium.  The  abdomen  was  some- 
times tlat  or  cup-shaped,  with  eveiy  i>ulsati(m  of  the  abdominal  aorta  plainly  visible,  at  other  times  tumid  and  swol- 
len or  meteoric,  resommt  and  iiiiubling  on  the  slightest  ))ressnre.  In  several  instances  distention  was  decidedly 
relieved  liy  the  introdnclion  of  llexible  tubes  j»r  <(iiiiiii  to  allow  the  gas  toescajie.  Tenderness  on  iiressure  was  one  of 
the  most  freiinent  phenouwna,  markedly  exhiliited  in  the  right  iliac  region.  When  slight  this  generally  displayed 
itself  by  an  involuntary  shrinking  or  a  contraction  of  the  rectus  to  protect  the  i)arts  beneath  from  pressure.  Some- 
times the  tenderness  extended  along  the  course  of  the  colmi  into  the  left  iliac  region,  and  occasionally  the  whole 
abdomen  was  afi'ected  and  the  jjatient  so  sensitive  as  to  shrink  from  oven  a  motion  to  bear  upon  the  parts.  The 
bowels  were  generally  irregular,  sometimes  constipated,  hut  more  f'ie([uently  affected  with  a  persistent  and  debilita- 
ting diarrlnea,  the  stools  usually  lilackish  in  color,  of  a  very  oti'ensive  odor  and  occasionally  bloody.  Vomiting  and 
gastric  irritability  were  by  no  means  i>rominent  symidoms  :  in  a  few  cases,  however,  it  was  found  impossible  to  relieve 
them,  the  matter  vomited  being  sometimes  yellowish  and  snielling  of  bile,  sometimes  watery,  sometimes  black  and 
in  one  instance  containing  blood  corpuscles.  Toward  the  end  involuntary  dejections  added  to  the  disagreeable 
symptoms,  though  .some  cases  recovered  after  reaching  this  stage.  The  muscular  coat  of  the  bladder  seemed  para- 
lyzed in  (luite  a  number  of  cases  and  reijuired  the  regular  use  of  the  catheter;  this,  however,  did  not  indicate 
their  gravity,  for  m.iny  such  cases  recovered. 

The  fatality  of  the  di.sease  has  been  'J'J  in  129  cases,  or  one  in  a  little  more  than  five  and  a  half  cases;  but  this 
rate  has  {)re.sented  great  variations.  Thus,  in  the  first  fourteen  days  of  .Seiitember,  15  deaths  occurred.  Not  only 
was  this  owing  to  the  fact  before  mentionetl,  that  at  this  time  the  custom  of  sending  only  the  most  serious  cases  to 
general  hospitals  was  strictly  adhered  to,  but  it  seemed  as  if  some  fatal  epidemic  influence  struck  suddenly  all 
tho.se  who  were  laboring  under  this  disease.  Those  wlio  entered  the  hospital  at  that  date  came  under  its  inrtuence, 
those  who  had  been  in  hospital  a  longer  time  were  eijual  sufferers,  and  the  same  mortality  extended  to  the  other 
hospitals  in  the  city,  both  the  neighboring  and  remote,  thus  proving  its  independence  of  local  causes.  I  have  been 
nuable  to  discover  anything  to  account  for  this  increased  mortality,  which  subsided  toward  the  end  of  the  month. 

The  (question  of  diagnosis,  while  of  much  interest,  is  one  which  an  elementary  report  like  the  present  cannot 
pretend  to  treat.  When^  an  assemblage  of  sym])toiris  such  as  I  have  enumerated  was  presented  there  could  l)e  of 
cours<'  no  doubt  in  the  diagnosis;  but  so  great  was  the  variety  in  the  miture,  number,  severity  and  combination  of  tlu' 
symptoms  as  on  several  occasions  to  arouse  the  suspicion  that  two  distinct  diseases  were  present  with  certain  features 
in  common.  The  closest  and  most  careful  investigation  of  the  symptoms  and  pont-mortem  appearances  failed  at  the 
time  to  confirm  such  suspicion,  and  every  day  and  every  new  observation  since  has  convinced  me  of  its  incorrectness. 
To  illustrate:  There  has  entered  the  hospital  a  patient  whose  previous  history  exhibits  all  the  symiitoins  of  an  ordi- 
nary pyrexial  attack.     At  iireseut,  however,  tl"<>  symi'toms  are  as  foUows:  Pulse  80  to  95;  face  but  little  congested; 


THE    CONTIKUKD    FKVKES.  HI") 

lit-at  of  skin  nearly  iiatni:il  or  not  ninch  iiicrca.seil  over  abdonieii;  tougue  clean  or  isoniewhat  dry;  very  sliglit  or  no 
pniii  or  tenderness  in  ilie  alidonicn  ;  Ijowels  rej;nlar;  apiietite  ini]iaired;  comidaint  ofNlif^ht  weakness,  nnieli  increased 
by  exertion;  sndaniina  and  iPiotnsi'  perspirations  but  no  eruption.  This  asseiublage  niiylit  easily  escape  rccoj^nition 
as  tlu)  combined  symptoms  of  a  fever  case.  If  this  luitient  be  carefully  treated,  coulined  to  his  bed,  the  state  of  the 
secri'tions  watched  and  reijulated  and  all  stimulatini^  food  disallowed,  the  jinlse  in  two  or  three  weeks  will  fall  to 
or  below  the  natural  standard,  the  tonjrue  assume  the  delicate  whitish  aiipearance  I  have  spidien  of  as  characteristic 
of  convalescence,  and  with  returninji  appetite,  strength  and  health  will  reapjiear.  Shouhl,  however,  the  case  be 
neglected  and  the  patient  continue  his  customary  or  other  work,  overlooking  the  premonitions  of  approaching  dis- 
ease, soon  the  unheeded  warning  will  speak  in  language  not  to  be  misunderstood.  Accelerated  imlse,  gastric  irrita- 
bility, bigb  febrile  action,  abdominal  teuderness  and  other  tyjdioid  symptoms  are  speedily  developed  and  death  is  the 
usual  issue.  Kow  the  question  aiises:  What  are  the  elements  common  to  two  such  dissinular  conditions  as  are  licro 
described?  Is  there  anything  that  nuiy  serve  as  a  connecting  link  by  which  these,  apparently  isolated  diseases  luay 
beJoiiK'd  as  one,  or  are  these  features  of  reseiublance  mere  coincidences  that  might  lie  expected  e<|ually  in  a  case  of 
delirium  trcuu'iis  or  carcinonuitous  degeneration  .'  I  shall  endeavor  to  give  my  impression  of  what  is  connnou  in  nil 
these  cases:  I  have  found  ab<lominal  tenderness  one  of  the  most  constant  phenomena  of  some  stage  of  this  disease;  in 
fact,  without  a  particular  reference  to  my  notes,  I  do  not  recall  a  single  instance  in  which  pressure  over  the  right 
iliac  legion  or  some  other  portion  of  the  abdonu^n  less  freiiuently,  did  not  elicit  symptoms  of  tenderness  or  uneasi- 
ness, either  an  acknowledgment  of  pain  or  an  involuutary  shrinking  from  the  jiressure.  The  occurrence  of  sudamina 
and  profuse  sweating,  without  jiossessing  any  great  jiathological  siguittcanco  that  I  am  aware  of,  has  yet  seemed  to 
me  to  possess  more  or  less  diagnostic  value,  and  though  some  cases  of  fever  ran  their  entire  course  without  them,  in 
the  majority  several  crops  have  luade  their  appearance,  filling  up,  bursting  and  leaving  the  skin  in  a  sort  of  brawny 
desquamation.  The  tongue  is  generally  altered  in  this  <lisease,  presenting  the  ajipearauce  I  have  before  described. 
To  be  sure  it  is  sometimes  coated  in  other  diseases,  but  to  me  the  typhoid  tongue,  with  sordes  on  the  teeth  and  lips, 
has  a  i)athognou\onic  apiiearance.  The  slight  acceleration  of  the  pulse,  too,  invarialdy  directed  my  attention  to  the 
true  state  of  the  case,  being  neither  natural  nor  yet  suflicicntly  rapid  to  arouse  suspicion  of  iutlamniatory  pyrexia, 
but  renuiiniug  for  a  number  of  days  at  a  certain  state  of  moderate  acceleration ;  and  here  I  desire  to  call  atl<nition 
to  a  idtenomenon  in  the  natural  history  of  the  disease  which  I  have  hitherto  neglected  to  mention,  viz:  the  occur- 
rence, in  freciuent  cases,  of  a  more  or  less  i)erfect  apyrcxial  jieriod  amounting,  in  some  instances,  to  almost  apparent 
convalescence,  which  lasts  for  several  days  and  is  followed  by  s<'Condary  tever  som(^tinu;s  more  severe  than  the 
preceding  stage,  but  generally  milder.  This  could  iu)t  be  considered  a  relapse,  for  generally  it  sccuumI  one  of  I  lie 
natural  occurrences,  a  part  and  portion  of  the  history  of  the  lirst  attack,  whose  termination  apjieared  to  approach 
iudilfcrently  either  by  some  "crisis,"  or  natural  evacuation,  or  else  by  some  gradual,  slow  and  regular  subsidence  of 
the  febrile  action. 

I'.ut  more  ((uiclusive  than  any  of  the  above  symptoms  as  to  the  perfect  identity  of  these  differently  mani- 
fested conditions  are  tha  post-mortfin  appearances.  Autopsies  were  held  in  most  of  the  fatal  cases,  and  the  lesions  in 
every  case  diagnosed  as  tyjihoid  fever  were  identical  and  perfectly  satisfactory  as  contirmatioii  of  our  diagnosis. 
The  following  are  the  jirincipal  and  most  constant  lesions  that  I  have  noticed — (and  here  let  me  stat(^that  tliej)iM(- 
niiirlim  examinations  in  these  cases  were  directed  principally  to  the  condition  of  the  small  intestine  and  ca'cum 
and  the  presence  or  absence  of  lesions  usually  recognized  as  typhoid.  In  (|uite  a  number  of  cases,  however,  the 
whole  intestinal  tube  was  examined  and  all  the  abdominal  viscera.)  In  the  ileum:  In  every  case  that  was  exam- 
ined Peyer's  patches  presented  enlargement  and  ulceration,  generally  extending  for  several  feet  up  the  intestine. 
In  only  two  or  three  instances  was  the  disease  so  little  advanced  as  to  present  nothing  more  than  the  shaven-beard 
appearance;  but  generally  the  glands  were  ulcerated,  sometimes  only  enlarged  so  as  to  remind  me  forcibly  of  the 
appearance  of  "  wheals''  upon  the  .skin,  and  in  one  instance  .so  large  as  to  project  over  one-third  of  an  inch  into  the 
cavity  of  the  intestine.  The  solitary  glands  iiresented  similar  appearances,  being  enlarged  to  the  size  of  a  8])lit-i>ea 
and  many  of  them  ulcerated.  Uoth  the  solitary  and  Peyer's  glands  contained  the  ty]ihoid  matter  in  the  shajie  of  a 
blackish  granular  de|)osit.  Sometinies  the  whole  mucous  membrane  of  the  ileum  seemed  covered  with  a  similar 
adherent  material,  and  at  other  times  it  seemed  as  if  the  matter  were  deposited  beneath  the  mucous  membrane  in 
great  black  blotches.  In  some  instances  the  walls  of  the  intestine  were  congested  both  externally  and  internally 
between  the  ulcerated  and  enlarged  patches.  The  greatest  extent  of  pathological  change  was  found  towards  the 
ca'cal  end  of  the  ileum,  gradually  diminishing  in  the  upper  part  of  the  gnt  and  extending  to  a  greater  or  less  extent 
in  different  cases;  but  in  every  instance  was  found  enlargement  and  ulceration  of  both  Peyer's  and  the  solitary 
glands  and  typhoid  deposit.  The  upper  end  of  the  colon  presented  similar  ap|iearances.  The  ileo-ca'cal  valve  was 
often  thickened  and  black.  The  mesentery  and  mesenteric  glands  were  geiieially  much  congested,  the  latter  enlarged 
to  the  size  of  acorns,  and  blaekisli-red  from  engorgement  with  venous  blood.  The  omentum  often  presented  an 
ai)pearance  as  if  it  had  been  for  a  long  time  macerated.  Sometimes  the  small  intestine,  was  nearly  empty  and  packed 
down  in  some  corner, — occasionally  bound  down  by  inflammatory  adhesions  ;  at  other  times  it  was  much  distended 
with  gas.  Where  perforation  had  occurred  redness  and  iieritoneal  effusion  were  generally  x>i"esent.  \othing  patho- 
gnomonic was  observed  in  the  other  viscera;  the  liver,  pancreas  and  kidneys  seemed  healthy  althougb  sometimes 
slightly  softened;  the  spleen  was  generally  much  congested,  enlarged  and  softened;  the  stomach  occasionally  con- 
gested and  its  mucous  membrane  softened,  sometimes  over  the  whole  organ. 

A  few  words  are  needful  regarding  complications.  Bronchitis,  ])neumonia  and  inflammation  and  abscess  of 
the  parotid  were  the  principal.  In  no  case  was  any  antiphlogistic  treatment  directed  against  the  intercurrent 
inflammation  more  than  blistering,  expectorants,  dry  cups  and,  distrustfully,  tartar-emetic.  The  treat uu-nt  adopted 
in  all  these  cases  was  stimulatinj;  and  supporting  from  the  outset.     Carbonate  of  annnonia,  wini'-w  hey,  milk-punch 


'MP, 


-YM  PTOMATOLOGY    OF 


and  esKcucc  (if  liecf  foniicd  our  chief  ii-liaiic<',  iiiliiiinisli-icd  in  giciili-r  oi'  loss  (]iiiiijtitifs  according  to  tiu;  prostra- 
tion of  th(^  patient;  tlio  pulse  was  our  jirincipal  jjuidc.  to  ijuantit.y.  The  rejfulation  of  tlio  bowels  was  generally 
attempted  liy  opiates  and  astrini;cuis:  I  liavi'  found  opium  a  very  rdialdi-  remedy  not  only  for  this  purpose  but  for 
calming  nervous  excitement,  ]clic\  inn  juctit.-ilion  and  delirium  and  producing  slecji, — its  conibinaticni  with  tartar- 
emetic  in  the  niowt  violent  cases  cd'  nervous  cxcitcmcTit  was  scuuctiuics  followed  by  the  liaiijiicst  effects.  Quinine 
was  used  in  numy  instances,  but  willi  little  if  any  benclil.  Blisters  and  other  derivative  a])plications  to  the  surface 
were  freely  used  for  the  ndief  of  the  many  distressing  abdonunal  symptoms,  somotiuu-s  with,  sonu-tiines  without, 
success.  Emulsion  of  turjientiue  was  also  eiuidoycd,  and  in  a  small  jiroportion  of  cases  with  benefit.  Hoffmann's 
anodyne  was,  next  to  opium,  the  best  uuti-spasmodie.  liut  after  all  our  main  oliject  was  to  support  the  patient, 
not  to  break  up  the  disease,  for  which  latter  ])urposo  no  nuMlicinc  was  of  any  avail. 

Typhoid  fever  iu  this  hos]dtal  has  shown  no  sign  of  contagion.  Two  of  my  medical  officers,  as  also  two  med- 
ical cadets,  were  affected  during  the  ei>ideniie  with  slight  symptoms  of  temporary  deraugenu'iit. 

I  shall  not  attempt  to  discuss  the  cause  of  the  disease.  J'he  change  of  life  from  home  to  camp,  and  exposure 
to  fatigue  and  wet  under  ni!W  aus]dces,  seem  to  have  dev(dopcd  it.  The  season  lias  l)eeu  a  remarkably  wet  one,  lint 
as  far  as  I  have  been  able  to  ascertain  not  an  unhealthy  one  among  the  residents  of  this  vicinity.  No  epidemics 
have  prevailed  save  the  cases  of  typhoid  fever;  and  tlie  cases  of  disease  outsi<le  of  military  camps  an<l  hosjiitals 
have  been  substantially  the  same  as  tho.se  occurring  in  our  own  exiiericuce.  The  reginu'nts  from  which  our  sick 
were  derived  luive  generally  been  actively  employed  er<'cting  f<irtifications,  laboring  in  tlu^  trencdies,  felling  trees 
and  standing  guard, — not  as  iiundi  exposiMl  to  fatigue  or  inclemency  of  weather  as  our  troops  ha\  e  ordinarily  been 
on  frontier  service, — and  generally  provided  with  good  water  an<l  tlii'  best  of  food.  Their  (lothing  has  been  suit- 
able to  the  season  of  the  year  and  the  men  themselves  have,  as  a  rule,  been  clean  and  tem|icrate. 

Surgeon  C.  J.  Wai.tox,  2\kI  Ki/.,  MunU  HI,  1(S(>2,  Green  Hirer,  Tai/lor  Coiintij,  Ki/. — Hut  the  disea.se  from  which 
our  troops  suffered  most  w'as  typhoid  fever.  This  is  not  to  lie  wondered  at  when  \^■^'■  take  into  consiileration  their 
situation  with  the  cii-cumstanccs  attending  them.  Aluuist  every  possible  predisposing  cause  was  in  oiicration  at 
the  same  time;  liadly  (irepared  food;  sleeping  ii)>on  the  dump  ground;  unusually  warm  and  wet  weather  for  the 
season  with  sudden  (  hanges  in  the  tim])erature  of  the  atnnjsphere;  want  of  personal  cleanliness;  camped  iu  the 
beud  of  the  river  and  ahuost  surrounded  by  it;  standing  guard  during  rainy  nights;  leading  inactive  lives,  not  drill- 
ing one  day  in  seven  on  account  of  mud  and  rain,  and,  in  a  word,  almost  everj-thing  that  tends  to  lower  the  vit.'il 
energies.  We  called  it  typhoid  fever,  for  we  could  not,  as  it  ap]ieared  in  our  regiment,  term  it  anything  el.se.  Then^ 
seemed  to  be  no  essiiitial  difference  between  it  and  the  oriliuary  tyiihoid  of  private  practice  except  that  the  symp- 
toms were  greatly  aggravated.  Some  practitioners  whom  I  have  met  d<i  not  consider  it  typhoid  but  <'amp  fever. 
Tliey  contend  that  it  is  a  disease  peculiar  to  camp  life;  lint  I  am  unable  to  trace  any  distinction  except  as  aliove  stated, 
in  the  aggravation  of  the  .symptoms.  Tho.se  who  were  taken  down  had  generally  sonus  prenuinitory  sympt<ims  :  Diar- 
rhcea,  dull  headache,  pains  in  the  bones,  some  s<ireness  of  the  llesh,  lassitude,  general  debility  and  loss  of  appetite. 
After  taking  to  bed  many  manifested  the  greatest  indifference  to  their  condition,  resting  (luietly  and  a.sking  for  noth- 
ing; when  eiKiniry  was  made  how  they  felt,  they  would  answer  re/;/  inll,  or  {feel  better  to-daij;  a  few,  however,  becanu; 
conscious  of  their  danger.  Some  were  delirious  from  the  beginning, — furiously  mad,  and  constantly  attempting  to 
get  up  and  leave  their  tents;  otliers  became  delirious  after  a  few  days.  In  these,  cases  typho-uumia  and  coma  vigil 
were  comuuin  symptoms.  Hemorrhage  from  the  bowels  occurn-d  in  two  cases.  A  few  cases  had  no  diarrhiea  and  ran 
their  course  to  a  favorable  teiniimition  without  any  alarming  symjitom  and  with  but  little  treat  uu'Ut.  There  was  in  a 
large  projiortion  of  the  eases  a  v<'ry  sluggish  state  of  the  circulation, — (he  hands,  feet  and  face  presenting  a.  purple-livid 
apjiearance  which  disappeared  temjiorarily  on  ])ressure, — a  condition  which  I  have  seldom  seen  to  any  considerable 
extent  in  jirivate  iiractice.  I  attribute  it  to  the  greater  degree  of  constitutional  depression  arising  from  the  peculiar 
circumstances  under  which  our  troops  were  iilaced.  Our  treatment  was  altogether  expectant.  After  the  disease  was 
fully  develojied  we  gave  nothing  but  that  which  seemed  plainly  indicated.  We  generally  began  with  a  few  doses  of 
(|uinine  and  opium  ;  but  these  were  discontinued  after  the  disease  was  fully  developed.  I  am  not  able  to  give  afavor- 
able  <i]iiniou  of  the  use  of  ijniniue  in  tyjihoid  fever,  although  I  have,  both  in  private  practice  and  in  the  army,  given 
it  a  fair  trial.  It  is  often  at  first  impossible  to  determine  to  what  extent  the  case  is  influenced  by  malaria,  and,  eon- 
tei|ueiitly,  to  be  on  the  safe  siile,  it  is  well  w  hen  doubt  is  entertained  to  begin  with  a  few  doses  of  quinine, — if  remit- 
tent the  case  will  be  controlled,  but  if  ty]ilioid,  my  opinion  is  that  no  good  will  be  effected.  Acting  on  the  view 
that  it  is  a  self-limited  disease  I  do  not  attemjit  its  arrest,  Init  endeavor  to  enable  the  patient  to  live  through  its 
usual  period  of  eighteen  or  twenty  days.  Hence  our  treatment  was  opium,  tannin  and  acetate  of  lead  for  the  diar- 
rhoea, and  stimulants  with  nutritious  diet  and  scrujiuhuis  jiersonal  cleanliness  for  the  general  condition.  Every  case 
was  well  washed  at  the  onset  with  tejiid  water  and  soap.  When  the  fever  was  at  its  height  the  patient  was  sponged 
with  cold  water,  which  exercised  a  very  salutary  effect.  Brandy  was  administered  freely  from  the  beginning.  In  a 
word,  everything  calculated  to  husband  the  resources  of  the  system  was  employed.  The  ))atients  were  fed  regularly 
whether  they  wanted  to  eat  or  not.  Xitrate  of  potash  was  given  in  solution  with  some  benefit.  After  all,  I  think 
that  opium  and  brandy  are  the  sheet-anchors.  The  liowels  must  be  cont Killed  and  the  patient  stimulated;  I  consider 
him  safe  when  the  bowels  are  jir(i|icrly  checked.  I  feel  no  uneasiness  if  they  are  not  moved  for  three  or  four  days: 
I  have  never  seen  any  bad  conseiiuences  follow  their  being  (diccked  suddenly.  I  have  used  tur[ieutiiic  in  a  few  cases 
in  which  diarrhiea  was  obstinate;  but  this  is  more  api)licable  to  eases  that  are  troubled  with  tympanites.  I  gave 
twenty  drops  every  two  hours,  ajiiiarently  with  good  results,  for  two  or  three  days;  but  every  case  that  had  tympa- 
nites died.  In  one  case  tympanites  disappeared  for  two  or  three  days  and  reappeared  before  death.  In  a  few  eases 
I  gave  minute  doses  of  calomel,  but  they  did  no  good, — I  think  harm.  We  had  no  hospital  and  had  to  treat  our  men 
in  c|uarters  during  the  tiist  six  weeks.  .Vfter  this  we  hail  good  hospital  shelters  and  nearly  all  our  cases  did  remark- 
ably well  exci'iit  those  that  had  been  on  hand  for  a  considerable  time. 


THE    cwNTINUKI'    FKVKK?'.  •>  I  / 

Surfimn  M.  K.  {i\GV.,'Stlli  il'ix.,  I'nluinliii.'^.  hi/..  Manh  :il.  1m;:>. — 'rypliiiiil  tV-vcj-  is  very  insidious  in  its  aiiprdacli. 
Many  days  nr  c.eii  weeks  si)ini-tiiiii-s  elajisi-,  dm  iui;  w  liiih  tlie  |ialii-iil  IVcIs  nut  well  nor  yrt  sniiii-icntly  ill  to  j;ive  up 
or  take  to  lied :  he  will  lie  in  mid  mure  m-  less  eniiiid;iiiiini;.  liis  asjieii  dull,  si  lipid  ami  an  \  inns,  (in  tlie  oeenrienee 
(if  delirium  lie  is  eitliei  animated  oi'  lii>l  in  a]ialliiiie  l»-\\  ildermenl.  (  illni  iliaii  Ima  eomes  on  early,  aecoin)ianied 
with  pain,  fenderncss  and  hardness  of  i  he  alidounn.  wliii  h  somet  inies  liei'omes  tynipanil  ie.  Usually  as  the  disi'ase 
priij;resse.s  the  diarrho'a  keeps  paee  with  it.  and  is.  no  iloiiht.  the  result  of  intestinal  irritation,  inllannnation  and 
uleeration.  K|iistaxis  is  frei|nently  jirest  nt  and  smnet  imes  iioulilesonie;  at  lirst  il  seems  lo  j^ive  relief  to  the  feelini; 
of  oppression  ahoiit  the  head.  Imt  if  eon  tinned  is  i|iiite  likely  to  heeoiiie  a  sonri'iMif  di'liilily .  and  ne<'ds  watehinj;  lest . 
before  we  are  awaic  thi'  patient  Ik'  found  siirrumliin;j;  lo  ils  dipiessinii  inllueiiee.  Somelimi's  we  observe  u]iou  the 
eliest  and  alidomeii  the  seatteied  eiuption  said  to  lii>  ehaiactei  isi  ie  of  typhoid  I'exi-i. 

Siiri/riin  .Ias.  V.  KenhaI.I..  mi  //k  /i  n /•■-  in  lln  luiiiji  nf  llii  1  Ill/A  .V.  1..  in  llir  iriiiltv  «f  l.S(i;!. — .\  lar^e  nuuiiiel  of 
the  (^'ises  at  the  eainp  at  .^ijuia  Creek  ednimeiieed  uradnally.  lln'  ]ialiiiil  seaieely  ieeoy;ni/,iii^  that  he  was  siek:  slifjjit 
(leraiiij;eineiit  of  the  liowels:  tonirue  nearly  natural:  eyes  dull  or  xellow  :  mine  in  aiioiil  one-half  tin-  easrs  nearly 
natural  at  first,  tliounh  many  had  paid  no  atleiiiinn  to  tlii'^:  loss  of  ap|ieiiie;  slight  rinm.  .alter  «  Inch  there  woiilil 
lie  an  af;j;ra\  at  ion  of  all  I  hi-  s\  nipioius:  I'losI  lal  ion  uie.it:  m  ine  lii.nli-eiihned  and  in  some  eases  i  m  hid  :  dianhn-.i 
increased  unless  cheeked  hy  anodynes  iir  ;isl  rini;enls  :  lonnue  red,  al'leiwards  dry;  some  teiiih'i  in'ss  of  liowels  and 
tyiniianites.  I'sually  I  here  has  lieeii  no  j^real  dillieiilly  in  rest  lainiiif;  the  disehai'f;es,  which  in  many  cast's  were 
lii[iii(l  and  yellowish  and  in  a  few  eases  bloody:  leiiesmns  was  present,  but  seldom.  In  two  there  were  latfie  inllani- 
inatory  swidlinjis  under  tln^  an^rle  of  the  rifiht  .jaw:  these  suppurated  and  i'ei|iiii'i'd  incision;  one  proved  fatal  and 
the  other  will  iirobably  terininalt^  in  the  same  manner.  'I'hree  cases,  after  liavlnji  been  sick  for  three  weeks,  com- 
plained of  severe  jiain  and  tenderness  of  the  feet:  in  two  of  thesis  the  feet  Ik^^iiii  to  MWidl  and  becaiiU!  jiurple,  aH  if 
K]ihacelatioii  was  1  hreateuinj;-.  Hy  the  use  of  warm  applications  the  pain  and  swellinsi;  diminished  and  tli(>  feet  arii 
now  but  litth^  discoloii'd.  liiil  the  worst  cases  lund  been  taken  down  with  ninch  more  \  ioleuce.  w  itliont  <leriinj;eiiu>ilt 
of  the  bowels;  Perhaps  the  lirst  reiiort  the  siir^'con  won  Id  ha\  e  of  them  would  be  thai  I  hey  were  era/y  in  their  tents. 
It  is  probable  that  they  had  been  taken  w  it  h  a  sudden  conueslion:  but  the  fact  could  not  be  definitely  ascertained. 
'I'hese  eases  ran  their  course  ra)iidly  to  a  fatal  termination  or  to  convalescence.  Some  eonlinued  wild  till  near  the 
fatal  endiufi;  and  then  became  nioileratidy  eoiuatose;  these  appeared  like  typhus  cases,  sliowiiiij  early  v ibices,  sordcN 
and  a  general  implication  of  Ili(>  nervoii.s  system,  nianifested  by  in\  (duiitaiy  stools  and  micturition,  but  without  any 

troublesome  diarrhiea.      In  one  ease,  that  of  Cajitaiii  W'heiOer.  (' jiany  1).  the  jiatieut  came  in  from  duty  and  was 

suddenly  taken  with  spasnis.  becoiniiif;  stii]iid  and  reimiiniiiij  so  lor  several  days,  (iradiially  his  iiilelli};enco  returni'd, 
the  tebrile  symptoms  diminished,  the  urine,  wliiidi  had  been  I  hick  with  se<limenl .  became  clear:  he  had  some  ajipetite; 
his  bowels  were  costive,  but  easily  iuovimI  by  aperients;  in  two  weeks  he  was  able  to  uiiderlake  the  jourin'y  to 
Wasliinj;ton,  and  has  since  fione  to  his  home  at  Syracuse. 

Siirijcun  W.  \V.  (Ji;.\N(;i;ii,  Voxt  liiinjiHnl,  lloimtoii,  Mil,  Iiic.  .'il,  WOL'. — On  the  (diaracler,  course  or  Irealment  of 
fevers  its  developed  in  this  ]iorti(iii  of  the  army  I  have  iiothinf;  to  add  to  tny  report  of  September  HO  e.veejit  in  ndatioii 
to  t.vpboid  fever,  of  which  only  a  casaor  two  had  then  falhui  into  my  hand.s.  The  largely  iiKM'eascd  ]iroportion  of  cases 
during  the  last  quarter  calls  for  an  outliiu'  <d'  the  symptoms  and  treatment.  The  small,  freipieiit  imlsi'.  dry  skin, 
continuous  but  rarely  intense  pyrexia,  narrow -|ioin  ted,  dry,  red-edged  and  glossy  or  cracked  I  oiigue,  sometimes  heavily 
at  others  slightly  furred  with  shades  varying  from  grayish-white  to  y(dlowish-liiowii  or  liiiihnrh-mlori'ii  and  even 
darker,  with  the  sordes-coated  teeth,  are  symptoms  too  constant  to  be  overlook(!(l.  Those  which  jioint  to  the  cerebral 
and  epigastric  regions  an!  less  constant  in  their  occurrence  as  well  as  more  variable  in  their  character,  (ireat  and 
jiersisting  w  akefuluess  in  some  eases,  which  no  ])rndeiit  aniount  of  ojiiate  st^enis  to  overcoimv  is  a  frei|ueut  but  by  no 
means  regular  symptom.  An  equally  unyi(dding  h'thargy  prevails  with  as  many  more.  Delirium  and  perfect  clear- 
ness of  intellect  are  e(|nally  distributed,  whether  among  the  comatose  or  the  wakeful,  .and  no  greater  fatality  seems  to 
attend  one  class  of  cerebral  symptoms  than  the  other.  Nausea  and  einesis  are  occasional  but  not  fre(ineiit  symiitoms. 
Tenderness  on  epigastric  pressure  is  a  frequent  but  by  no  means  certain  occurrence,  and  w  Iiilo  some  of  the  ])atients 
have  diarrh(pa  in  the  course  of  the  disease,  as  large  ;i  jiroportion,  from  tirst  to  last,  reiiuire  purgatives  to  procure 
ahine  discharges  every  fort.v-eight  hours,  and  not  a  few  have  regular  evacuations  throughout.  The  treatment  has 
been  in  all  cases  tonic  from  the  start,  with  terebinthinate.  vinous  or,  in  the  absence  of  the  latter,  dilute  ;ilcoh()lic 
stimulants  in  the  low  stages,  close  attention  to  incidental  or  transient  symptoms  and  a  bland  and  easily  digesteil 
diet.  Anodynes  (opiate  when  not  contramdicated  by  cerebral  symptoms)  and  diaiihoretics  have  been  enipl(iye(l 
as  occasion  demanded.  Tepid  and  cold  sponginfj  have  proved  most  etticient  in  soothing  the  disturbed  brain  and 
restoring  healthy  action  to  the  skin.  Mercurials  1  have  nirel.v  had  occasion  to  use  in  this  disease,  but  in  one  or  two 
instances  decided  benefit  followed  the  use  of  calomel  and  chalk  in  small  doses  for  the  purpose  of  exciting  the  .secre- 
tions, especially  the  salivary.  In  no  case  has  it  been  necessar.v  to  push  the  remedy  to  jit.yalism  or  even  to  fetor  of 
the  breath.  Quinine,  turpentine  and  wine,  cold  or  tejiid  siionging  and  cleanliness  of  person,  bed  and  clothing,  with 
well  ventilated  wards,  have  proved  so  reliable  as  curative  agents  that  I  have  not  yet  lost  a  case  of  this  disease. 

Ass't  5«r(/.  Ch.\rle8  E.  Cady,  138^/>  Pa.,  ReUui  Roiiir,  Md.,  Oct.  31,  18(52. — Many  of  our  cases  of  typhoid  fever 
were  of  a  highly  aggravated  character.  The  invasion  was  fre([nently  most  rajiid  and  prostrating.  In  several  cases 
the  men  performed  duty  on  the  day  before  reporting  themselves  ill,  and  on  the  third  or  fourth  day  all  the  patho- 
gnomonic symptoms  would  l)e  unmistakably  present.  Our  mortality  has  been  as  low  as  is  usual  in  private  practice. 
The  treatment  adopted  was  that  in  use  in  the  Pennsylvania  hospital,  Philadelphia;  (iood,  full  and  easily  digested 
diet;  milk  and  brandy  in  punch:  eggs;  Dover's  powder,  castor  oil,  sinapisms,  neutral  mixture,  etc, 

Surgeon  J.  T.  Calhoun,  lith  K.  Y.,  I'ec.  31,  18U1. — f)ne  of  the  patients  while  convalescing  from  typhoid  fever 


318  SYMPTOMATOr.OilY    OK 

very  iiiipi-iKlcutly  ate  a  (lU.'inlity  of  i)cuMiit.s  and  Jelly;  u  latal  iclapsii  ensued.     This  was  (he  lir.sf  death  thnn  disease 
that  occuned  in  the  icgiiiient. 

Suv<i<(in  J.  15.  I'oTTKl'.,  'Mill  Ohiii,  FiiiiiltirilU',  April  2,  IKIiL'. — Our  typlmid  is  not  the  disease  so  reeiif;ni/,eil  liy 
medical  nii^n  in  i>rivato  i)raptiee,  but  a  eontinnod  fever  of  a  typhoid  tyjie,  nioditied  liy  ehange  of  lialiits  an<l  to  a 
certain  extent  by  climate.  Many  oases  wlien  first  leportcd  are  delirious,  with  cold  extremities,  eonfrestion  of  the 
supertieial  caiiillaries,  free  perspirations,  rapid  and  feeble  pulse,  l-'O  to  Kit),  and  profuse  watery  diarrloea.  These 
terminate  fatally  in  forty-eight  to  seventy-two  Lours.  Such  cases  require  ([ninia,  carbonate  of  ammonia,  brandy, 
etc.,  from  the  coramenceinent. 

Siirr/enn  li.  Hoiikkr,  Wth  Pa.  Hrncrvcn,  Cam})  riirpnnt,  Va.,  hccemhir,  tSOl. — We  have  had  much  less  disease  of 
malarial  origin  than  was  anticipated  from  our  near  location  to  the  Potomac.  Citizens  long  resident  here  say  that 
they  have  had  less  ague  in  their  families  this  season  than  for  many  years,  and  attribnte  the  favorable  <'hange  to  the 
fre(jueut  heavy  rains  which  Hooded  the  streams  and  thereby  removed  the  cause.  Intcrmittents,  with  few  exceptions, 
have  been  of  the  quotidian  type  and  readily  yielded  to  riuinine  :  lecurrenocs  have  been  infrequent.  Keniittents  hav(! 
been  somewhat  peculiar  in  their  character:  Many  have  show  n  symptoms  which  are  generally  considered  pathogno- 
monic of  enteric  fever,  such  as  rcse-colored  spots  and  sudaniiiia,  and  iu  consequence  have  been  recorded  as  typhoid  • 
by  several  surgeons  of  adjoining  regiments.  I  have  been  occujiying  the  same  apartment  with  the  sick,  giving  Ihem 
my  whole  attention,  observing  them  closely  both  day  and  night,  and  have  come  to  the  ccmclusion  that  the  fever  is  of 
malarial  origin  and  of  the  bilious  or  remittent  type.  The  grounds  for  this  belief  are:  1st.  Absence  of  epistaxis, 
hemorrhage,  obstinate  diarrho'a,  tympanites,  deafness  and  stu|ior  or  delirium  after  the  fifth  day,  the  delirium  being 
invariably  an  early  syn\ptoni.  2d.  The  early  convalescence  of  all  and  no  new  cases  occurring  after  one  or  two  heavy 
frosts.  Nearly  all  when  brought  to  the  hospital  were  delirious,  that  being  the  first  symptom  to  attract  the  atten- 
tion of  their  messmates,  who  thought  them  either  drunk  or  crazy.  In  conversation  they  seemed  rational  enough, 
but  wheu  left  to  themselves  they  would  give  way  to  incoherent  expressions  or  endeavor  to  make  their  escape. 
Several  succeeded  by  stratagem  in  getting  out  of  the  hospital  and  ran  to  the  {juarters,  half  a  mile  distant,  at  night 
with  bare  feet  over  the  frozen  ground.  The  patients  complained  of  being  chilly,  although  their  surface  was  warm 
to  the  touch  and  thi'y  were  well  covered  and  sunounded  with  bottles  of  hot  water;  the  pulse  varied  from  100  to 
120,  the  tongiu".  was  slightly  coated  and  there  was  great  thirst.  This  condition  lasted  from  six  to  thirty  hours.  The 
cerebral  disturliance  iu  some  instances  continued  two  or  three  days,  and  as  it  abated  and  the  patients  Iiecame  more 
rational  they  complained  of  pain  in  the  head,  tenderness  upon  pressure  iu  the  ejiigastrium  and  general  aching  and 
soreness.  The  skin  was  hot  and  dry:  there  was  a  tendency  to  diarrh(i>a,  no  matter  liow  mild  the  purgative,  and 
the  evacuations  were  dark,  at  times  almost  black.  After  the  thiid  or  fourth  day  the  pulse  became  less  frecjuent 
and  the  tongue  dry,  smooth,  glossy  and  red  or  cracked;  tlie  tenderness  over  the  eiiigastrium  was  aggravated,  the 
urine  scanty  and  high-colored  and  the  eyes  slightly  tinged  with  yellow.  From  the  sixth  to  the  ninth  day  the  rose- 
colored  eruption  anil  sudaniina  made  their  appearance,  also  a  dry  Iironchial  cough,  and  by  the  twelfth  or  fifteenth 
day,  with  one  excej)tiou,  they  were  sufficiently  convalescent  to  move  al)Out  the  room.  If  delirious  when  brought 
into  the  hospital  wet  cujjs  were  applied  to  \\u\  back  of  the  neck,  and  if  these  afforded  no  relief  a  blister  was  apjilied 
over  the  same  place.  A  purgative  of  calomel  was  followed  by  castor  oil,  and  in  the  morning  from  4  to  10  o'clock, 
when  1  could  discover  a  slight  remission,  from  hfteen  to  forty  grains  of  quinine  were  administered;  during  the  day, 
at  intervals  of  four  luuus,  small  doses  of  calomel  and  ipecacuanha  were  given.  Turpentine  was  used  when  the  tongue 
was  dry  and  cracked.    Milk  diet  was  employed  and  barley-water  used  as  a  drink, 

Siin/mii  DkWitt  C.  Van  .St.yck,  iliilh  \.  Y.,  FuJIn  Clinrch,  Va.,  Oct.  20,  ISIil. — During  the  months  of  August  and 
September  more  than  five  hundred  cases  of  fever  were  treated;  the  duration  of  these  was  from  four  or  five  days  to  as 
many  weeks.  'I'lio  first  cases  were  intermitting  in  type,  with  a  tendency  to  enteric  disease.  The  fever  soon  after 
took  oil  a  remitting  form  and  finally  assumed  a  low  typhoid  grade,  iu  many  cases  exceedingly  malignant.  The  treat- 
ment consisted  of  a  mild  mercurial  laxative,  generally  blue  mass  followed  by  large  doses  of  quinine,  and  occasionally 
anodynes  and  sudoritics.  From  twenty  to  sixty  grains  of  sulphate  of  quinine  ])er  day  were  administered,  and  if  these 
doses  did  not  entirely  eradicate  the  disease  within  the  first  week  they  modified  and  reduced  its  malignancy  and 
duration.  No  other  method  of  treatment  was  effective.  Mixed  and  complicated  cases  were  treiited  accoriling  to 
the  indi(^ations.  During  the  last  stage  stimulants  were  given  with  manifest  advantage.  In  nearly  all  the  malignant 
cases  sudaniina  and  |ietecliiie  covered  the  abdomen.  From  the  abdominal  tcndeiriess  and  obstinate  diarrhiea  which 
these  cases  exhibited  it  was  evident  that  the  mucous  follicles  of  the  intestines  were  seriously  involved  ;  this  condition 
was  freijuently  protracted  and  greatly  retarded  convalescence.  It  is  regretted  that  no  opportunity  was  att'ordcd 
for  jxmt-iiiortem  examination  in  the  two  cases  that  proved  fatal.  Convalescence  was  slow,  and  in  many  cases  relapse 
followed  imprudence  in  diet  and  exercise. 

Siirf/idn  A,  P,  Mayleut,  U,  S,V,,  General  Field  UmpitahArmn  of  the  Ohio,  before  Corinth,  1»G2, — The  cases  of  disease 
treated  in  this  hosi)ital  were  very  similar  in  character,  yet  were  such  as  could  scarcely  l)e  correctly  named  by  any 
term  in  nosology.  The  patient  was  usually  much  emaciated,  the  skin  of  a  light  waxen  or  rather  clay  color;  the 
pulse  small,  compressilde,  variable  in  character  and  quickened  under  the  least  exertion;  the  tongue  thin  and  broad, 
moist,  and,  with  the  lances,  almost  natural  in  color,  or  perhaps  of  a  darker  tint  than  in  health;  in  many  the  gums 
were  spongy  and  Med  readily  upon  pressure  The  skin  wa.s  generally  moist ;  there  was  .seldom  nuich  fever.  The 
appetite  was  somew  hat  capricious— usually  no  desire  for  food  was  manifested,  but  when  fresh  vegetables  or  ficsh 
beef,  8uital)ly  cooked,  were  offered  they  were  evidently  relished  except  in  the  graver  cases.  The  alvine  evacuatiuns 
were  more  frequent  than  natural,  thin,  but  otherwise  healthy  in  appearance,  except,  perhaps,  somewhat  darker,  and 
in  some  cases  slightly  ting<>d  with  blood;  they  were  not  often  attended  with  pain,  Tliere  was  rarely  tym])anite8, 
and  usually  ))ut  little  tenderness  on  jnessure.    In  many  cases  one  or  ))oth  parotid  glands  were  e-xteusively  iijtiained; 


this  oocarrcd  in  the  laliT  8tnKi'M)f  tlif  iliscasc  anil  tiTiiiiuaU'il  (jicasinnally  in  siipinnal  ion.  I'luliaiily  onc-Iialf  of  tlicso 
wiTo  fatal.  I  kiKiw  of  nothinjj;.  in  tlic  cases  which  recovered,  to  ilisi  in^riiisli  lliem  from  those  wliich  terniinateil 
fatally  except  that  jH^rliajis  in  the  former  suiipniation  was  earlier  estalilishi'd.  The  functions  of  the  luain  and 
nervous  system  were  often  considerably  impaired:  In  all  cases  the  ]iatieiit  was  languid,  weak  ami  disjxised  to  he 
i|niet  and  sleei)  ns  much  as  possihle;  there  was  almost  total  want  of  .jnd,L;ment.  the,  memory  was  defective  anil  the 
mind  waiidcririjj;;  the  delirium  was  always  mild  in  characti'r.  In  short,  lliis  diseas(^  was  tcrmi'd  variously  remit- 
tent fever,  typhoid  fever,  diarrhiea,  dysentery  or  seorlnitiis.  aceordinf^  to  t  lie  synijiloms.  In  eacli  cas»>  was  a  dyserasia 
resnltinji;  cliietly,  as  I  apprehend,  from  exposure  and  lack  of  siiitalde  nourislimcnl .  I'oat-iniirli m  <'xamination  usually 
showed  a  conifeste<l  condition  of  the  small  inicstinc,  seldom  aniountini;  to  dciidcd  inllammation  and  rarely  attended 
with  ulceration.  Thoro  was  fjenerally  a  dirt\  ilaiU-red  aiiiiearaine  ol  llie  iiiiicnus  niciiihiane,  wliich  was  somewhat 
softened,  beinj;  reailily  removed  by  rulihinfj;  with  the  hack  of  the  scaliiel.  In vajiinations  of  tlic  small  intestine 
were  fre(|nontly  found  hiit  wen^  never  strauf;nlatcd.  'I'lic  nall-Iiladder  was  id'tcu  distended  with  liil<'.  Tlie  ventri- 
cles of  the  luaiu  and  the  pericardial  sac  contained  a  little  more  seiuni  than  natural.  Fiei|UiMitly  a  lihrinous  clot  was 
found  in  one  or  both  ventricles  of  the  heart,  and  sometimes  this  was  so  larj;e  as  to  disteml  the  heart  or  at  least  kei'p 
it  of  normal  size.  \o  other  abnormal  aiiiiearamis  were  c(uisi  ant  except  fjcueral  cmaciatiiui  and  a  llabliy  and  atrojihied 
condition  of  the  mnscnlar  system.  In  many  ciises  the  blood  ajipcarcd  thin  and  nncoaj;ulalde  iu  both  arteries  and 
veins.  A  few  cases  of  sudden  death  showed  a  dcj;ii-c  of  i)ulmoiiary  ciuij;cstion,  or  even  ]>iilmiuiary  apopli'xy,  evi- 
dently induced  by  heat  exhaust  ion  in  iiatieuts  already  threat  ly  reduced  by  blood-poisoninj;.  The  treatment  consisted 
mainly  in  careful  nursing  with  nourishing  diet,  whiMc  il  iduld  be  jLliven,  and  stimulants  combined  in  some  cases 
with  i^tiinia. 

Suri/<'i»i  .1.  Ij.  tlACKso.v,  lUl.s/  {'.  .S'.  ('')/()rc(?  I iifa ii I r i/ ,  Miijixr'dlc,  h'li.,  l')'liniiirii,lH(i'<. — Kdward  (Jray,  Taylor  l'hillii)s 
and  Kobert  Xtdson  were  brouf;ht  to  hospital  alioul  the  same  liuu^  in  a  state  of  collai)s<',  with  cold  extrendties,  sh)W 
and  weak  i)ulse,  a  vacant  stare  ami  mental  hallucinations;  subsultiis  lendiuum  was  jireseiit,  especially  on  attempt- 
ingtoiuovo.  They  loathed  food  and  jiresentcMl  a  scorbutic  app(^araiice.  There  seemed  to  bean  eiifjorKement  of  the 
W'hole  system,  particularly  of  the  liver.  They  would  ikjI  acknowledf^e  themselves  sick,  and  raine  to  hosiiital  by  order 
of  the  company  coinmander.  who  said  he  considered  them  nearly  dead.  Hepatic  aj;ents,  couiiter-irritanis,  stimulants, 
tonics  and  auti-scorbittics  were  employed,  without  manifest  efl'ect  cxce|)t  that  in  Taylor's  case  lu'avy  bilious  stools 
were  ])rocured;  but  there  was  no  res])onse  on  the  ])art  of  the  mu'viuis  or  circulatory  system.  The  jiaticnts,  if  allowed, 
would  rise  and  walk  almost  to  the  hour  of  their  death.*  (iray  died  on  the  second  day  after  enterinj;  hospital  and 
Phillips  on  the  fourth  ;  Nelson  lived  some  days  longer:  Diarrlnea  set  in  abcuit  the  sixth  day,  the  most  simple  diet  pass- 
ing unchanged;  injections  were  tried  lint  mine  were  retained.  He  contiinicd  with  little  change  of  luiiul  or  body, 
except  enuu'iation,  iiutil  death. 

These  men  had  been  in  camp  about  threi^  wcc^ks.  They  <:aiue  from  the  rural  districts  and  had  been  accustomed 
to  fresh  air  and  mixed  diet.  When  they  Joiiu'd  tin-  weather  was  intensely  cold  at  night.  Thiy  were  sliut  up  in  their 
tents  tilled  with  coal-dust  and  smoke,  and  of  course  lived  on  the  soldier's  ration.  They  sull'ered  severely;  subsu- 
i|Uently  they  were  removed  to  a  large  building,  well  lighted  but  with  a  low  ceiling -and  only  one  stove.  The 
intensely  cold  weather  made  it  necessary  to  p.-iitition  off  a  id(un  about  25  by  liO  feet,  w-here  for  about  tt^n  days  fifty  or 
sixty  men  were  crowded  together  day  and  night.  During  this  state  <if  things  these  three  cases  were  developed,  and 
all  cases  of  measles,  fever,  diarrlnea,  etc.,  from  that  company  assnmiMl  a  malignant  typo  tind  inclined  to  typhoid  or 
scurvy.  The  commanding  officer  was  made  aware  of  this,  and  as  soon  as  jiossible  had  liis  ([narters  exjiaiided,  drilled 
his  men  every  day  in  the  open  air  and  furnished  thci«  with  plenty  of  mixed  diet.  Iu  little  over  two  weeks  all 
diseases  became  more  amenable  to  treatment. 

Extriict  from  the  recirrdH  of  the  Chimhorazo  UnnjiitaJ,  liichtiii>nd,  Id. —  The  typhoid  fevers  (djserved  during  the 
winter  l^(i3-64  have  been  geiu'ially  prolonged,  but  less  so  as  s]iring  aiipioached.  Tliere  has  been  almost  uniformly 
a  loose  state  of  the  bowels,  the  characteristic  thin  stools,  but  less  oft'eusive  than  is  usual  w  hen  turpentine  and  chlo- 
rate of  potash,  which  are  the  routine  here,  are  not  employed.      Few  have  exhibited  much  abdomimil  tenderness, 


*Kdward  Batweli,,  SnrgiMin  14th  Midi.  Vol.  Inf.,  In  ;ui  aa'ount  of  a  fever  tluit  |in'vjiil(il  at  Cainji  Bit?  Spriiitts,  3Iiss.,  in  .June,  Isr.-J,  pulili>ilii><l 
in  Vol.  XIIT,  Med.  ami  Siinj.  lirjinrfei;  I'tiila.,  IStj.'j,  p.  :i04  ^f  snj.^  rt'iuirts  that  afti'i"  the  cvaruation  nf  Cciriritli,  ami  ilnriiijr  the  innvenieiit  dT  tlie  iiursiilni; 
army  tnwanls  Buonsville,  inteii>e  lieat  sneceeiled  to  a  copious  riiinfall.  ilnrin;?  wliirli  tlie  soIdieiN  were  exiios<'<1  witliont  tents  or  siiltietent  ejotliiiit;. 
iiaviiif;  left  these  Jiehind  in  flie  camps  at  Faniiintitoii.  .\s  tliere  was  a  lieartii  of  jmre  water,  tlie  sta;;naiit  etmtents  of  iinols  were  tlruiik  hy  men  ami 
mules  alike,  the  strong  sulplmrettwl  water  of  the  artesian  wells  lieinK  used  only  in  urgent  m-cessity.  At  this  time  ehills  and  fever  apjK-ared  among  the 
troops,  the  fehrile  action  finally  becoming  continued  and  of  a  low  tyjie.  After  falling  hack  to  Ilig  .springs  an  auoiuatous  fever  invaded  the  army.  It 
commenced  with  malaise  ;  the  skin  was  cool,  the  tongue  moist  and  natural,  the  j.ulsc  never  ahove  inland  the  urinary  and  al  vine  secretions  regular.  There 
was  "no  chill,  no  fever,  nothing  to  indicate  anything  wrong;  the  appetite,  if  anything,  was  increased ;  no  want  of  sleep  vvju*  coniplaineil  of,  nor  did  a 
single  symptom  present  itself  indicJitive  of  diseasi'd  actittn.  Despite  all  this  there  was  a  look  ahout  your  patient,  an  expression  of  countenauee  that 
finiily  eonvineed  you  that  it  was  not  a  case  of  malingering  you  had  to  treat.  This  condition  lasted  for  s<tiue  days,  when  restlessness  and  a  tendency  to 
delirium  supervened."^  There  was  an  irresistihle  propensity  to  walk  ahout ;  imfhiiig  hut  foree  could  keep  the  jiatieiit  fnuii  leaving  his  iH'd,  and  this 
IH'culiarity  hecanie  more  marked  as  the  case  apjiroached  a  fatal  teriuination.  Fnim  theconnuenceiuent  of  ihi-  eomplaint  then*  was  a  I'apjd  lo-s  of  llesli  and 
the  jiulse  hecame  languid  and  feeble.  Restlessness  lasted  from  ahout  the  twt-Ifth  to  the  twentieth  day,  after  which  there  was  le>s  dlsiiosition  to  begin 
walking,  hut  the  jiatient  would  move  over  a  greater  distance,  .\fter  one  of  these  walks  ln'  would  express  himself  as  feeling  lietter,  go  to  bed  and  die  In  a 
fewininute.s.  There  occurred  eighteen  of  thes<' fatal  cases  In  the  regiment,  all  varying  but  little  in  their  symptoms.  The  mortality  wa.s  also  great  in  other 
regiments,  some  of  the  sick  dying  on  their  way  to  general  hospital.  The  disease  was  called  typhoid  lever  hy  army  >urgeoiis,  hut  ItATWKl.i.  says  that  he 
** failed  to  trace  a  single  point  of  similarity  of  the  symptoms."  .\  Ilk-.-iI  practitioner  of  whom  he  made  lni|uiries  descriU-d  the  diseiise  accuratidy.  <-allliig 
it  the  iraU-ing  fei-er,  and  saying  "It  was  pe<'uliar  to  that  section  of  !>Iississippi,  and  that  change  of  hh-ation  aione  exercised  any  influence  over  It ;  that 
strangers  were  more  especially  attacked,  and  it  generally  i)roved  fatal."  Little  benefit  was  derived  from  tri-atment.  which,  froni  the  atisence  of  anything 
that  might  Iiave  tieen  considered  a  positive  indication,  was  "entirely  expectant  or  mther  empirical."  tjuinine.  stimulants,  counter-irritants,  alteratives 
were  resorted  to  as  trial  n'medies.  "/*e,s/-«;oWc»t  examinations  were  mad(^  hut  they  failed  to  develop  any  lesion  ;  all  the  internal  organs  seiMued  of  a  healthy 
cliaracter  and  nothing  iudlcatetl  diseast-d  actioii." 


320  SYMPTOMATOl.OiiV    OK 

sonic  none  at  all.  Snl)-(1(>liriii;n  lia.s  been  fr(>(|nent, ;  violent  tlcliiiiun  has  never  oconned.  Maenljp  havo  been  absent. 
Tlie  gastric  typo  has  beiMi  rar<^;  tew  have  eoniphiined  of  irritatiiiu  induced  by  turpentine,  which  is  given  in  emul- 
sion in  ten-droj)  doses.  Neither  cuiiping  nor  ])ui;j;ing  lias  l)ecn  eiu)iloyed.  Ill  some  cases  caloniol,  ipecacuanha  and 
opium  Lave  been  given,  seldom  with  appreciable  lienetit.  The  stiinu'ant  method,  with  whiskey  or  brandy  toddy, 
egg-nog  and  animal  broths  has  been  eni]il(>yed  from  the  first  in  nearly  all  cases,  and  continued  to  convalescence. 
The  intervals  between  the  evening  and  uHirning  meals  have  been  too  long  for  some  patients,  and  it  is  to  be  noted 
that  no  soniiH  or  food  other  than  dry  bread  is  usually  kept  over  night  iu  the  wards.  It  is  desirable  that  attention 
should  be  directed  to  this  point  and  that  the  intervals  of  uourishiiieiit  as  well  as  of  stimulation  should  b<'  distinctly 
described.  Hronchial  irritation  has  bi^eii  comnum  as  a  complication  and  pneiiuuniia  not  rare.  The  hospital  phar- 
macy is  deficient  or  has  been  so  in  pectoral  remedies.  Cough  mixture  often  lacked  some  of  its  intended  elements  and 
afforded  but  slight  ]ialliatiou.  The  balsam  tar-water,  sanguinaria  and  asclepias  tuberosa  would  form  important 
additions  to  the  pectoral  budget.  Some  cases  presented,  without  violent  delirium,  the  most  intense  irritation  of  the 
nervous  centres — continual  twitching  of  features,  museles,  etc.,  and  working  out  of  bed  and  throwing  off  the  bed- 
clothes.    The  resources  of  the  hospital  in  the  way  of  antispasmodics  are  deplorably  limited. 

IlfiiKtHx  nil  llii:  Siqiulii'  of  ('hickdlinminy  Fiver,  Act.  J.s»7  Siirij.  J.  M.  Da  Cost.v,  U.  S.  A.,  Dec.  lil,  18()2. — .-Vmoug 
the  soldiers  returning  from  th(!  Peninsular  camjiaign  a  form  of  fever  was  observed  marked  by  features  of  uncommon 
character.  It  is  not  my  ]iurpose  to  attemiit  a  description  of  this  malady,  lint  rather  to  speak  of  the  nuirbid  states 
met  with  after  the  fever  proper  has  left,  and  which  may  therefore  be  regarded  as  its  cousec|Ucnces  or  sequehe ;  nor 
can  I  say  that  my  delineation  will  include  all  the  possible  results  of  this  grave  disease.  Others  may  have  encoun- 
tered other  issuers.  I  can  do  no  more  than  sketch  what  I  havo  seen  and  endeavor  to  reproduce  those  outlines  which 
I  believe  to  be  most  significant,  and  which  have  become  fiimiliar  to  me  from  personal  observation;  and  first  of  the — 

General  appearance. — A  striking  sign  left  by  the  fever  is  great  emaciation.  The  patient  rises  from  his  sick  bed 
the  shadow  of  his  former  self.  In  some  cases  tlir  loss  <jf  tiesh  is  so  excessive  that  the  muscles  of  the  body  apjiear 
literally  to  have  been  absorbed.  The  hair  falls  out  in  ((uantities  and  the  whole  apiiearaiiee  is  that  of  a  person  hope- 
lessly reduced  :  yet,  unless  diarrliiea  be  present,  the  tlesh  is,  under  generous  diet,  rapidly  regained.  Nay,  I  have  seen 
individuals  soon  accjuire  more  than  they  had  lost  by  tlio  attack  of  fever.  The  countenance,  produced  in  part  by 
emaciation  and  in  )iart  liy  a  iiecul  iar  hue,  is  strongly  characteristic.  No  disease  has  a  more  remarkable  physiognom_y. 
The  eye  is  not  heavy  nor  reiiiarkably  languid;  the  conjunctiva  is  clear  or  injected,  never  yellowish,  thus  forming  a 
marked  contrast  witli  the  pallid  and  yellowish  color  of  the  face.     The  peculiar  look  may  last  for  a  month. 

Iiehililil. — lioth  body  and  mind  remain  for  a  considerable  period  enfeebled.  The  weakness  of  the  former  shows 
itself  in  an  inaliility  to  bear  exercise  or  undergo  fatigue  of  any  kind,  whilst  the  debilitated  state  of  the  latter  is 
plainly  seen  in  the  loss  of  memory  so  Constantly  couiiilaiued  of.  The  exhaustion  of  strength  is  at  times  so  great 
that  the  patient  who  for  a  week  or  two  has  been  able  to  leave  his  bed  is  found  to  be  again  losing  ground  and  hqises 
into  a  typhoi<l  state  in  which  he  ])erishes: 

P.  I'urcell,  tilth  N.  Y.;  age  45;  was  admitted  August  7  from  Harrison's  Lauding.  He  was  just  recovering  from 
the  fever  and  was  much  exhausted  by  his  journey  from  the  James  Kiver.  After  a  few  days  careful  nursing  ho  rallied 
and  was  soon  able  to  walk  about.  He  continued  to  gain  slowly  until  the  20th,  yet  was  easily  fatigued,  and,  though 
craving  alcoholic  stimulants,  was  unwilling  to  eat  much.  From  this  time,  without  any  assignable  cause,  he  lost 
strength  daily,  and  by  the  SOtli  was  confined  to  bed.  All  appetite  was  gone  and  it  was  with  th((  greatest  difficulty 
that  he  could  be  jiersuaded  to  take  any  nourishment  whatever.  lie  commenced  to  vomit  green  matter;  his  eyes 
were  injected,  pulse  feelde  and  skin  coid.  His  stools  were  at  times  liquid,  at  times  natural  and  not  of  unusual  fre- 
quency. On  September  4  the  ii'ritability  of  the  stomach  had  to  a  great  degree  subsided;  but  a  violent  diarrhrea 
set  in  attended  with  severe  pain  and  uncontrolled  by  opiates  and  astringents.  (_)n  the  8th  he  died  in  a  state  of  utter 
exhaustion,  yet  retaining  his  senses  almost  to  the  last.  I'ont-mortem  examination:  Extreme  emaciation.  Both 
lungs  with  old  pleuritic  adhesions,  but  the  organs  themselves  healthy.  Heart  flabby;  right  ventricle  contained  a 
small  clot.  Spleen  lake-red  in  section.  Liver  somewhat  enlarged  and  fatty.  Stomach  and  intestines  dist<'nded 
with  air.  Inflammation  in  patches  in  the  ileum;  its  glands  healthy.  Inflammation  of  Ciecum  and  sigmoid  flexure, 
a  less  degree  in  rectum  and  a  feel)le  degree  in  ascending  and  descending  colon;  there  were  also  a  number  of  small 
ulcers  about  the  size  of  a  pea  in  the  sigmoid  flexure  and  rectum.  Solitary  glands  with  black  deposit  but  otherwise 
healthy.     Kidneys  normal. 

In  looking  over  the  history  of  this  case  the  question  suggests  itself,  was  not  this  rather  a  relapse  of  the  orig- 
inal malady?  The  absence  of  fever,  of  cerebral  disturbance  and  the  post-mortem  evidence  seem  to  disprove  such  an 
idea.  The  man's  death  was,  I  think,  produced  by  progressive  exhaustion,  and  hastened  by  an  attack  of  colitis 
wliich  his  enfeebled  frame  was  unalde  to  withstand.  In  one  other  case  the  same  result  took  place,  except  that  there 
was  little  or  no  preceding  diarrho'a  Another  case  recovered,  the  irritability  of  the  stomach  yielding  to  mercurial 
purges  and  repeated  <loses  of  dilute  sulphuric  acid. 

Chnngnt  in  the  hlood. — In  a  large  number  of  cases  the  blood  is  jirofoundly  altered.  The  clinical  evidence  of 
this  is  found  in  the  pale  look  of  the  t(mgne,  the  jiallid  face,  the  blood  iiuirniurs  and  the  spots  that  appear  on  the 
skin.  These  spots  are  like  those  of  purpura;  they  do  not  disappear  on  pres.sure.  Sometimes  they  are  isolated,  at 
others  confluent,  giving  a  purple  or  dark-liluish  look  to  large  patches  of  skin.  In  the  following  case  this  appearance 
was  very  marked : 

Thomas  Kose,  49th  Pa.;  age  20;  was  attacked  with  diarrh(ea  while  on  duty  on  the  Chickahominy.  This, 
after  the  lapse  of  a  month,  was  followed  by  fever  attended  with  great  prostration  and  mental  wandering.  In  this 
condition  lie  came  under  my  care  on  August  7.  He  was  stimulated  and  carefully  nourished,  and  by  the  14th  the 
fever  had  subsided,  the  diarrhcea  remaining.    This  was  treated  with  pills  consisting  of  the  sulphates  of  morphia 


Tin-:  lONriNTKii   i'k\'ki;s.  ■~'-| 

and  iron,  for  whicli,  on  11i(>  27tli.  Iiumic  Mcid  was  siilpsi  it  iitcd  witli  tin-  liai>iii<'st  cftV'cts.  From  Scpti-iiilior  1  loose- 
ness of  tlic  liowels  eeased  to  lie  :i  liriuiiiiiint  syinptciMi.  Almiit  tlii>  lime  diirk-Miiisli  spots  were  imlieeil  oil  Ills 
cliest.  iiiichaiiiied  liy  |ilessine  ii.;d  cif  \ai.viii<;-  size.  Sipuu  at'terwaiils  tlieV  made  t  licir  a|i)iearaiiei' on  t  lie  alidemeii 
an<l  tlien  (111  11,,.  i.xticmities.  (in  ilir  trunk  |d,iecs  id'  a  lout  in  diaiiirti-r  I'lmld  lie  found  onwliiidi  no  healtliyskjn 
could  lie  siTii,  not  Ii  inn  Iml  dark  s|iois  on  a  \  ai  ioii>ly  tin  tod  |iui  jdo  leirk  ;;ioiind.  I'he  j;iiiiis  wnc  linn  and  Inall  li,\  - 
lookini;,  the  toiiirne  <deaii.  tlie  abdomen  Hat,  eerlainly  not  clistended,  tln'  skill  cool,  pnlso  Irelde  and  102  |ier  miimle. 
There  was  very  };reat  emaeiatioii  ami  diddlity  and  oeeasioiially  sore  tliroiit:  the  \oiee  was  liiisky  and  rarely  niised 
above  a  \vhis]ier.  The  bowels  were  on  I  lir  whole  remilai .  one  or  two  w  aleiy  )iassaij;es  oeeun  inj;  d.iily.  'I'he  ]iatient 
remained  muedi  in  this  <'omlition  until  liis  df.iili,  m-itlirr  the  mimial  aeids.  the  sails  of  iron  nor  a  liln'ial  ami  varied 
diet  eheekiii};  (lie  spread  of  t  lie  pnipiiion^  spots.  rnKtiiuni,  m  examinat  ion  :  iiodx  ronsidi'iably  rmaeiah'd  and  e\  ery- 
where,  ee(diyiiiosed.  Lnnijs  noniial.  Heart  liealthy;  a  w  bite  i  lot  in  the  iii;ht  vent  liidi'  extending  into  t  lie  pnlmoiiary 
artery,  amdher  in  fhe  left  atiriele  and  a  third  In  the  eonimenrriin-nt  of  the  am  t.-i.  Spleen.  li\cr.  kidneys,  siipia- 
reiial  bodies  and  jianereas  natural.  Stomaih  with  inthimmal  ion  of  the  mneons  mi'iiilnaiie  more  or  less  dlll'nsril, 
mingled  w  ith  small  patelies  of  <;reater  intensity.  Iiillaminat  ion  in  iiatilies  of  the  mmoiis  membrane  of  the  ih'iim, 
increasing;  in  intensity  towards  the  termination:  siditary  irhands  enlarged,  iiillamed  and  conlaiiiint;  black  matter; 
ajfniinaled  jjlands  w  itb  ldaid<  dejiosit  Imt  olheiw  ise  apiiareiitly  healthy.  Colon  distended  w  ilh  air,  exi'epl  deseeiid- 
iiig  iiortion,  whi<di  was  narrowly  eontra<-ted  and  not  iiillamed:  (Miniii,  aseemliiiii  and  transverse  colon  inllaiiied: 
solitary  f^latids  consiiiciioiis  and  eontaiiiiiif;  blatdi  matter. 

(-'nlortniiiitcdy  no  (dieniieal  examination  was  made  of  the  blood  in  this  ease— one  of  a  series,  inelmllnn  many 
lii^liter  ones,  whi(di  liave  been  eonfonmled  witli  ty|ihiis  fe\cr.  lint  the  dilfeleiiec  is  palpable  in  spito  of  tlie  Himi- 
lavity  of  tlie  crii]itioii  to  that  of  some  of  the  stajjes  of  ly]diiis, — there  is  an  utter  abseiiie  of  the  liiffli  fover,  tin'  cere- 
bral Kym)>toms,  the  jihysio^noniy  and  the  early  ciitaneous  rash  whiidi  mark  tliat  disease. 

Cardiiic  (/I'smv/i  r.v. — The  warils  of  all  the  hospitals  are  crowded  with  men  coiiiplainiiif;  of  a  disc.isc  of  lluvlieart. 
What  the  initiire  of  it  commonly  is  let  the  followiiif^  cases  answi'r: 

J.  IS.  Waters,  corporal,  Co.  ,\.  I'd  X.  Y.:  au:e  21;  was  admitled  .\iif;nsl  111  fiom  Harrison's  l.andiiii;,  where  lie 
had  been  si(d<  with  fever  since  .luly  II.  The  disease  was  |)recede<l  by  dysenleiy.  'I'he  febrile  syniptoins  siihsided 
within  a  weid<  after  his  admission,  but  the  man  icmained  prostiate  and  was  iiii.ible  to  sit  np  until  the  last  week  in 
Aiifiust.  Diirini;-  Ibis  slow  convalescence  he  siilfered  muidi  from  tlatnlence  and  w;is  lionblcd  with  jialpitation  and  a 
feeliiij;  of  uneasiness  in  the  cardiac  rcf^ion.  An  examination  of  the  heart  showed  increased  action  without  ini-ri'ased 
])eicussioii  diiliiess.  The  second  soniid  was  very  distinct  :  the  lirst  was  reidaced  by  a  soft  systolic  iniirmiir  marked  tit 
the  base  lint  also  extcndini;  towards  the  apex.  This  state  of  thinf^s  eontiimed  until  December,  the  blowing  sonml 
becomiiii;  giiidiially  fainter  and  only  b<>ing  distinctly  heard  after  exercise.  The  patient  is  now,  the  iL'th,  in  good 
general  lieallli,  and  does  not  siiU'er  unless  he,  walks  much,  when  his  breiithing  becomes  op]n-essed :  the  ics)dralionK 
ai<^  si  ill  i|niek,  thirty  a  niiniiic,  and  he  can  not  slee|p  on  his  left  side;  an  examination  of  the  heart  shows  the  tians- 
vetse  percnssion  d illness  to  be  three  and  tliree-i| natter  iiicli(!s,  the  longitudinal  three  and  a  half  iiiclirs  :   the  iinpulsi- 

remains  forcible  and  is  felt  in  two  intercostal  sjiaoes;  the  s< nd  sound  is  very  distinct,  but  the  tiist  dull;  a  slight 

linni  is  yet  heard  in  the  cervical  veins.  The  treatment  comprised  the  administration  of  iininiiie,  iron  and  stiyclinia, 
rejilaced  by  verattnm  viride  when  the  heart's  action  was  violent;  the  cardiac  uneasiness  was  mmdi  ridieve<l  by  a 
bidladonna  iilaster  worn  over  the  heart.  This  ease  is  tyjiical.  The  a))pearance  of  the  heart  trouble  after  the  fever, 
its  long  coiitiiiiiance,  the  systidic  blowing  sound  and  Its  gradual  disapiiearanci',  the  irritable  stale  id'  tlii'  organ 
remaining  long  after  the  general  health  was  in  every  other  resjieet  fully  rei'stablislied,  all  f6rm  a  clinical  combina- 
tion of  very  great  interest  and  fre(|nency.  Many  smh  jiatients  are  thought  to  have  liyi>ertrophy  and  valvular  dis- 
ejise,  hut  although  here  and  there  a  case  of  doubtful  (liagnosis  may  occur,  it  is  generally  not  ditlicnlt  to  distinguisli 
between  these  cardiac  maladies.  The  previous  history,  the  abscuco  of  increased  percussion  duliiess,  the  tenipfuary 
duration  of  the  blowing  sound  are  just  the  opposite  from  the  visibly  augmented  size  of  the  ln%irt  and  the  perma- 
nent mnrniur  of  valvular  dksease.  Then,  too,  the  character  and  site  of  the  mnrinur  are  iieculiar:  It  is  never  rough, 
always  attends  the  inipnlse  and  is  very  oftt^n  associated  with  a  hum  in  the  Jugular  veins.  It  is  iilainest  at  or  near 
niidsternnm  and  is  thence  transmitted  in  the  course  of  the  aorta  or  ])iilmonary  artery;  it  is  rarely  distinct  over  the 
apex  of  the  heart.  It  is  freciuent,  but  it  would  be  a  mistake  to  suiijiose  it  invariably  present  in  the  class  of  cases 
just  described.  V(!ry  often  the  first  sound  of  the  heart  is  dull,  short,  ill  dclined  and  nnatti'iided  with  a  uiurmur;  the 
second  sound  I  have  invariably  ol)»erved  to  be  clear  and  sharp.  In  some  patients  the  impulsii  is  very  irregular 
and  the  cardiac  rhythm  niueh  changed. 

John  Bricker,  8th  Pa.  Cav.;  ago  24;  was  taken  sick  at  Fair  Oaks  Station,  June  7,  with  severe  diarrliiea  accom- 
panied with  excessive  griping  pains  and  followed  by  tlio  discharge  of  consider.able  Id 1.     About  the  21st  lie  was 

seized  with  fever  coinnienciug  with  rigors,  pain  on  the  left  side  of  the  chest  and  in  the  loins,  lie  noticed  that  any 
attempt  to  stand  brought  on  dimness  of  sight  and  dizziness,  and  also  that  his  tongue  was  very  dark,  loaded  and  dry. 
About  the  2"Jth,  while  the  fever  still  existed,  he  was  moved  to  Harrison's  Landing,  then  to  Fortress  Monroe  and 
thence  to  this  hosjiital,  where  he  arrived  July  7.  On  his  arrival  he  had  little  or  no  fever,  but  the  diarrlnea  was  still 
bad,  from  live  to  six  passages  daily,  not,  however,  containing  blood.  He  stated  that  he  had  expectorated  blood 
once  or  twice  shortly  before  he  was  sent  here,  and  that  before  the  attack  of  fever  he  had  been  in  good  health. 
Shortly  after  his  admi.ssion  he  had  a  slight  hemorrhage  and  complained  much  of  ]>aiu  in  his  left  breast,  which  ho 
described  as  constant,  of  a  sharp  cutting  character,  not  increased  in  intensity  by  any  circumstance  he  noted,  and 
reaching  at  times  from  the  lower  ribs  up  to  the  third  or  fourth.  As  soon  as  he  commenced  to  walk  about  he 
observed  palpitation  of  the  heart:  the  action  of  the  organ  was  very  irregular  and  attended  with  a  blowing  sound. 
He  improved  much  under  treatment,  and  now  has  a  very  goo<l  appetite  and  enjoys  his  food.  The  diarrhu-a  has 
Med.  Hist.,  Pt.  111—11 


322  fiVMPTOMATOI.oilV    OK 

<lisa))))i'are(l  ;iii(l  Iii>  lias  nearly  rogainod  liis  sti'i'iii;tli :  Init  any  excitrinont  or  labor  aj^itatos  liiiii  and  brings  on 
violent  beating  iiftlie  heart.  I'cveusNioii  gives  liiiii  pain;  it  shows,  if  iiert'oniietl  with  care,  the  transverse  (lianiet<'r 
to  be  slightly  increased.  The  apex  strikes  at  its  normal  position,  but  the  impulse  coininnnicated  to  the  linger  is 
every  now  and  then  of  a  throbbing  eharaeter,  extended  and  intiMinittiiig.  On  .auscultation  the  lust  souiid  is  dull 
and  a  innrniiir  of  low  ])itch  is  ])(U(i'ived  with  the  systole  following  the  niarki'il  intermission:  a  blowing  sound  is  at 
the  sanio  time  heard  in  the  carotiil:  there  is  also  a  continuous  hum  in  the  cervical  veins.  The  pulse  is  aliont  !Ml, 
intermitting  every  third  to  seventh  beat.  It  is  very  likely  that  here  the  walls  of  the  heart  have  undergone  8onu> 
change,  tu\i\  that  the  lack  of  tone  nuiy  lea<l.  if  it  has  not  already  led,  to  a  dilatation  of  the  ventricles.  J'hat  org.anic 
changes  nuiy  indeed  be  ]iroduced  by  the  unvaried  abinirmal  action  I  have  no  doubt.  I  have  seen  such  cases.  One 
was  for  months  under  uiy  ob.scrvation  in  the  hospital,  the  signs  of  dilated  hypertrophy  develojiing  themselves 
more  and  more  clearly.  Jf  it,  then,  be  possible  for  organic  disease  to  follow  long-continue<l  functional  distnibance, 
the  very  grave  question  aris(^s  whether  men  convalescing  from  fever,  with  the  state  of  the  heart  desciibed,  are 
fit  for  further  service.  I  think  not:  certainl.v  not  when  this  condition  of  the  organ  outlasts  a  marked  ini)>rovement 
in  the  general  health.  Amendment  is  slow,  and  for  perfect  recovery  to  take  ])lace  long  rest  of  body  is  es.seutial. 
Active  exercise  would  be  the  misaiis  most  likely  to  lead  to  organic  disease^.  The  medical  treatment  whiidi  I  have 
found  best  suited  to  the  class  of  cases  under  discussion  consists  in  the  administration  of  iron  and  nux  vomica:  to 
this  belladonna,  both  externally  and  internally,  may  be  added  with  advantage,  especially  if  there  be  much  pain 
in  the  cardiac  region.  When  the  heart's  action  is  very  violent  I  havi^  lowert^d  it  by  veratrum  viride,  tem])oraril}' 
suspending  the  tonic  medication,  or  sometimes  employing  both  agents  conjointly. 

J'hligmaHia  alha  doleiiD. — Two  ca.ses  of  this  strange  morbid  condition  have  come  under  my  notice.  Both  occurred 
during  convalescence  from  the  fever,  and  in  both  recovery  took  ])lacc.  In  the  first  thc^  tense  smooth  swelling  occu- 
pied the  whole  thigh  of  the  left  side,  especially  the  upper  and  inner  part.  It  was  particularly  hard  in  the  course  of 
the  saphcua  vein,  which  seemed  enlarged.  A  blister  was  appli(Ml  over  the  course  of  the  vein  and  the  swollen  thigh 
]«'\>t  constantly  swathed  in  lead-water  and  laudanum.  The  tumefaction  subsided  very  gradually  and  did  not 
disa))iiear  entirely  for  several  months.  In  the  second  case  there  was  much  pain  ahuig  the  (Miurse  of  the  femoral  vein 
and  in  the  calf  of  the  right  leg,  which  was  much  increased  in  size  for  four  or  five  days,  sensitive  to  the  touch, 
o'dcmatous  and  partially  paralyzed.  After  that  it  slowly  resumed  its  natural  appearance,  but  the  man  does  not  even 
now  walk  without  lameness. 

I)itliimm<ititm  of  the  purolUJ  ijliind  tending  to  suppuration  is  occasionally  encountered  in  this  fever.  Of  four  cases 
that  came  undi'r  my  notice  three  recovered,  one  proved  fatal.  In  one  of  those  having  a  favoralile  termination  both 
glands  became  seriously  affected.  Here  the  disorder  appi'ared  before  the  febrile  signs  had  left.  In  the  following  case 
the  inllainmation  set  in  after  the  commenccnient  of  convalescence: 

.Iac(di  Kisley,  Co.  F,  tith  Pa.  Cav.,  was  seized  with  fevev  and  diarrhfea  about  .Inly  11  at  Harrison's  Landing. 
When  admitted  into  this  hos])ital  on  August  7  he  was  very  prostrate  and  sutfered  much  from  diarrhu-a,  but  had 
little  or  no  fever.  He  soon  commenced  to  improve  and  after  a  few  days  was  able  to  sit  up.  On  the  16th  a  tumor 
was  observed  at  tlie  angle  of  the  jaw  attended  with  much  pain.  It  soon  increased  and  appeared  to  involve  the 
whole  right  side  of  the  face.  It  was  moderately  tender  on  pressure,  not  accomjianied  by  much  external  redness  and 
unassociated  with  any  signs  of  inflammation  of  the  tonsils  or  throat.  An  eH'ort  was  made  to  produce  residiifion  by 
painting  with  iodine,  but  it  did  not  succeed.  An  indistinct  fluctuation  soon  showed  that  snp]iurafiou  had  taken 
place.  The  abscess  pointed  at  the  angle  of  the  jaw  and  was  o|iened,  discharging  a  teacu]>ful  of  offensive  matter. 
The  discharge  c(mtinued  six  weeks;  the  cut  then  healed,  but  to  this  day  the  patient  frequently  complains  of  pain  in 
the  region  of  the  duct,  which  can  be  felt,  hard  and  round,  just  below  the  nuilar  bones.  Otherwise  he  is  now  in  ])er- 
fect  health.     The  diarrho-a  yielded,  before  the  discharge  ceaseil,  to  the  use  of  sulphates  of  copper,  iron  and  mor])hia. 

Diarrhiia. — This  is  one  of  tlie  most  fretiuent  and  at  the  same  time  one  of  the  gravest  sequels  of  the  fever. 
Indeed,  hardly  a  ca,se  of  Chickahominy  fever  recovers  without  great  irritability  of  the  bowels  remaining  for  months 
afterwards,  and  under  unfavorable  circumstances  this  irritability  la|)ses  into  uncontridlable  diarrluea.  The  relation 
the  diarrluea  bears  to  the  fever  is  very  close.  It  generally  ])reccdcs  it,  sometimes  by  weeks,  is  a  i)rominent  sym|)tom 
throughout  its  course  and  outlasts  it.  It  rarely  if  ever  occurs  where  it  has  not  been  present  during  the  fever.  In 
describing  its  characteristic  traits  1  shall  dniw  rather  from  a  group  of  cases  that  I  have  noted  than  give  the  history 
of  any  one  in  particular:  The  man  who  is  the  subject  of  thl^  disease  convalesces  from  the  fever  very  slowly.  He 
takes  but  little  nourishment,  since  if  he  eats  much  freciuent  stools  are  the  result:  yet  he  has  scarcely  any  gastric 
disturbance,  does  not  vomit,  does  not  loathe  food;  his  tongue  is  moist  and  clean.  The  abdomen  is  distendeil  with 
gas,  the  seat  of  a  dull  jiaiu  but  not  painful  on  pressure.  If  asked  what  troubles  him  most,  he  generally  refers  to  the 
flatulency,  ])oints  to  the  inability  to  button  his  clothes,  and  may  often  be  heard  to  declare  that  he  is  less  annoyed 
when  he  has  many  passages  than  when  they  are  checked,  since  in  their  absence  he  becomes  bloated.  His  features  are 
pale;  his  eyes  clear;  he  docs  not  bear  fatigue  well,  though  on  the  whole  it  is  often  a  iiuitter  of  wonder  that  the 
countenance  is  so  healthy-looking  and  his  strength  not  more  impaired  than  it  is.  He  may  remain  in  this  condition 
for  weeks,  either  slow  ly  gaining  or  on  the  other  hand  slowly  losing  ground.  In  the  former  case  he  is  liable  to  the 
diarrluea,  which  has  been  checked,  breaking  out  from  time  to  time;  in  the  latter  he  becomes  much  emaciated,  iind 
dies  utterl.v  worn  out  after  months  of  siitfering.  Among  the  symjitoms  mentioned  the  state  of  the  tongue  and  gums, 
the  stools  and  the  abdonunal  pains  reijuire  a  more  extended  notice.  The  tongue  is  smooth  and  moist,  somi»tiiues  very 
pale,  but  almost  always  clean;  only  in  a  few  ca.ses  is  it  observed  to  be  coated.  The  <inmn  are  generally  hard:  now 
and  then,  probably  from  antecedent  scurvy,  they  are  spongy  and  red,  but  this  condition  is  not  nearly  so  fre(|uent  as 
the  former,  nor  can  I  say  that  I  have  found  where  it  existed  any  difference  in  the  othei'  symptoms, — the  diarrluea  did 
not  seem  to  me  either  to  yield  more  readily  or  to  be  more  intractable.     The  slmtU  are  ahvays  thin  and  remain  so  long 


THK    roNTlNrKIi    FKVKRS.  ;)23 

after  they  are  ri'dnoed  in  frciiMPiicy.  Iii  color  tlicy  arc  mostly  yt-Uowisli,  soniotimes  jcroeiiisli,  rarely  dark  or  very 
otn-uslve.  In  not  more  than  one  case  in  liCiy  d(]  tlii'V  contain  hlood.  They  are  f'reiiiient,  varying  from  five  to  twi'nty 
or  npwards  in  the  twenty-four  hours.  The  passafji^s  are  not  att<'n(hMl  with  much  jiain  or  toiiesmiis,  still  tliere  are 
niimeroiis  exceptions  to  this  rule,  and  tljeii  hemorrhoids  seem  to  result  from  the  constant  heariiif;  down.  .Ilnloiiiiiiiil 
}i(ihi  is  often  com[>laincd  id'  liy  the  patient.  It  is.  )icrhaps.  a  sense  of  sorenes.s  and  uneasiness  nu)re  than  i>f  |iain, 
increased  froia  time  to  (inic  hy  exacerhal  ions  of  colic.  It  is  not  as  a  rule  auj;inenti'd  hy  pri'ssnre.  and  this  ahsence 
of  tenderness  is  veiy  remiirUahle.  Wlini  aTi\  lender  siiots  .■xisi  tln-y  are  t;cnerall.\  disco\cred  in  the  course  id'  the 
Iarf;e  intestine.  Sonic  few  spi'ah  id'  a  wi'i^lily  frcliui;  in  the  iei;ion  id'  the  spleen,  which  or^'an.  on  iiercnssion.  is 
found  to  he  increased  :  yet  enlarj;enieiit  of  the  vpirrn.  con  nary  to  e\  |icelat  ion.  is  not  a  frci|ucnt  seiiuel  ot'  the  fever. 
In  some  cases  the  urinary  organs  are  diMani;ed  ;  I'lieie  is  a  consiani  disposii  ion  to  pass  water,  which  lieeonu's  a  soiirce 
of  ^reat  annoyaiH-e  to  the  (lal  lent .  I' he  uiiiie  \  oided  is  copious  and  pale,  of  low  siiecilie  i;ravity  and  contains  neillier 
«af;ar  nor  alhumen.  The  di:i;inosis  of  the  diarrliiea  is  \er,\  easy.  I'liere  is  only  one  comidaint  with  which  it  may  lie 
ronfoumled — dropsy:  hnt  careful  peieussion  soon  shows  that  the  distention  is  owin;;  to  wind  and  not  to  lii|nid. 
Drops.v  is,  indeed,  very  rr.iely  nut  with  after  Chickahominy  fever;  I  have  encountered  hnt  one  instance  of  tlie  kiinl, 
ami  there  it  was  associated  with  allmuieii  in  t  he  ni-inc.  The  jittsl-iiiiii-!nii  .-iiiiiearanecs  are,  as  far  as  I  have  lieen  aide 
to  pursue  the  matter,  the  same  as  in  the  Chiekahoniiny  diarrhcea  without  preccdinii  fever.  There  is  an  ahscnee,  for 
the  most  part,  of  nlceratioli  or  Ihickeninj;  of  the  mucous  mendiTane,  acconnlin';  thus  for  the  want  of  lendeincss. 
Tliei'c  are  jiatches  of  inllaniiual  ion  near  the  ilco-ca'cal  \  ah  e,  in  the  colon  and  smnel  inies  t  lii'onfihont  the  ileum.  The 
aj;minated  fjlands  are  pronunent  and  contain  Idaidiisli  pij;ment ,  ami  so  do  t  h(^  solitary  j;lands.  The  exeitiiif;  cause  of 
these  eurioiis  inoilud  cliani;es  is  veiled  in  ohscnrity.  This  much,  however,  apjiears.  There  muHt  ho  in  thi^  poison 
givinj;  rise  to  the  fever  soniethini;  cajiahle  at  the  same  t  imeof  pioduciiif;  the  dianlnea, — in  other  words,  the  same  cailNe 
may  occasion  hoth.  The  treatment  of  the  diarrhiea  consei|Uent  upon  the  fi'ver  is  the  same  as  Hull  of  the  diarrliiea 
without  antecedent  fever.  Hot  li  are  alike  olistinate  anil  dillienll  to  iiilliieiiee.  Iiihotliall  iiicdieines  often  fail.  TIi(> 
best  results  have  in  ni\  hands  heeii  derived  from  carefully  rei;iilatin};  the  diet  and  adiuinislerin;{  lar^je  doHOs  of  tan- 
nic acid  conjoined  with  o|iiuin.  live  .11; rains  of  the  former  with  from  oned'ouitli  to  one-third  of  the  latter,  in  jiill,  four 
times  daily.  The  medicine,  can  he  home  for  weeks  at  a  time  without  nauseating;.  The  suhiiitiate  of  hisiiinth,  the 
sulphate  of  coiipei  and  the  nitrate  of  silver  stand  next  in  ellicaey,  and  sometimes  succeed  where  tannic  acid  fails. 
The  ])ernitrate  of  iron.  i;iven  in  from  llfteen  to  thirty-iiro])  doses  lliree  times  a  day,  is  occasionally  of  service:  hut  on 
the  whole  it  has  disappointed  me.  Opium  alone,  does  not  answer,  allhouijh  u.sefiil  when  .joined  to  other  afii'iits.- 
()))ium  su])positories  or  eneniata  K'^'^'  t'"'  patient  rest  at  niijht  and  are  thus  of  henelit.  The  tinctures  or  iufiisions 
of  catechu  and  kino  only  act  advanta.i;eim.sly  in  lif;ht  ca.ses.  l'"rom  acetate  of  lead,  tincture  of  the  chloride  of  iron, 
tiiriientine,  I  he  niiner.al  acids.  Hope's  mixture,  i|uinia,  strychnia,  saline  purgatives  and  Kovei's  powder  1  have  seen 
little  or  no  jiood  cH'eid.  although  I  have  ffiveii  each  of  tluMii  a  fair  trial,  (iariniuatives  exert  only  a  tcmiioiary 
inllueiice  on  I  he  Ihil  uleiicy.  In  one  case  hoth  this  troufdesome  symiitom  and  the  diarrliiea  yielded  to  charcoal.  I  >iar- 
ihiea  is  the  last  of  the  issues  of  Chickahominv  fever  I  shall  notice.  A  few  of  the  less  ]uoinineiit,  such  as  jiain  in  the 
limhs.  the  occasional  ocenrrence  of  t.vnipanites  without  diarrhiea,  I  shall  merely  indicate  without  specially  descrihiu};. 
Ill  taking  a  survey  of  the  syni))toins  thus  struiij;  toi^ether  the  similarity  to  those  enconntcred  during  ]>ri)tractcd  con- 
valescence from  ty|)hoid  fever  hecoines  at  once  apparent,  hnt  the  dissimilarit.v  is  also  manifest.  Where,  for  instance. 
are  the  iinliuonaiy  tronldes  so  eoniinon  in  the  latter  eoniiilaiiit  f  An.v  further  disenssion  is.  however,  here  out  of  |ihice. 
To  ascertain  whether  Chick  ihominy  fever  he  modified  typhoid  fever  or  a  distinct  disease  would  rei|uire  further 
data  and  other  trains  of  reasoniiif;  than  are  here  adinissihle.  Let,  then,  this  report  ho  accepted  as  an  uiihiased 
clinical  eontiihntion  to  the  histor.vof  one  of  the  moat  interesting  hnt  unfortunatelv  most  destructive  forms  of  fever 
that  this  generation  of  physicians  has  heen  called  upon  to  study. 

v.— TYPHUS  FEVER. 

There  Kcerns  no  doul)t  that  occasional  cases  of  typhus  fever  were  treated  in  tlie  general 
liospitals  dui'ing  tlie  war,  but  it  is  probable  that  in  mo.'^t  of  these  the  disease  was  due  to  civic 
and  not  to  military  contagion.  We  have  the  high  authority  of  Dr.  Austin  Flint  for  two 
of  the  cases,  7  and  8/''  that  have  been  submitted,  in  one  of  which  it  is  explicitly  stated 
that  the  fever  was  contracted  while  the  soldier  was  at  his  home  in  Xew  York  Citv.  Cases 
5  and  6,  treated  at  the  same  time  in  the  Cuyler  hospital,  Philadelphia.  Pa.,  the  subject  in 
one  instance  being  a  contract  nurse,  and  in  the  other  a  patient  who  had  been  in  hospital  for 
nearly  three  months  with  a  rheumatic  affection,  a}>pear  also  to  have  been  true  typhus;  ami 
in  this  connection  389  of  the  post-mortem  series  may  be  referred  to,  as  presented  by  the 
records  of  tlie  same  hospital,  showing  restless  delirium  alternating  with  comatose  quiet,  sup- 
pression of  urine,  petechioe  and  death  on  the  fourth  dav  with  no  abnormal  condition  of  the 
intestines.  Case  1,  which  occurred  in  a  patient  recovering  from  gunshot  injurv  in  the  hos- 
pital at  Annapolis,  Md.,  was  probably  tyi)hus,  as  the  clinical  record  is  supported  by  the 

■  *,S/ij.i-.i,  p.  'JC.'J. 


824  SYMI'TOMATdl.OdY     CiK 

possibilitv  of  eontact  Avitli  ti'Ui>  Ix-pliiis  tlicii  i-ccoiiiiizcil  as  |ir('scii(.  in  om^  ol  the  Avanls. 
( 'aso  9.  ill  llic  Li'\iii!i-tnii  avt'Huc  liospital,  aW'W  Y(>rl<  ('ity,  may  also  liave  liccii  lyplius,  Imt 
ill  ]t>,  iVoiii  tin-  i-(>ci)nls  (if  tlif  saiiif  liospital,  the  cviiL'iu'O  is  iiisiiflicifut,  id  slmw  that,  the 
soldier  contracted  this  fever  at  SamK'  Hook,  ^M..  or  in  cainji  ]n'ii>r  to  the  date  of  liis  ship- 
ment from  that  point. 

Tn  fact  tlio  records  do  not  fiirnisji  a  single  instance  of  undoubted  tvphus  as  liaving 
occurred  among  our  troojis  in  tlio  tield.  In  cases  12  and  lo  there  is  nothing  to  substan- 
tiate the  diagnosis.  In  11  the  disajipearance  of  the  ei'upti(jn  under  pressure,  the  diarrhcea, 
tympanites,  c])istaxis  and  bronchitis  suggest  typhoid  I'ather  than  typhus  fever.  In  o  and  4, 
both  received  about  the  same  time  from  the  119th  111.  regiment  at  Quincy,  111.,  tlie  pre- 
sumption is  in  favor  of  tv])hoid;  in  the  former  a  recrudescence  is  recoi'ded,  with  dt'atli  from 
the  gravity  of  the  intestinal  lesions,  hastened  by  exhaustion  from  copious  hemorrhages; 
in  the  latter  a  historv  of  tvplioid  with  violent  cerebral  symptoms,  diarrhcea  at  first  but  not 
in  the  later  stages,  pcrsjiirations,  red  spots  on  the  body  and  face  on  the  sixteenth  day,  and 
death  on  the  twenty-second.  In  2,  which  may  have  been  tvjihus,  the  jiatieiit  was  a  hospital 
inmate  convalescing  from  measles;  his  face  was  suft'used  and  spotted,  and  deatli  occurred  on 
the  thirteenth  day,  but  the  other  symptoms  were  such  as  were  frequently  found  in  doubtful 
typhoid  cases. 

Moreover,  the  experience  of  other  armies  shows  definitely  that  if  the  contagion  of 
typhus  had  gained  access  to  our  camps,  no  search  of  the  records  of  individual  i-ases  wmild 
have  been  required  to  substantiate  the  fact.  The  death-roll  of  our  medical  officers  and 
hospital  nurses  would  have  been  a  sufficient  demonstration.* 

Undoubtedly  there  occurred  in  our  camps  a  number  of  febrile  cases  presenting  dusk- 
iness of  skin,  intense  cerebral  symptoms,  dark-colored  spots  and  petechia;  on  the  chest,  abdo- 
men and  even  on  the  face,  unaccompanied  with  well  defined  symptoms  of  an  enteric  lesion. 
It  is  not  surprising  that  such  cases  were  regai'ded  as  typhus  by  some  of  our  medical  officers, 
for  in  an  epidemic  of  typhus  fever  they  would  certainly  have  been  ascribed  to  the  e|»idemic 
cause,  and  even  occurring  as  they  did  in  isolated  cases,  their  generally  rapid  and  fatal  course 
was  sufficiently  striking;  to  warrant  those  who  saw  them  for  tlie  first  time  in  fearino-  that 
they  had  before  them  something  dangerously  different  from  the  familiar  typhoid.  But  as  a 
larger  experience  demonstrated  the  comparative  non-contagiousness  of  these  cases,  and  post- 
mortem examination  showed  in  them  the  characteristic  lesions  of  tj'phoid,  they  became  less 

*St'e,  for  instance,  Fllix  Jacquot — Dii  Typhus  de  VAnii'e  (V f'ti-ifiit,  Paris,  1S5S,  p.  .5(5  ef  mj. — Tlie  two  typlius  epideniiis  in  the  Crimea  liefran  with 
the  first  hard  frosts  of  December,  1854,  and  December,  185.5.  <_)ri(:inatinj;  in  both  ,vears  in  the  Crimea,  the  disease  showed  itself  in  the  distant  hospitals 
one  month  after  its  outbreak  amunj;  the  troops  in  the  Hvhl.  These  hospitals  became  in  their  turn  active  foci  whence  the  fever  was  propagated  by  conta- 
gion, and  where  probably,  aceordinj;  to  >r.  .lActiCoT,  it  also  ori;?inateil  in  some  instances,  in  view  of  the  concourse  of  so  many  individuals  retlnced  by 
exhaustion  and  privation  and  alt'ei  ted  by  scurvy  and  other  diseases.  The  Knglish  troops  were  the  first  to  become  infecteil,  but  in  a  little  time  the 
French  army  commenced  likewise  to  suffer.  The  condition  of  the  latter,  thoufih  ndatively  liettcr  than  that  of  tin-  Kngjlish,  who  bi'came  engaj^cd  iu  a 
great  continental  war  without  being  preiHired  for  it,  was  nevertheless  far  from  satisfactory.  The  Russians,  according  to  Drs.  5I(K[ti\(}  and  Alfkkief, 
were  tainted  with  typhus  even  before  the  allied  armies  showed  any  sign  of  it.  The  Russian  and  Ttu-kish  troops  in  ,\sia  opially  fidi  a  prey  to  it.  In  a 
word,  typhus  was  develojH'd  wherever  were  found  aggregations  of  men  expose.l  to  fatigue  and  anxieties,  badly  ipuirtered,  poorly  clad,  and  wliose  nourish- 
ment was  not  of  such  a  nature  us  to  counteract  these  hygienic  drawbacks.  About  a  month  after  its  development  in  the  Crimea  it  broke  ont  in  all  the 
French  hospitals  in  Constantinople,  as  also  iu  the  English  hosjiital  at  Scutari.  *  *  *  In  December,  IH.Vt,  the  English,  who  in  the  meantime  had  com- 
pletely modified  their  system  and  reformed  their  adniinistrdtion,  who  were  better  located  and  qnartereil,  better  clothed  and  fed,  less  fatigued  and  exempt 
from  scurvy,  which  prevailed  fearfully  in  the  French  army,  escaped  visitation  from  typhus,  while  the  latter  sutfered  from  it  to  a  far  gn-ater  extent  than 
in  the  jirevious  year.  The  Italians  were  a  little  less  affecteil  than  the  French.  In  .January,  ls,"»(l,  typlius  was  imported  into  Constantinoide  ;  )nit  tlie  Eng- 
lish hospital  at  .>*cutari  escapeil,  as  did  their  troojis  in  the  ('rilinii.  All  the  Freuili  hospitals  were  invadeil,  those  sitilateil  on  the  plateau  extending  from 
Rjimis-Chifiick  to  Daoud-Pacha  and  the  Candilie  hosjiital  on  the  Bosphorus.  There  were,  including  extemporized  establishments,  twenty  ho.spitals  in 
and  around  Constantinople,  ami  not  one  of  them  escapeil.  The  disease  appeared  also  in  the  hospitals  at  Callipolis  and  Nagara  on  tin'  Dardauelles.  The 
crews  of  merchant  and  government  vi'ssels  engaged  in  the  transport  of  sick  and  wounded  were  decimated.  Typhus  was  introdiici'il  into  the  hospitals 
at  Marseilles,  Toulon,  Porqnerolles,  Frioul,  Avignon  and  into  the  Val-de-Grace  in  Paris;  and  isolated  cases  died  in  many  localities,  as  at  Chalon-sur- 
Saone,  Nenfchateau,  etc.  Fortunately,  in  Constantinople  as  well  as  in  France,  tlie  disease  did  not  spread  outside  of  the  hospitals  ;  but  in  hesiegeil  cities 
or  overcrowded  places  where  troops  were  quartered  in  Itarracks  aide  by  sido  with  the  population,  as  for  instance  in  tho  village  of  Tchistinakaia  near 
Simferopol,  the  livil  population  was  more  or  less  aifected.  In  Russia  it  passed  from  the  Crinrea  to  Odessa,  Nicolaieff  and  several  other  localities;  Varna, 
occupied  by  th.'  French,  was  likewise  atbcted,  and  finally  tlii'  Turkish  and  Russian  armies  in  Asia  Minor  paid  a  heavy  tribute  to  this  fever. 


THE    CO^"TINUKD    FEVER8.  325 

frequently  reported  as  typlms.  Tlie  clinical  feature:^  v(  idiopatliic  fe1)rilo  affections  are  not 
circumscribod  but  confluent.  It  lias  alroaJy  been  shown  in  this  volume  that  it  was  not  pos- 
sible in  all  cases  to  Jetennine  tVuin  the  symptoms  alone  that  a  fever  was  malarial  or  typhoid. 
80  ill  cotem|)oraneous  epidemics  of  ty]ihus  and  typhoid,  it  is  not  possible  in  all  cases  for  the 
clinician  to  distinguish  between  them.*  Even  in  typhoid  epidemics  the  practitioner  is  some- 
times at  first  uncertain  in  his  diagnosis. f  The  disease  in  its  onset  seizing  those  who  have 
the  strongest  predisposition,  may  run  a  quickly  fatal  course  in  individual  cases,  leaving  to 
future  cases  or  post-mortem  inquiries  the  determination  of  the  specific  form  of  fever.  The 
first  case  may  be  considered  typhus,  but  when  the  ty]>hoid  nature  of  the  ej)ideniic  has  been 
established,  other  such  cases  occurring  theri^aiter  receive  a  proper  recognition.  Again,  in 
malarious  districts  fulminant  febrile  cases  with  cerebral  sym{>toins  terminating  speedilv  in 
death  by  coma  and  attended  with  cutaneous  hemorrhagic  blotches  wore,  wdien  first  st'cn, 
regarded  doubtfully  as  typhus,  cerebro-spinal  meningitis  or  congestive  malarial  fevers,  until 
a  larger  experience  showed  their  etiological  relations  with  malaria  rather  than  witli  other 
specific  causes  of  disease.  Thus  are  explained  the  tyjihus  cases  reported  l)y  our  medical 
officers  in  the  field  during  the  war.  The  relatively  large  number  during  the  first  year,  2.8-4 
per  thousand  of  strength,  decreased  during  the  second  year  to  1.44,  and  continued  to  decrease 
to  .52,  .51  and  .30  respectively  during  the  third,  fourth  and  fifth  years  covered  by  our  statis- 
tics, as  these  fulminant  cases  were  found  to  lack  the  contagiousness  of  true  typhus  and  to  be 
associated,  from  the  etiological  point  of  view,  with  the  typhoid  and  typho-inalarial  cases 
which  were  prevailing  in  our  camps. J 

Thus,  Surgeon  Zknas  Fj.  Bliss,  U.  S.  Vols.,  noted  a  fatal  case  of  typhus  in  his  command 
while  at  Yorktown,  the  patient  dying  with  superficial  ecchyniotic  blotches  and  hemorrhages 
Irom  the  nose  and  bowels;  no  post-7)wrtc"ia  examination  was  held  in  this  instance,  but  at  the 
same  time  about  forty  cases  of  typhoid  fever  were  under  treatment,  and  in  such  oi  these  as 
jiroved  fatal  the  patches  of  Peyer  were  found  to  bo  ulcerated. §  l^rigade  Surgeon  J.  H. 
Wakrkn  and  Medical  Inspector  Peter  Pineo,  U.  S.  A.,  reported  early  in  the  war  the  pres- 
ence of  typhus  fever  in  the  camps  near  Washington,  D.  C.  About  the  same  time  Surgeon 
Barr,  36th  Ohio,  recorded  the  assumj)tion  of  a  typhus  character  by  fevers  prevailing  at 
Summerville,  West  Va.,  and  Surgeon  Irish,  77th  Pa.,  and  Act.  Ass't  Surg.  0.  K.  Reynolds, 
U.  S.  A.,  15th  U.  S.  Inf.,  reported  similar  cases  from  Camp  Wood,  Munifordsville,  Ky.  At 
a  later  date  fulminant  typhoid  among  undisciplined  recruits  at  New  Albany,  Ind.,  gave  rise 

*Tlius  a  certain  niim!)er  c)f  the  e;iseH  t'umiint;  the  (latsis  i)f  Flint's  t'lhiirttl  HrpwU  mi  C^mlimii'd  Fevem,  Butfalo,  1H;12,  were  relMtrted  att  ilmiht/vl ;  liirt 
cases  nunihered  1(14,  and  of  these  73  were  undou!)te<l  caises  of  typhoid  and  r».5  e(|uatly  iindouhted  cases  of  typhus,  hut  "iti  were  rases  in  wjiicli  tlie  diajincsis 
as  lietween  typhus  and  typhoid  was  not  positively  determined.  The  official  Metlimt  ami  Smyk-nl  lliMttry  of  Ihf  liriti^h  Armij  ivhuit  Kfrrfd  in  Tttrkftj  ami  the 
CYmen  <lnnn(i  Uip  irar  aijahutt  limma  in  the  years  1  S.^4-.'Vi-5(;,  London,  18o8,  does  not  attemjit  to  differentiate  liefween  the  malarial  and  typlioid  fevers  wliich 
prevaileil  anioiij;  the  troops  while  n|)erating  in  Itu]f;aria,  nor  between  the  typlioid  and  typlius  wiiicli  scnurf^ed  them  durinjr  ttie  winter  of  lsr>4-.'-i.^  in  tlie 

Crimea  ;  lint  Ilr.  Kobkut  I>.  Lyons,  in  his  Ilfpurt  „ii  tlie  I'athilo'jii  nf  the  Z>w-,i*..»  ../  the  .Irmi/  in  the  Ru>t,  Lonihm,  IMoH,  sliows  that  at  the  ti if  liis  \  isil  to 

the  hospitals  and  camps  both  typhus  and  typhoid  were  iiri-vailinn,  the  latter,  however,  heinj;  tli(!  prominent  disease.  IIi-  reai-hed  Scutari  towards  the 
close  of  .\pri!,  18,55,  when  all  hut  the  expirin-:  emher^  of  the  terrible  eiiidemic  of  the  previous  winter  had  disapiwarini.  .Xfrain,  Scuivk,  in  his  Itelatiim 
MMieo  Chintrijirale  ile  In  Campatpw  d' Orient,  I'aris,  U.57,  describes,  p.  418,  a  titphnu  a  fonne  tt/phn'tle. 

t  It  is  at  the  outbreak  of  an  epidemic  that  f  u-  severest  attacks  manifest  themselvc-s.  Tin-  first  two  cases  observed  at  Lyons  by  .M.  DrssotRT  differed 
entirely  from  the  stereotyped  typhoid  f(!ver.  Thoy  were  consequently  considt'red  typlius  cases,  espe«-ially  on  accmiut  of  the  rapidity  of  their  fatal  term- 
ination and  the  absence  of  intestinal  lesions.  There  existed,  no  doubt,  a  co-relatitm  iM-tween  these  two  facts,  the  atiscm-e  of  lesions  beiiiK  due  to  the  short- 
ness (tf  the  malady,  for  in  all  otlier  autopsies  made  durinp  the  same  epidemic,  MM.  SIahmv  anil  ,\i,[x  found  tlie  usual  chan(;:es  couseipu-nt  iiiwin  typhoid 
fever.    See  Lf:os  Colin,  />'  la  Fi^vre  Tiipho'tde  daia*  V Anni'e,  Paris,  IHVS,  p.  IS. 

t  James  Bryan,  Brij^ade  Surgeon,  Burnside's  Exisiiition,  New  Berne,  N.  C,  lUtslo  i  Med.  and  Snnj.  Jemr.,  Vol.  L\V.  \st','l,  p.  ii'.il,  says,  in  smne  obser- 
vations on  the  diseases  of  the  army  iu  the  Deiiartnient  of  North  Carolina,  that  typhus  fever  was  not  unfreiiuenlly  observed,  and  was  iu  some  cases  of 
great  malignity,  a  character  which  was  more  iiarticiilarly  noticed  in  young  llesliy  subjects.  In  one  such  case  the  imtient  was  brought  into  the  hospital 
in  an  insensible  condition,  with  the  cellular  tissue  of  the  neck  filled  witli  air  and  serum  and  the  legs  and  feet  purple.  But  we  have  already  wen  the  |ier- 
nicious  character  of  the  malarial  fevers  of  this  military  dejiartment.  On  the  other  hand  .1.  .1.  IjeV[ck,  iu  an  article  on  Miafmalir  Typhaid  Ferer,  Ameriean 
Jmir.  Med.  Sciences,  Vol.  XLVII,  1864,  p.  404,  when  referring  to  the  aggravated  character  of  the  cases  tliat  arrived  at  the  Pennsylvania  hospital  from  the 
.\rmy  of  the  Potomac  in  the  autnmn  of  18(;2,  says  that  in  no  cas*-  was  the  true  typhus  fever-rash  observed,  nor  a  single  instance  in  which  the  disease  was 
known  to  have  been  communicated  to  another,  notwithstanding  that  many  cases  were  much  like  typhus. 

g  Appendix  to  I'art  First  of  this  work,  p.  85. 


32G  SYMPTOM ATOLOt  i  Y     OK 

to  a  repoi't  of  typlius  c;  spotted  fever.  In  186:]  Ass't  Surii,;.  AVautj-ix  Wkistkk,  U.  B.  A., 
who  liiiil  s<H'ii  Eui'opcan  typlius  in  ]>oston  Harbor  I'roia  IS.");')  to  18(30,  lifcanie  alarmed  at 
tlie  presonec  in  tin;  12tli  x\riny  Corps  of  yomu  cases  wlileli  api)i'arcd  to  present  all  the  clini- 
cal features  (;f  true  typhus,  and  in  his  rejtort  to  the  Medical  I)irector  of  the  Army  the 
utmost  care  was  enjoined  for  the  ])rotection  of  the  troops  against  the  contagion  of  this  deadly 
disease.  A  month  later  Dr.  Wei'.ster  was  called  upon  to  investigate  some  cases  reported 
from  the  11th  Ai-my  Corps,  but  etiological  considerations  were  ojiposed  to  the  recognition  ol 
th(;se  as  I'^aculated  typhus.  A  few  cases  of  t\'phus,  from  two  to  seven,  were  reported  during 
th(>  year  1S(U  from  each  of  eight  regiments  in  the  Army  of  the  Potomac.  In  accordance 
with  instructions  from  the  Medical  Director  of  the  Army  the  history  of  these  cases  was 
investigated,  and  in  every  instance  in  which  the  surgeon  who  made  the  report  w^as  still  on 
duty  with  the  command,  it  was  found  that  he  had  ceased  to  consider  the  disease  to  have  been 
typhus.  Concerning  the  cases  repoiied  fi'om  the  Army  before  Corinth,  Medical  Director  K. 
MuKliAY,  U.  H.  A.,  was  of  opinion  that  il'  the  experience  of  Burgeon  Maylekt,  U.  B.  Vols., 
who  was  ill  chai'ge  of  the  general  field  hospital,  furni>hed  no  evidence  of  tyjihus,  there  was 
assuredly  none  among  the  troojis.  Bui'geon  May].ki:t"s  report  on  the  fevers  of  this  army 
lias  already  been  presented.*  Those  treated  at  the  Bt.  James  hospital,  Xew  (Jrleans,  La.,f 
wcre  derived  from  General  Buti.kr's  regiments,  which,  with  few  exceptions,  had  been 
ci'owded  to  excess  on  transports  from  New  York  to  Bliip  Island,  j\liss.  The  passage  to 
the  Gulf  occupied  thirty  to  tort}'  days,  and  many  of  the  troops  were  closely  }>acked  on  ship- 
board for  sixteen  days  on  the  trip  up  the  river  to  Xew  Orleans.  After  this  some  of  the 
regiments  were  sent  to  the  forts  at  Garrollton  and  othei's  to  the  swanips  opposite  Vickslnirg, 
]\Iiss.  The  report  of  Surgeon  Eugene  F.  Baxoer,  U.  B.  Vols.,  gives  expression  to  the  con- 
ditions affecting  these  men  and  the  prol»able  character  of  the  fevers  from  which  they  sufferod. 

Ilrii/urle  tSitrtj.  J.  H.  W.vkhex,  1.s(  lirhjmh-,  Cimci/s  IHri-noii,  fVa^liinijIuii,  IK  C,  Jan.  2'),  lSti2.— The  1st  brigatln 
is  finel.v  Bitiiated  on  Meridian  Hill,  :i  very  liealtli.v  location,  tlio  cairip  well  policed  and  drained.  Tlie  internal 
arraiif^oincuts  of  the  barracks  are  very  had,  as  the  veutilation  is  not  siifiieieiit,  and  is  olistructed  by  partitions  aeros.s 
the  l)nildin{;  at  intervals  of  ten  or  fifteen  feet,  (bistroyinj;  the  free  circulation  of  air.  If  this  defect  is  not  imme- 
diately remedied  we  shall  have  camp  or  typhus  fevep,  as  it  has  already  made  its  appearance  in  the  56th  N.  Y.,  and 
in  one  ease  puived  fatal. 

Briyudd  Siir)j.  J.  H.  Wakhkx,  an  the  niinl'diiiii  of  ike  lllli  X.  1'.,  .laii.  '21,  IStiL'. — This  regiment  Is  ciieaniped  on 
the  western  slope  of  Meridian  Hill.  The  i^ronnd,  owing  to  its  gravelly  and  porous  natuie,  is  as  well  adapted  for 
a  camp  as  any  in  the  vicinity,  the  atmosphere  is  impregnated  with  a  malarial  odor,  arising  from  an  ojien  Held 
where  a  large  number  of  dead  horses  are  deposited  on  the  surface  and  allowed  (o  remain  and  deeomiiose.  'I'll  is,  with 
the  rather  jxxir  policing  of  the  camp,  has  given  rise  to  tyjdnis  fever,  from  which,  1  regiet  to  say,  we  have  lost  some 
ten  or  twelve  men  alicady.  The  tents  are  the  wedge-tent,  and  have  a  wall  of  boards  built  u])  some  three  feet  high, 
with  the  tent  placed  on  top.  As  they  havi^  no  door,  using  the  lly  as  such,  the  men  steji  over  the  boarding  down  into 
thisbox  arrangement,  which  generates  one  of  the  most  fetid  and  vile  atmospheres  that  human  beings  can  possibly 
be  placed  in.  I  suggested  that  the  banking  of  earth  atiout  the  boanling  should  be  at  once  removed,  and  holes  nui<le 
through  the  walls  near  the  lloor  that  a  free  circulation  of  air  may  be  had.  I  would  also  suggest  that  the  regiment 
be  removed  to  the  grounds  opposite  the  Colundiian  hospital.  The  men  should  sleep  upon  cedar  leaves,  which  can 
readily  be  obtained  at  a  short  distance  from  here.  They  should  not  bo  allowed  to  keep  fires  iir  their  quarters  but  a 
few  hours  by  day  and  the  same  at  night,  nor  should  they  be  allowed  to  wear  their  overcoats  or  eat  in  the  tents.  A 
disinfecting  agent  shoulil  be  thrown  around  their  (|uarters  and  a  strong  solution  of  linre  inside  and  out.  Should 
these  suggestions  be  adopted,  I  think  all  forms  of  tyxihus  will  sjieedily  disajipear  from  the  regiment. 

Hrpoi-t  OH  Tiiplui'i  hij  Malical  Iiisptvtor  Peteu  Pin'EO,  tJ.  S.  J. — The  2Hd  N.  Y.  moved  Sept.  28,  l«(jl,  from  Arling- 
ton, wlieie  il  had  been  eneam|ied  some  months,  to  fpton's  hill.  Because  of  what  was  considered  a  military  neces- 
sity, the  regiment  occu])ied  a  hillside  facing  the  northeast,  the  soil  being  a  tenacious  clay;  the  streets  were  very 
narrow,  the  A-sliaped  tents  were  close  to  each  other,  and  the  camii  eoulined  to  the  smallest  possible  si)aee.  During 
October  andNovember  I  urged  unsuccessfully  its  removal  to  a  more  salubrious  locality.  The  importance  of  striking 
the  tents,  careful  police  and  cleanliness  was  also  urged  upon  the  colonel  and  surgeon  of  the  regiment,  but  without 
avail.  An  almost  total  neglect  of  all  hygienic  precautions  ensued,  superadded  to  which  was  the  fact  that  live  or 
six  soldiers  slept  in  each  small  tent,  and  as  cold  weather  advanced,  their  habit  was  to  hermetically  seal  the  tent  as 

*»<jira,  II.  318.  t  .Srjd-.r,  p.  208. 


TlIK    iXiMlNTKh    KKVKl;s 


:V27 


ni'aily  :is  jidssililc,  .sl«'i']iiiij;  in  a  space  uf  hut  lilllc  n-  than  oiu-  liiniilii'd  niliic  t'l-ct.     'I'lic  ciiciilatiiiii  of  air  in  snrli 

a  tent  is,  it  si-i-ins  to  mi',  of  tlu-  t'olldw  iui;  cliarariii  :  Tlic  ian\a>  iMiniils  tln'  iii^irss  anil  of^ir.ss  ut'  almost  no  air 
whatever.  The  exi)ii'ed  air  bcinn  heaii-il  and  liirlUrr  i  isrs  to  i  he  top  and  sides  ol'  t  he  lent ,  u  here  it  is  ininiediati-ly 
condensed,  and  iallinj;  to  the  ))ottoiii  is  a^'iin  respired;  this  process  i>  ii|ieati'd  eonstanlly  during  the  ni,t;hl.  pro- 
diicinn  necessarily  a  condition  scarcely  rivallecl  liy  the  ••  lilack  Hole." 

This  regiment  was  composed  of  as  line  a  liody  of  stout  and  inttdlij;ent  yoniif;  men  as  any  I  have  Heen  in  the 
army;  yet  in  Xovcmlier  a  large  sick  report  "as  noticed,  and  in  Decemtier  tlie  sickness  and  mortality  became  so 
alarmiiijr  that  I  institnted  a  ciirefnl  investigation.  In  one  tent  was  fotitnl  a  soldier  who  had  kept  his  tetit  for  a  day 
or  two,  had  scarcely  coin]ilalned  at  all.  Imt  was  in  niiiciiU)  iiinrlh.  The  patients  generally  on  first  coming  nmler 
notice  of  the  surgeon  presented  grave  symptoms:  they  were  listless,  stupid  and  greatly  deiiressed,  though  iiniMin- 
plaining.  Cerebral  symjitoms  were  shortly  manifested  with  sorib's  aliont  the  month  and  lei'th.  ra|iid  and  irregular 
l)ulse  and  death  by  coma  often  in  from  t  wi'iity-fonr  to  seveiity-t  wo  honis  after  entering  hospital.  Thi're  was  almost 
no  convenience  (ov  jinxt-iiKirtnii  observation,  yet  in  two  or  three  casi's  autopsies  wcie  madi'  by  Snrgeon  W'lU'ox,  L'lst 
N.  Y.,  at  one  of  which  I  was  present.  The  external  appearance  of  the  body  was  darker  than  iisiial  anil  slight 
pnrpviric  sjiots  were  present.  No  organic  lesion  was  discnvered,  but  tliere  was  iinnsnal  congestion  of  the  internal 
organs  generally.  The  syni])toms  above  enumerated,  with  the  history  of  the  camp  anil  the  |ialh(dogical  ajipcar- 
aiices,  led  me  to  regard  the  cases  as  ''typliiis  gravior."  the  rcsnit  of  "crowd-imison.''  It  shonid  be  staled  that  mala- 
rial fever  was  the  prevailing  disease  in  the  regiment  jirevions  to  this  alarming  eondilion.  It  is  also  worthy  of 
special  notice  that  almost  every  case  of  sickness  of  grave  character  came  fiom  the  shady  side  of  the  streeto  where 
no  direct  rays  of  sunlight  ever  found  access.  The  21st  N.  Y.  was  situated  w  ithin  a  few  rods  of  the  'SMI,  in  a  vtilley, 
the  situation  being  nearly  or  ((uite  as  ob.jeotionalile.  This  regiment'had  ,sei  veil  in  and  about  Fort  Kiinyon,  and  had 
strongly  marked  manifestations  of  malarial  ilisea.se:  but.  the  ]ioliee,  cleanliness  and  ventilalion  were  carefully 
attended  to,  and  the  regiment  had  only  one  death  from  disease  in  a  year. 

The  camp  was  at  length  broken  up  and  removed  to  a  delightful  s|iot ;  a  foundation  of  logs  tliree  or  four  feet 
high  was  built  on  which  was  ])laced  the  tent;  the  streets  weie  broad;  cleanliness  and  ventilation  were  carefully 
attended  to;  the  hospital,  which  had  been  in  a  small  bouse  with  low  ceilings  and  much  crowded,  was  moved  to  a 
s])acious  ehurcli  at  Kails  Church  Village,  and  from  being  alarmingly  unhealthy  the  regiment  in  a  short  time  becatm' 
one  of  the  liealtliiest  in  the  army. 

Ahstntct  of  a  Itcport  ttf  Siiri/idii  K.  N.  Haiih.  ;i(l//i  Ohio,  for  thf  four  moiilhn  mdiuij  Div.  31,  IXdI."  [During  this 
period  the  regiment  lost  '11  men  by  death  from  disease:  1(!  of  the  deaths  occurreil  among  1(41  eases  of  fever  and  7 
among  L'2  eases  of  typhoid  pneumonia.  The  mean  strength  of  the  coiumand  in  November  was  .'!S  ollieers  and  '.•XI 
enlisted  men.  It  was  stationed  at  iSummerville,  West  Va.  |  Kever  made  its  appearance  in  this  regiment  shoitly 
alter  its  ariival  at  ."snmmerville  in  September,  The  tioops  relieved  by  it  had  snlfered  from  typhoid  fever  ;inil  left 
behind  them  in  a  crowded  building  about  forty  cases  of  the  disease.  Even  in  the  earlier  cases  there  were  dilferences 
from  typhoid  as  ordinarily  observed;  I'rostratiiui  was  greater,  and  there  was  severe  occipital  jiain  with  stitfncss  and 
soreness  of  the  museles  of  the  neck,  particularly  the  sterno-niastoid.  The  chills  in  miasmatii'  cases  were  slight  but 
came  on  at  tegular  inter\  als,  usually  in  the  early  part  of  the  day;  and  in  the  intermittent  forms  tlio  febrile  stage 
eontiniied  until  late  in  the  evening.  The  tongue  was  largo  and  broad,  indented  by  the  teeth  along  its  margin  and 
creased  in  the  centre,  thickly  and  darkly  coated  on  the  dorsum  and  red  on  the  tip  and  edgi^s;  it  was  tremulous 
and  protruded  with  diflieulty  in  the  severer  cases.  Diarrluea  was  of  frei|uent  oecnrreiiie  luit  not  (distillate.  As  the 
season  advanced  and  a  ty  iilious  condition  became  more  and  more  developed  diarrluea  became  less  freiiuent,  and  often- 
times the  bowels  would  not  move  spontaneously  in  two  or  three  days.  Antiperioilies,  oven  when  remissions  were 
decided,  acted  but  inditleiently,  often  increasing  the  cerebral  and  vascular  disturbance  and  the  dryness  of  the  tongue 
and  fauces;  but  during  convalescence  quiniue  iu  snuill  doses,  given  in  conjunction  with  wine,  had  a  happy  eti'eet. 
By  the  middle  of  October  cases  of  what  seemed  true  tyi)lius  fever  nuide  their  appearance.  The  pulse  was  frei|iient 
and  feeble,  the  skin  dry  and  dusky  but  not  hot,  the  urine  scanty  and  high-colored  and  the  secretions  geneially 
deficient;  the  sclerotic  had  a  bronzed  a|ipearance.  From  two  days  to  a  week  from  the  beginning  of  the  attack 
delirium  or  coma,  partial  or  comiilete,  would  ensue;  sordes  collected  about  the  teeth  and  lips  and  the  tongue  became 
dry  and  crisped.  There  was  occasionally  trotiblesomo  gastric  irritability,  but  .seldom  any  tendency  to  diarrhoea:  no 
tympanites,  and,  excepting  sudainina  in  rare  cases,  no  eruption.  If  the  i)atient  survived  this  stage  a  piofiise  cold 
persjiiration  would  come  on,  the  tendency  to  coma  would  disajipear,  and  for  a  few  days  there  might  bi'  a  partial 
return  to  consciousness.  Hemorrhage  from  the  bowels  was  not  unusual,  recurring  at  freiiuenl  intervals  for  several 
days;  in  these  cases  tenderness  in  the  iliac  regions  was  found  to  exist,  and  occasionally  diarrluea.  During  this 
sweating  stage  glandular  swellings  were  present  in  almost  every  case  of  any  severity,  generally  atfecting  the  parotid 
and  submaxillary  glands,  and  in  two  cases  the  testicles;  the  swellings  were  large  anil  terminated  iu  siiiipuration 
more  freiiuently  than  iu  resolution.  Abscesses  in  other  localities  were  also  common,  and  from  them  would  come  an 
incredible  amount  of  purulent  discharge.  Another  singular  syinptoiu  was  the  occurrence  of  an  exerueiating  pain, 
ajiparently  neuralgic,  beginning  iu  the  great  toe,  gradually  extending  lo  the  other  toes  and  sometimes  involving 
the  whole  foot  and  ankle  joint;  there  was  no, swelling.  This  jiain  was  invariably  the  harbinger  of  convalescence. 
This  was  so  ajiparent  and  uniform  as  to  be  observed  by  the  attendants,  and  Dr.  I!\uu  i|iiotes  the  nurse  as  saying  to 
hiiu:  "Such  a  man  is  going  to  get  well,  for  he  has  been  groaning  all  night,  or  all  day,  with  a  iiain  in  his  big  toe." 
About  the  beginning  of  December,  while  the  daily  average  on  the  sick-list  was  'JW,  an  ounce  of  whiskey  was  given 
morning  and  evening  to  every  man  on  police  or  guard  duty,  and  to  others  engaged  in  exhausting  labor  or  exposed  to 
inclement  weather;  this  allowance  was  also  given  to  nurses  in  hospital,     (iood  results  were  expected  "because  of 

*  Tliis  roi)i.rt  «ii»  )iublislii-cj  tjy  .Singi'.iu  U.vkr  in  tliu  uhi,,  Mr,l.  :iiiil  .s'nr./.  Juiinial,  \'el.  XIV,  Ism,  [i.  U.'i. 


OZS  RVMPTOMxVTOLO(iY    OF 

the  i^rt'at  (lc|prL-N.si(j|i  of  t  lie  vil;il  ciicrjiii'.-.  ajul  iin[):iiiiiirii  I  (if  iiiiu-r\  :it  ion  not  only  of  those  on  the  sick-li.>t  Imt  (pf  Iho 
wholo  caniii."  ](  is  iisscrlcil  tliiil  almost  iininciliatrly  after  this,  new  cases  of  fever  lieeanie  iiifreciuenl  and  of  a  milder 
eliaiacter.  and  that  in  thfeis  wei'ks  \eiy  few  oeemicd.  Alllion^h  the  hospital  was  well  ventilated,  niiis<-s  weio 
l're(|uently  attacked  liefufu  the  use  of  the  stiniiilant.  hut  after  its  icj;nlaf  is^u^■  Mich  cases  liecame  rare. 

Jli.'pdit  on  'I'lipliitx  hjj  Siiri/ii}ii  V\i\SK[,is  Jitisii,  77//)  I'u.  Wili. — Dnrinj;  the  month  of  .Jaiiuaiy,  ISliL',  a  few  oases 
of  ;,;ontiinc!  tyiihns  fever  made  their  aiijicaraneo  in  tliis  rcj^iincnt  wliilc  ciieamiu'd  at  MuinfordsviUe,  Ky.  Tlio  cases 
all  occurred  in  a  jicriod  of  aliont  ten  ihiys  during  a  protracted  spell  of  cold  and  w  et  weather  vvhicli  eonlincd  the  luoii 
to  their  tents,  the  mud  bein;,'  so  dec])  in  the  vicinity  of  the  camp  as  to  inti'rfere  with  the  usual  iiarade.s  and  exercises. 
Tho  cases  Jiroseiited  tlie  ri'jiiihir  jielechial  iilotehes  iiiimeroiisly  distrilmted  o\er  the  hody:  they  were  attended  with 
sudden  and  excessive  physiciil  jirost  ration  and  terminated  fatally.  j;enerally  IVoin  the  lifth  to  the  tenth  day.  death 
being  ustially  preceded  a  few  hours  liy  delirinm.  I  lielie\(>  these  cases  to  have  lieen  identical  with  the  spotte<lor 
petechial  fever  of  the  Ijooks;  in  short,  typhus  fever  of  a  most  malignant  type.  In  most  instances  the  disease  w  as  per- 
fectly intractahle.  the  most  active  and  vigorous  stimtilant  treatmetit  failing  to  rally  or  sttstain  the  terrihly  dei>ressed 
vital  powers.  1  am  nntihle  to  trace  it  to  any  malarious  origin.  It  disappeared  as  suddenly  as  it  came,  iind  I  do  not 
know  of  its  having  ai>peared  in  any  of  tlie  surrounding  camps.  I  believe  it  to  have  been  the  result  of  the  vitiated 
air  of  the  tents,  together  with  the  deiiressing  infltieuce  of  long  continued  e(jhl  and  wet  weather,  insulheieiit  exercise 
and  depraved  diet  surreptitiously  bought  from  camp  hticksters. 

Hi-port  on  Tijpluix  hi  the  l'>th  V.  S.  Inf.  at  Camp  D'ood,  Kij.,  Inj  Act.  .Us't  ^unj.  ().  K.  Ei:yxoi.ixs,  U.  .S.  .  1. — 1  )iiring  tho 
period  of  niy  service  with  the  1st  liattalion  of  this  regiment,  four  cases  of  true  typhus  gravior  were  observed.  No 
similar  easc'S  occurred  in  the  brigade,  nor,  as  I  bidicM',  in  the  division.  The  disea.ses  i)revailing  tit  thc!  time  were 
chronic  diairlnea,  dysenteiy  and  typhoid  fever,  and  in  many  of  the  febrile  ca.s<'s  then^  weic  evidences  of  malarial 
inlluence  seen  not  only  in  a  l<'n(leiicy  to  ]ieriodicity.  but  also  in  the  color  of  the  skin  aiul  in  hepatic  deiangemeiits. 
la  most  cases  three  things  were  w  (Ut  hy  of  lemnrk  :  1st .  The  ad  \  nam  ie  <-onditioii  id'  |iat  ieiils  w  hen  llrst  brought  to  the 
liosi>ital  ti-nt.  L'd.  Intestinal  <Miiigeslions.  .'M.  The  alvine  cvaeuations,  which  wcie  geneially  of  a  l)ille  dirty-yellow 
color  and  (|nite  t  liin.  not  olteiisi  ve  at   lirst,  but  iibomiuably  so  aftei  a  few  days  exposuic  in  the  sinks  to  a  warm  sun. 

The  two  hosjiital  tents  of  the  battalion  were  situated  on  low  ground  near  the  head  of  a  sintill  ravine;  thcne 
was  a  shallow  sink  not  unue  than  twenty-live  feet  behind  one  of  them  and  above  it,  tlie  gronrrd  being  higher  bidiind 
than  in  front.  The  patients  lay  on  old  straw  which  could  not  lie  repla<-ed  by  reason  of  the  scarcity  of  that  article. 
Vegetation  commenced  nniler  the  straw  ,  which  was  kejit  moist  1>y  its  close  proximity  to  the  earth.  The  four  tyidius 
cases  occurred  in  the  ti-nt  on  the  low  grtuuid  near  the  sink.  These,  vvhi-n  tirst  brought  in,  exhibited  few  symiitoms 
that  were  not  common  to  every  casi^  of  cam))  fever, — there  was  jieihaps  rather  more  debility  and  nervous  ])rost ration 
than  in  other  cases;  but  a  lew  days  after  their  ailniission  into  the  liosjiital  tent  st  iijior  and  low  delirium  sujier veiled, 
and  the  sto(ds  became  less  frequent  and  scanty,  darker  in  cohjr  and  more  olfensive;  the  (iiiantity  of  urine  became 
diininished  and  the  catheter  was  sometimes  re(|uired;  sudamiua  weri^  seen  in  all  and  the  rose-colored  eruption  in 
two  of  the  cases,  about  the  end  of  tlni  lirst  week,  continuing  tiiilil  death.  In  one  case  cpistaxis  was  troublesome. 
In  all  the  pulse  was  small,  weak  and  freiiueiit  and  the  tongue  dry,  brow  n  and  fissured;  sordes  accumulated  rajiidly 
on  the  teeth,  gums  and  litis,  and  stiqior  deepened  as  the  disease  jirogressed.  Brigade  Purgeon  Ciiaki.kS  Scilfssi.KU, 
under  whose  orders  I  was  tln'ii  acting.  regarde<l  these  ea.ses  as  true  typhus.  In  searetdy  any  other  ca.scs  of  fever  at 
Camp  Wood  did  I  observe  the  disorder  of  iiitelh.'cl  attending  these  cases:  tile  iiatieiits  were  generally  rational  even 
just  before  ih'atli. 

Since  eaiii]!  fever  jirevailed  in  all  tln'  neighlioring  regimental  camps,  while  few  if  any  other  eases  of  tyjilius 
occurred,  flie.se  four  cases  may  reascuiably  be  aitiiluiteil  to  local  causes.  Tliese  1  believe  to  have  been  tin;  fetiil  gas 
arising  from  the  sink  and  the  vajior  exhaled  from  the  earth  saturated  with  putrescent  tluids  under  the  straw  on 
wbieli  the  patients  lay.  I!ut  as  there  were  nine  men  in  the  tent,  it  may  be  asked  why  did  not  more  cirses  occur? 
I'robably  because  some  were  less  reduced  Ulion  entering  the  tent  and  others  remained  only  a  few  days  exposed  to 
its  miasms.  I  believe  that  any  febrile  case,  if  exposed  to  similar  pathogenic  causes  for  a  length  of  time,  would 
\levelope  symptoms  of  a  true  typhus. 

Kitrnct  from  uii  Inspection  liiport  of  Uronih  Nvspitol  So.  (!,  .Wir  Atbamj.  hid.,  In/  Midiciit  Iiixpictor  J,.  Hi'.MrilKKY.s, 
U.  S.  J.,  Jan.  14,  IStil. — [The  camp  from  wliich  the  New  Albany  cases  were  derived  is  thus  described  under  <late 
March  8:  The  troo|)S  consisted  of  seven  companies  of  undisciplined  recruits  intended  for  the  cavalry  service, — present 
-IH'J,  alisent  with  or  without  l<;ave  l^Ul:  total  ti.'^l;  number  sick  in  camp  hosiiital  (iX;  severe  eases  are  sent  to  general 
hospital  at  New  Albany.  The  piev  ailing  diseases  are  measles,  jineumonia  and  intermittent  fever, — typhus  reported 
present  in  .lanuary  has  entirely  sulisided.  The  camii  is  in  the  fair  grounds.  There  is  but  little  natural  drainago  and 
almost  no  attempt  has  been  made  to  improve  it.  The  soil  is  Idue  water-holding  elay  which  at  tho  present  time  is 
worked  up  into  mud.  The  wuter-snpply  is  from  cisterns  and  wells;  the  well-water  contains  iron  and  magnesia  and 
produces  diarrhoa  in  those  who  use  it.  The  quarters  are  exceedingly  lilthy;  the  men  cook,  eat  and  sleej)  in  them. 
The  grounds  of  the  camii  are  covered  with  garbage  and  tilth.  The  sinks  are  so  foul  from  deposited  excrement  that 
'they  cannot  lie  ajiproaehed  without  defilement.  The  unusually  large  nunibii  of  sick  in  hospital  is  the  legitimate 
result  of  a  want  of  [iroper  cleanliness  and  discipline,  | 

There  are  a  luimber  of  cases  reported  by  our  medical  ollicers  as  typhus  or  s|iolted  fever  in  this  and  other 
branches  of  the  general  hospital  in  this  city.  Tho  cases  have  all  occurred  aimnig  the  recruits  at  Camj)  Noble,  a  siiort 
distance  from  town.  AVhen  admitted  they  present  delirium,  gretit  depression  of  the  nervous  centres,  with  obstinate 
vomiting,  constipation  of  bowels  and  pain  in  the  head;  surfaci'  of  the  body  cold,  with  tendency  to  collapse;  pulse 
over  100  and  comjiressible;  jietechia'  oil  the  extremities,  the  spots  reddish  at  lirst,  siibsei|iieutly  turning  dark;  the 
attack  gem-rally  sudden,  running  to  a   fatal   ternjinatinn   in   a   few  days.     I  saw  one,  case  just  received  in  hospital 


TIIK    riiNTl.\ri:i'    FKVKJ'.S. 


329 


Avliicli  liail  wc'll-niarkcd  .syiiiiitoius  of  cinOno-siiiiial  uieiiiiiiritis.  but  j>OKt-iiiorttm  cxaiiiinatiim  affonls  iici  oviilciicp  of 
iiillaiiiiiiatidii  of  tlicsi!  tissues.  Tln'  tildciil  in  lln-  cailaviT  is  rf]"irteil  to  l)i'  in  a  lic|ui(l  statr.  as  in  casis  ot'dralli  troiii 
oU'ctricity.  Fil'lccu  m  I  wmlv  cases  of  I  his  iy|ie  ol'  disease  lja\  e  oeemieil.  many  i>f  llieiii  tenuiiialinj:  family.  Sonic 
of  the  ineii  in  ('ani]!  Ncil)le,  fiulouLrlwil  to  tlieir  hunies.  liecanie  alVeiteil  afier  aiiivin^  at  theii-  ii'sidences,  otlior 
iiieiiilpeis  of  tlie  family,  in  some  instanees.  tal^inl;■  tlie  disi'asi'  aii]iarenlly  liy  eonta,i;iun.  'Ilie  eases  in  hos]utaI  were 
all  treated  with  tonies  and  stimiihnits.  Neatly  all  iuhUi'  this  ti'eatnient  diid.  I'ntit-iiini-li  in  aiiiii'ai'an<-e8  iiidieiitin;; 
the  use  of  an  oxidizini;  remedial  aj;ent,  eases  oeeiii  linj:  snbse(|nenily  wi'ie  Heated  liy  a  tree  use  of  (dilorato  of  jiota-sh 
conjoined  witli  stinnilants,  tonies  and  opiates,  fiider  this  imxle  of  tieatini'nt  nearly  all  eases  of  this  disease  have 
reoovered.     Cases  hiiv(!  oceiirred  amontrst  the  citizens  of  the  country  alioni  Xew  Albany. 

In  ho.spital  this  so-ciilled  '•  spotted  fever"  is  isolated  in  a  ward  with  li.ODU  cubic  feet  of  sjiaco  to  caeli  patient. 

.Is-i'l  Siir<i.  W.\i;i:i;\  WkcstkI!.  ?".  S.  .(.,  mi  Tiijihiix  in  lln-  V2th  Annii  Curpt!,  .triiiii  nf  the  /'(i/ioiiiic,  Miinli  '<,  INi:!. — 
f'l'liis  iiis))ectioii  was  occasioned  by  the  ie]iorted  oeemnnee  durini;  l-'ebrnary,  l^<(ili.  of  t wo  fatal  cases  of  tyjilius 
fever  in  tlie  12:id  >.'.  Y.  and  live  cases  with  four  deaths  in  the  llUlh  N.  V.  The  monthly  rejvoit  of  SiM};eoii  .lollN 
MoNEVl'f.NNY.  of  the  foiuier  ifjiinient ,  cont  a  ins  the  following  leinaiks:  Tlio  rcf^inu'iil  moved  into  an  old  eamiiinj; 
firound  situated  near  Stalfoid  Court  House,  \:i.  I'lic  camji  is  locatid  in  a  liollow  between  two  riil^;es,  near  tlie  edjj;e 
of  a  brook.  The  soil  is  jiomus  and  tlu^  water  lilteriuj;  tliiougli  it  is  in  my  opinion  imiircfinated  with  an  uniliie  iiuaii- 
titv  of  ^efjctable  debris.  We  broui;ht  rubeola  with  us  from  our  last  cami>  at  Kaiii'ax  Station.  'I'he  men  had  made  a 
hard  march  throiifili  the  storms  of  December.  The  rations  were  salt  and  dclicicnt  in  ciuantity.  After  the  first  \veek 
of  camp  life  here  diarrlKca  of  scmic  erade  showed  itself:  this  was  fcdlowi'd  by  cases  of  remittent  fever,  ni'iierally 
assiiminsj  alow  type;  then  typhoinalarial,  ty|ilioid  and  typhus  fe\eis  made  tlii'ir  aiijiearaiKX'.  Two  of  the  ca.ses, 
repoitcd  as  ty)diiis,  oceurre<l  after  ci.n\  aleseeiiei'  iVoui  nibenla.  rnenmonias  were  of  a  tyjihoid  type  and  dysentery 
assumed  the  sfinu'  sinliiii^  cha  racier.  I  lie  lieallh  of  i  he  camp  is  bail,  the  si  I  nation  is  bad  and  the  weather  has  been 
unfavorable  for  us  to  move;  but   I  lia\e  chosen  aiiol  her  locality  and  w  ill  jn'obahly  ell'cct  the  chaiiffe  next  week.] 

<»n  my  arrival  Medical  iJireclor  .Mi  Ni  i.i  v  inforimd  nic  I  hat  the  only  ic!j;imeiits  in  which  the  fever  had  existed 
were  the  VJ'Ad  and  1  lilt  h  N.  Y.,  and  tjial  t  lierc  was  now  lull  one  case  in  each  regimen  I.  Thecasi'  in  the  latter  rei;inient 
wa.s  not,  in  his  oiiiiiion,  of  .so  maliiiiiant  a  tyjic  as  the  pieccdini;  cases  in  that  regiment,  and  the  case  in  the  other 
conimaud  liail,  ho  believed,  niideiuiine  decided  aniendment.  Jle  also  infonied  me  that  the  canips  of  the  infci'lcd 
reKinieiits  liad  been  ieinii\ed  to  sites  olferiiii;  in  his  judeiiient  the  best  available  combination  of  sanitary  condi- 
tions. JJotli  jiatieiits  are  isolated  in  se]iaiale  hospital  teiils  ]ilaccil  at  a  considerable  distance  from  the  old  and 
new  encanilimcnts  of  the  respedive  rei;iiiients. 

The  reports  tilready  made  by  the  medical  director  have  ij;iven  information  of  the  number  of  cases  <d"  tyjilms 
rc]iorted  by  rciiimcntal  surj;eiMis  as  oeeiirrinf;  in  these,  two  reuimenis  and  the  number  of  deaths  resiiltin;;  therefrom: 
I  ihercfore  need  not  lefei  to  them  except  to  say  in  iiassiiii;  that  w  bile  my  ini|iiiries  lead  me  to  doiilil  whether  all  the 
cases  .so  re])orted  were  ■.genuine  typhus,  it  is  iindonbtcd  that  most  of  them  wcKMlistiiictly  marked  cases.  Of  the  two 
existiuj,;  instances  there  cannot  be  (|Uestioii.  Jly  opiiiion.s  on  the  Hiibject  coincidi^  fully  with  those  of  Siiif^eon 
McXfl.TY,  whose?  tlioiuin;li  professional  training;  and  extended  observation  of  the  disca.se  in  New  York  City  make 
him  cspeciall.N  acute  in  t  he  recoL'iiil  ion  of  \\\f  characteristic  sym)itonis. 

In  coiiipliaiice  w  itli  ordeis  to  ini|iiire  into  the  causes  of  this  formidable  alfection,  I  have  to  say  that  I  deem 
the  close  a^'j;ic,i;ation  ot  the  men  of  the  two  regiments  in  lints  of  defective  construction  and  on  ground  having;  a  wet 
sub-soil  imiierfectly  drainef  and  jdcviously  occniiicd  by  troops,  to  be  a  conspicuous  promotei  id' the  disease  now  under 
consideration.  The  VSAd  icnimeiit  was  i|uartered  in  lints  llXtiXl  feet,  with  eislit  men  to  a  hiit.  These  huts  had 
b.-eii  recently  a.bandoned  by  (Jencral  Siyel's  troops,  and  the  New  York  rej;iment  arriving  upon  the  jrroiind  lato  at 
liij;ht  occupied  and  remained  in  them  w  itiiont  proper  cleaiiinj;.  Many  were  within  one  or  two  feet  of  eaili  other. 
Jn  the  interveiiinj;  sjiaces  liumaii  ordure  had  been  deposited:  and  I  learned  from  the  re},'iiiieiital  suriicon  that  much 
of  it  had  lieen  allowed  to  remain  there  up  to  a  recent  time,  (tlial  was  also  deposited  from  time  to  time  in  oll'ensive 
proximity  to  the  camp.  Hiit.s  originally  intended  for  the  aicommodation  of  a  sinf,de  rcfjiinent  have  been  inhabited, 
since  the  arrival  of  the  IL'thCoriis.  by  two  re;iiments  recruited  six  months  a-io,  and  tlierefore  not  reduced  in  numbers. 
'J'he  thin  tent-cloth  with  w  liich  the  huts  were  roofed  admitted  some  air  of  course,  when  dry,  through  the  interstices 
of  the  fabric,  but  when  wet  it  was  almost  imiierviotis.  No  system  of  ventilation  was  jiracticed,  and  the  draina>;<-  of 
the  camp  was  unattended  to  altlioiijjh  the  face  of  the  f;rouiid  presented  every  facility  therefor.  The  reason  assij;ned 
for  these  snriirisinj;  nejilects  is  that  the  command  was  daily  exjiectiiig  to  move.  This  reirimeiit,  when  organized  in 
northern  New  York  in  August,  IMIL',  consisted,  I  am  told,  of  a  tine  body  of  !»!':{  men.  It  has  been  in  camp  at  \Vasli- 
ington,  Arlington  Heights,  Pleasant  Heights,  Lomlon  Valley,  Fairfax  Station  and  in  the  locality  I  am  describinf;, 
and  at  each  of  these  places  except  the  last,  caniiis  were  <;enerally  made  on  Kronnd  not  Indole  occupied.  Its  duty 
has  been  picket,  fatifjiie,  guard  duty,  marching  and  tlie  customary  drills,  and  its  sanitary  eonditiim  has  in  general 
been  quite  good.  Diarrlnea,  malarial  disorders,  measles  and  a  few  ca.ses  of  tyidKud  have  occurred.  The  present 
typhus  patient,  who  fell  sick  February  5,  was  in  a  partially  excavated  hut,  (>xT  feel  in  area,  in  which  five  men  had 
sh-pt  during  the  first  fortnight.     More  receully  the  invaliil  and  one  or  two  well  men  occupied  the  hut. 

On  the  M  iust.,  day  before  yesterday,  the  rcgiiiieiil  was,  wjth  the  exception  of  the  sick,  removed  to  a  new 
camping  ground  selected  about  a  week  ago.  A  new  hospital,  just  obtaincil,  and  favorably  located  near  by,  contains 
the  typhus  patient.  On  visiting  the  new  camp  I  found  the  site  good,  but  the  huts  built  irregularly  and  much  too 
close  together.  As  the  lesnlt  of  a  conference  with  Dit.  McNfl/rv  jind  niy.self,  the  cidonel  of  the  regiment  deter- 
mined to  immediately  tear  down  the  huts,  build  anew  over  a  larger  ana,  and  allow  no  excavation  of  the  tloors 
or  heaping  up  of  earth  on  the  outs'ide  of  the  walls,  lie  resolvid  also  to  drain  the  camp  systematically,  protect 
from  surface  water  by  cat  eh- water  drains,  venlilale  the  lints  thoroughly  each  day,  exercise  a  rigid  police  of  the  camp 
Ukd.  Hist.,  1't.  Ill— 12 


S^O  SYMl'T(jM.\r()lAJ(iY    OF 

and  inteiidi'  iif  the  liiitN,  eiiforco  cleanliness  )iy  batliiiin,  wliiili  liail  ne\ei-  been  attendeil  to,  ami  eaii.si'  tlu'  iinder- 
Karinents  of  the  men  to  1)(^  fVe.|Uently  wa.shed.  An  insjieetioii  cil'  Ihe  per.son.s  of  th(!  men  l),v  mc^  was  nnneeessary,  as 
it  was  franl<ly  admitted  that  tliey  wei'e  in  a  filthy  state.  Their  ]iliysioj;iiomy,  ho\ve\cr,  did  not  indicate  the  eaehexy 
which  their  «  letehed  habits  led  me  to  expect;  on  the  coiitiary  I  was  snrinised  \i\  tlieir  eomiiaiatively  healthy 
appearance.  I  found  in  the  regiment  seven  gravis  eases  of  tyidioid  fever,  wliieli,  althoiifih  not  liesi't  by  the  same 
daii;;erous  elements  of  infection  and  solf-propafjat ion  as  typliiis.  still  call  as  loudly  for  correction  of  tlie  sanit;iry 
neglifjence  which  has  given  rise  to  both  the  allied  diseusi's:  and  now  tliat  the  iiisalulirions  locality,  Ihe  defective 
acconnuodations  of  the  troops  and  the  tainted  atmosidiere  to  which  they  were  snbjecti^d  have  been  changed  and 
isolation  with  improv<'d  treatment  of  the  single  ty]phns  case  secured,  W(^  uiay  confidently  ho])e  for  the  speedy  erad- 
ication of  these  formidable  disorders  of  the  ri'ginu'ut. 

The  existence  of  typhus  fever  in  the  other  regiment,  the  ll'Jth  N.  Y.,  is  attributable  to  inlluences  similar  to 
those  reported  above  as  having  prevaile<l  in  the  123d.  '  *  ■  *  JIuch  credit  is  due  llajor  General  Sloc'C.m  for 
the  promptness  and  energy  with  wliicli  he  has  employed  the  measures  suggested  to  arrest  the  8j)read  of  fever  and 
prevent  its  assuming  an  epidemic  prevalence.  He  yesterday  issued  a  general  order  jiositively  prohibiting  throughout 
his  command — Ist.  The  habit  of  sinking  the  floors  of  tents  and  huts  below  the  surface  of  the  ground.  '2d.  Occu- 
pation, in  encamping  troops,  of  spots  recently  used  for  that  purpose;  and  od.  Employment,  in  the  construction  of 
new  huts,  of  any  jKirtion  of  old  ones.  The  practice  of  using  iiortions  of  abandoned  huts  in  the  construction  oi' 
new  ones  on  adjacent  ground,  in  order  to  avoid  the  labor  of  proi'uring  other  materials,  is  so  general  that  it  made 
necessary  the  third  ]>aragraph  of  this  order.  Many  points  of  improvement  were  urged  upon  theofticers  of  the  infected 
troojis;  l)ut  it  was  deeuKMl  unnecessary  to  request  General  Sloci'M  to  publisli  them.  The  troojps  are  now  snlliciently 
aware  of  their  commanding  general's  earnestness  in  the  nuitter  to  insure  ob.servance  of  verbal  sugg<'stions,  and  the 
intelligence  and  energy  of  Surgeon  McXi'Lty  will  accomplish  everything  to  be  desired  of  the  medical  officers  under 
his  direction.  I  think  the  officers  with  whom  we  conversed,  line  as  well  as  medical,  are  convinced  of  the  general 
injurious  consequences  certain  to  flow  from  overcrowding  and  defective  ventilation,  and  more  especially  how  much 
the  jirevalcMcy  and  futality  of  typhus  depend  upon  the  nature  of  tlie  in-door  acconunodation  with  which  thi^  soldier 
is  provided.  Inatt<'ntion  to  the  purity  of  the  air  in  each  tent  or  hut,  to  jiersonal  eleunliness,  constant  supplies  of 
fresh  clothing  and  bedding,  (b'fective  cooking  and  the  accunnilation  about  camps  of  decomposing  vegetable  and 
animal  nuitters  liave  lieen  i)ointcdout  to  them  as  potent  influences  in  thei)roductiou  of  <'amp  fever.  Advice  was  given 
to  the  attending  medical  officers  with  reference  to  the  management  of  the  di.sea.so,  and  if  fresh  cases  should  occur  they 
will  use  the  ])romptest  means  to  isolate  the  patients  and  will  urge  the  commanding  officer  to  the  adoption  of  any 
measure,  no  nnitter  how  extreme,  necessary  to  arrest  the  evil. 

Asx't  Siirii.  Waukkn'  Weustkr,  U.  S.  A.,  on  mqiposi-d  Ti/pltioi  in  the  llth  Army  Carps,  Armij  of  the  I'utonnu-,  April  17, 
18('>H. — I  have  the  honor  to  report,  after  careful  investigation,  that  I  am  not  convince<l  that  the  sudden  death  of  one 
of  the  (luarternuister's  employes  at  Ho])e  Landing,  reported  by  Medical  Director  SfCKLEV,  llth  Army  C'orjjs,  was, 
as  he  believes,  a  case  of  maculated  tjiphus;  nor  do  I  think  that  any  active  hygienic  or  precautionary  measures  need  be 
taken  to^prevent  a  spread  of  the  disease  existing  in  tlio  connnand  there. 

The  two  regiments,  the  lOTth  and  134tli  N.  Y.,  composing  the  command  at  Hope  Landing,  have  snllered 
greatly  from  sickness  since  their  entry  into  service  about  eight  months  ago.  Uefore  and  since  their  arrival  at  that 
point,  two  months  ago,  tyi)li((id  fever  has  been  very  prevalent  and  fatal,  assuming  during  the  autumn  and  fall  months 
unusually  .S(!vere  enterii^  sj-niptoms  and  during  the  winter  marked  cerebral  complications.  The  latter  synijitonis 
were  by  some  of  the  mi^lical  officers  interpreteil  to  denote  ty|>hns,  )iarti<ularly  as  several  of  the  cases  so  charac- 
terized were  sjieedily  fatal  an<l  tlie  diarrhn'a  and  nu'teorism  usually  attending  enteric  fever  were  absent  or  slight. 
I  can  learn,  however,  of  two  cases  only  which  iiresented  cutaneous  eruiitious  ditfering  materially  from  those  peculiar 
to  typhoid  fever,  and  they  were  rather  extensive  ecchymotic  patches  of  subcntaneous  extravasation  varying  in  size 
from  a  grain  of  wheat  to  one's  hand,  than  the  peculiar  eruption  deemed  distinctive  of  contagious  typhus:  One  of 
tlu?se  was  the  case  of  the  quarteruuister's  clerk;  the  other  occurred  in  tlu;  KiTth  New  Y'oik  reginu'Ut  aliout  a  week 
ago.  Both  were  nuirked  by  nearly  the  same  course,  death  resulting  in  less  than  twenty-four  bonis.  The  jiatient 
(a  few  hours  liefore  in  aji])arent  good  hearth)  com]ihiiiied  to  the  surgeon  of  violent  jiain  in  the  head,  back  and 
extremities,  and  the  ai)|>earaiice  of  the  couiitenanei>  and  hue  of  the  skin  presented  evidence  of  great  internal  conges- 
tion. The  pulse  was  small  until  death,  at  times  almost  imperceptible.  I'ersistent  vomiting  charaeterizid  the  last 
case.  Delirium  was  not  violent,  but  comatose  sym])toms  soon  prevailed.  The  jiatients  suffered  from  involuntary 
urinal  and  fa'cal  discharges.  An  examination  of  the  first  patient  a  few  hours  after  the  attack,  and  of  the  other 
shortly  before  death,  revealed  cutaneous  ecchymotic  patches  of  extravasated  blood  varying  greatly  in  form  and 
size,  and  invading  the  body,  limbs  and  even  the  face.  \o  pust-mortem  investigation  was  made  in  either  case.  Tlie 
treatment  consisted  primarily  of  cn]>s,  mustard  ajqilicatioiis  to  the  extr<miities  anil  a  large  dose  of  calomel  and 
rhnbarli,  with  the  siilise(|Ueiit  emiiloyment  of  camphor,  (luinine  and  alcoholic  stimulants.  This  treatment  was 
attended  with  only  partial  reaction  and  improvement  of  the  pul.se.  The  siddier  thus  affected  liad  been  on  duty  as  a 
teamster  for  two  mouths  previous  to  the  attack,  was  proviiled  with  good  and  well-piepaieil  food,  an  abundance  of 
vegetables  and  anqile  clothing,  was  reju'esenteil  to  lie  iiiiiisiially  cleanly  in  his  personal  habits,  mid  liabilualiy  slejil 
ill  his  wagon,  which  had  no  other  tenant  during  the  night  but  himself.  The  quartermaster's  clerk  was  a  man  of 
scrupulous  personal  cleanliness,  lodged  in  a  well-ventilated  .Silih'y  lent,  and  had  the  reputation  of  being  a  free  rather 
than  a  spare  liver.  The  favorable  relations  of  these  men  to  air,  food,  clothing  and  personal  attentions  certainly  c<iii- 
tradict  the  supposition  that  they  were  victims  of  tyjihus.  The  character  and  stage  of  aplieariinee  of  the  cutaneous 
eruption,  and  the  slight  degree  of  delirium  which  cliaiacterized  the  cases  are  also,  in  my  opinion,  in  ojipositiiHi  to 
the  existence  of  the  suiiposed  disease.     If  it  be  claimed  that  tyxihus  was  communicated  to  them  liy  contagion,  I  do 


Till-:    iDNriNfKli    KKVKi;.<.  o'M 

not  uiiiki'stand  wIumc  was  tli.'  ((intaLiinus  .■.unicf.  \ii  otlirr  rases,  aiisnciiiif;  ovpii  as  well  as  tlifso  to  tlu'  charac- 
ters of  ty])liiis.  li;uc  existed  in  the  com  maud.  No  e\]iiisinc  In  t'limiies  is  liUelv  to  l]a\  e  occiured  ;  nor  was  the  second 
suttVrer  known  to  have  lieen  suhmitted  to  i-oiii:ii;ion^  |iin|iin.|nii  \   m  ihr  liist. 

.Snriieon  l-'l.ooD  of  tlie  rcfiinu-nt  in  wiiieh  the  tiisi  uf  ihi'>e  iny>lerious  eases  oeenrred  infoniied  me  lliat  tlie 
t.vjilioid  fever  of  the  command  liad,  within  two  wcelis.  almost  eomidelely  lost  its  tendency  to  eerelnal  con;;esl  ion. 
and  that  ]nicuiMonia  was  now  the  prcvailiiij;  oomidication.  ( Inc  ii'uiment  yi'slciday  removed  lo  near  llrook's  Station: 
the  other  daily  expects  to  change  its  hicatiou.  In  view  of  these  t'acis  1  deem  it  iieeessaiy  neither  to  draw  yonr  allen- 
tion  to  the  oUjectionable  oxiiosnre  of  Hope  Landing;  to  venetalile  m;ihiria  nor  to  recommend  at  pri-sent  any  .sanitary 
reforms  in  the  regiments  hitely  composing  the  command. 

Siirfieoti  Ef(;KNK  F.  Sancicu,  U.  S.  J'oh..  Third  Hh-hiiiii,  WHli  Aniiij  Curjix,  mi  Ihr  /■ViTz-.s  tliiil  jirtriiilitl  in  \tir  Orhaiin 
mill  ill  riviiiilii  in  1862. — Four  imiiortaiit  elements  <'nteriMl  into  the  causes  ot'  so  much  disease  ami  suidi  fearful  nM)r- 
tality.  1st,  Scorhiitus:  The  diet  had  been  unifoiuily  salt  meal,  hard  lircad  and  cotfee.  'I'hc  Ir.insports  wcri'  too 
crowded  to  admit  of  thorough  i)olicing.  and  llie  public  liuildings  ami  eotlon  presses  wcic  too  ilarU,  damp  or  hot. 
After  long  confineinent,  poor  diet  ami  habitual  uueleanliucss.  ihcr.-  was  imlhiug  in  the  surroundings  of  the  uu'u  lo 
excite  their  pride  or  arouse  them  to  a  ]U'o])cr  appreciation  of  the  importance  <d'  aHcuti(ui  to  hygienic,  measures. 
2d,  Tijiihnx  poiaiin :  The  entire  conimaiul  luid  been  situated  for  many  uuniths  where  systematic  ablutions  could  not 
be  ])crforiucd.  The  skin  was  active  ami  perforun-d  inijiortant  functions;  it  supplied  the  [ihu-c  of  the  kiilm\vs  largi'ly 
in  carrying  <iff  the  di.sintcgrated  tissues.  Men  lay  <lown  in  clothing  salnrated  with  cll'eic  animal  matter  and  were 
com])elle<l  to  breathe  constantl.v  the  poisonous  exhalations  of  thi'  human  body.  Hcabsorjition  necessarily  followcil. 
3d,  Typhoid  Jioixiniiiiii :  .Scorbutic  diet  soon  began  to  l(dl  upon  the  sliumich.  destroying  its  nervous  energy;  food  fi-r- 
nujnted,  noxious  gases  formed,  tln^  bowcds  became  irritated  and  imperfect  digestion  and  iiulrition  followed  with 
emaciation,  debility,  diarrlnea  and  fever.  Ith,  Muluria  :  .As  early  as  May  <lnmb  agues  appelated,  and  by  June  inler- 
mittents  and  remittents  prevailed  generally.  The  city  iirojicr  was  free  from  uialaiia.  The  Mtli  Me.,  while  quartered 
in  the  city  during  the  months  of  June  and  duly.  sulViicil  ba<lly  frcuu  typhus  but  was  entirely  free  from  malaria.  On 
the  immediate  banks  of  the  river  at  ('arr(dIton  the  troops  wrw  geni' rally  cxi'uipt  from  malaria;  the  12tli  Conn.  (■Ncai)ed 
almost  entirely.  On  the  other  hand,  regiments  in  tlie  fortilicalions  running  liack  frnni  and  at  right  angh's  lo  the 
river,  towaid  the  swamps,  su  lie  red  terribly, — the  1  Ith  Me.,  statioiu'd  at  Carrol  1 1  on  during  .Seplemher  ami  ( )ctolier, 
w.is  reduced  from  700  strcuig  for  duty  lo  5(1  in  about  twculy-irighl  days.  About  .June  1  six  rcgimenis  einliarkcd  Ibr 
I  he  swainjis  o]i]iosite  N'ieksbnrg  and  ri'uuiined  exjioscd  to  the  inclemencies  of  I  he  weather  and  pestiferous  luiasms  Ibr 
more  than  six  weeks. 

(Jeneral  Ibillcr's  command  origiiiiilly  consisted  of  seventeen  regiments  with  batteries  and  some  cavalry,  and 
iu  the  course  of  eight  nion  I  lis  almost  I  he  cut  ire  force  suirered  from  I  he  causes  cd' disea.se  abo\  e  enumerated.  The  Killi 
(dun.  was  a  noteworthy  exception;  It  eml)arke(l  at  New  York  late  in  March,  and  hail  a  short  passage  loSliip  Island, 
where  it  remained  nutil  the  city  siirriuidered;  at  New  Orleans  it  was  i|uarleriMl  in  tlu^  eustomdiouse.  ll  had  belter 
accouimodatious  at  sea,  was  con  lined  on  slii]dioard  for  a  shorter  period  and  was  more  rigid  iu  jiol icing.  I'll  is  regiment 
lost  very  few  men  during  tlie  sniiimer. 

I  did  not  test  the  uceuracy  of  my  diagnosis  ]>y  posl-morlnii  examinatioiiH,  and  I  have  md,  the  record  of  a  cas<! 
showing  iin])licatioii  or  exemption  of  I'eyer's  patches,  but  the  symptoms  were  sullicienlly  c(Miviucing.  1  invariably 
fouml  the  patients  extremely  debilitated  from  the  first,  with  early  tendency  to  slip])ing  dow  n  iu  lud  and  deafness, 
dark-brownish  and  dry  tongue,  ])ete(diial  eruption,  small  and  feeble  pulse,  tense  and  Hat  bowels,  at  fust  C(Uisli|)ated, 
lollowed  by  hemiurUages  and  diarrhieas.  (Quinine,  whiskey  and  lieid-teu  were  the  only  remedial  agents  admissible. 
1  was  in  the  habit  of  combining  a  little  opium  with  lh<>  (luinine  to  corn^et  its  cinchoni/iugeli'ects,  and  ipecacuanha  lo 
stimulate  the  cajdllaries.  The  Mtli  Me.,  (inartered  in  Lafayette  Hall,  lost  as  many  as  twenty  cases  of  typhus  during 
.lime;  some  of  these  die<l  at  their  regimenlal  hosjiital,  the  (dhers  at  the  St.  .lames.  This  regiiueul  became  so  thor- 
oughly used  up  that  over  3U0  incu  were  discharged  from  it  during  the  months  of  .Juni^  and  .Inly  on  surgeon's  certifi- 
cates, and  as  many  aecliniateil  men  enlisted  at  New  Orleans.  Other  regiments  had  disliuctive  typhoid:  I  remember 
seeing  in  one  regiment  some  thirty  w cll-iuarked  e.isc.s — bei'f  tongues,  rose-red  spots  and  tympanitic  bowels. 

The  regiments  that  suffered  most  were  the  7lh  Vt..  :iOth  Mass.  and  iltli  Conn.  ArrUiiig  at  New^  Orleans  worn 
and  debilitated,  scorbutic  in  habit  and  saturated  with  zymotic  iioi.son,  they  were  allowed  but  a  few  days  at  that 
city  and  Carrollton  before  they  were  sent  to  Vicksbiirg.  Thence  they  retiinn^d  to  liaton  Uouge,  participated  iu  a 
brisk  fight  on  August  (i,  and  were  compelled  to  abandon  the  place  alxuit  tlu^  euil  cd'  that  month.  <»n  their  retiiiu  to 
\ew  Orle:ms  these  regiments  were  a  sight  to  beliohl.  Tlie  seeni'S  (Ui  board  the  boats  which  brought  the  sick  beggar 
description — the  dead  and  living  locked  in  onis  embrace.  Keduced  to  shadows  by  diarrlnea  and  fever  a  single  jiar- 
oxysni  sufficed  to  snap  the  cord.  Men  put  on  board  at  Malon  Koiige  for  siniph^  debility  were  enveloped  in  their  wind- 
ing sheets  before  they  reached  New  Orleans:  I  counted  seven  de;id  boilies  on  one  boat.  These  remittents  or  iiiter- 
mittents  had  but  one  paroxyni;  seldtuu  would  there  be  any  febrile  reaction.  The  collapse  was  almost  as  perfect  as 
111  cholera — features  sunken,  skin  cold  and  livid,  voice  husky,  pulse  small  and  i|uick,  stomach  irritable  and  niiml 
tor|)id.  The  patients  complained  of  burning  in  the  stoimuh  and  exhaustion;  they  seemed  wholly  iinconci'rned 
whether  they  lived  or  died,  aiid  continually  tossed  lo  and  fro  until  dcilli  relieved  them  from  their  siitl'erings.  Warm 
frictions,  stimulants  and  large  doses  (d'  (luinine  occasionally  reviv<'d  I  hem. 

The  Ttli  V'l.  lost  ;J00  men  in  the  eight  months  friuii  May  to  Decemlier,  the  30th  Mass.  21.">,  and  thelith  Conn., 
a  small  regiment  of  less  than  700  men,  Hi'.'.  During  this  tinu'  I  think  we  must  have  lost  (jnite  20  per  cent,  of  the 
entire  command  by  death,  to  say  nothing  of  those  discharged  for  disability. 

Nevertliele.'^s,  altliougli  typlubs  was  rortmiixU'ly  a  btrangei'  to  our  camps,  there  appears 


« 


332  bY.Mi'Tu.MATul.ULiY    Ui-' 

strong  ground  for  belicvniiL!;  that  an  opitli'inic  of  this  disease  prcvaiKxl  auionii,'  some  rescued 
and  paroled  priscaiers  reeeived  at  \V!hirniii-t<iu  from  SaUsliurv,  X.  ('.,  in  the  spi'ing  of  18f)5. 
The  number  of  prisoners  was  S^lUH),  and  of  tliesc  3,4()0  liad  to  be  cared  lor  in  Wihiiinuton 
as  they  were  unable  to  undertak(;  tlie  vovat;-e  noi'tliward.  The  disease  spreail  from  them 
not  only  to  the  troops  of  the  garrison  Ijut  alsD  tn  tlie  i-iti/.eus  of  tlie  town  and  the  resident 
of  the  surrounding  country.  Burgeon  1).  A\'.  ITa-N'o,  V.  S.  Vols.,  then  ^[edical  Director  of 
the  l)e[)artment  of  Noiih  Carolina,  hu'iiished  a  special  repeal  uf  tliis  epidemic,  which  he 
considered  to  bo  undoubted  typhus.  It  is  addressed  to  the  Burgeon-General  of  the  Army 
and  reads  as  follows: 

WiLMINOTOX,  N.  C,  J/((/tA  10,  IXfifi. 

(iKXEHAl:  I  liavc  the  lioiioi'  to  r(^i>oit  tliat,  in  compliance  witli  your  instructions,  I  liavo  collccteil  all  avail- 
able facts  relating  to  the  epidemic  fever  that  prevailed  here  in  the  spring  of  18l>r>. 

Wilmington  surrendered  February  22  of  that  year,  and  our  troops  on  entering  found  the  city  in  a  very  lilthj' 
condition  and  the  inhabitants  that  remained  in  a  violent  state  of  alarm.  The  city  up  to  that  time  had  been  quite 
as  healthy  as  usual,  and  no  eiiidemie  had  ])revailed  among  the  Confederate  troo])s  that  foiined  its  garrison. 

On  the  25th  and  2(>th  of  February  H,(iUO  I'nion  prisoners  were  exchanged  at  Northeast  Station  and  imme- 
diately sent  down  to  this  city.  Of  this  number  about  8,100  were  too  sick  or  weak  to  bear  transportation  I)}' common 
transports  and  hail  to  be  eared  for  in  hospital.  Under  the  direction  of  .Surgeon  Edwaiu)  Siiii-rKX,  XT.  S.  Vols.,  at 
that  time  senior  medical  oliicer  in  Wilmington,  they  were  placed  in  public  buildings  and  deserted  dwelling  houses  iu 
all  jiarts  of  the  town.  The  si('k  from  the  troops  on  duty  near  Wilmington,  and  also  those  sent  from  Fayetteville  by 
General  Shernuin,  were  admittf^d  indiscriminately  to  these  same  hospitals. 

During  the  lirst  week  of  March  or  very  .soon  after  the  arrival  of  these  jirisoners  an  epidemic,  which  was 
undoubtedly  fjiphiin  in-  jdil  frrfr,  appeared  in  the  hospitals  and  rapidly  extended  to  the  eiti/.en.s  in  the  town. 

I  find  that  lietween  February  2(1  and  Junc^  ,S0  about  1,200  w  liite  soldiers  and  300  colored  soldiers  died  of  di.seaso 
in  Wilmington  and  its  viciuity.  The  ei)idemic  fever  prevaile<l  from  Jlarch  1  to  Junc^  1  and  caused,  so  far  as  can 
now  be  ascertained,  about  6,50  of  these  deaths,  viz :  liOO  exchanged  pri.soners,  200  other  w  hite  soldiers  and  1.50  colored 
.soldiers.  The  records  of  the  Wilmington  hospitals  are  so  incomplete  that  no  estimate  can  be  nuido  of  the  number 
of  soldiers  who  suffered  from  an  attack  of  this  fever. 

Owing  to  the  jieculiar  state  of  local  all'airs  at  that  time  tlu;  nunilier  of  deaths  among  citizens  cannot  be  ascer- 
tained; but  the  resident  physicMans  testify  that  the  fever  spread  extensively  amcuig  them  and  that  many  died- 
Among  the  refugee  negroes  sent  down  to  Wilmington  by  (ieneral  Sherman  it  was  particularly  fatal ;  several  tlxmsand 
of  them  were  put  in  camp  about  April  1  near  Fort  Anderson  on  the  Cajie  Fear  Hiver,  and  it  is  thought  over  1,000 
deaths  from  ty)ilui»  fever  occurred  anutng  them. 

It  was  noticed  by  the  medical  ollicers  that  the  attendants  and  other  soldiers  about  the  hospitals,  who  con- 
tracted the  fever  from  the  returned  prisoners,  had  it  nu)re  violently  than  the  prisomis  themselves. — the  weak,  half- 
starved  )ui.soners  having  a  better  chance  of  recovery  than  the  strong,  healthy  attendants.  Most  of  the  medical 
otticers  and  attendants  contracted  the  fever.  Five  surgeons  and  assistant  surgeons,  two  chaplains  and  .about  eighty 
detailed  attendants  were  among  those  who  died. 

The  evidence  <m  all  sides  is  conclusive  that  this  fever  was  brought  into  Wilmington  by  the  exchanged  prison- 
ers. No  doul)t  the  crowded  and  badly  ventilate<l  hospitals  intensified  the  poison  ;  but  lam  satisfied  this  type  of  fever 
existed  anmug  the  prisoners  at  the  time  they  were  received  within  our  lines. 

It  was  coiitityionn. — Several  of  the  most  intelligent  i)hysicians  iu  Wilmington  think  it  only  prevailed  as  an  e))i- 
demic  and  was  no  nmre  contagious  than  yellow  fever;  but  some  facts  have  come  to  my  knowledge  which  show  that 
it  was  more  than  that.  Of  the  ofbcers  and  men  employi'd  on  the  steamboats  that  brought  the  i)risoners  frou)  North- 
east Station  to  this  place  nearly  all  took  the  fever  and  several  died.  They  were  not  known  to  have  been  in  or 
about  the  hos])itals  after  the  prisoners  were  landed  in  Wilmington.  It  is  known  that  typhus  or  a  low  form  of  fever 
prevailed  in  the  families  of  several  )>lanters  in  this  state.  con\eyed  to  them  by  negroes  wlnj  had  lecently  returned 
from  Wilmington,  rarticularly  was  this  the  case  in  Richmond  and  Kobinson  counties,  on  the  line  of  Ueueral 
Sherman's  nuuch.  The  negroes  followed  the  army  to  Fayetteville,  and  thence  ])a.ssed  down  to  Wilmington;  but 
finding  it  a  hard  place  to  live  in  many  went  back  to  their  old  masters  in  May  and  June  and  carried  with  them  the 
fever  that  was  prevailing  in  the  city.  Mrs.  Gilchrist,  living  near  Montiielier,  Richmond  county,  101  miles  from 
Wilmington,  had  some  of  her  negroes  come  back  in  this  way.  Several  had  the  fever  after  their  return.  Mrs.  Gil- 
christ suffered  a  violent  attack,  but  recovered:  her  son,  aged  twenty-one  years,  died.  Other  white  persons  in  the 
same  family  afterwards  had  the  fever  but  recovered.  Mr.  McF.ahan  lives  on  fheLumbi'r  River,  three  mUes  aliove 
Mrs.  tiilchrist's  |)lace;  his  negroes  carried  the  fever  from  Wilmington,  and  several  nuMubers  of  the  family  took  it; 
one  daughter  died.  Mr.  D.  St.  Clair,  in  the  sanu;  neighborhood,  had  a  like  experience  and  lost  his  daughter.  Dr. 
John  Maloy,  in  Robinson  county,  had  his  negroes  who  remained  at  home  infected  iu  the  same  way  and  lost  several. 
His  family  was  mildly  attacked. 

The  physicians  in  Wilmington  estimated  the  jieriod  of  incubation  of  this  fever  at  from  four  to  twenty  days. 

Sym2>to)iin. — It  liegan  like  an  ordinary  fever  with  a  chill,  followed  liy  more  or  less  heat  of  skin  and  great  weari- 
ness with  pain  in  the  back.     The  languor  was  excessive.     Violent  headache  does  not  seem  usually  to  have  accom- 


TllK    coNTlNn:!!     I'KVKHS.  833 

j);uiiiMl  il  :  I. Ill  llic  i-ycs  \\,vr  ii-il.  wmIitv  and  ininl.TMiil  ul'  lii,'lil.  Tlif  tiiiif;iic  \v:is  ilry  in  llic  iiiiilillc  with  Ird  ti)) 
and  cdjii-s:  s(irdi->  :iii|i(:nvd  raiU  on  iIm-  trnnis.  anil  ilien-  "as  i;ri-ai  tMirsl.  Alinii.-.|  from  llii'  lM-;;innihf;  tliiTi-  was 
iilicasini'ss  cu  pain  in  llic  .-.timiarh.  w  illi  Irnilriin'ss  ovi-r  tin-  w  lioli'  alidiiiLH'H  ;  f;iif.i;liM;;  was  In'ard  in  the  ri^lit  iliac 
re;;i(in.  and  L;rnfiall>  tlicrc>  was  diarrlin:i.  In  tlir  laid'  stajii's  ln'in(inhat;<'  I'lDni  ihc  ImiwcIs  was  nut  iincciiiinioii.  Tin' 
nrinc  was  sianty  ami  lii;;li-C(>liiicd.  ami  in  I'ad  casi-s  lVr(|mMilly  cntiirly  .sM|i)ir<'ssfd.  'I'lic  jpuIsk  was  I'nII  and  slinv. 
ol'liii  cjnl>  l.'i  III  (ill  ])(■!■  Ill  inn  If.  Inn  i  :isil\  run  ipnvssildi-.  11  ii'  skin  was  lVri|iii-iitly  batlird  with  jpi'ispiial  inn  w  itliipiit 
llir  IrviT  nr  lirat  of  skill  aliatiiii;.  I'ririhia-  a|iiii'avi'd  iMily.  and  also  at  liiiirs  an  i'iii|itii>n  like  intiraiia.  'I'liwanls 
till-  I'lid  simls  liki'  |ini|Miia  nlini  ainwan'd.  .laundici'  finiiii'iil  1  \  sii|ii-iMnril .  tlir  skin  and  ciinjiinrl  i\  a'  licroniin.^ 
inti-nsidv  srllow.  N'miiilint;  ul'  a  dai  k-inliin-d  iliiid.  w  liirh  w  Inn  drinl  on  a  rinlli  aiijiraird  sonn-w  lial  yidlow  .  was 
also  not  iini'oniinon.  Soiiirl  inics  i  In-  iiatiiiil  ilii-d  on  tlir  foiiil  li  or  lift  li  da,\  \v  illi  syin|iiiinis  of  conin-st  ion  ol'  tlu'  1 1  la  in 
or  IniiiTs;    Inil   usually  llir  casr  ran  on  fioin  lonitrrii  to  tliiily  days. 

Fioni  till'  iioii-s  of  Ilr,  .1.  1".  KiNo.  a  iiioiniin-iil  ini-dii-al  man  in  \\'iliiiini;tiiii.  who  srivrd  for  soini'  nionllis  in 
IWl")  as  a  coiiliact  physician  in  the  Iiosiiitals  tlicic.  1  sciiri  two  cases  as  fair  cxaniphs  of  tin- disease: 

Cask  1. — .SVi-ov ;  i-ctiiJIhii/  in  dcKth. — Mr.  liiyniin.  cii  i/eii :  :\'^v.  28  years:  weight  17."i  pcninds;  inodetately  leiii- 
jieiate;  full  lialiil  ;  cnjoyini;  uood  heallli  dnrinir  whole  life,  visited  a  si<k  friend  in  hospital.  'I'wo  days  later,  March 
11,  eoni|>lained  of  loss  of  appetite;  was  lanu;nid  and  opprcssi'd:  had  soreness  id'  nftisidcs:  took  :i  piiriiativc  dose  of 
Idiic  mass.  That  iiij;hl  had  a  chill  willi  liyois;  iiiiudi  )Hosl  ral  ion  :  fulness  and  tcmli'rness  in  the  epifjastriiiiu  :  nmi- 
sea,  ami  \  oinitini;-.  I  saw  him  next  day:  Kexer:  pulse  al>oiit  HO,  full,  easily  com  press  i  1  de ;  toll)J;ll<^  dark,  ilry,  with  red 
edijcs.  at  Icndeil  with  nr^enl  thirst  ;  <;ieat  exhaustion;  hn-al  hiiin  acccleraled.  wii  h  occasional  Nielli"};  lUid  liroiicliiul 
coiij;li;  sordes  mi  the  teeth  and  lips;  skin  hot  and  husky;  howels  loose;  discliiuf^i's  yidlow,  watery  and  excessively 
offensive;  ffiirfjlini;  in  rifjlit  iliac  rejjion  ;  tenderness  o\  cr  the  I'litire  alidoiiien,  ]iarticiihirly  in  the  c]iiy;astriiiiii :  urine 
very  scanty,  passinij  only  about  a  talih'spoonfiil,  very  dark  and  olfeiisive;  hrealh  extrenndy  fetid.  Adininistered 
stimulants:  jiotassic  chloras  in  cam  jilior  juleps;  mnslard.  lira  inly  and  pepper  externiilly,  etc.  The  ahove  symptoms 
continued  until  the  fourth  day,  when  Ihc  coiinten.inie  hecaine  diiifjy  (livid)  with  Unshed  cheeks;  injected  eyes, 
ilark-vellow  in  ajipcaiance  iind  hea\y.  with  nnsteadiniss  of  vision  and  intolerance  id'  li^^ht.  'I'lie  whole  surfaci>  was 
covered  with  ii  miliary  eiiijilion  and  liadly  j.iiindiccil ;  violent  dcliiinni;  fjreiit  Jirostratioli ;  jiassed  no  urine  for 
eifjhtceii  hours :  coiiyli  dry  and  fici|  iieiil  :  iiiinli  nausea  ;  liowels  loose.  I'i/lh  (hn/:  Somewhat  lieller;  retained  ii  little 
nonrishment  ;  voided  ahoiil  two  ounces  of  iiiinc.  Sijili  ddi/:  Alioul  the  same.  Scniilli  ii(iij,enrl)i  mornimj:  .Skin  clear; 
voided  ten  (inncis  of  urine  diirinj;  the  nitrhl;  less  delirium;  retains  nourishment  and  stimulants.  10  .1.  .I/.;  ,Skiii 
jaundiced;  delirium  violent;  involnnlary  dis<diaii;es  of  clotteil  Idooil.  :!  /'.  .)/.;  Surface  iiiiich  paler;  ahatcment  <d' 
dcliriiini;  skin  hot  with  slii:lit  )ierspiiat  ion  ;  bowels  chcidicd  ;  threat  ])rosl  ration.  7  /'.  M.:  Hied.  .Surface  of  a 
i;reciiish-ycllow  color. 

Cask  l'.  —  Mililn-:  ncunrii. — Mr.  M.  .loliiison,  Quartermaster's  Dc]iartmeiit,  coniphiimd  April  JO  of  loss  of  a|)pe- 
tite,  lanuiior,  soreness,  fiiliirss  and  tenderness  in  ejiiiiastriiim,  followed  by  prostration  and  rigors  with  fever:  I'lilsc 
about  llMI,  full,  easily  compressed;  toiij;iic  brushed  over  with  a  white  fur;  nrfieni  thirsi;  nausea  and  vtiinilin^: 
breath  illi;  somewhat  ai'ccleratcd  with  slii^ht  coiij;'i :  skin  rather  hot,  but  (diilly  when  the  covering;  is  rcinoviMl ;  oeca 
sional  attacks  of  swcatinf;  of  short  duration,  unattended  with  any  abatement  of  the  fever;  eoiintenance  din^y; 
cheeks  tinslicd;  eyes  watery  and  intolerant  of  lifjht;  pain  in  back  of  head;  deafness;  pain  in  loins;  urine  free; 
bowids  constipated,  Fiflli  doji:  Not  nimli  alteration  excejit  red  toiiij;uc  with  elevated  cd^'cs  and  hard  dry  centre; 
restless  and  somewhat  delirious;  slcejis  only  from  effects  of  oiiiatcs.  Tirclflh  (tai/:  ITrine  rather  scanty;  bowels  in 
good  condition;  skin  hot  with  gentle  iieispiration ;  delirium;  tendcrneKs  ovor  the  abdonien ;  pulse  i;i,"i,  NiiciiliTiitli 
ildji:  Not  much  alteration  except  the  tongue  more  moist;  increased  ((uantity  of  urine;  bowels  constipated.  Tiren- 
tidh  iliiy:  Decided  improveiiK'iit ;  tongue  slightly  coated  with  a  yellowish  fur  and  moist:  didiriuiu  lessened;  sleeps 
more  quietly;  ])ulse  110.  After  this  the  patient  gradually  recovered,  having  been  able  to  leave  his  room  and  go 
down  stairs  on  the  thirty-first  ilay  irom  the  beginning  of  the  attack. 

No  post-iiKiiiem  cjrtimhKitioiiK  of  an  otlicial  i  haractor  were  made.  This  is  miu  h  to  be  regretted,  but  under  the 
circumstances  cannot  much  be  wondered  at.  The  physicians  of  the  city  were  greatly  depressed  in  spirit  and  many 
of  them  sick;  and  the  medical  oOicers  of  the  army  were  overwhidmed  with  the  vast  amount  of  work  so  Nuddenly 
thrown  upon  them.  Hut  although  no  systematic  aiito]>sical  investigations  were  instituted  the  intestines  were  exam- 
ined in  a  number  of  cases  in  none  of  which  was  there  any  affection  of  the  glands  of  I'eyer.  Personally  I  conducted 
two  examinations  for  the  determination  of  this  point. 

Trent iiictit. — Stimulants  were  re(|uired  from  the  beginning,  and  rarely  could  a  pnrgative  dose  of  medicine  be 
given  with  safety.  Medical  officers  at  the  hosjiitals  noticed  that  on  two  occasions,  when  the  supply  (d'  stimulants 
was  exhausted  for  a  few  days,  the  mortal  ty  became  much  increased.  Chlorate  of  |)otash  was  useful  in  small  doses, 
and  camphor  seemed  the  best  anodyne  because  (if  its  stimulant  etfeet.  Those  patients  a|)pareiitly  did  best  that 
received  little  medicine,  but  whose  strength  w  as  sustained  by  the  regular  administration  of  nourishment  and  brandy 
or  whiskey.  Quinine  was  of  no  apparent  benefit.  Oil  of  turpentine  does  not  seem  to  have  been  much  used,  but  in 
a  few  cases  it  was  given  and  apjieared  to  relieve  the  intestinal  irritation. 

This  fever  appoar.s  to  have  prevailed  also  ainono-  those  of  the  released  prisoners  who 
were  considered  able  to  undertake  the  journey  to  i^ew  York;  but  there  is  no  direct  n-fer- 
ence  to  a  contagious  quality  in  the  only  sanitary  repoi't  which  speaks  of  it. 

Medical  Inspector  Geo.  H.  Ly.max,  U.  S.  A.,  on  fthnle  cnses  at  IhtvUr^  Uland.  ,V,  ir  Yorl:  llurhor.  May,  186.">.— A 
form  of  low  fever  with  eruption  prevails  among  the  recent  arrivals  from  (ieneral  Sherman's  trooiis.     It  is  unusually 


334  POST-MORTEM    r.EOORDS   OF 

fatal,  and  tliongli  difleriii^j  somowliat  from  tnio  lyjiliiis,  lioars  iiuno  icseiiibliincc  t(i  it  in  its  essoiitiiil  foatiiips  tliaii 
any  otlicr  fever  I  liave  met  wi'.li.  The  released  prisoners  from  Cliarlotte  and  Salisliuiy  arrived  in  i)itialile  conditioM. 
In  some  instances  both  lower  extremities  were  lost  from  the  etiects  of  frost. 


IV.— POST-MORTEM  EECORDS  OF  THE  CONTINUED  FEVERS. 

In  presenting  the  post-mortem  recofds  of  the  continuecl  iVvcrs  it  lias  hoen  deoineil  ailvis- 
able  to  submit,  in  tlie  first  instance,  surh  cases  as  may  he  nf  N'ahic  in  ilctiM'miiiiiiu-  the 
nature  of  the  large  numher  rcportcil  as  typlio-malarial  subsequent  to  June  30,  1S()2.  Since 
this  title  was  intended  to  include  only  modified  typhoid  fever,  the  posf-viort cm  lesions  of  that 
fever  sliould  of  necessity  have  been  found  in  all  cases.''-'  Dr.  Woodward,  sixteen  months 
after  the  introduction  of  the  term,  described  the  intestinal  lesions  of  tyitlio-mtilarial  fever 
as  consisting  of  tumefaction  and  ulceration,  with  the  occasional  deposit  of  pigment  in  the 
closed  follicles  of  the  small  intestines ;f  and  from  this  it  may  be  inferred  that  all  the  lyplio- 
malarial  cases  brouglit  to  his  notice  up  to  that  time  had  presented  ulceration  of  the  intes- 
tinal glands  due  to  the  action  of  the  typhoid  poison.  But  as  has  already  been  shown,  the 
mortality  statistics  of  the  cases  reported  as  typho-malarial  are  inconsistent  with  the  idea  of 
an  ever-present  specific  enteric  element;  and  this  doubt  as  to  the  nature  of  these  febrile 
cases  becomes  strengthened  by  observing  that  the  records  of  the  Seminary  hospital  attach 
a  higher  rate  of  fatality  to  typhoid  fever  when  modified  by  malarial  manifestations  than 
when  not  thus  modified. J 

To  pursue  this  inquiry  it  is  needful  to  compare  the  anatomical  lesions  of  the  two  classes 
of  cases.  This  has  been  done  incidentally  while  arranging  certain  of  the  jjost-viortevi 
records  for  publication.  Submitted  below  are:  1st,  such  febrile  cases  as  have  the  diagnosis 
typhoid  more  or  less  sustained  by  the  recorded  symptoms;  2d,  cases  entered  as  tjipJio- 
vialarial,  whether  accompanied  or  not  by  their  clinical  histories;  and  3d,  cases  which, 
although  recorded  as  typhoid,  nevertheless  present  in  their  history  symptoms  suggestive  of 
malarial  complications.  To  permit  of  the  ready  comparison  of  these  three  sets  of  cases  as 
well  inter  se  as  with  the  remainder  of  the  jjost-mortcm  records  of  the  continued  fevers,  they 
have  been  arranged  in  accordance  with  the  characters  of  the  intestinal  lesions  so  far  as  it 
has  been  possible  to  determine  these  from  the  records. 

*  See  lu'tf,  i«ige  27^,  sifjtra. 

+  In  his  (tuUint's  of  the  Chipf  Cunip  hisfi(uti.'S  of  the  United  Sintes  Army,  Phila.,  Pa.,  ISr.^,  pp.  IfiO  et  fu/<j,:  "In  tlic  solitanj  fnlHolcB  of  tlio  Pinall  intestine 
the  If-aion  in  nmnift'fiteil  as  a  grafhial  cnlai'Kt'Mient  of  these  organs,  the  contents  of  whieh  become  soft,  pulpy  and  very  frequently  bhickened  from  lieponits 
of  pigment.  AH  po.ssihle  Ktage.s  may  In*  observed,  from  a  barely  perrejitible  enlurgenient  to  a  litth'  tnmor  the  size  of  a  pea,  or  even  Uirger,  eorresponding 
to  the  8itu;ition  of  tlie  follicde  ;  the  summits  of  the  larger  of  these  tumid  follieles  are  frequently  the  seat  of  a  sniall  ulcer.  Such  ulcers  are  especially  to 
be  observed  in  the  ileum,  but  the  enlarged  follicles  arc  encounti-red  throughout  the  whole  length  of  the  small  intestine.  The  ulcer,  originating  thus  in 
a  single  closed  folli(  le,  may  remain  of  snnill  size  (one  to  tliree  lines  in  dianieterV  or  it  may  enlarge,  invade  the  surrounding  tissues  and  produce  an  ulcer 
(six  lines  to  un  inch,  or  even  more,  in  diameter)  rescnilding  the  ulceriitions  of  tlie  patches  of  Peyer  in  chanuter,  tbougli  not  in  sliape  or  situation.  Tho 
aginiuatfd  glands  or  i)atches  of  Peyer  luidergo  similar  cijanges.  As  a  general  rule,  every  patch  is  more  or  less  involved,  tliose  high  in  the  intestine  being 
h*ss  affected  and  the  tumefaction  being  most  intense  towards  the  lower  ytart  of  the  ileum.  The  characteristic  ulcer  occurring  in  the  patches  of  Peyer  is 
oval  in  shape  ;  ucciipies  more  or  less  completely  tlie  tumid  group  of  follicles  ;  its  edges  are  jagged  and  irregular,  often  undermined.  The  base  of  the  ulcer 
is  of  a  dirty  ash  <(>lor,  often  with  a  y(dlowi>h  tinge,  occasionally  mottled  with  diuk,  blackish  points  from  the  presence  of  pignuTt.  It  may  o<cupy  any 
fraction  of  the  thit'k.iess  of  the  in  neons  mendirane.  Somet  lines  it  is  limited  to  tlie  follicular  apparatus ;  in  its  later  stages,  however,  it  usiuil'y  invao.- 
more  or  h-ss  profoundly  the  submucous  connective  tissue,  and  it  may  even  involve  the  muscular  coat.  In  the  latter  event,  it  Hoin<'tinie8  p^netnites  tin 
muscular  layers,  erodes  the  subjH-ritotieal  connective  tissue,  and.  in  extreme  cases,  jtenetrates  the  peritoneum  and  prtwlnces  a  perfomtion,  through  which 
the  intestinal  contents  may  tind  their  way  into  the  general  cavity  of  "the  atHhimen  arul  give  rise  to  a  fatal  peritonitis."  At  this  time  Dr.  Woijdwauu  wah 
inclined  to  regard  the  ulcerations  of  typho-malarial  fever  as  characterized  Ly  certain  |M*."u.iarities  often  sufficiently  distinctivt^  to  enable  the  ainitrimist 
to  recognize  the  fever  by  the  jinai-^iorteiu  api^'arances  alone  ;  but  a  larger  exjterience  demonstrated  to  him  that  these  ulcerations  differeil  in  no  n-spect  from 
those  prtMluced  by  typhoid  fever.  See  p.  3G  of  the  j)amphlet  edition  of  liia  y|</</re»«  <■(!  Tirpfto-nialarial  Fever  in  tho  Se(-tion  of  Medicine,  International 
Medical  Congress,  Pliila.,  1870. 

X  Siipra,  JJ.  308. 


TiiK  roxTiNrKn  kkvkks.  335 

Cases  in  wiik  ii  riii-.  i)iA(iN(i.sis.  i  vi^iioii',  is  mc)1;i;  m:  i.kss  srsi  ainkh  iiy  i  mk  cmnhai.  iiisioiiv — 50  casks. 
(./.;    /'<//(■)■■»  i)iiUli(«  idrd-atiil  iiKil  tilt   III  mil  or  siiiiin  iiilintiiii-  only  iiffitliil — -0  cdsci. 

('ASIC  1.— rri\,iti-  .Idsliuii  \\  atsdii.  Co.  (',  TtU  Fla.:  u,i;i'  10:  wns  :i(iMiiltcil  Marcli  L'2,  IHtJI.  lie  Iiiul  Ix'i'ii  sick 
lor  sdiiic  tiiiii'  .iiiil  was  iinicli  ililiilil:ilril :  his  skill  Iml.  tiiii;xiii'  <liy.  Ii'i'lli  I'ovrrcil  willi  soriti's,  pulsr  (|iil<'k  and 
Kiiiall.  ciiiiiilriiaiici'  (lull,  rN]iics.si(m  vacant;  llirir  was  Iciulciin-ss  ami  i;ini;liiii;  ill  t lii'  I'i^jlit  iliac  ri'^icin.  (hi  llie 
2rilli  lie  was  Hiiildciilv  attacl<i(l  with  syiii]it(iiiis  of  aculi-  laiy  iij;it  is,  icKiilliiii;  iiidcalli  tlm  Kaiuc  day.  I'oxliiiorltm 
ex;iniiiiati()ii  :  The  glottis  and  siiiidiiiHliiij;  ]iaits  were  swollen,  a|>])arciil  ly  froMi  lilirinons  exudation  lienealli  tlio 
iniiciins  lueinlirano.  The  patcln's  of  I'evcr  weii'  thickened  and  iilcerati'il. — .Ic'.  .txx't  Siirij.  M.  A'.  (UriiKiiii,  llurk  Inland 
Jliispilill.  III. 

Cask  li. — Conscript  I'liineas  Moody:  a};e20;  was  adniittod  Sp))t.  S,  lS(i:i.  lie  was  taken  si<'k  August  6  with 
diarrliiea  which  continued  a  week,  ami  was  I'ollowid  liy  a  cliill  ami  fever.  On  admission  the  luilse  was  SMi,  the 
toiiKiie  dry  and  lirow  ii :  he  had  some  iliarilnea.  sliijlit  delii  inni.  se\  ire  and  constant  coii;;h,  with  ninciiUH  rales  in  lioth 
liin^s,  lint  no  rose-colored  s|)ots.  Two  days  later  sonic  red  Idotches  appeared  on  the  face,  aims  and  chest,  anil  there 
was  diilness  w  ith  siibcrepitant  nlles  in  the  low  er  lobes  of  liolli  liin^js.  Six  ounces  of  whiskey  were  taken  diiily,  liul 
on  account  of  inostration  the  iiiiantity  on  the  lOtli  was  increased  to  sixteen  ounces.  Il'th:  Skin  moist;  toiifjuo 
furred  yellow;  no  delirium.  Whiskey  reduced  to  six  ounces,  lie  continued  to  iniprove  under  this  tieatiiu'nt  until 
the,  25tli,  when  fever,  dysimiea  and  f^icat  prostration  set  in,  with  coll  ii|  native  diarrlnea  1  wii  days  later,  ami  death  on 
Octolier  3.  /'(wZ-i/iDc/rm  examination  ten  hours  alter  death :  Koily  emacialed :  limns  eont;esled  ;  liver  enlar;;ed  a:ul 
fatty;  splciMi  enlarf;ed  and  puljiy;  kidneys  lar;;"'  :iiid  i^rannlar;  many  of  I'eycr's  |iatches  ulcerated,  especially  thuse 
near  the  ileo  ca'cal  valve Cnilnil  I'ttrk  Hiinpital,  .V.  )'.  Citii. 

Cask  3.— I'rivato  Nathaniel  Newell,  Co.  K,  18fith  N.  Y.,  was  admitted  Nov.  :iO,  18(H,  from  City  I'oint,  V»., 
where  he  had  been  sick  two  weeks  with  tyjihoid  fi'ver:  loiijiiie  dry  and  brown;  Hordes;  anorexia  ;  diarrlnea;  invol- 
untary stoids;  extreme  tenderness  over  small  intestine:  low  deliriiiin;  pulse  120,  weak,  treinnloiis.  He  dieil  next 
day.  I'osl-morlim  exaniinatiiin  :  I'eyer's  |iatclies  much  ulcerated;  spleen  enhnf;ed  and  sultened;  Iniifjs  ledeiiiatouH 
posteriorly. — Tliinl  Dii-himi  llnijiiliil,  Ahxunilrhi.  In. 

Cask  I.— Private  James  Foster,  Co,  A,  KiiUli  I'a.:  ajje  20;  was  adniitted  March  II,  ISOl.  On  the  Kith  the 
abdomen  became  tyiiip:initic  and  there  was  fjiirjjliiif;-  in  the  rijjht  iliac,  fossa,  lie  died  on  the  21th.  I'lml-miirtim 
examination  six  liniiis  after  death:  I'eyer's  iiatihcs  extensively  ulcerated;  solitary  follicles  enlarged  ;  other  or;;ans 
bealth,v. — Third  liiri«i<iii  llnxiiitnl,  Jli.riiii(lri<i,  I'li. 

Cask  .">.— Private  Wni.  It.  Hartley,  Co,  (J,  22d  Pa,  ("av.,  was  admitted  Ot,  10,  ]Wil.  Ktth:  Delirious  at  nifjlit  ; 
peteehiie  on  abdonieii  and  extreniities;  pulse  120;  toiijjuo  moist ;  slight  tyinjianites;  8iil>cre](itant  rales  and  friction 
Hounds'on  tin-  li^lit  side  of  the  chest.  Prescribed  stimulants,  eggs,  and  twelve  grains  of  sulphate  of  iininine  daily 
in  divided  doses,  lltli:  The  soft  tissues  over  the  right  liij)  and  sacriim  began  to  slough;  renioveil  iiatient  to  a 
water-bed.  He  sank  rajiidly  and  died  at  10  p.  m.  I'nst-mortrm  examination  disclosed  the  lower  lobe  of  (he  right 
lung  in  the  tliiril  stage  of  pneumonia  and  jiart  of  the  middle  of  the  left  Iiing  in  the  second  stage;  the  right  lung 
was  lightly  adherent  to  the  walls  of  the  chest,  and  the  cellular  tissue  in  the  neighborhood  was  somewhat  emphy- 
sematous. The  eidon,  dnodenuni  and  Jejunnm  were  distendeil  with  gas;  the  ileum  contracted;  I'eyer's  glands  more 
or  less  inllained.  and  many  of  those  near  the  ileo-Ciecal  valve  ulcerated. — .(c/.  .1™'/  Surij.  W.  I,.  iVilln,  MiChUun 
lf<>.i}>it<d,  I'liiliiih'ljihiK,  I'll. 

Cask  (!. — Private  Jeremiah  O'Hrien,  Co,  (i,  24th  N.  Y,  Cav.;  age  lit;  was  admitted  .July  21,  IStU,  having  been 
sick  a  week  with  t.vjiboid  fever.  On  admission  his  pnlse  was  88  and  full,  bowels  soluble  and  tongue  moist;  but 
there  was  jiain  in  the  right  iliac  fossa,  w  ith  delirium  and  sle<'plessness.  The  juilse  becaine  more  fre(|ueiit  and  less 
full,  the  abdomen  tynipaiiitic,  the  stools  involuntary  and  the  urine  n^tained,  necessitating  callieterization.  He  died 
on  the  27tli.  7'o.s/-wior/rm  examination ;  The  right  lung  was  con.solidated  posteriorly;  the  intestines  contained  five 
lumbricoid  worms  and  an  nnusual  amount  of  fa'ces,  natural  in  color  but  soft.  Peyer's  jiatches  wore  thickened  and 
inflamed,  those  near  the  ileo-ca-cal  valve  ulcerated;  the  solitary  f(dlicles  also  were  inllanieil. — .let.  .iim't  tiurij.  Henry 
Gibbons,  jr.,  Doiiyhm  Ilnnjiital,  Washington,  D.  C. 

Ca.sk  7. — Private  Edward  Brown,  Co.  H,  3.5tli  Mass.;  age  18  ;  was  adniitted  Pec.  l(i,  18(H,  with  tyjihoiil  fever. 
The  patient  was  but  partially  conscious,  had  fre(|nent  involuntary  st^iols,  e]iista.xis,  iinick  pnlse,  tenderness  over 
abdomen,  particularly  in  right  iliac  region,  rose-colored  sjiots  and  well-marked  sudainina;  he  had  miittei  ing  didirium 
and  picked  at  the  bedclothes.  On  the  18th  his  tongue  resembled  a  jiiece  of  unpolished  mahogany  and  his  teeth  and 
gums  were  coated  with  sordes.  He  died  next  da,v.  I'ost-mortem  examination  five  hours  and  a  half  after  death  :  The 
brain  was  normal.  The  larynx  and  trachea  were  healthy ;  the  right  lung  weighed  twenty  oiiiicos  and  a  half,  the  left 
seventeen  ounces,  the  lower  lobe  of  each  in  a  state  of  red  heiiatization  and  the  inferior  portion  of  the  upper  lobe  of 
tlie  right  lung  congested  ;  the  heart  was  normal.  The  liver  weighed  seventy-two  ounces  and  was  somewhat  flabby; 
the  spleen  sixteen  ounces:  several  of  Peyer's  patches  were  ulcerated ;  the  solitary  glands  much  enlarged  .and  many  of 
them  ulcerated;  the  left  kidney  somewhat  congested. — Aet.  Ass't  Snrf/.  II.  M.  Dean,  Lincoln  Hospital,  W'anhinylon,  I).  V. 

Cask  8. — Private  Herliert  Vaness,  Co.  1),  171st  Pa.;  age  20;  was  adniitted  July  8,  18():!,  w  ith  tyjdioid  fever  of 
twelve  days'  duration,  which  progressed  favorably  until  tlie  9tli,  when  diarrlnea  set  in.  On  the  l.'ith  there  was 
delirium,  with  dry  and  tremulous  tongue,  sordes  on  the  teeth  and  swelling  of  the  abdomen  ;  a  troublesome  hacking 
cough  was  also  present.  He  died  on  the  17th.  J'ost-mortem  examination  ten  hours  after  death  :  The  brain  weighed 
fifty-eight  ounces  and  a  half;  its  membranes  were  considerably  congested  and  its  substance  rather  soft;  a  small 
quantity  of  fluid  was  found  in  its  ventricles.     The  trachea  was  much  congested,  of  a  purplish-red  color  and  filled 


33G  rOST'MORTEM     Rl-lroRDS    OF 

witli  luDiiiliiiil  (st'i-vc;  i(in  :  tlit^  Iviiiiiliiitii'  i;laii(1s  :il  its  hiI'mi'Ml  ion  wen-  ciihirncil,  lil;i(k<'in!(l  and  Sdl'lcni'd.  'I'lic  n|i|i.  r 
lolio  111'  the  iifj;lit  Inn.i;  was  hifil'ly  conii'r.sti'd,  c.spci'i.-illy  :it  llira|ic\:  the  middle,  lolie  was  also  sonnM\lial  conj^i-stcd 
and  jiirseiiti'd  evidences  of  liiii'ii-liitis  posti'viorly  :  the  lowir  l.iliiwas  intensely  enj,'oi>;ed,  jini'iile  in  color  ami  in 
some  places  almost  Mack.  The  left  lunj;  was  ^'enerally  eonu<'sted  :  then'  was  a  eoiisideralile  transndation  of  Idood 
l)eiieat  li  the  jdcMia  at  lis  middle  and  jiosleiior  pail  :  its  lower  lolie  contained  si)leiiilied  lobides,  Idack  in  color,  and 
sepafated  from  <'acli  oilier  liy  pi'rmi'alile.  tissini.  The,  lif^lit  Innj;  weighed  t wenly-fonr  onnees  and  ii  half,  the  left 
twenty one  ounces  ami  a  half.  A  thin  tihrinons  elol  adhered  to  the  anterior  wall  of  the  rifjht  anricde,  and  extemled 
tliroui.;li  the  ventricle  into  the  ]iiilnionary  artery:  the  left  auricle  also  contained  a  lilirinoiis  clot  extendiiij;  into 
the  v<'ntri(le  and  attached  to  themilral  valve.  The  fundus  of  the  stomach  was  of  a  dull  lake-red  and  the  ])ylorle 
portion  jialer;  it  contained  li ve  Inmhricoid  worms.  The  liver  was  soft  hut  of  iiornial  color,  its  cajisule  easily  torn. 
Tho  spleen  was  of  a  innlherry  color  aiid  moderately  lirm.  The  mueous  iiieiidirano  of  the  jejunum  was  rather  soft 
and  the  villi  were  easily  sc,rape(l  oil'.  The  linini;  nn'ndiiane  of  the  three  feet  of  tlu!  ileum  nearest  io  thii  ileo-ca'cal 
val\i'  was  t^reatly  congested,  and  I'tyei's  jiatches  were  ulcerated  thoujih  not  peroeptihly  thickened;  the  first  ulcer 
was  small,  superlieial  and  of  a  darker  (!olor  than  the  surrounding;  memlirane;  aliout  a  foot  ahove  the  valve  a  large 
patch,  softeiu'd  and  very  hy])era'inic  lint  not  cdevated,  presented  near  its  horder  an  ulceration  aliout  tho  size  of  a  pea, 
with  elevated  walls  and  Idackened  centre.  The  kidiu'ys  wei<'  somewhat  injected,  the  cortical  suhstancc^  firm  ami 
pale. — Axn't  Siii-f/.  Iliiniyioii  Alliii,  f.  .s'.  .1.,  lAiiculn  Uoxpilal,  Jl'dxliiiii/lon,  1).  C. 

f'A.sK  9. — Private  William  Crigj;er,  Co.  E,  liOth  Ind.;  a>;e  19  :  was  admitted  Xov.  24,  18W,  with  bronchitis,  from 
which  he  recovered  and  was  transferred  to  Convalescent  liarracks  Jan.  1,  18()5.  lie  was  readmitted  April  8,  with 
pulse  100  to  110,  skin  hot  and  dry,  toiifjue  hrowu-coated  with  red  edges,  bowels  loose,  abdomen  tympanitic.  Active 
delirium,  snbsnltiis  teiidinum  and  pneumonic  symptoms  appeared  on  the  13th  ;  after  the  l.">th  there  was  continued 
insomnia  anil  on  the  ITtli  in\  olunfary  stools.  I'riifiise  sweats  and  coma  ushered  in  death  on  tlit^  I'Otli.  J'oat  morltm 
examination  twelve  hours  after  death  :  The  brain  weighed  lifty-four  ounces;  there  were  six  ounces  of  serum  beneath 
the  arachnoid  and  a  large  iiuantity  in  the  lateral  ventricles;  the  cortical  jiortiou  of  the  brain  was  highly  congested 
and  the  puiicta  vasciilosa  ])ronilnent.  There  were  jdonritic  adhesions  on  the  right  side  ;  the  lower  lobes  of  the  lungs 
were  hepati/ed.  The  heart  was  normal.  The  spleen  was  euormoiisly  engorged,  weight  forty-one  ounces  ;  liver  and 
kidneys  normal;  stomach  congested  in  patches;  Uriinncr's  glands  congested;  small  intestine  congested  in  lower 
portion;  Peyer's  jiatches  near  ileo-ca'cal  valve  extensively  ulcerated;  mesenteric  glands  greatly  enlarged;  bladder 
healthy. —  IIoHpilid,  IMiiilUnii,  TikJ. 

Case  10. — I'rivate  Daniel  ]..  Keeney,  Co.  C,  110th  Pa.;  age  21;  was  admitted  July  11,  1803,  with  a  tlesh-wouiid 
of  the  right  hand,  wliich  granulated  kindly  until  the  22d,  when  small  ulcers  were  noticed  on  the  inside  of  the  cheek 
and  on  the  tongue,  for  which  a  mouth-wash  containing  sulphate  of  zinc  and  tincture  of  myrrh  was  piescribed. 
During  the  ne.xt  few  days  he  hecame  weak  and  languid,  complaining  on  the  29th  of  some  diarrhiea.  Sniall  doses 
of  calomel,  o])iiim  and  ipecacuanha  were  administered,  to  which,  on  August  9,  a  solution  of  citrate  of  ]>otassa  was 
added.  <  >n  the  12tli  he  had  slight  cough  w  ith  sonorous  and  sibilant  rales,  and  there  w  as  iliac  tenderness.  Next  day 
the  red  spots  of  enteric  fever  appeared  on  the  abdomen  and  chest  and  the  aJidomen  became  tender  all  over.  On  the 
13th,  as  the  tongue  was  very  dry  and  the  strength  failing,  the  treatment  was  changed  to  turpentine  emulsion,  wine, 
milk  and  beef-essence.  Occasional  delirium  followed,  and  mucous,  sonorous  and  sibilant  rales  became  audible  over 
the  right  side  of  the  chest.  Four  dry  cups,  carbonate  of  ammonia  and  raw  eggs  were  ordered.  On  the  18th 
increasing  diarrhiea  was  recorded  with  subsultus  tendinum,  stupor,  difficulty  of  swallowing  and  sloughing  of  the 
wound  in  the  hand.  Death  occurred  next  day.  Pont-iiiortnii  examination  seventeen  hours  after  death:  Abdomen  Hat; 
lungs  congested,  especially  the  right  ;  heart,  liver  and  khlneys  normal;  ileum  congested,  glands  of  Peyer  thickened 
and  near  the  cecum  ulcerated;  jejunum  normal.  [S]>eciniens  lil.'j  and  31(i,  Med.  Sect.,  Army  Medical  Museum,  nlcer- 
atiou  of  ilenm,  are  from  this  case.] — Act.  Atss't  Surg.  II'.  L.  Jl'ilh,  .UcCUUau  Huh^iUuI,  I'hilu(kl2)liia,  I'a. 

Case  11. — Private  John  11.  Winland,  Co.  D,  llOth  Ohio ;  age  23;  was  admitted  Xov.  C>,  1861,  with  typhoid  fever. 
On  admission  the  jjatieut's  skin  was  hot,  tongue  dry  and  bowels  somewhat  loose,  tympanitic  and  tender.  He  was 
treated  with  quinine,  oil  of  turpentine  and  chalk  mixture  until  the  14th,  when  he  seemed  very  much  exhansted, 
presenting  subsultus  tendinum,  hurried  breathing,  anxious  countenance  and  a  scarcely  perceptible  pulse.  Under 
milk-punch,  beef-tea  and  camphor  and  opium  improvement  took  place;  on  the  24th  the  tougne  was  moist,  there  was 
some  appetite  and  no  delirium.  On  Deceinlier  3  he  coughed  incessantly  and  his  Iireathiiig  became  hurried.  Ho  died 
on  the  (ith.  I'oKt-moriem  examination  thirteen  hours  after  death:  Heart  soft  and  jlabby  ;  lungs,  siileen,  kidneys  and 
stomach  healthy;  liver  much  enlarged,  weighing  live  ponnds  and  a  ijuarter;  ileum  inllamed  in  nearly  its  whole 
length  and  Peyer's  patches  ulcerated  in  tifteen  places. — Act.  Asu't  Surg.  Stimplr  Ford,  C  S.  A.,  Cumberland  IIo«pit<il,  Md. 

Case  12. — Private  John  L.  Palmer,  7th  Mich.  Cav.;  iige  21;  was  admitted  April  30,  1865,  convalescing  from 
measles.  On  May  22  the  nurse  reported  him  as  having  been  ailing  for  several  days;  he  had  headache.  Hushed  cheeks, 
increased  jiulse,  90,  dry  tongue,  tympanitic  abdomen,  pain  in  right  iliac  region,  a  good  deal  of  iliarrluea  and  some 
rose-colored  spots.  Diarrha'a  continued  troublesome  for  several  days,  the  pulse  becoming  more  freijuent  and  the 
teeth  covered  with  sordes;  delirium  and  pneumonic  symptoms  made  their  appearance  and  death  occurred  June  5. 
Pont-mortem  examination:  The  areolar  tissue  of  the  front  of  the  neck  was  ledematous,  the  epiglottis  swollen  and  the 
anterior  mediastinum  tilled  with  lymph  and  serum.  Kach  pleural  sac  contained  a  large  quantitj'  of  serum;  the 
whole  of  the  right  lung  and  the  lower  lobe  of  tho  left  were  much  congested.  The  spleen  was  large:  the  ileum 
inflamed  and  Peyer's  patches  ulcerated. — Act.  Aas't  Surg.  II.  J.  JViesil,  Cumlnrldnd  H(inpital,  Md. 

Case  13.— Private  William  H.  Green,  Co.  I,  161st  N.  Y.,  was  admitted  Nov.  19,  1862,  delirious  iuid  greatly  pros- 
trated from  typhoid  fever.     Uo  had  diarrhuja,  sordes  on  the  teeth  and  lips  and  a  well-marked  rose-colored  eruption. 


TllE    CUNTINL'KD    KKVKKS.  337 

Hii  was  ticati-d  wilh  laiiilaiiiiiii  and  liiaiiil>  ,  issi'iiOf  ni"  beet'  and  milk.  Tlic  iliairli(i-a  was  clicckcd  and  llic  drliiium 
lessened,  Imt  tlie  jmlso  l)eeaiiie  more  l'n(|uiiit  and  feeble,  the  ]ir(pstrati(in  iueicased  and  tlie  jiatient  ilied  liv  asthenia 
on  the  ITitli.  Piixt-morliiii  examination;  An  alnnidant  ty|dioid  de|iosit  in  the  jjlauds  of  I'ever  and  solitary  j;Uinils 
was  in  proeess  of  sloufihini;:   the  nle^enIelie  inlands  weii'  j;really  enlaifjed. — /,(i(/i(.f'  Ilnmi   llii^pilnl,  .V.   )'.  Vihj. 

C'ASh:  II. — Sergt.  Kdwin  Aveiy,  Co.  1,  ICdst  \.  V.,  was  ailmitled  Nov.  lit,  l,sti2,  with  typhoid  fever.  Ili-  liad 
been  sliijhtly  sick  for  live  days  before  admission,  his  case  jiresentinj;  moderate  diarrluea,  meleorism  and  tenderinss 
in  the  iliac  region,  rose-C(dored  spots,  mtieh  iirostration  and  frei[Ment,  feeble  pnlse,  but  no  delirinin — imleed,  shortly 
before  death  Ik^  gave  directions  with  regard  to  certain  family  matters,  lie  was  treate<l  with  anodynes  in  moderate 
doses,  alcoholic  stimulants  and  a  sustaining  diet,  lie  died  by  asthenia  December  L'.  I'ont-morlim  examination:  .\ii 
abnndant  typhoid  deposit  in  the  glands  of  I'eyeranil  solitary  glands  was  in  jprocess  of  sloughing  ;  the  correspomling 
mesenteric  glands  were  greatly  enlarged. — Lndiia'  Ilniiic  Iliixjiitiil,  .V.   Y.  Cili). 

(',\.SE  15.— Private  .J(jhn  t'aillot,  Co.  1,,  Ith  \.  V.  Cav.;  age  21;  was  admitted  July  lit,  IStW,  with  hot  and  dry 
skin,  freciiicnt  and  feeble  i>al.se,  diarrlnea.  tymjjanites,  abdominal  tenderness,  taches  rouges  over  ehest  ami  abilomen 
and  muttering  delirium,  lie  died  on  the  Hist.  /'e.sV-mor/iHi  examination  eighteen  hours  after  death:  Kmaciation; 
alidomen  tumid:  lower  lobe  of  right  lung  coiigesteil:  heart,  liver  and  kidneys  healthy:  spleen  enlarged;  guMter 
oiru'iitmu  much  injected;  mesenteric  glands  enlaigi'<l  and  inllamed:  intestines  tilled  with  a  li(|uiil  resembling  jius  : 
mucous  membrane  of  snuill  intestine  softened;  I'eyer's  ])atclies  thickened  and  ulcerated. —  Third  Diviaiun  Iloxjitlnl, 
Jlrruiiiliid,  1(1. 

Cask  K;. — Private  .lames  Heckwith,  Co.  \\ 'Jd  Me.;  age  2li ;  was  admitted  Sept.  ti,  IMCil,  with  typhoid  fever 
occurring  as  a  relapse.     The  patient  had  a  full  strong  ]Milse,  120,  lieavily  coaled  and  dry  tongue,  hot  and  dry  skin. 

()n«^  onmi^  <d' sulphate  of  magnesia  wasor<leied.     He  rested  ] rly  during  the  nigh  I,  having  had  some  head  symptoms; 

his  bowels  were  moved  twice,  allliongh  by  mistake  the  K|)Som  salt  ha<l  not  bl^en  taken,  llis  skin  at  the  midnight 
visit,  Septiunber  7,  was  waiin  and  jierspiring,  tongue  dry  and  brown  in  the  centre,  pulse  full,  111.  Half  an  ounce  of 
tincture  of  rhubarb  with  ten  drops  of  oil  of  anise  was  adiuinislered,  by  which  the  bowels  were  moved  rapidly.  In  the 
evening  he  was  umouscious,  and  during  the  night  delirious  with  involuntary  stools  of  a  brown  color.  Next  day 
tlieri^  was  r:il  her  less  fever  ;  jiulsi'  101.  t^iiiniiie,  which  had  been  given  the  jncvions  day,  was  continued  in  eight-giaiii 
do.ses,  with  whiskey-punch  and  beef-essence,  ami  an  astringent  injection  at  night.  His  bowels  were  moved  twice  on 
this  day,  the  Kth,  and  he  had  temlerness  in  the  right  iliiKt  region.  During  the  following  night  there  was  walking 
delirium,  ami  a  few  minute  red  spots  were  discovered,  w  liich  di<l  not  disapiiear  on  |)re.ssure.  \t  11  A.  M.  of  the  ilth 
he  had  a  seveit!  congestive  chill;  during  the  paroxysm  his  pulse  was  si  long  and  rai)id;  he  raved  and  showed  much 
strength.  Morphia  was  given  to  iiuiet  him.  His  bowel.s  were  moved  involuntarily  during  the  day.  and  he  was  very 
restless,  requii  iug  to  be  held  in  bed.  On  the  10th,  after  a  ([uiet  night,  he  was  dull  ami  stupid,  his  pnlse  117,  skin 
hot,  face  llnshed,  teeth  covered  with  sordes  ;  in  the  evening  be  became  drowsy  and  w:is  (|uiet  during  the  night. 
Turpentine  emulsion  was  given.  On  the  11th  his  jiiilso  was  (luiek  and  weak,  130,  tongue  cracked  ami  ]irotruded 
witli  dilliculty,  stools  involuntary,  countenance  haggard  and  eyes  lixed  ;  he  had  also  subsulttis.grimling  of  the  teeth, 
rose-colored  spots  and  sudamina.  In  the  evening  his  skin  became  cool,  the  prostration  iiu'ieased  and  the  involuntary 
stools  were  large  ami  fetid.  On  the  12th  the  syniidoms  were;  I'nlse  137,  soft,  small  and  wi'ak;  res)iirati(m  11; 
skin  hot  and  moist ;  hands  and  feet  cold  ami  clammy;  face  pale;  nose  pinched:  eyes  and  uu)uth  half  closed:  lips 
livid;  nausea;  subsultiis:  black  vomiting.  He  died  iit  3  f.  Ji.  /'(/»^HlO/•^')H  examination  :  The  ileum  was  much  thick- 
ened, inllamed  ami  tilcerated  for  live  feet  above  the  ileo-ca'cal  valve;  I'eyer's  glamis  were  elevated,  extensively 
ulcerated  and  perforated  in  two  places  near  the  valve.  No  fa'cal  matter  was  fomul  in  the  peritoneal  cavity.  The 
stomach  was  not  examined. — Stmiiiuri/  Ilospital,  Gciiryctoivti,  I).  C. 

t'.vsK  17. ^Private  James  1).  I'rickett,  Co.  H,  Ilth  Va.;  age  21 ;  was  admitted  .Sejjt.  lit,  \H(ii,  with  typhoid  fever. 
According  to  the  statement  of  a  comrade  this  imm  had  been  in  service  about  two  years,  during  which  he  ha<l  jm'I  tbrmeil 
his  duties  with  little  interruption  from  ill  health.  On  admission  he  was  delirious  and  almost  moribund.  He  had 
a|i]i:irently  been  jityalised  by  some  prei)aration  of  mercury  before  his  arrival.  Morphia  was  orilered  for  the  purpose 
of  procuring  rest  and  sleep.  On  the  21st  his  pulse  was  111),  feeble  and  thread-like,  tongue  dry,  red  and  glazed,  gums 
spongy,  teeth  covered  with  sordes,  breath  tainted  with  the  fetor  of  sali\-atiou,  abdomen  tympanitic  and  temler, 
countenance  darkly  Hushed,  skin  cool  and  dry;  thete  had  been  delirium  during  the  night.  A  hot  8i)oiige-bath  was 
ordered,  with  fomentations  to  the  abdomen,  quinine,  turpentine  emulsion,  whiskey-punch  and  solution  of  chloriite 
of  potassa  as  a  mouth-wash.  Under  this  treatment  the  tongue  becauu',  somewhat  moist  and  the  sordes  disappeared 
from  the  teeth,  but  the  delirium  continued  through  the  night  with  drowsiness  during  the  day.  He  had  epistaxis, 
partly  induced  by  picking  at  the  nose.  On  the  25th  he  seemed  slightly  improved,  but  next  day  persistent  vomiting 
set  in  with  slight  hiccough,  the  abdomen  contiiniing  distended  and  extremely  sensitive.  He  died  comatose  on  the 
27th.  I'oai-Mortcm  examination  seventeen  hours  after  death:  liody  not  much  emaciated.  There  were  recent  ))erito- 
neal  adhesions  and  a  large  (luantity  of  serum  in  the  abdominal  c;ivity.  The  intestines  were  distended  with  tlatus. 
The  mucous  membrane  of  the  small  intestine  was  congested  and  of  a  dark-red  color  from  the  pylorus  to  the  ileo-ca-cal 
valve;  the  glands  of  Peyer  and  the  solitary  glands  were  inflamed  and  ulcerated,  and  tliere  were  several  minute  per- 
forations. The  liver  was  normal;  the  spleen  slightly  enlarged  and  congested;  the  kidneys  congested  and  greatly 
enlarged,  the  right  weighing  thirteen,  the  left  ten  ounces.  The  brain,  thoracic  viscera  and  colon  were  not  examined. 
.let.  J.i.f't  Siiry.  .1.  n'.  Haldol,  CiimhirUnid  Jlospilid,  Md. 

Case  18. — Private  Abraham  Lindsley,  Co.  E,  15th  N.  Y.  Cav.;  ago  2t> ;  was  admitted  ."^ept.  fi,  1861,  with  tyjdioid 
fever.    This  man  enlisted  in  July,  1863,  and  had  good  health  until  March  10  follow  ing,  wlien  he  had  an  attack  of  diar- 
rhoea lasting  six  weeks,  for  which  he  was  treated  in  regimental  hospital.    Exposure  in  the  tield  during  Hunter's  raiil 
Med.  Hist.,  Pt.  Ill— 43 


S38  I'OriT-MOKTKiM    KKCOKDS    uK 

tliroiif;li  West  Viif^iiiiii  hroiinbl  mi  ii  I'ccinrom'e  of  his  diarilHru,  which  coiitiiiiicd  diiriii;;  tlic  wholi'  (if  llial  scvi-iii 
caiu|i;iij;ii  iinil  for  llirei!  wocks  iifler  its  tciiiiiiiiitioii.  Wliilo  «h)\vly  iiiiproviiig  in  the  rojiiiiiditul  hosjiital  hv  iicconi- 
imuii'd  liis  rogiiiicut  on  ii  foiccd  iiiaich,  diiriii!;  whicli  his  strtjiiyth  utterly  j^ave  way,  and  lie  was  sent  to  Hancock, 
Md.,aiid  tlicncc  to  this  lios|)ilal.  i  hi  his  airival  liis  syiii[itoms  wci'c  those  of  typhoid  fevef — pulse  lapid  and  initalile, 
countenance  darkly  llutilied,  skin  dry.  eyes  languid  and  dull,  toiijjiie  red  and  dry,  abdomen  tender  and  tympanitic. 
He  had  frcriirent  slimy,  watery  stools,  with  some  tenesmus,  and  was  so  weak  that  he  could  scarcely  speak.  Morphia 
and  astrin<;ent  mixtures,  ([iiinino  and  milk-punch  were  administered,  hut  without  improvement.  On  the  11th  his 
toufjue  had  become  brown  and  dry,  his  alidomen  extremely  sensitive  and  his  stools  tliiu  and  fetid.  On  the  followinj? 
uight  he  had  some  delirium,  and  next  day  was  drowsy  ami  unconscious  most  of  the  time,  occasionally  picking  at  the 
liedclothes  and  lingering  the  air.  He  C(nitinue(l  thus  for  two  days,  his  jiulse  becoming  more  rajiid  and  feeble  and 
his  tongtie  swollen,  glazed  and  brown,  with  red  margins.  On  the  14th  there  was  a  slight  amelioration  of  the  symiitoins, 
but  next  day  the  pulse  ran  nji  to  lilt,  the  eyes  became  glassy,  the  pupils  dilated,  and  death  occurred  after  an  interval 
of  deep  coma.  I'ont-mortcm  examination  seventeen  hours  and  a  half  after  death:  liody  moderately  emaciated.  Exten- 
sive congestion  of  the  omeutmn,  recent  adhesions  and  other  indications  of  peritonitis  were  observed.  The  intestinal 
mucous  mend)ranc  was  red  and  injected  from  the  duodenum  to  the  ileo-cu'cal  valve;  Pcyer's  patches  were  extensively 
ulcerated  and  several  of  the  ulcers  had  penetrated.  The  liver  and  kidneys  were  pale  and  fatty;  the  spleen  enlarged 
and  dark  colored.     The  colon  was  not  examined. — .let.  As.rt  Surij.  J.  If.  lloJih-n,  Ciimlnrlutid  Ho^pHul,  Md. 

Ca.sk  19. — Private  S.  C.  Cole,  Co.  F,  77th  N.  Y.;  age  2();  was  admitted  Aug.  1,  18tU,  with  diarrho'a,  nausea, 
vomiting,  great  prostration,  weak  voice  and  feeble  pulse,  80,  which  continued,  but  with  some  abatement,  until  the 
10th,  when  he  was  seized  with  a  sudden  and  violent  pain  in  the  hypogastric  and  right  iliac  regions  and  became  greatly 
prostrated,  the  countenance  anxious,  surface  cold  and  moist,  voice  coarse  and  husky,  pulse  small  and  increasing  iu 
freijuoncy  and  abdomen  hard  and  tender  but  not  tympanitic.  Magendie's  solution  gave  some  relief  to  the  paiu,  but 
he  sank  rapidly  and  died  on  the  12th.  PoKl-iimrlcm  examination  fourteen  hours  after  death:  Peritoneum  pur])le, 
much  congested,  nnadherent,  and  cavity  containing  thirty  ounces  of  a  yellow  li(]uid  mixed  with  fa'Cal  nuitter.  8mall 
intestine  much  congested;  ileum  within  a  foot  of  the  ileo-ca'cal  valve  presenting  many  ulcerations  of  Peyer's  glands, 
with  five  circular  perforations  from  three-fourths  of  an  inch  to  one  inch  iu  diameter. — Sury.  Ilitirif  K.  Steele,  Stii  Ohio 
Car.,  Ilosjiital,  Frederick,  Md. 

Cask  20. — Private  Henry  R,  Reflor,  Co.  15, 13th  Regulars,  was  admitted  on  board  hospital  steamer  D,  A.  January 
March  17,  1863,  at  Young's  Point,  La.  On  admission  he  stated  that  he  had  been  sick  for  some  weeks,  and  from  liis 
description  it  was  evident  that  he  had  sutiered  from  a  mild  attack  of  typhoid  fever.  He  was  convalescing;  he  sle]it 
well  and  had  a  good  appetite.  When  about  to  leave  the  boat,  on  March  23,  for  transfer  to  the  convalescent  hospital 
at  Milliken's  ]5eiul,  he  was  suddenly  attacked  by  severe  pains  in  the  lower  part  of  the  abdomen  and  was  at  once  carried 
liaek  to  bed.  He  had  a  pale,  anxious  countenance  and  was  bathed  in  a  profuse  cold  perspiration  ;  pulse  i}0  and  feeble. 
Half  a  grain  of  sulphate  of  morphia  was  ordered  and  hot  applications  to  the  abdomen.  Castor  oil  was  adminis- 
tered and  afterwards  an  enenni,  btit  neither  relieved  the  constipation  of  the  bowels.  In  the  evening  there  was  much 
pain  and  distention.  Sulphate  of  morphia  was  given  every  two  hours.  He  became  intensely  prostrated  and  died  at 
midday  of  the  2t3th.  There  was  no  vomiting  in  this  case.  I'ost-mortem  examination  ten  hours  after  death:  Thoracic 
viscera  normal.  The  jieritoneal  sac  was  inllamed  and  contained  a  large  (|uantity  of  greenish  lluid;  the  abdominal 
viscera  were  glued  to  each  other  by  layers  of  soft  coagulated  lymph.  The  mucous  membrane  of  the  ileum  w  as  in 
some  jilaccs  injected,  and  in  its  lower  part  near  the  c;ecum  were  some  cicatrized  ulcers  of  Peyer's  glands ;  one  ulcerated 
patch  had  perforated  the  coats  of  the  intestine. — Sunj.  Alexander  U.  Iloff,  TJ.  S.  V.,  Hospital  Steamer  D.  A.  January. 

(Ii.)  reyer's patches  ulcerated  and  the  lanje  iutentine  also  implicated — 13  cases. 

Cask  21. — Private  Richard  Clark,  Co.  M,  2d  Mass.  Cav.;  age  21;  was  admitted  July  lit,  1863,  having  been  sick 
for  an  unknow-u  jioriod;  tongue  dark  brown  but  red  along  the  edges;  pulse  130,  small ;  delirium;  epistaxis;  diar- 
rhea; abdomen  tympanitic  and  covered  with  petechias.  His  condition  improved  iiiuler  the  influence  of  camphor, 
valerian,  quinine,  acetate  of  ammonia  and  sponging  with  alcohol  and  water,  but  on  the  2ith  pain  was  developed 
in  the  right  lung  with  dnlness  and  crepitant  rales  over  its  lower  lobe.  Cupping  was  followed  by  relief;  but  his  skin 
continued  hot  and  dry.  On  August  2  he  passed  a  niiart  of  blood  from  his  bowels  and  a  small  ([uantityon  the  follow- 
ing day.  He  died,  exhausted,  on  the  5th.  Poxt-martem  examination  seven  hours  after  death:  Right  lung  congested 
throughout;  left  lung  healthy.  Stomach  bloodless,  its  coats  somewhat  thickened  and  its  pyloric  orifice  ooutracted; 
Peyer's  patches  ulcerated;  ileo-cacal  valve  extensively  ulcerated  and  disorganized;  ascending  colon  containing  a 
considerable  quantity  of  blood. — Act.  .Iss't  Surij.  T.  Turner,  Third  Division  Uospital,  Alexandria,  Va. 

Case  22. — Private  Henry  Royer,  Co.  C,  148th  Pa.,  died  June  30,  1863,  from  an  attack  of  typhoid  fever.  Post- 
mortem  examination  twenty-four  hours  after  death:  .Slight  cadaveric  rigidity:  much  bloody  froth  issuing  from  the 
mouth  and  nostrils.  The  mucous  lining  of  the  stomach  was  irregularly  colored;  it  was  of  a  slaty  hue  at  the  pylorus, 
mottle<l  reddish  and  blackish.  Ueneath  the  epithelial  lining  of  the  duodenum  a  quantity  of  gas  was  found,  supposed 
to  be  due  to  putrefactive  changes.  IJelow  this  point  the  mucous  membrane  w  as  of  a  dull  whitish  color,  very  inelastic 
and  easily  torn.  Eight  feet  from  the  ileo-ca-cal  valve  I'eyer's  patches  commenced  to  be  involved ;  at  first  the  upper  and 
lower  parts  of  the  patch  were  swollen, livid,  not  ulcerated,  the  centre  being  natural;  lower  down  some  were  entirely 
livid,  with  no  ulceration;  about  one  foot  from  the  valve  was  one  very  large  patch  with  thick  high  walls,  ulcerated 
centre  and  numerous  small  ulcerated  points  in  its  area.  These  portions  were  of  a  lighter  hue  than  the  non-ulcerated 
portions,  luit  none  of  them  perforated  the  gut;  the  largest  patches  gave  the  intestine  a  honey-combed  appearance 
from  the  peculiarity  of  the  ulceration.  The  large  intestine  was  of  a  grayish-slate  color,  its  mucous  membrane  soft- 
ened but  not  ulcerated. — AssH  Sunj.  Uarrinon  Allen,  U.  S.  A.,  Lincoln  Hospital,  Washington,  V.  C. 


niK    Cti.NTJJSTKlJ    FKVEES.  339 

Cask  2;i.— I'rivati-  DiuUev  WUitlock,  IVi.  K,  ."itli  Mich.  Cav.:  a^'c  17:  was  adinill.'d  Marcli  '_'."),  IXC;).  On  Apiil  1 
his  f(]ii(lili(ii[  »  as  iKiti'd  as  toUows:  Weak  :  toiif;iie  dry  and  oiiatrd:  |iu1nc  II 1, 1'dniini-ssililc:  rcs|iiiatii)n  llti,  dilliciill : 
bowfls  regular:  skin  hot  and  dry  :  ln-d-suros  on  liark  and  liips:  urine  passed  invohintarily :  dulness  (in  |M>rcussiiin  over 
cacii  luug,  most  marked  jiosteridrly:  greatly  increased  vocal  resonance:  lironehial  ri'siiiratioii :  irrilaldi'  cough,  .'id: 
Pulse  i:>0;  lespiration  (H):  sputa  somewhat  tenacious,  (llli;  Stronger:  jirid'nse  senii-iiurulenl  discliaige  from  i-acli 
ear.  7th:  lJiarrh<ea,  seven  stools:  pulse  110:  respiration  11:  tongue  moist.  10th:  Diarrhoa  coiuinuis:  he  refuses 
mcdichii'.  Body  sponged  with  w  hiskcy  :  medicine  gi\  en  l.y  enem:i.  llth;  I'ulse  l."iS:  n^sjiirat  i<ui  L'l :  weak:  de;ith. 
I'usl-jiiiiiiriii  examination  twenty  hours  after  death;  liigoi  uuirtis;  emaciation.  lirain  normal.  'I'racluM  ami  bronchi 
tilled  w  ith  white  viscid  sputa  :  mucous  MU'iiiliraue  dark  i>urplish:  bronchial  glands  lirui,  of  a  dull  liviu-  C(dor  nun  tied 
blackish  in  ccntie.  Lungs  solidilied  ami  dark  piirplo  Jiosteriorly,  reddish  anteriorly;  minute  whitish  points  iu 
central  iiortions;  pleuritic  ettusion  on  left  side.  Heart  contained  snuiU  white  clots  on  both  siih's.  Liver  mottled 
l)urplc  and  pale  yellow  ,  intiMlobular  are;is  yellowish;  twenty-six  drachms  of  ilark  bile  in  gall-bladdiM'.  Sjileen  linn, 
dark  mulberry  eidor.  (Ksojihagus  pale:  mucous  incuibraiu^  of  slounicli  uuittlcd  a  delicate  pink  cohu-:  deposit  of 
black  pigment  on  jiyloi  us.     Sm:ill  intestine  in  upper  jiarl  jiale  yellow  ish:  duodonnin  lille<l  with  thick  stringy  mucus: 

I'eycr's  patches  inirnuil  to  within  eight<-eu  inches  of  ileo-cacal  valve,  when^  they  were  thickiiud, elevated gested 

and  in  many  placiw  indurated  and  ulceiated,  the  nh'crs  having  wi'll-di'lincd  edges  an<l  in  some  instani'cs  rcdilish 
bases;  solitary  follicles  the  si/e  of  small  shot.  Mucous  nu'inliraiu' of  large  intesi  iiu' pale,  ruga' dark  red  ;  solitary 
glands  prominent,  dotted  with  pignuiit  in  centie;  lower  ixirtion  of  intcstini^  iircsenting  luiiny  minute  superlicial 
ulcers  unconnected  with  solitary  glands.  Kidneys  jialc;  suprarenal  c:ipsules  mollied. — .I.skV  .S'lov/.  Iliinisnn  Alteii, 
U.  S.  A.,  lAnculn  llonpUiil,  Hunliiiijildii,  1).  C. 

Vxav.  2\. — Private  .John  North,  Co.  E,  ."ith  Mich.  Uav.,  was  iidinitted  Marcli  '1\<.  bSliii,  having  been  sick  for  .some 
time  in  regiuu'iit.al  hospital.  !!(■  w:is  deliriiuis  and  had  high  fever,  a  tremulous  full  pulse, sindes  upon  the  nmuth  :iiid 
tooth,  a  typhoid  fever  tongue,  some  cough  and  expectoration,  pain  ill  the  right  iliac  fossil  ami  diarrluea,  the  evacu- 
ations soon  becoming  inv(duntaiy  and  otlensivo.  lie  died  on  the  28tli.  I'oxt-iiiortitn  examination  twelve  liouis  after 
death:  No  emaciation  :  rigor  mortis  marked;  apparent  age  21  years.  The  brain  was  healthy.  'I'lie  right  lung  was 
cong<'sted  and  weighed  twenty-lixc  oiim'es;  the  left  tw'j^nty-six  ounces,  its  lower  lobe  being  intensely  engiugcd  ami 
in  S(>ml^  parts  hejiatized.  The  right  side  of  the  heart  contained  a  blackish  clot  of  moderate  size:  the  left  venlricle 
a  smaller  clot.  The  liver  was  p:ile,  its  acini  well  delined,  its  texture  .sofliu'  than  usual,  its  weight  si'venty-lhree 
oniKcs  and  a  half:  the  gall-bladder  contained  live  drachms  of  deep-yellow  llaky  bile.  The  spleen  w;is  soft,ilcei) 
liurplish-black  ;ind  weighed  eighteen  ounces.  'I'lui  pancreas  ami  kidneys  were  noriual.  The  stomach  was  red  :it  the 
fundus.  I'eyer's  ]>:itches  were  indnrati^d,  thickened  and  in  many  j)laces  ulcerated.  The  solitary  glands  were  so 
nuuicroMs  that  on  a  si|uare  inch  .selected  at  raiuloni  lifteen  were  counted;  they  were  large,  about  two  lines  in  diameter. 
The  uiucoiis  membrane  of  the  large  intestine  was  generally  mottled  red,  but  in  the  ;iscending  colon  it  w;is  of  a  light 
slate  ccdor  mottled  with  red  :  the  solitary  glands  in  the  ca'ciim  were  enlarged  and  several  of  them  iilci^rati^d. — Ami't 
^^(i•;/.  Ildnixnii  Allen,  ('.  ,S'.  ./.,  I.hicolii  llospitnl,  ll'iisliiiiyloti,  I).  C. 

Cask  2'k — Private  Edward  E.  Hice,  Co.  I),  12od  N.  Y.,  was  admitted  ,Iaii.  11,  IXti;).  During  the  inti'tval  between 
his  admission  ami  his  death  on  the  llth  extreme  agitation,  hurried  re8])iration,  delirium  and  tenderness  in  the  right 
iliai^  fossa  were  noted,  rost-murhm  examination  seven  hours  after  death:  The  lungs  were  crowded  into  the  ujijier 
pari  of  the  thorax  by  tlie  distended  intestines;  the  left  luug  was  slightly  congested  jiosteriorly;  the  ujiper  and  miildle 
lobes  of  the  right  lung  were  partially  oongested  and  solidified,  apparently  the  result  of  liypostasis;  the  blood  was  fluid. 
The  liver  was  large  and  pale:  the  spleen  large,  congested  and  soft;  the  kidneys  pale  and  exsanguine.  The  intes- 
tines were  inflated  w  ith  gas:  the  ileum  congested ;  Peyer's  patches  enlarged  and  ulcerated,  some  to  a  marked  degree; 
the  ca'cum  congested;  the  mesenteric  glands  enlarged. — Snry.  II.  Urijdnl,  V.  S.  I'uh.,  I.iinoln  IIoKintnl,  lyaithitKjIon,  1>.C'. 

Case  2ti. — Private  Jos.  McVangh,  Co.  D,  147th  Pa.;  age  45;  was  admitted  July  2H,  l«6:i.  He  was  very  feeble 
and  delirious,  with  au  iiiclLnation  to  stupor;  his  tongue  very  dry  and  red;  skin  cool  and  claiiiiny ;  pulse  113,  small 
and  weak;  bowels  moved  about  ten  times  daily;  abdomen  hard  and  tender, especially  iu  the  right  iliac  region.  In 
the  progress  of  the  case  the  stools  became  less  frennent,  but  all  the  other  symptonis  increased  in  severity;  the  pas- 
sages during  the  night  before  death  were  involuntary.  He  died  August  2.  PDnt-morhm  examination  seven  hours 
after  death:  The  brain  weighed  forty-live  ounces;  the  pia  mater  was  somewhat  congested  ;ind  the  choroid  plexuses 
tilled  with  minute  air-bubbles.  The  trachea  was  greenish  but  contained  healthy  sputa;  tlw  mucous  membrane  of 
the  o'soi)hagns  was  pale,  yellow  -stained  near  the  cardiac  orifice  and  presented  numerous  whitish  points.  The  right 
luug  weighed  eleven  ounces  and  was  slightly  engorged  in  its  upjier  and  middle  lobes.  The  left  lung  weighed 
fifteen  ounces ;  its  upper  lobe  was  much  shrunken  and  contained  but  little  air;  towards  its  apex  w  as  a  small  circular 
elevation  about  the  size  of  a  chestnut,  surrounded  by  a  livid  purplish  zone  about  three  inches  iniliameter:  on  oiieniug 
this  spot  a  (luantity  of  air  escaped  and  a  few  drops  of  bloody  fluid;  the  lower  lobe  was  engorged  with  venous  blood. 
The  heart  contained  a  small  fibrinous  clot  iu  the  right  cavities  and  a  mixed  clot  in  the  left:  the  pericardium  con- 
tained two  drachms  of  bloody  fiuid.  The  stomach  was  unusually  firm  and  its  mucous  membrane  pale-red  in  color 
throughout.  The  liver  weighed  fifty-three  ounces  ami  w  as  slightly  congested ;  the  gall-bladder  contained  ten  ounces 
of  bile  of  a  browuish-ochre  color,  filled  with  a  fiaky  substance  which  did  not  precipitate.  The  spleen  weighed  five 
ounces  and  was  flabby,  soft  and  of  a  mulberry  color.  The  right  kidney  weighed  five  ounces;  its  external  surface 
was  of  a  bluish  color  spotted  with  numerous  dark-blue  points;  an  abscess  about  the  size  of  a  horse  chestnut,  with 
ecehymosed  walls,  containing  discolored  pus,  was  found  on  the  anterior  surface  near  the  outer  margin.  The  left 
kidney  weighed  five  ounces  and  a  half;  it  was  much  congested;  a  small  cyst  containing  serum  was  found  on  its 
anterior  surface.  The  small  intestine  was  healthy  to  within  three  feet  of  the  ilco-ca'cal  valve,  but  from  this  point 
downward  the  mucous  menilirane  was  of  a  reddish-purple  color,  thin  and  somewhat  softened;  Peyer's  patches  were 


340 


l'U81''.MOUTKM     1:KC()UI)S    oK 


(liscoldied  ami  iilioiiittil,  especially  iieiir  (he  valve,  where  patehes  i>f  a  darU-hlue  stiine  eohir,  fully  an  iiieh  in 
tlianieter,  were  eroded.  Tlie  laifjt^  intestine  was  j;ieenisli  hut  free  IVoni  uleeiatii)n ;  the  solitaiy  fjland.s  were  white, 
and  eonspiuiioUB. — Ans't  Hiiri).  llan-ixnn  AUiu,  ('.  S.  .(.,  l.iiicohi  ll().-<pUal,  W'tisliiiKjIoii,  IK  ('■ 

Case  27.— I'livate  Martin  Ihirnes,  Co.  (i,  Kilth  N.  Y.;  a>;e  :.'():  admitted  July  17,  lS(i-">,  liaxin.i;  lieen  siek  ahoiit 
three  weeks  without  medical  attendanee.  Low  delirium  set  in  on  the  19th;  dianlnea,  whieh  was  troiililesonie  at 
tifst,,sul)Mi(led  by  the  2l8t.  On  the  2;id  blood  to  the  amount  of  two  ]iints  was  passed  from  the  bowels,  and  he  died 
exhausteil  four  hours  thereafter,  i'^.v^-miw/oji  examination  nine  hours  after  death:  The  intestines  were  half  lilled 
with  a  frothy,  semi-llui<l,  bloody  mass;  I'eyer's  patehes  were  uh'erated  into  deej)  exeavations  lionnded  by  Ihiekeiied 
and  indurated  ed^es;  the  solitary  follielcs  were  ulcerated  throuf^houl  both  small  and  larjte  intestines:  many  i>f  the 
ulcers  iienetrated  to  the  peritoneum.  The  spleen  was  enhir(j;ed  and  softened;  the  other  orj;ans  normal. — ./</.  .t.s-.v7 
Siiry.  (iconic  I'.  IhnuncuU,  Doitylan  Ilufipitnl,  U'lisjiiiujioii,  I).  C. 

Cask,  2><. — Private  Castor  Seebold,  Co.  E,  51st  I'a.:  aj;e  10;  was  admitteil  May  7,  1S61,  present injj;  some  emacia- 
tion, dry  tonfiue,  sordes  on  teeth,  teiulerness  in  rif>lit  iliac  fossa,  and  restlessness,  with  a  fre(iuent  pulse,  IL'O.  Next 
day  rose-eolored  spots  were  observed,  and  lu'  had  epistaxis  and  diarihiea,  with  a  more  vapid  pulse.  He  was  ti-eated 
w'ith  acetate  of  anniionia  and  morphia,  milk-punch,  ejigmii;  ami  beef-tea.  He  died  on  the  llth.  Puil-iiiorlcni  exam- 
ination four  hours  after  death:  Lnuf^s  conjicsted;  heart,  liver  and  kidneys  healthys  spleen  somewhat  softened  and 
conjjested:  ileum  and  ca'cum  very  nmch  congested:  Peyer's  patclu's  and  the  solitary  glands  in  the  ileum  nnudi 
enlarged  and  ulcerated. — Tiiriicfs  Lane  Hospital,  riiihidclphia,  I'u. 

Case  29. — Corporal  .1.  B.  Richardson,  Co.  E,  2d  Mich.;  age  2(i;  admitted  Feb.  8,  lWi3,  having  been  affected  for 
two  weeks  with  anorexia,  tympanites,  diarrlnea  and  cough,  and  inesenting  a  hot  ami  dry  skin,  fnrre<l  tongue  and 
injected  eyes;  delirium  and  involuntary  stools  occurred  on  the  llth,  and  deatli  took  place  on  the  17th.  I'iinl-)ii<)rlciit 
examination:  The  brain  was  normal.  The  bronchial  tubes  on  both  sides  presented  imlieations  of  indap.unation,  and 
the  lower  lobes  of  the  lungs  contained  hepatizations  from  the  size  of  a  chestnut  to  that  of  a  hen's  egg.  The  liver 
and  spleen  were  large  hut  unaltered  iu  texture;  the  gall-bladder  was  sumll  and  half  full  of  dark  bile;  tin-  kidneyo 
healthy;  the  pancreas  enlarged  and  .somewhat  hardened.  The  mesenteric  glands  were  enlarged  and  indurated;  the 
mucous  membrane  of  the  stomach  much  injected;  the  duodenum  and  jejunum  inflamed  in  patches;  the  iU'um  con- 
gested, thickened  and  soiteneil,  and  its  agminated  glands  ulcerated,  tlie  ulcers  having  thick,  hard,  prominent  edges. 
The  colon  was  inllamed  in  patches  and  its.  mucous  membrane  thickened. — HarewDiid  Honjiitiil,  l\'<i«Jiiii(itoii,  1).  (.'. 

Case  80. — Private  Edgar  .Sanborn,  Co.  I),  6th  N.  II.;  age  15;  was  admitted  .luly  24, 1S(U,  with  feeble  and  frequent 
pulse,  great  heat  of  body,  dry  lirown  tongue,  sordes  on  teeth,  slight  diarrhcea  and  great  tenderness  in  the  right  iliac 
region.  On  the  28th  his  face  became  dusky  and  stupor  supervened.  He  died  on  the  30th.  Post-mortem  examination : 
Much  bronchial  secretion;  lungs  congested;  heart  and  liver  normal;  lower  half  of  ileum  slightly  inflamed,  with  com- 
mencing ulceratioti  of  Peyer's  glands  and  cicatrices  of  old  ulcers;  csecum  presenting  two  ulcerations;  rectuiu  much 
inflamed. — Act.  Asu't  Siiry.  A.  H.  Hiircn,  Fuirfox  Seminary,  Va. 

Case  31. — Private  Oscar  Snow,  Co.  H,  3d  \t.;  age  20;  was  admitted  Oct.  1,  1861,  witli  typhoid  fever.  He  had 
been  sick  a  week,  but  he  was  so  <lull  that  he  could  give  but  little  infornuition  concerning  the  early  part  of  his  sick- 
ness. A  bath  was  ordered  for  him,  and  Dover's  powder  at  night.  Next  day  his  face  was  flushed,  pulse  135,  full, 
skin  liot  and  dry,  tongue  slightly  moist  but  thickly  coated  brown;  he  liad  sliglit  delirium,  some  deafness  and  ten 
or  twelve  characteristic  rose-colored  spots;  his  bowels  were  loose,  tender  and  tympanitic.  From  this  time  the 
condition  of  the  jiatient  gradually  changed  for  the  w  orse.  His  bowels  for  some  time  were  not  loose,  but  tenderness, 
nieteorism  and  borborygnuis  were  ]>re.s<'nt  throughout  :  on  October  12  he  had  three  involuntary  passages.  Ilis  pulse, 
wliieh  at  first  was  rapid  and  full,  lost  its  fulness  but  retaiiunl  its  rapidity,  becoming  small,  w<>ak  and  lluctuating. 
His  tongue  became  dry,  ami  on  the  9th  he  was  unable  to  protrude  it;  on  the  same  day  sordes  appeared  on  the  teeth. 
The  rose-colored  sjiots  disappeared  on  the  llth.  From  being  somewhat  dull  mentally,  with  occasional  mild  delirium, 
he  fell  into  a  prostrate  condition,  lying  on  his  back  with  his  lower  jaw-  dropped  and  his  eyes  open,  taking  no  notice 
of  anytliing  going  on  around.  On  the  8tli  his  breathing  became  hurried;  mucous  and  sibilant  rales  were  heard  iu 
the  right  lung,  and  on  the  12th  a  leathery  creaking  sound  was  distinguished  over  lioth  lungs.  On  the  llth  the 
parotid  gland  was  found  to  be  swollen.  The  treatment  consisted  of  (luinine,  turpentine,  brown  mixture,  nourish- 
ment and  stimulants.  On  the  evening  of  the  I3th  his  face  was  ashen-gray  in  color,  lips  cold  an<l  bloodless,  head  and 
extremities  cold;  there  was  some  deafness  and  it  was  very  difficult  to  arouse  Iiim;  he  had  also  a  mild  delirium, 
speaking  of  going  home,  and  had  no  idea  of  his  condition.  His  pulse,  about  110,  was  weak  and  barely  percejitible 
at  the  wrist ;  the  superticial  circulation  was  almost  suspended — an  iniinession  ma<le  with  the  fingers  remained  a  long 
time.  He  had  no  hemorrhage  from  the  nose  or  bowels;  his  bowels  moved  occasionally  involuntarily,  the  passages 
being  very  thin;  the  abdomen  was  acutely  tender  and  borliorygmus  frequent.  His  re8i>iration  varied  from  fifty 
to  sixty  per  minute;  a  rattling  sound  was  heard  in  the  throat  during  expiration,  as  though  from  mucus  whieh 
he  had  not  strength  enough  to  eject;  his  breath  was  very  offensive  for  the  first  time  since  his  illness.  His  urine,  acid 
and  albuminous,  had  a  specific  gravity  of  1011,  and  contained  mucus,  epithelium,  urates  an<l  a  few  blood-discs. 
The  parotid  gland  continued  much  swollen.  On  the  evening  of  the  Uth  he  aroused  himself  and  sp(d<e  very  rationally; 
his  eyes  shone  brilliantly  for  a  few  minutes;  he  tried  to  rise  from  bed,  but  fell  liack  from  weakness;  the  rattling 
sound  in  the  bronchial  tubes  increased,  and  after  a  fi^w  deeji-drawn  lireaths  he  was  dead.  I'lint-miirtcm  examination 
fourteen  hours  after  death:  .Side  of  face  swollen;  parotid  infiltrated  with  pus.  The  pleural  cavities  contained  a 
number  of  large  blood-clots;  the  derivation  of  the  hemorrhage  was  not  ascertained.  The  lungs  were  congested, 
but  were  not  closely  examined  for  want  of  time.  The  stomach  contained  a  pint  of  very  offensive  yellowisli  matter; 
its  mucous  membrane  was  thick  and  congested.    The  liver  and  gall-bladder  were  enlarged  but  healthy;  the  spleen  and 


THE  (■(iMlMKii    i-i;vi;i;s.  all 

kidneys eulavj;('il  and  congested.  'I'lir  peritdiionni  was  nuu-h  inllaiiicd.  TIh-  i_'laiids  of  I'l^ycr  and  tlic  solitary  glands 
of  the  ileum  wore  miioli  nlroratt'd.  Afoot  :nid  a  half  tVoiii  the  ili'o-cacMl  \  al\  e  the  ileum  presented  a  duc-it  ieiiliiin 
aliout  four  inches  long,  as  wide  as  the  gut  from  whieli  it  w  us  (leri\c(l.  and  lil<<-  it.  lilackened  and  nuich  iih'i'iated. 
Th(Miicsenteric  glands  were  cnhirged.  tin-  uu'sentery  minh  rongested  and  inllaiiu-d.  The  mucous  nicmhrane  of  the 
eolon  was  dark  in  color  lint  not  nlci'iated. — •<iiiii}iiirii  llfi-ipiliil.  doi-i/i  hum.  I).  ('. 

Cask  .'il'.— I'rivate  Christian  Sehnll/.  Co.  K.  lllh  Conn.:  age  VJ:  was  admitted  Dec.  U;.  1m;l'.  Iia\  ing  hi-en  sick 
for  two  or  three  months  with  rheiunatism.  He  complained  only  of  jiains  in  his  hack  and  limlis  until  .Ian.  1,  ISli!!, 
when  he  was  taken  with  Iieaihiehe,  trembling,  a  fall  coniiiressible  pulse  and  other  manifest  at  ions  of  ner\  mis  derail  gi"- 
ment;  his  tongue  was  moist  and  coated  witli  a  white  fur.  He  was  ordered  a  teas])oonfiil  of  east  or  oil.  which  operated 
six  times  in  tlie  twenty-four  lionrs.  Xo  noticeable  change  occurn-il  until  tin'  llth.  when  some  tympaiiiles  w:is  obser\  ed 
and  one  tache  rouge  close  to  the  umbilicus.  ( In  the  !itli  I  he  jiulse  liccamc  small  and  <MUiiiircssililc.  the  tongue  dry,  t  he 
face  flushed  and  the  diarrlnea  persistent,  while  an  increasing  temlency  to  drowsiness  was  manifest.  Ten  days  lali'r 
the  diarrhiea  became  checked  and  tlie  tongui'  dry,  raw  and  cracked:  he  had  heriietic  I'rnptions  on  the  lower  lip,  a 
trcMiblcsomc  e(High,  and  was  so  mnedi  jirostratcd  as  to  slide  (hiwn  in  bed.  On  the  L'lst  his  bowels  were  moved  in  hanl 
inas.ses  after  an  interval  of  forty-eight  hours;  next  day  his  ptilsi'  was  strongir.  tongui'  cleaning  and  more  moist 
and  skin  clammy,  but  the  cough  jiersistcd  and  was  distressing.  On  the  liOth  he  was  considered  c(mvalescenl,  and 
liis  case,  with  careful  attention  to  diet,  jirogicssed  favorably  until  I'i'brnary  '_',">,  when  tlieii'  occurred  uiimistaUable 
evidence  of  a  rclaipse.  On  March  :i  the  pat  lent  presented  the  ta(dies  rouges,  and  was  alfected  with  dulue.ss  of  hearing, 
opistaxis,  tympanites  and  <liarrhu'a:  on  the  Sth  he  vomited  matter  which  looked  like  alteied  blood,  and  complained 
of  pain  in  the  left  hypoeliondrium.  During  the  next  few  days  the  vomiting  coutiniicd  and  a  c<uigli  with  bloody  sputa 
was  develo]ied.  On  the  14tli  the  respirations  were  50  per  minute  and  the  pnls<>  fre(|uent  and  feeldi'.  lie  died  on  tlie 
20th.  I'lml-nuirlim  <>xaminatiou:  The  inncons  membrane  of  tlii' trachea  and  bronchial  tubes  was  inllamed:  th(>  bron- 
chial tulies  were  tilled  with  mueo-pnrnleut  matter.  In  the  right  lung  were  several  liejiatized  no<lules  the  si/.^^  of 
Wiilliuts,  the  surfaces  of  wliicli  were  atfaclied  by  ri'cciil  pseudo-membrane  to  the  costal  ]ih'ura:  the  left  pleural  sao 
eoiitaini'd  about  two  i|uarts  of  yellow  serum  mingled  with  pus  and  thin  jelly-like  fibrinous  coaguhi.  I'lie  in-art 
was  tilled  with  black  ami  white  clots.  I'eyer's  glands  were  tliickeneil  and  a  nnniber  of  tlieiii  ulcci:ili'il.  I  liree  of  tlio 
latter  having  perforated;  but  there  was  no  evidence  of  iieritonitis.  The  cacuiii  was  moderatidy  iiillained  and  i>re- 
Kented  a  number  of  siinill  ulcers:  the  colon  showed  a  few  streal<s  of  in  Ham  ma  I  ion.  I'licre  was  intralobular  congestion 
<d"  the  liver.     'I'lie  spleen  was  s<ift. — Act.  .Iix'l  Niov/.  ■I(>.i(ph  Liiilji,  fiatlrrla   llunjiitdl,  riiihiddjihiii. 

Case  Xi. — Scrgt,  (Justave  Van  I'.cken,  Co.  V,  Indeiicudent  battalion,  N.  Y.;  age  l!(l;  was  admitted  from  lleaufort, 
•S.  C,  with  typhoid  fever:  I'rostratioii,  pulse  IL't),  tongue  dry  and  brown,  sordes,  diarrluea,  red  eruiition,  delirium, 
and,  forty -eight  hours  before  death,  tympanites.  I'dsl-iiiiirlrm  examination  eighteen  hours  after  ileatli :  I'l'yer's  pat<die8 
I'Mi'iisivi'ly  nlccrati'd:  mucims  membram^  of  large  intestim^  ulcerated;  ca'cuiu  perforated  at  two  ]ioinls:  abilominal 
(M\  ily  containiuL;  a  large  i|uant  ity  of  fa'cal  matter  and  showing  but  slight  evidcni'cs  (d'  pet  it  on  it  is:  kidneys  fatty; 
s|p|ecn  enlarged. — .Ic^  .l.i.sV  Siirij.  .S.  Tcdtit,  Cuntral  I'ark  llaxjiitnl,  S.   \  .  (ily. 

{ ('.)   Voniliiioii  of  I'ti/rr's patchcK  mil  .slahd ;  ili  inn  or  kiikiII  iiihxtiiic  iilciriilid — lii  <anfii. 

Cask  lil. — Private  Hen.jamin  (hinningham,  Co.  ]),  Xt;th  \.  V.;  age  21;  was  adtnitled  Feb.  lf<,  1S(;2,  having  been 
sick  tor  siuiic  time  with  chills,  headache,  jiains  in  back  and  limbs,  loss  of  ai>pctite.  epistaxis,  diarrho'a  and  inability 
to  sleep.  On  March  I  his  pulse  was  recorded  as  rapid  and  wc.ik.  skin  warm  and  moist,  cheeks  Hushed,  tongiio 
smooth  and  nat  oral,  abdomen  tympanitic  and  covered  witli  vibices  and  a  few  siidamina  ;  lie  had  little  appetite,  great 
thirst  and  one  or  two  watery  and  sometimes  involuntary  passages;  he  was  somewhat  deaf  but  appeared  sensible; 
respiration  was  Imrricd  and  tliere  was  some  cough.  Treatment:  I'uueh,  lieef-e.ssence,  turpentine  emulsiiui  and 
tincture  of  iron,  with  mustard  to  the  abdomen.  Frcuii  this  lime  he  imjiroved:  His  \vat<^ry  jiassages  gave  place  to 
more  natural  and  regular  dischargi-s, — indeed,  on  the  Kith  his  bowels  were  noted  as  rather  constipated,  he  slept 
well,  his  appetite  returned  and  liis  general  aiipearance  and  strength  seemed  improving:  but  his  tongue  was  con- 
sidered to  be  too  sniocdh,  and  at  times  his  mind  did  not  appear  to  lie  clear.  He  was,  however,  considered  as  in  a  fair 
way  to  recovery.  On  the  15th  he  complained  that  his  hips  were  sore  from  long  continued  pressure,  and  next  day  that 
lie  had  lost  the  sense  of  taste — that  he  could  feel  his  food  when  in  his  mouth  but  could  not  taste  it.  Bed-sores  over 
the  sacrum  were  noted  on  tlie  17th,  and  great  debility  witli  enlarging  sores  over  the  left  troehaiiter  on  tlie  2(>th,  on 
which  day  al.so  he  was  seized  with  a  severe  ]iain  in  the  left  side.  This  pain  increased  on  the  27tli,  the  breathing 
becoming  hurried  and  prostration  extreme;  his  mind  was  clear,  pupils  dilated,  the  sclerotic  showing  to  an  unnatural 
extent.  He  ilied  on  the  29tli,  diarrluea  returning  a  few  hours  before  ileath.  I'ont-morli  in  examination:  The  mucous 
meinbraiie  of  the  ileum  was  much  intlamed  and  ulcerated  (Uglitcen  or  twenty  inches  above  the  ileo-ca'cal  valvo. — 
iSciiiiniirii  UoKpita},  (Irori/ctown,  D.  C. 

Case  35. — I'rivate  .Jacob  Davis,  Co.  I,  (Slid  I'.i.;  age  21;  was  admitted  Oct.  1(1,  lSt!;{,  with  emaciatiiui.  debility 
and  diarrhn>a,  a  dry,  brown  tongm?,  cracked  in  centre,  teeth  covered  with  sordes,  respiration  ([Uick  and  feeble  and 
pulse  over  90.  He  lingered  without  much  change  until  the  \><Xh.  when  he  diiil.  lie  was  given  concentrated  nourish- 
ment and  Ktimulants,  sweet  spirit  of  nitre  and  turpentine  emulsion,  with  nitrate  of  silver  and  opium  for  the  diarrluea. 
I'oHt-iiiorli'iii  examination  six  hours  after  death:  The  small  intestine  was  ciuisidcrably  congested  and  for  several  feet 
was  jiatclied  with  ulcerations,  some  of  wliich  were  as  large  as  a  i|Uaiter  ibdlar;  sph^iui  somewhat  enlarged.  Other 
organs  healthy. — Ael.  Ans't  Surg.  J.  K.  Smilli,  luiirfiix  Siiiiiniirii,  I'n. 

('a.se  :{().— Private  Albert  Tucker,  Co.  A,  2Sd  Ohio;  age  30;  was  admitted  Oct.  IS,  18(!t,  as  a  eonvahsccnt  from 
typlioid  fever.  He  looked  pale  and  weak,  had  little  ajipetite,  luit  was  in  good  s]drits  and  able  to  walk  alioul  tlie 
ward.     He  had  from  six  to  ten  stools  (biily,  which  were  occasicnially  streaked  with  blood;  liis  lower  extremities  were 


342'  rOPT-MORTKM    RKi;<iRDS    OK 

(I'duiiiatoua  and  there  was  Hoini^  .slight  alxloiniiial  etru.sii)ii ;  he  liail  a  sliglit  (-'oiiftli,  and  tlio  licart -sounds  sconicd  distant 
and  masked.  Ast  linfjcnts,  anodynes  and  diiiicties  wen' einploycd.  lie  died  rather  suddenly  on  ihe  2llli  after  an 
attack  of  dysjincea  and  severe  ])ra'Cordial  jiain.  I'dxt-iiiortcm  examination  :  Hea<l  and  ni)])er  jiait  of  liody  eeejiymosed  : 
lower  extremities  (edematous  ;  lirain  normal  ;  thoracie  cavity  contain  in  j^  a  pint  and  a  half  of  serum  :  Innf^s  conj^ested 
and  lyni|)Ii-coate(l  posteriorly;  ]ierieardium  containinjj  considerable  c^tVusion  ;  tricuspid  valve  ap])arently  thickened  : 
onu'utnni  almost  devoid  of  fat:  liver  and  stomach  healthy,  spleen  somewhat  eularjjted;  mesenteric  f;li>"il^  enlari;ed; 
small  intestine  presenting;  many  and  hufje  ulcerations,  especially  near  the  ilco-ca'cal  valve;  kidneys  very  nuich 
enlarged  hut  a])iiarently  normal  in  structure. — Cui/ler  Ilonjiitul,  rhUadclphin,  I'a. 

Ca.sk  37. — Private  William  H.  Harrison,  Co.  H,  11th  Ohio;  age  19;  was  admitted  .lune  22,  IWit,  pres<'ntinii  a 
rai)id  ])nlse, dry, furred  tougui^,  anon^x la,  thirst,  alidoudnal  tenderness,  diarrhiea,  restlessness,  delirium  and  the  ty|dioi<l 
rose-rash.  These  symptoms  continued,  varying  in  intensity  from  day  to  day,  until  ,July  2,  when  they  assumed  so 
aggravated  a  form  as  to  leave  no  hope  of  recovery.  He  died  on  the  4th.  Postmortem  examination  eight  hours  after 
death;  Hody  emaciated;  Mood  oozing  from  right  ear;  right  lung  firmly  adherent  to  costal  jileura,  its  npper  lobo 
congested;  spleen  three  times  the  usual  size;  liver  enlarged,  its  right  lobe  congested ;  left  kidney  twice  the  normal 
size,  its  calyx  enlarg('d;  lower  part  of  ileum  ulcerated,  in  some  places  through  to  its  serous  coat;  mesenteric  glands 
enlarged  and  inllamed. — Act.  Ann't  Siirj/.  C.  E.  Boylr,  Scmiitary  Hosiintal,  Colmnbus,  Ohio. 

Cask  38. — Private  l)aiu(d  Dewey,  Co.  E,  liKith  Ohio;  age  23;  was  admitted  April  5,  18()r),  in  a  very  feeble  and 
emaciated  condition  ;  Skin  dry  and  husky,  neckand  breast  covered  with  sudanuna,  right  elbow  and  knee  joints  swollen 
and  very  painful,  tongue  dry  and  cracked,  teeth,  lips  and  gums  covered  with  sordes;  he  had  diarrhcca  and  a  hoarse 
cough,  with  dillicult  r(^spiration  but  not  much  expectoration.  He  died  on  the  22d.  I'ost-morlcm  examination  ten 
hours  aftei'  death  :  Hody  extremely  emaciated.  Small  dejjosits  of  pus  were  found  between  the  fibres  of  the  pectoralis 
major  of  the  right  side.  The  ejiiglottis  was  o'dematous  and  ulcerated;  the  vocal  cords  ulcerated;  the  mucous  mem- 
brane of  the  larynx,  trachea  and  bronchial  tubes  intensely  inllamed;  the  left  lung  lu'patized;  the  a]>ex  of  the.  right 
lung  <Migorged  and  infiltrated  with  sero-i)urulent  matter.  The  liver  was  large,  pale  and  soft;  the  sjileen  enlarged 
and  nnudi  engorged  ;  the  ileum  inllamed  and  ulcerated.  There  was  a  large  di^posit  of  pus  in  the  cavity  of  the  right 
knee  joint  and  an  etfusion  of  sernm  in  the  surrounding  parts.  The  left  wrist  joint  and  the  right  elliow  joint  also 
contained  pus. — .1(7.  .Ins't  Surg.  S.  B.  U'csl,  Ciimhirland  HoHpital,  Md. 

Cask  3(1.— Private  Franklin  D.  Hicks,  Co.  K,  ir>7tli  N.  Y.,  was  admitted  Nov.  IS,  lS(i2,  with  typhoid  fever.  The 
rose-c(dor(^d  sjiots  were  very  distinct  and  the  siidamina  abundant.  He  died  on  the  2l)th.  /*o.s/-Hiy/7('/H  examination 
forty-eight  hours  after  death:  In  the  lower  portion  of  the  small  intestine  the  peritoneal  coat  was  much  injected  and 
readily  peeled  off,  and  the  mucous  membrauo  was  extensively  softened  and  ulcerated.  The  m(\sentery  was  consid- 
erably injected  and  the  nuisenteric  glands  much  enlarged. — Third  Diri.'iion  IIonpit((l,  Alexandria,  fa. 

Cask  40. — Private  JosialiCheever,  Co.  H,  15th  Vt.,  was  admitted  April  11,  18()3:  Headache:  occasional  delirium  ; 
pulse  100,  compressible  ;  hot  and  dry  skin;  six  to  eight  stools  daily:  short,  dry  cough  ;  sibilant  rhonchus  distinct  over 
chest  anteriorly:  abdomen  tyiupanitic.  Cai(Mnel,  opium  and  ipecacuanha,  iu  small  doses  alternating  with  e,IVerv('S(^ing 
mixture  auudiorated  his  condition.  The  chest  and  head  symptoms  subsided,  but  tlui  abdomen  remained  distended 
and  tender  and  the  diarrluea  continued.  On  the  22d  his  tongue  becanu' cracked  and  ])ulse  feeble,  120.  He  died  on 
the28tli,  notwithstanding  the  administration  of  turpentine,  alcoholic  stimulants  and  amnuniia.  I'ost-morlem  examina- 
tion: Thoracic  viscera  normal.  Mucous  membrane  of  small  intestine  injected,  lower  ileum  iiresenting  eight  large 
ulcers;  corresponding  mesenteric  glands  enlarged. —  Third  Division  Hospital,  Alexandria,  I'd. 

(!a8K  41. — Private  lienjamin  Tice,  Co.  E,  13th  N.  J.;  age2t;  was  admitted  Oct.  29,  18(i2,  with  diarrluea,  iliac 
tenderness,  nervous  disorder  and  four  taches  rouges;  the  skin  was  hot  and  dry,  pulse  lre(|uent  but  not  very  feid)h(, 
tongue  coated  with  dark  fur;  there  was  also  a  slight  cough,  accompanied  by  very-  little  ]>ain  in  the  chest  but  with 
most  distressing  dyspno'a  and  almost  complete  aphonia;  the  chest  was  resonant  on  percussion.  Small  dost^s  of  blue 
mass,  opium  and  ipecacuanha  seemed  to  relieve  the  chest  symptoms  and  cheek  the  diarrluea.  Later,  dulness  on  per- 
en.ssion  was  noted  over  the  lower  portion  of  the  right  lung.  Dry  cups  were  a])]>lied  and  stimulants  administered. 
After  this  the  ]>uls(\  became  more  fre(|uent  and  feebhi,  the  t(nigue  fissured,  the  teeth  and  gums  covi^red  with  sordes, 
diarrhd-a  iirofuse  ami  tympanites  extreme.  He  died  November  (>.  /'()s/-m())7((«  examination  :  The  heart  was  healthy; 
the  left  lung  extensively  congested;  the  middle  and  lower  lobes  of  tlu^  right  lung  hepatlzed.  TluMimentiim  was 
engorged  withdark  blood:  the  liverandspleonenlarged;  the  mucous  membraue  of  the  stomach  slightly  reddened;  the 
duodenal  glands  much  enlarged;  the  lower  part  of  tlu^  Ileum  ulcerated  In  eight  large  patches.  The  large  intestine 
was  not  examined.     The  kidneys  were  healthy. — Third  Division  Hospital,  Alexandria,  I'a. 

Cask  42.— Private  Martin  V.  Murphy,  Co.  F,  123d  Ohio,  was  admitted  May  4,  18l>l,  from  hospital,  Alexandria,  Va. 
He  had  no  hereditary  tendency  to  disease  and  enjoyed  excellent  health  up  to  fourteen  months  ago,  when  he  was  seized 
with  a  cold  while  on  a  scout  at  Winchester,  Vsi.,  which  in  a  few  days  was  followed  by  fever.  This  confined  liim  to 
bed  for  six  or  seven  weeks,  after  which  he  partially  recov(Med  and  went  home  on  furlough,  where  ho  had  a  r(dapse 
whl(di  disabled  him  for  four  or  live  wt^eks.  He  so  far  recovered  from  this  as  to  be  abl<!  to  walk  several  n^h^s  and 
continued  to  improve  for  two  months,  when  he  was  taken  with  dysentery,  which  lasted  two  or  three  weeks,  and  since 
that  time  he  has  not  fully  regained  his  strength.  He  returned  to  his  regiment  and  remained  with  it  for  about  four 
weeks  while  it  was  in  camp  at  ISrandy  Station,  Va.,  but  during  that  time  he  was  untit  for  duty.  When  the  army 
moved  he  was  sent  to  hosjiital  at  Alexandri.a,  where  he  remained  a  month,  after  which  he  was  transferred,  as  al>o\  e 
stated.  When  adiuitted  he  was  suffering  from  debility  conse(inent  on  typhoid  fever  and  dysentery.  He  was  ]iut  on 
tonics  ai;d  astringents,  with  the  best  diet  the  hospital  afforded.  He  unproved  gradually  until  the  14tli,  when  he 
complained  of  .i  sharp  ])ain  in  the  lower  part  of  the  right  breast,  aggravated  by  deep  lusjiiration  and  coughing;  jiulse 


Heliotype. 


James    K     Osgood  c^   Co.,  Boiton. 


PKRF0KAT1N(;   LLCER  OF    THE   ILEUJvl. 


No.  45:.     Mi:i.)ICAL  SECTION-. 


TlIK    cnNTINI-Kli    KKN'KliS.  34;') 

120  ami  small:  ti>iigiu'  moist  and  ifil :  (•(iiii^li  witli  wliitt-  IVotliy  ex  pectin  at  ion :  ilcciiliitus  (in  Irt't  siilo:  skin  vciy  hot. 
This  jiU'iiritic  attack  lasted  until  the  LTitli.  after  which  conN  aU-scence  jirojjie.ssed  satist'actoiilv  until, Inly  11.  when  lie 
complained  of  dianhd'a  with  some  tenesmus,  which  steadily  increased,  vesisl in;,' all  elVorts  fm-  its  iidii'f.  He  died 
July  2.5th.  Pohit-iiiorlem  examination  sixteen  lionrs  alter  death:  llody  much  emaci:ileil.  A  larjjc  amonnt  of  si'rnm 
was  found  lieneath  the  dnva  mater.  Iictwei'n  the  layers  ol'  the  arachnoid  and  in  the  \cnlriclcs:  the  suhsiancc  of  the 
lir.-iin  was  soft.  The  rijj;lit  pleural  cavity  was  tilled  with  imrulcnl  scrum  and  the  pulmonary  and  costal  jvleura-  w<Me 
I'omph^tely  lined  with  a  libro-allmminous  <lepo8it :  the  Innn  was  consolidated  hy  inessiire  and  hound  to  the  posterior 
wall  of  the  chest :  hoth  Innjis  were  tnlierculons:  one  tnliercnlar  nicer  in  the  rijjht  lunj;  hail  i)crt'oratcil  the  )inliuon.iry 
jileura.  Tubercles  were  ditfused  over  tlie  surface  of  the  heait  iinil  pciicardinm.  The  liver  was  healthy:  spleen  small 
and  hard  ;  kidiu'ys  small  in  size  hut  healthy  in  ai)pearance.  Ulcers,  with  their  Ion <;■  diameters  at  rifjht  aiifjles  to 
the  lenjith  of  the  gut,  were  found  throughout  the  small  intestine. — .Ut.  Aik'I  .s'hiv/.  ('/Kirhx  P.  Tiill,  Siiilirh(  JIii!<pil<il, 
I'liiliidclpliio,  I'll. 

Case  I.S.— Private  E.  ,J.  Williamson,  Co.  C.  179th  N.  Y.:  age  20;  was  admitted  Nov.  30,  18GI,  having  hcen  sick 
forahont  twelve  months.  His  tongue  was  dry,  dark  and  cracked  and  had  a  glazed  edge  ;  teeth  covered  with  sorilcs; 
ahdomeu  tympanitic  and  tender:  bowels  loose.  There  was  no  rose-colored  eruption  and  but  little  cerebral  excite- 
ment. Turpentine  emulsion  and  wine  were  giveti,  and  the  case  progtcssed  favorably  until  December  :i,  when 
]inenmoniii  set  in.  Ni^xt  d.ay  the  pulse  was  120,  the  delirium  marked,  cough  harassing  and  t^xjiect  oral  ion  scanty.  He 
died  on  tlu^  .")th.  Poxl-iiiDrli'm  examination:  riceration  of  the  ileum,  esi)ecially  about  the  ileo-ca'C:il  v:il\c.  Posterior 
portions  of  both  lungs  hepatized.  [Spirimiii  \'>'2,  .Med.  Sect.,  Army  .Medical  Museum,  from  this  ciise,  show.s  perforation 
and  peritonitis  to  lia\c  existed.] — Act.  Axx'l  Siir<i.  II'.  C.  Miimr,  Tkiid  Diri.iinii  Ilonjiital,  .llixiiiiilrin,  I'a. 

Case  44. — Private  William  V.  Hart,  Co.  A,  llth  V.  S.  Inf.,  was  admitted  Aug.  14,  lX(i;{,  with  such  symptoms 
of  typhoid  feverasadrv  and  cracked  tongue,  sordes  on  teeth,  small,  weak  and  rapid  pulse, iiuiet  lUdirinniaud  tympa- 
nites. Abdominal  tenderin^ss  became  aggravated  and  he  died  on  the  Kith.  I'oxl-mortem  examinatiou:  Perforation  of 
the  lower  ileum:  tirm  adhesions  of  intestines. —  Tliird  ZJiri.viii«  llu.spitdl,  AUxaiidria,  la. 

C.V.SE  45. — Private  Silas  Toinlin.son,  Co.  K,  21th  Mich.,  was  admitted  Nov.  30,  18))4.  The  patient  had  been  sick 
for  some  time  in  hos|)ital  at  City  Point,  \'a.;  he  suliered  much  and  received  but  little  attention  during  his  journey  to 
Alexandria.  On  admission:  Pulse  weak,  thiead-like  and  from  00  to  100  per  minute;  skin  hot  and  dry:  tongue 
very  dry,  red  and  slightly  coated :  thirst  iiigent:  ai)i)etite  small :  epistaxis:  deafm^ss:  exjnession  stupid:  delirium; 
abdomen  generally  tender,  tympanitic  and  showing  a  few  sudamina  and  many  petechial  spots.  Deceiidicr  1:  No 
change.  2d:  Pulse  somewhat  stronger,  fuller  aiul  less  fr(M|Ucnt:  tongue  less  dry;  expression  of  countenaiice  brighter 
ami  hearing  improved:  diarrhiea  less  active,  but  tenderness  and  tympanites  of  the  abdomen  umdianged.  lid:  Pulse 
XO  and  decidedl.v  stronger;  diarrhiea  checked  ;  tongue  thiowiiigolf  its  fur  :  a]ipctite  improved:  patient  intelligent. 
4th  ;  The  favorable  symptoms  continued  :  tenderness  of  the  abdomen  lesseucil.  51  h  :  At  2  a.  M.  a  change  for  the  worse 
took  place  :  the  pulse  became  weak  ami  lan  nji  lo  100:  the  patient  had  slight  chills;  his  tongue  became  dry  and  red 
and  sordes  gathered  on  his  teeth,  gums  and  lijis,  w  hile  the  whole  surface  was  bathed  In  a  cold  clammy  sw  cat ;  petechial 
s])ots  assumed  the  ai)))earance  of  \iurpHsh  blotches,  iind  the  abdoiueii  became  exceedingly  tender,  swollen  and  tympa- 
nitic, Ten  hours  after  this  change  took  place  the  patient  had  several  involuntary  stools  of  a  dark-greenish  color, 
after  which  he  fell  into  a  semi-stupor  from  which  he  could  with  difticulty  be  aroused,  and  when  aroused  gave  imperfect 
answers  to  questions  proposed;  his  face  was  sunken  and  there  was  much  twitching  of  the  muscles  of  the  upjier 
extremities.  He  died  on  this  day.  7'o»<-«ior(cHt  examination  tweiity-three  hours  after  death:  A  few  purple-colored 
points,  said  to  be  of  auto-raortem  fornnition,  were  not  iced  on  the  chest  and  abdomen;  there  was  also  purple  hypostasis 
of  the  posterior  part  of  the  body.  There  was  a  quantity  of  fluid  under  the  arachnoid  at  the  vertex  of  the  brain,  but 
the  substance  of  the  brain  was  normal.  The  heart  was  dilated  on  its  right  side  and  almost  completely  filled  by  a 
large  semi-transparent  clot.  The  left  lung  was  crepitant,  although  somewhat  dark  colored  posteriorly.  The  right 
lung  was  closel.v  adherent  by  firm  tissue  and  apparently  compressed  or  drawn  over  to  the  right  side:  the  posterior 
part  of  its  upper  lobe  was  of  a  dark  brown-red  color,  softened  and  with  minute  points,  apparently  bronchi,  tilled  w  ith 
a  yellow  froth;  the  remainder  of  the  lung  wasnormal.  The  liver  was  large  and  of  a  niiiforndy  pale  clay  color;  the 
spleen  large  and  softened;  the  cortical  part  of  the  left  kidney  of  a  yellow,  semi-latty  appearance.  .Vbout  twelve 
inches  from  the  colon  the  small  intestine  was  perforated  by  a  black-margined  aperture  the  size  of  a  small  shot ;  recent 
lymph  glued  the  perforated  coil  of  the  ileum  to  the  bladder  and  sigmoid  flexure.  Liquid  fa'ces  of  a  yellow  color  had 
to  a  small  extent  escaped  into  the  pelvic  cavity. — Act.  Asu't  Surf/.  II'.  C.  Miiwr,  General  Hospital,  Ah'jraiidrin,  I'a. 

Case  46. — Private  Thomas  Williams,  Co.  11,  8th  Md.;  age  32;  was  taken  with  fever  at  Camp  Bradford  (strag- 
gler's camp)  Aug.  1,  18(i3.  He  was  admitted  on  the  13th:  Countenance  heavy:  face  flushed;  skin  hot:  pulse  about 
100;  respiration  difficult ;  diarrhiea  with  ochre-colored  passages  ;  urine  scant.y  and  high-colored.  4'reatment :  Acetate 
of  ammonia,  camphor  and  quinine,  with  opiate  eiiemata.  On  the  1.5th  he  was  restless  and  Inid  considerable  subsultiis; 
the  tongue  was  protruded  with  difficulty;  respiration  was  accelerated;  much  viscid  mucus  was  brought  up;  auscul- 
tation revealed  bronchial  breathing,  and  the  right  lung  was  dull  on  percussion.  Extract  of  valerian,  sweet  spirit  of 
nitre  and  carbonate  of  ammonia  were  administered  and  turpentine  stupes  a)>;)lied  to  the  chest.  On  the  19th  ho  was 
greatly  depressed,  the  diarrhiea  frequent  and  exhausting.  Carbonate  of  ammonia  iu  two-grain  doses  was  given 
every  two  hours.  Next  day  the  pneumonic  symptoms  were  nnclianged,  the  sputa  adhesive  and  tinged  with  blood. 
A  blister  was  applied  to  the  chest.  Both  iliac  regions  were  tympanitic  and  tender.  On  the  21st  the  patient's  extrem- 
ities were  cold.  Brandy  was  sulistituted  for  milk-punch,  which  had  been  given  freely  sinci'  the  18tli.  On  the  23d 
his  mind  was  clearer  tlian  at  any  time  since  his  entrance.  At  8  a.  .m.  of  the  following  day  he  was  seized  with  viident 
pain  and  tenderness  in  theabdomen  followed  by  persistent  vomiting.     He  died  on  the  25th.     Post-mortem  examination 


344  POST-MORTEM    RKCORPS    OF 

shortly  after  (lentil :  The  ])eritoiieiim  sluiwed  marks  of  extensive  iMllainiiuitioii  and  contained  about  eij^lit  onnees  of 
]i(|uid  matter  siinilar  in  charaeter  to  the  dejections  dnrinjj  life.  The  mesenteric  ylands  were  enlarf;ed  and  tlie  ilenni, 
for  the  distance  of  three  feet  above  tlu^  ileo-ca'Cal  valve,  was  inllamed  and  ulcerated:  a  larger  perforation  was  situ- 
ated fourteen  inches  above  the  ca'(nini.  The  tlioraeic  and  cranial  cavities  were  not  opened. — Med.  Ciiilct  W.  L.  llntd- 
hij,  McKim's  Minmion,  lialiimorv,  Md. 

(D.)   Condition  of  I'ei/fr's patchrx  not  stated;  iliiim  or  ><mall  iiitrntinc  lilcrroti'd  <iiid  larijr  inioiline  iiffcitcd — ic<t!^cs. 

Case  47. — Private  Elias  lirink,  Co.  R,  137th  \.  V.:  age  53:  was  admitted  Jan.  18,  1803,  having  been  sick  two 
weeks.  He  spoke  of  having  hurt  his  back  and  ruptured  himself  by  a  fall  while  on  the  march,  and  complained  of  ]iaiu 
in  his  back.  Symptoms  of  what  was  supposed  to  bo  pericarditis  made  their  appearance  ou  February  7,  and  next  day 
veratrum  viride  was  prescribed.  Ou  the  11th  he  was  noticed  to  be  very  deaf;  his  pulse  was  .slow  and  weak,  and  vomit- 
ing bad  set  in.  The  veratrum  viride  was  discontinued.  Next  day  he  lapsed  into  stu])or  and  when  aron.sed  with  ditii- 
culty  from  this  state  his  answers  were  incoherent:  his  breathing  was  rapid.  On  the  1  Ith  an  eruption  like  that  of 
typhoid  fever  made  its  appearance  on  his  body  and  extremities:  he  coughed  much  and  muttered  to  himself:  there 
appeared  to  be  some  iliac  tenderness:  his  urine  required  to  lie  drawn  off  by  catheter.  Next  day  his  evacuation.s 
became  involuntary.  He  ilied  on  the  19th.  I'ost-mortim  examination  four  hours  after  death:  15ody  emaciated;  rigor 
mortis  marked.  The  brain  weighed  forty-six  ounces:  it  was  light-colored,  of  firm  consistence  and  contained  much 
fluid  in  its  ventricles.  The  heart  was  healthy.  The  right  lung  weighed  fifteen  ounces,  the  left  thirteen  onnees;  the 
right  was  full  of  blood,  the  upper  lolie  lieing  somew  hat  congested  and  the  lower  universally  so;  the  upper  lobe  of  the 
loft  lung  was  congested:  collapsed  lobules  were  observed  in  the  lower  lobes  of  both  lungs;  the  bronchial  tubes  were 
congested  and  some  of  the  smaller  ones  contained  pus.  The  liver  weighed  fifty-four  ounces  and  was  universally  con- 
gested: the  gall-ldadder  contained  eleven  drachms  of  dark-green  bile:  the  spleen  weighed  five  ounces  and  a  half  and 
was  of  a  dark-slate  color  externally,  dark-red  iuteinally  and  moderately  firm  in  consistence:  the  ki<lneys  weiglied 
four  ounces  and  a  half  each  and  were  of  a  rather  dark  color;  the  stomach  was  slightly  congested.  The  mucous  mem- 
brane of  the  small  intestine  was  softened,  especially  near  the  ileo-ca^cal  valve;  it  was  slightly  congested  in  the. jejunum 
and  upper  third  of  the  ileum,  decidedly  so  in  the  lower  two-thirds  of  the  ileuni,where  a  number  of  ulcers  were  observed. 
The  ciecum  was  of  a  d;irk-slate  color;  the  rest  of  the  large  intestine  was  normal.  The  me.senteric  and  mesocolic  glands 
were  enlarged,  especially  the  latter. — Ass'l  Sitry.  (Icor/jc  M.  McGiU,  U.  S.  A.,  f.iiiculii  llonpitnl,  ll'(i.'<hiii<iluii.  1).  ('. 

Cask  18.— Private  William  Duryea,  Co.  I,  lOiHh  N.  Y.;  age  21;  was  admitted  May  11,  18()t,  with  a  gunshot  ib'sli 
wound  of  the  left  forearm,  wliich  healed  kindly.  On  the  18th  he  was  furloughcd  for  thirty  days,  and  on  his  return, 
June  18,  he  was  placed  on  light  hospital  duty,  his  wound  unfitting  him  as  yet  for  active  service.  On  July  28  he  was 
taken  with  headache  and  nocturnal  delirium ;  his  pulse  100  and  his  tongue  coated  with  a  dark  fur.  A  few  days  later 
some  ditficulty  of  breathing  was  noted,  with  slight  diarrliiea  and  twitcliiuf}s  of  the  tendons,  the  delirium  having  mean- 
while become  constant.  His  condition  remained  unchanged,  but  for  ]>rogressive  weakness,  until  August  7,  when  he 
died.  Poat-moiti^m  examination  six  hours  afterdeath:  The  lungs  were  congested.  The  heart  was  pale  and  contained  no 
clots.  The  liver  was  of  normal  size  but  congested;  the  galMiladder  fille<l  with  viscid  bile:  the  spli'cn  dark -colored, 
slightly  enlarged  and  congested;  the  kidneys  normal.  The  mucous  membrane  of  the  stomach  was  liglit-colored, 
thickened  and  softened.  The  lining  membrane  of  the  small  intestine  was  soft  and  somewhat  thickened  down  t<i 
the  lower  portion  of  the  ileum,  in  which  there  wore  large  ulcers  at  different  points  some  distance  from  each  other: 
near  the  ileo-ca'cal  valve  it  was  greatly  thickened  and  congested,  and  presented  very  large  ulcers  surrounded  by  reil 
areolie  and  penetrating  to  the  muscular  coat.  The  nuicous  membrane  of  the  large  intestine  was  greatly  congested  and 
its  .solitary  follicles  slightly  enlarged.  The  mesenteric  glands  were  enlarged.  [Spicimfii  3.")2,  Med.  Sect.,  Army  Med- 
ical Museum,  ulceration  of  ileum,  was  obtained  from  this  ca.se.] — Act.  Axx't  Sin-g.  (>.  I'.  Sivcct,  Carver  Hospital,  fVash- 
ini/toti,  D.  C. 

Case  49.— Private  Hannibal  Tichout,  Co.  H,  2d  U.  S.  Sharpshooters :  age  20 ;  was  admitted  Sept.  16, 1863,  having 
been  sick  for  eight  weeks  with  typhoid  fever.  His  features  were  sunken,  conjunctiv.e  congested,  cornea  ulcerated, 
lips  dry  and  coated  with  sordes,  imlse  feeble,  120,  and  bowels  loose:  petechial  spots  on  chest  and  thighs.  He  sank 
gradually,  dying  on  the  2(itli.  Treatment  consisted  of  lead  and  opium  for  the  diarrlnea  and  of  (juinine,  wine  and 
beef-tea.  Post-mortem  examination  twelve  hours  after  death:  Extensive  jieritoneal  intlammation  and  ulceration  of 
ileum  and  caecum. — Act.  Ass't  Surg.  John  FUckiiigir,  First  Division  Hospital,  Alexandria,  Id. 

Case  .W. — Lieut.  J.  W.  Lowe,  Co.  H,  9th  N.  Y.  Cav.,  was  admitted  Sept.  21,  1863,  with  his  neck  somewhat 
swollen  and  stiff,  the  result  of  a  blow  from  a  rebel  musket  at  Brandy  Station,  Va.,  Aug.  1, 1863;  his  general  health  was 
good.  On  the  30th  he  went  home  on  leave  of  absence.  He  returned  November  14  much  improved,  stating  that 
duriughis  absence  he  had  an  attack  of  diarrho'a  which  lasted  only  a  few  days;  the  attack  was  preceded  by  vomiting, 
and  was  attribute<l  by  him  to  some  error  of  diet.  He  felt  well  and  expressed  himself  as  able  to  join  his  n^giment. 
Hut  at  mi<lniglit  of  the  18tli  the  officer  of  the  day  was  called  to  see  him  as  be  had  been  seized  with  a  violent  ]>ain  in 
the  testicle,  without  swelling  but  with  great  tenderness.  An  anodyne  lotion  relieved  him  and  he  fell  asleep,  but 
awoke  about  daylight  vomiting  a  pale-green  licpiid  and  with  great  tenderness  over  the  stomach.  The  alidonien 
soon  became  tympanitic,  the  pulse  sank,  the  vomiting  became  constant  and  the  countenance  livid  and  anxious. 
A  blister  was  ajiplied  and  laudanum  given  by  inje<fion.  At  noon  the  vomiting  became  less  fre(|uent  and  he  was 
able  to  swallow  small  i[uantities  of  lirandy  and  water  with  morphia;  the  pulse,  however,  was  scarcely  perct^ptible 
and  the  face  and  hands  were  covered  with  cohl  sweat.  He  died  at  3.30  v.  M.  after  vomiting  as  much  of  a  jiea-greeu 
li(|uid  as  half  filled  a  common  tin  basin.  I'ost-mortem  examination;  The  thoracic  viscera  were  healthy.  The  jieri- 
toneal  cavity  contained  two  oun<es  of  pus.  The  whole  intestinal  can.al  was  in  a  state  of  acute  infiammation;  tln^ 
ilenni  was  perforated  in  several  places,  some  of  the  openings  being  large  enough  to  admit  the  end  of  the  little 


THK    CONTINI'KP    FFIVKHS.  345 

finger.  Tho  inflaniniatory  roiiilitiiui  cxtciuliil  to  all  tlie  alxldiriinal  visc(>ia.  "  How  this  Ktat<'  i>t'  tliin;is  cxistrd  with- 
out syniptouis  for  a  loiigci-  jifrinil  t  han  liftccu  Ikhiis  I  am  at  a  lo-ss  to  explain  lu-  even  coiijtM'lini'.  'I'hr  iikim  was  not 
oiiiariated:  on  the  coiitiary  he  had  ijaiiicd  in  tlfsli  dniinj;  his  visit  home.  I  am  inloinucl  \i\  his  InotlK'V.  wlio  iaMi«' 
ft)!'  his  remains,  that  he  had  com|dained  at  times  of  a  ]>ain  in  thi'  liowi'ls.  hnt  of  so  slii;ht  a  ehar.-icter  as  not  to  .it  tract 
mneh  attention  and  whieli  was  nsnally  ri'lie\e<l  by  a  drauLiht  of  warm  iringer-tea."  [,S'y/,ii»«  h  77.  Med.  .'^eet..  .\rniy 
Medical  Miisenm,  sliiiwini;  tyiihoiil  iileeration  and  perforat  ion,  is  from  this  ease. J — Siir;/.  II.  II.  Ildnii-lnl,  I  ■  >'.  '  ., 
SriiiiiKirii  llus/iiliil.  <!i  m-i/tloini.  I).  ('. 

Casks    KMIJIKD    .\S   TYI'IIn-MAI.AIil.^r,  with    on   WITIIOT'T   \    UKCOl:|)   (•!••    SV.MI'TOM.S    1(1   .srnsrANllATK   THE 

lUACNCVSIS 11.'    I'A.SES. 

(A.)    I'cjiir'n  piildii  X  iilci  vdlid  tuul  llir  ih  urn  nr  xiiiall  iiil(stiiif  mihi  KffccUil — 1 1  ciisiit. 

Cask  ."il. — Corjioral  K.  .1.  Inins.  Co.  L,  (Ith  Mieh.  Cav..  was  adTnitled  .Inly  L'S.  lM;:i.  Dia^'nosis — typlioinalarial 
fever.  On  admission  lie  hail  cliarrhosi.  dehility  and  slight  lever,  which  was  lather  remittent  in  eliaraelc>r  ;it  lirst, 
lull  liecMiiic  i\phniil  on  Au;;nst  7.  <,>iiiniiic  u  as  ^  i\  en  and  1  lie  dian  hcca  was  coiil  idHiil  li\  liuvei's  po\\  dcr.  lead, 
tannin  ami  opiinii:  Iml  llii'  pioslialion  incrc-ased  ami  a  I'ew  rcisecohired  siiols  appeared  on  lliealiddmcn.  l>ealli 
to(dv  Jilace  (111  ihe  lllili.  I'lisi-imirli  iii  examinatioM:  Liin^s  (■(iiif;cstc(l ;  liver  enlarfjed  and  sol'leiicd:  I'cyei'-'  patches 
inllaiiicil.  llijcUciicd   and  elevated    lull    \  cry    little   nlceraled. — Ad.   Ans'l   Siii-i/.   A.   I'.    II  i7/i((/»N.  SI.   .I/oi/mils    Hnijiilnl, 

It'llKhillfllnil.    1 1.    ('. 

Cask  ."iJ. — I'l  ivate  I'.y  roll  C.  Crane.  ISth  \.  V.  Indciiendeiil  Hal'y,  was  admitted  Sc|i| .  L'l.',  I  Si!  I.  iVoiii  Washin^lon 
Klreet  prison,  liiajciiosis — ty]ili(>-inalarial  fever.  He  had  high  lever  with  daily  exacerlial  ions  folloued  hy  swcal  iiig: 
his  tmii^ne  was  IhicUly  coaled  and  ihcic  was  miicli  eereliral  excitement,  with  luitehingsof  the  liiinds  and  lingers 
and  niimliiiess  of  the  Icci  and  legs.  (,iiiiiiiiie  \v,is  ;;iven  freidy  and  Minderei  lis' spji  i|  every  six  lioiirs.  On  thuL'lilh 
there  was  profuse  and  a  linos  I  eiMistant  sweat  in  i;.  w  il  li  hot  sKin,  lil  I  le  appel  lie.  inel'eascd  I  w  ilcliiii;;s,  reNtlessiic.HS  and 
lint  lilllc  sleep.  ,\lilU  punch  was  ordered  and  I  he  acetate  of  ammonia  omil  led.  The  sIceplessiicNS  eont  iniied  mil  il 
the  lint  11. on  \\  liicli  dale  const  ijia I  ion  w  .'IS  noted.  .\cl  i\(' delirium  sel  in  iic\ I  day  w  il  h  miKdijael  il. 'it ion.  and  continued 
lllitil  death  on  (Iclolicr  I.  I'lml  inarli  in  examination  twenty  lour  hours  after  death;  .^'^mall  iiilesline  extensively 
inllamed  and  I'eyers  patches  deeidy  nlceiated  ;  spleen  very  dark:  liver  normal:  Uidneys  much  congested;  liings 
normal:  pericardium  injected  and  coiilainin;;  an  iiiere:ised  (|nant  ily  ol'  lliiid.  <  )lliei  \  iscei.-i  not  evamiiicd. —  Thiiil 
I>irixiiiii  llosjiihil.  .Ilcidiidrifi.  I  II. 

Cask  .".:!.  —  l'ri\.'lle  llciiix  Williams.  Co.  |).  1  list  N.  V.;  age  1 1  :  was  admitted  .Inly  'JX.  IKi;;;,  having  lieen  sick  for 
alioiil  a  Week  willi  I'cNcr  of  a  lyphoid  type.  I'iagnosis — ty|iho-iiialai  ial  fever.  <  )|i  admission  he  had  a  red.  moist 
toneiic,  a  IVei|iieiil  and  recMc  |iiilsc,  much  pros!  lal  ion,  ahdoiiiinal  Icndeiness  .-iiid  slii^lil  dtarilKca.  Morning  remis- 
sions were  iiolcd  on  .In  l\  HI .  .Viinnsl  1 ,  2,  I,  111  and  IL',  on  which  diiys  lie  was  Heated  \\  ii  h  from  ten  to  I  liirty  grains 
of  (|iiiniiie  (hiil.\  — on  I  lie  ol  her  (la.\  s  opiates  and  aromal  ie  snlphiuic  acid  w  eie  i;i\  en.  Iml  I  lie  diarrhd-a  increased  to 
six  or  s(\cn  w.iler\  sic.nU  ikiiiy:  imIcs  were  heard  in  the  lower  lol>es  of  llie  lung's  on  1  lie  .Mli.  and  I  he  parotid 
liecame  sw  (dlcii  on  (lie  lti|  II.  lie  lieeame  (lull  and  drowsy  on  I  he  IL'I  li  and  died  next  day.  /'e^/-Hlc|■^  m  examinal  ion  : 
I'neiimonia  «(  lower  lolies  dC  liin;;s  ;  follicular  inllamiiiation  and  sol'leiiing  at'  iiiiicons  meiiiliiane  id'  simill  intestine; 
I  wo  typhoid  ii  leers  in  ileiini :  liver  enlaiged  and  fatly;  heart  liy  perl  iiiphied.  weii;lil  six  I  ecu  ounces,  slight  t  liicKeiiing 
of  mitral  valve.       i  itlni  ortians  healthy . — Shnitoii  //iixpiliil,  ll'iixliiiiiiltni,  I).  C 

Cask  '>\. — I'rivate  I'eter  A.  IteanHoii,  Co.  A,  .">2d  \.  V.;  agii  liH;  was  admitted  Nov.  L':!,  IStlH.  having  heen  siek 
live  we(  ks  with  typhoid  fi^ver  (niahu'ial).  There  was  no  tenderness  in  the  right  iliac  icgioii;  the  tongue  was  coated 
with  a  Idack  fin  and  the  skin  tinged  yellow;  lie  liad  ii  )inrnlent  (tiH(dlarg(^  from  the  ear.  I'l'iKlslent  diarrlnea  set  in 
(m  Iicccinliei  II,  with  occasional  d(diriiiin  and  great  ]iroHtration.  Krysiptdas  attacked  the  face  on  the  17th  and  the 
piilieiil  liecame  comatose  and  had  convulsive  Iwitchings  of  tho  limlw.  lie  died  ne.xt  day.  I'ost-mortim  examination 
on  tho  lUth :  liody  not  mneh  emaciated.  'I"he  iiharynx,  larynx  and  trachea  were  inllamed  and  ulcerated :  the  mncoiis 
memlirane  was  of  a]inrplish  color  excejit  aliont  the  (diordie  vocales,  where  it  was  stone-gray;  the  epiglottis  w  iis  nlcei- 
ated on  liolh  sides,  the  fold  of  mncoiis  memlirane  riinninj^  from  it  to  the  coriin  major  on  the  left  side  was  also  ulcer- 
ated; the  mncoiis  memlirane  over  the  arytenoid  eaitilages  was  much  tiimelied:  there  was  a  small  aliscess  lielween 
the  cricoid  cartilage  and  the  pharynx.  The  lungs  were  congested  )iiisleriorly  lint  otiierw  ise  healthy.  Ihe  liver  waN 
healthy.  I'eyer's  jiatehes  were  ulcerated  lint  not  elevated,  the  ulcers  hlackish  and  with  thick,  sharply  delined  edjies: 
the  liases  of  soiiu^  were  so  discolored  that  the  dark  hue  was  conspicnons  through  the  jiei  itonenm  :  the  solitary  glands 
were  not  seen. — .tmi't  .S'/d'f/.  IlarriKon  .llloi,  V.  S.  .(.,  Liucoln  Jl(>.'<jiiUil,  lI'dxhiiii/liiH,  />.  C 

Cask  '<:>. — I'rivate  James  Underwood,  Co.  IJ,  180th  N.  Y.;  age  lil;  was  admitted  Nov.  MK  ISilt,  with  remittent 
fever  wliich  liecame  continued  on  Dtu'enilier  3,  ]iresenting  deliriiini  and  typhoid  symptoms;  afterwards  lironehitis 
occurred,  with  an  uncontrollalde  and  exhausting  diarrlnea  and  great  alidiiminal  tenderness.  He  died  on  the  l.'ith. 
I'oxt-mortcm  examination:  Lungs  (edematous,  with  indications  of  ]ineniiionia  as  well  as  linnichitis;  I'eyer's  patches 
extensivtdy  ulcerated. — .S'l/r*/.  A'.  liintUij.  U.S.  f'.,  Third  lUiisUm  Iltisjiilnl.  .Ih  .ninilrhi,  \'n. 

Cask  "ill. — I'rivate  Clianncey  <>.  I'archer,  Co.  E,  l.'Jtli  \'t..  was  admitted  I'cc.  1 1.  L^liL'.  with  ty|iho-malarial  fevi'r. 
This  patient  had  so  far  convalesced  as  to  sit  up  a  jmrt  of  the  time,  when  a  relaii.se  occurred,  from  which  also  he 
recovered.  After  this  he  liejraii  to  coniidain  of  great  ]iain  in  the  ii;;lit  ear.  In  which  an  aliscess  finned  and  was 
dischari^ed  with  relief  to  the  jiain.  lint  the  ear  liecaiiKi  a  second  time  the  seat  of  severe  pain,  which  extended  to  the 
whole  head  and  was  particularly  .severe  in  the  occi]iut.  Delirium  followed  and  he  died  Feb.  ."i.  lS(i:>.  alioiit  forty-oight 
hours  after  its  accession,  coma  having  in  the  meantime  supervened.  J'uxl-mnrti  m  examination  oiii'  hundred  hours 
after  death:  Tin;  hody  was  not  much  emaciated.  Nothing  alinoiinal  was  detected  in  the  lirain.  Tho  thoracic  and 
Med,  Hist.,  I't.  Ill— 14 


i")46  POST-MOrvTKM    1;KC()FU)S    of 

alidoiiiinal  viscera  a])|)oaird  healthy  witli  tlie  ex('e|ition  (iC  the  ileum,  in  which,  esjieeially  tiiwanls  the  ileo-<':i'(  al 
valve,  a  iiiiinher  of  I'eyei'H  patches  were  eiilarj^ed,  iiillaiiied  and  ulcerated,  tlie  ulcers,  however,  seemed  well  advanced 
in  till'  ]iroceMH  of  cicatrization. — Third  Ilirisidii  IloxpiUil,  Alcxniidi-in,  In. 

C.VSK  ,")7. — Private  William  I'ncapher.  Co.  II.  MOfli  l"a..  was  admitted  July 'J2,  18(i3,  with  ty]di(i-nialarial  fever. 
He  .sank  f;radiially,  dyinj;  comatose  on  Auf^nst  10.  I'i»:t-iiiorti  m  examination  tdeven  hours  aftei  death:  'I'here  were 
pleuritic  adhesions  on  the  left  side  aiul  hypostatic  congestion  in  the  posterior  parts  of  both  lungs,  but  otherwise 
the  Inugs  appeared  healthy.  The  heart  was  llabby.  The  liver  was  much  enlarged:  the  spleen  weighed  a  pound 
and  thr(^e-i|uarters;  the  kidneys  were  uonual;  the  bladder  contracted  and  nearly  empty,  reyer's  patches  wcii'  thick- 
ened and  ulcerated;  tlic  solitary  glands  of  the  ileum  were  enlarged  to  the  size  of  small  shot.  The  mesenteric  glamls 
were  greatly  swollen;  some  presented  yellow  s])ots  of  softening  and  others  contained  a  creamy  dark-yellow  llnid. 
— Jarris  Knspital,  lialtimore,  ild. 

Case  ,08. — Private  Jesse  Cassel,  Co.  C,  ITilth  I'a.;  age  L'l ;  was  admitted  July  2,  bst;;!,  with  typho-malarial  fever, 
which,  after  a  few  days,  became  typhoid  and  accompanied  with  diarrho'a.  Opiates  ami  astringents  failed  to  restrain 
the  diarrluea,  which  became  colliciiiative.  lie  died  delirious,  picking  at  the  bedclothes,  on  the  2()th.  rnKl-iiKirtciii 
examination  "revealed  nothing  hut  slight  ulceration  of  Peyer's  glands." — Ann't  Siiry.  C.  C.  Lee,  U.  S. ./.,  Doyyhin  Ihw- 
pitiil,  If'ashington,  D.  C. 

Cask  '>9. — Private  Thomas  Hurten,  Company  C,  140th  Ind.;  ago  18;  was  admitted  .Jan.  2il,  18ti,">,  with  ty]>ho- 
malarial  tcver.  He  died  Kel)ruary  H.  I'ost-iiiortem  examination  eleven  hours  after  death:  Lungs  hypostatically  con- 
gested; postinior  pleuritic  adhesions  on  left  side:  heart  tiabby.  Liver  weighed  seventy-six  ounces;  s|)leen  twenty- 
eight  ounces;  mesenteric  glamls  greatly  swollen,  varying  from  the  size  of  a  pea  to  that  of  an  almond,  some  containing 
a  ereiiiiiy  dark-yellow  llnid,  and  one  presenting  some  yellow  points  of  softening:  Peyer's  jiatchis  enlarged  ••ind 
ulcerated  in  the  lower  jiart  of  the  ileum, — in  the  upi)er  part  was  a  patch  four  incites  long:  solitary  glands  much 
enlargeil,  feeling  like  small  shot  beneath  the  mucous  membrane;  kidneys  normal. — Douglas  Honpilul ,  Washington ,  I).  C. 

(;ase  (!(). — Private  Oscar  F.  Hunt,  Co.  H,  iHli  Mich.:  age  20;  was  admitted  Dee.  (!.  IS(U.  with  typho-malai  ial 
fever,  and  died  on  the  Kth.  rotit-iiiovlein  examination  twenty  hours  after  death  :  Thoracic  viscera  norm;il ;  large  intes- 
tine greatly  distended  with  air;  appendix  vermiforinis  inllamed:  ileum  contracted  in  its  calibre,  and  Peyer's  patches 
elevated  and  in  varioits  stages  of  softening  aud  ulceration. — Honpitiil  So.  8,  XaxhriUe,  Teiiii. 

Ca.sk  til.— Private  James  Stone,  alias  Paul  Shay,  Co.  F,  (ilst  N.  Y.;  admitted  March  H,  IStU.  Died  14th,  of 
ty]iho-malarial  fever.  I'o.ft-morte)u  examination  five  hours  after  death:  The  body  was  much  emaciated.  The  lungs 
and  heart  were  healthy,  but  the  ])ericardiuin  contained  a  large  f|uantity  of  serum.  The  liver  weighed  sixty-one 
ounces;  the  gall-bladder  was  empty.  The  spleen,  stomach,  duodenum,  jejunum  and  large  intestine  were  healthy: 
the  ileum  was  much  congested  and  inflamed  throughout .  and  many  of  Peyer's  patches  prcsenti-d  large  ulcers. — 
Act.  Axn't  Surg.  Lloyd  Dorsig,  Ilareuood  Ilospittil,  Woxhinyton,  I).  ('. 

Case  02. — Private  Eber  Elmer,  Co.  E,  186th  N.  Y.;  age  17;  admitted  Oct.  21,  186L  Diagnosis — typho-malarial 
fever.  Died2lth.  /*08/-muri<m  examination  thirty  hours  after  death:  Body  muscular  and  well  developed  ;  sndamina  on 
chest  and  abdomen  ;  sordes  on  teeth;  slight  suggillation  posteriorly.  Lungs  congested;  lower  lobe  of  left  and  upper 
aud  lower  lolies  of  right  lung  hepatized  posteriorly:  base  of  left  lung  covered  with  recent  lymph  :  each  pleural  cavity 
containing  two  ounces  of  bloody  serum;  bronchi  congested  and  tilled  with  frothy  mucus  :  bronchial  glands  normal. 
Heart  healthy,  small  clots  in  the  left  and  a  large  clot  in  the  right  cavities.  Stomach  tilled  with  air  and  dark 
grumous  blood;  snuill  intestine  congested  and  inilamc'd;  I'eyer's  patches  much  thickened,  especially  near  ileo-ca'cal 
valve,  where  there  was  one  small  ulcer;  mesenteric  glands  dark  and  enlarged;  colon  and  rectum  healthy.  Liver 
large,  healthy ;  gall-bladder  containing  six  drachms  of  dark  bile ;  spleen  enlarged,  softened,  quite  dark  in  color ;  pan- 
creas, kidneys  and  bladder  healthy. — Second  Divinion  Hospital,  Alexandria,  Va. 

Case  ^>',i. — I'rivate  Kdward  Martin,  Co.  II,  12th  Vt.,  admitted  Dec.  12, 1862.  Diagnosis — ty  i)hoid  remittent  fever. 
Died  17th.  I'oHt-niorteiii  examination:  The  abdomen  was  moderately  tympanitic;  recti  muscles  very  much  injected 
and  in  their  sternal  third  ecchymosed.  The  anterior  ]K)rtion  of  tlie  abdominal  surface  of  the  diaphragm  was  coaleil 
with  plastic  lymph;  the  omentum  was  greatly  injected  and  adherent  by  recent  lymph  to  the  abdominal  parietes; 
the  mesentery  was  injected;  the  mesenteric  glands  greatly  enlarged.  The  mucous  membrane  of  the  ileum  was  con- 
gested, especially  near  the  ileo-ca!cal  valve;  Peyer's  patches  -were  ulcerated  and  the  peritoneunr  corresponding  to 
each  patch  was  dark-colored. — Third  Dirixion  Hoxjntal,  Alexandria,  Va. 

Ca.'^e  64. — Private  Wallace  T.  Fowler,  Co.  C,  42d  Mass.;  age  lit;  was  admitted  ( >ct.  2H,  ISlil,  having  been  taken 
sick  a  week  before  with  a  decided  chill  followed  by  hot  skin,  thirst,  severe  headache  and  backache  and  a  diarrho  a 
of  two  or  three  passages  daily.  On  admission  there  was  no  delirittm,  epistaxis,  deafness  nor  tympanites;  pulse  120; 
tongue  furred  and  <lry;  some  bronchial  irritation.  Diagnosis — typho-malarial  fever.  He  improved  under  small  doses 
of  blue-pill  and  ipecacuanha,  acetate  of  potash,  squill  and  spirit  of  nitre  until  November  12,  when  his  resiiiration 
became  hurried  and  his  pulse  accelerated.  On  the  l.^th  he  expectorated  rusty  sputa,  although  none  of  the  physical 
signs  of  pneumonia  were  present.  Until  the  day  of  his  death,  the  17th,  he  did  not  a]ipear  to  be  very  ill.  Pain  in 
the  epigastrium,  feeble  pulse,  great  ]irostration  and  vomiting,  at  first  of  green  liijuid  anil  afterwards  of  matti'is 
reseml)ling  ciitlee-gronnds,  preceded  death  for  some  hours;  his  mind  was  clear  to  the  last.  I'oxl-morleni  exaiEiination 
sixteen  hours  after  death:  Not  much  emaciation;  suggillation  posteriorly.  Omentum  inflamed;  intestines  ri^ddeiied 
and  iuteradherent ;  peritoneal  cavity  containing  two  pints  of  a  turbid  yellow  liiiuid  emitting  an  unpleasant  fical 
odor.  There  was  a  perforation  one-eighth  of  an  inch  in  dianu^ter  about  the  middle  of  the  ileum,  the  result  of  ulcer- 
ation in  one  of  Peyer's  patches  [Spivimen  No.  439,  Med.  Sect.,  Army  Medical  Museum],  and  there  were  several  thick 


THE    CONTlNrKI)    FKVKRS.  347 

i'iii-(l  and  iilciTutcd  liiitclii.'S  near  llu'  jicilorution  and  in  tlu'  lower  jiait  of  tlic  iliiiin.     Spleen  enlaifjed  and  sortened; 
liver  dark.     Otliei- oij^ans  not  examined. — <»)■;/.  /•,'.  Iluilht/,  V.  S.  I'.,  Sinind  Ilii-i'>i<iii  llnxjiilnl.  Aludiiilrin,  In. 

(H.)  rcjitr's  ptdvliis  -iilcd-dtiil  iiiid  llif  h(r<j(  iiili-'liiii  alsa  iiiiiiVniitnl — 1  iii.si.s. 

C.\SE  (i.'i. — I'livate  .J(din  1).  Kvans,  Co.  H.  1st  'MicU.  Cav.:  ajje  I'S;  ailniitted  .hil.v  I'll,  ISCl,  iVoni  Canip  llisliUm- 
tion,  Va.  ])iaj;nosis — tyi>li()-nialai'ial  I'eviM-.  lli'  liad  frontal  lieadaelie.  jiain  in  linil>s  and  Ip.ieU.  anorexia,  sii  Uni--s  al 
stonnndi,  tronldesonie  diarrliiea,  lieetie  llnsli  on  elieelis,  irritative  i'on};li,  di'aCnes.s  of  ri;;lit  I'ar,  lonj;ni'  vellow-eoaled 
anil  eyes  suti'iised  and  .vellowisli.  Sinajiisnis  were  ajijilied  over  the  rijjid  Inn;;  and  liver,  and  tinelnre  of  a<'onite  in 
acetate  of  ammonia  was  jjiven  every  two  lionrs,  witli  snliseipiently  Ilo|ii''s  mixtnre  and  wine  liilli'rs.  He  seemed  to 
iin|irov(^  for  some  days,  Init  on  .\nf;nst  1  he  refnsed  food  alto^jetlii'r;  his  eoni;h  inereaseil.  lieeomin;;  <lry.  iiritalile  .and 
paroxysmal,  lasting  for  ten  minntes  at  a  tinn-  and  l)reventinf;  sleeji:  liis  nrination  lii'eame  dillienll,  tnil  lliis  was 
relieved  liy  extract  of  Inu-iin  an<l  sweet  spirit  of  nitre:  and  tin'  rii;hl  iiarolid  lieea mi' enlarged,  indnrati'd  and  painful. 
Next  diiy  then'  was  a  very  ofi'ensive  fetid  diseharjre  from  ihe  nose  ;ind  mnllerinj;  (hlirinm  sit  in,  tiillowrd  liy  death. 
/'os(-mo)7(')H  examination  two  Inmrs  after  death:  K'ohnst.  nuiscnlar.  K'ii^lil  Inni;  and  plenra  soimuliat  iiillamed.  l:Hf;e 
ahKcess  in  tlie  middlo  lolie:  liver  mneli  eoniiested :  ii'so|ihai;ns,  stom:ieli  and  intestines  inllameil  I  lironnliont :  I'eyer's 
patehes,  ea'eiim  and  eoliin  iileerated. —  Third  Dirisinn  lliiKjiildl,  Alixdiidriii,  In. 

Case  (i(>. — Private  Adam  ('nil.  Co.  I>,  'JMi  Mieh.:  ;ii;e  L'."):  admitted  Feh,  l:f.  1X(;.">.  l)i;if,'niisis — lyplio-malarial 
fever  and  eoiiKest  ion  of  Innfis.  Died  llHh.  /'e.s/-»iiir((  hi  examinat  ion  fonileen  hours  after  death  :  Well  developed  ; 
larije  de]>osit  of  I'al  :  recent  lilister-niarks  on  neck  ;ind  chest:  sli;;hl  snj;f;illal  ion  postei  ioi  ly  :  fjreal  rij^idily.  I'len- 
ritic  adhesions  on  linth  sides:  rii;hl  lnn<;  congested,  crepitant  in  upper  lolie.  Stom.ieh  distended  with  :iir:  l'e>er's 
patches  inllameil,  in  many  places  ulcerated;  large  intestine  congested.  I/iver  nutmeg:  spleen  enlarged:  kidiievH 
small;  odier  viscer.-i  normal. — Third  Ihri-iinii  lltisjiilnl,  .lltxiiiiilriii,  I'n. 

C.\.sK  (17. — I'rivate  As.i  C.  Went  worth.  Co.  II,  liMh  Me.:  was  admilted  Nov.L't!,  IMCH.  wil  h  Jaundice.  [This  man 
appears  on  the  register  of  Ihe  rcginn'nlal  hospital  as  admilled  on  the  IHIh  with  typho-malarial  lexer  .and  sent  to 
general  hospital  on  the  2LM.  |  Died  , Ian.  113,  IHIil.  l'o«l-iii(irlriii  examimition  Iwenly-lwo  hours  after  dealh:  The 
l)liarynx  and  larynx  were  inllann'd;  the  soft  ]>alale  hard,  slid'  and  while:  the  tonsils  iinalVected :  lielween  Ihe 
))harynx  and  right  arytenoid  c;irtilage  was  a  large  abscess  with  haul,  yellowish-white  walls;  the  c;irlilage  mentioin'd 
was  the  seat  of  a  jirotnlierance,  ])rolpalily  :i  collectioit  of  pus:  there  was  also  ii  small  ahscess  immediately  .ahove  the 
left  greater  ciirnn  of  the  hyoid  hone:  Ihe  vocal  chords  and  the  n|iper  snrface  of  the  epiglottis  wcri^  ledem.atons. 
Ihe  pet  icardinm  contained  seventeen  draehms  of  yellowish  fluid:  the  heart  was  very  soft.  The  liver  was  Inoii/ed 
.■mil  mottled  with  hard  lardaceons  spots,  the  gall-liladiler  fnll  of  dark-brown  viscid  bile:  the  spleen  was  rather  small 
and  exticmcly  soft  :  the  pancreas  soft  and  of  a  dnll-red  color:  Ihe  kidm'ys  congesteil.  In  the  ileum  the  villi  were 
M'i\  sot't  :  I'eyer's  )>alclics  were  not  raised,  but  one  of  them  ])resentcil  an  nicer  uilh  low  ronnilcd  edges,  at  the  base 
of  u  hiili  the  liansveise  miiscnlar  libres  could  be  sei-n ;  the  ileum  had  the  ironed  imt  appeaiance.  Ihe  colon  \\  .as 
sl.ate-coliired,  its  solitary  follicles  whitish,  with  eoiisjiieiions  (lark-N]iotted  centres. — .Is.h'I  ,S'»/v/.  llnrri^on  .lllni,  ('.  .S. 

.1..    I.ilUltll!    Illlsllillll,    II  lisllillllhlll,    l>.   ('. 

('\sr:  t;s, — I'livate  Chailes  llangson,Co.  I,  1  Ith  ('onn.;  age  27;  was  admitted  Oct.  lit,  ISlili,  with  typho-malarial 
fever,  lie  had  been  sii'k  for  twelve  days  and  on  admission  was  in  a  sonu-coinalosc  condition  :  tongue  dry,  gla/ed 
and  red  at  the  tip  and  edges:  )>nlse  I'Jd.  full,  hounding  and  incompressible.  On  the  L'7th  t  he  piil.se  was  1(W  and  scarcely 
perceptible  at  the  wrist  ;  the  |),itient  had  somi^  eongh  with  thick,  tenacions  yidlowish  sputa.  The  ileo-e;ecaI  region 
was  tender,  but  no  criii)tioii  was  observed.  Death  oeoiirred  on  the  2!lth.  At  (irst  tiiictiiro  of  aconite  was  given, 
for  which,  on  tho  25th,  quinine,  carbonate  of  aiinnoiiia  and  whiskey  were  siibsti tilted.  I'ont-morlim  examination  fonr 
honrs  after  death:  Tli«  trachea  was  palish  but  mottled  at  its  bifurcation;  several  ecchymotie  spots  were  observed 
on  its  posterior  snrfaeo.  Tlie  lesophagtis  was  pale  a7id  its  mneoiis  membrane  (irm.  The  right  lung  was  perfectly 
healthy;  the  left  lung  weighed  thirty-one  onnces  and  a  half,  its  n))per  lobe  being  congested  geiu'rally  and  soliditied 
in  its  central  jiarts  and  its  lower  lobe  mottled  witli  dark-brown  sjiots  abont  the  size  of  a  jiea.  'Ihe  heart  lonlained 
fibrinous  elots  in  its  right  chambers.  The  liver  WiiH  congested  and  weighed  seventy-two  oiinies:  the  spleen  lirm, 
fourteen  onnces  and  a  half:  the  pancreas  normal;  the  kidneys  congested.  The  small  intestine  near  the  ileo-ca'cal 
valve  was  of  a  darker  I'olor  than  elsewhere;  its  mncons  membrane  w.as  healthy  to  within  ten  feet  of  the  valve,  at 
which  point  it  became  nnnsnally  vascular  and  softened,  I'eyer's  ])atehes  and  Ihe  solitary  glands  being  of  a  dee]i 
pink  color;  lower  down  I'eyer's  glands  became  enlarged,  whitish  and  hard,  with  abrnpt  edges;  still  lower  down 
they  were  ulcerated,  which  condition  freipiently  existed  in  the  centre  of  a  patch  while  its  margins  remained 
enlarged  and  hard:  the  glands  near  the  valve  were  ulcerated  in  their  whole  sii)iertices,  some  of  them  looking  not 
unlike  Ilnnterian  chancres;  the  ulceration  did  not  extend  deeper  than  the  mucous  membrane:  thi'  solitary  glands 
were  enlarged  and  of  a  dark-])nri>le  color  in  the  lowi^r  part  of  the  ileum,  and  som(^  near  its  termination  were  nlcerated. 
The  mucous  mend)raiu^,  of  the  ca'cum  and  ascending  colon  was  of  a  dark-bluish  lolor:  lower  down  it  was  pale  and 
in  some  jdaces  pink;  the  solitary  glands  were  conspicuous  but  not  elevated,  appe;iring  as  whitish  s])ols  with  jiig- 
mented  centres. — AsaH  Surg.  Uarrixoii  .lUin,  U.  S.  .(.,  Lincnlii  llnxpittd,  ll'a^hiixjtnn,  I).  ('. 

(C.)  Cnndition  i>f  I'ri/cr'n  palchtH  not  utatid  :  Ihe  inli  slim .\  rdriouxlii  nfficlid — l.""  vukck. 
Case  (10. — Henry  Heynolds.Co.  C,  7ilth  N.  Y.,  «.as  admilted  Aug.  21.  lS(>:i, having  been  sick  ten  days  with  he;id- 
aclie  and  weakness  of  limbs,  followed  by  fever.  Diagnosi.s — typho-malarial  fever.  He  was  weak  and  somewhat 
emaciated:  his  pulse  feeble  and  compressible ;  tongue  slightly  coated ;  appetite  poor:  bowels  reguhir.  He  died  on 
till' 2lith.  /'(l.^^molV*'nl  examination  thirty-one  hours  after  death:  Lungs  much  congested:  a  large  amount  of  serum 
in  right  ideural  cavity;  heart  normal,  containing  a  large  clot;  liver  somewhat  congested;  gall-bladder  much  dis- 
tended; spleen  enlarged,  I'ongesteil  and  softened  ;   mesenteric  glands  enlarged. —  ll'cs/  End  JfiiKj)ilitl,<'iiii;inniili.  <>. 


348  POST-MORTKM    RECORDS    OF 

Oase  70. — Priviite  Josepli  K.  Ilinlson,  Co.  A.  Gonlnn's  Ark.  rci;iiiioiit :  nao  10;  adiiiiltcd  Dec.  10.  ISGl;  tyiilio- 
inahirial  fever.  On  ailiiiissidu  ho  liiiil  t'cver  and  cliiinlid'a  ;  his  tiuiijiic  was  .sliijlitly  cuaicd.  jiulsi^  Km.  appetite  lair, 
i-espiratidii  uoiiiial,  legs  .swollen  IVimi  tlie  km-es  down.  He  rested  well  and  in  a  tew  days  tlie  swellini;-  of  tlie  lej;s 
Ueeaine  souiewluit  vedueed,  l)nt  tlie  diarrlnea  ]iersisted.  He  did  not  sutler.  Imt  j;rew  weaker  and  dii'd  on  tlie  22d. 
I'ost-iiiorlnii  exanuinition :  There  was  enni elation  with  (edema  of  the  legs  and  feet :  the  Idood  was  very  jioor  and  thin. 
The  Inugs  and  heart  were  normal;  the  spleen  ahont  three  tinu-s  the  iu>rnuil  size;  the  gall-liladder  distended  with 
hile;  tlie  inesenterie  glands  so  enlarged  that  the  ine.sentery  had  the  apiiearanee  of  heing  one  eontinnoiis  gland;  tlii^ 
solitary  glanils  disorganized  and  the  mneoiis  eoat  of  the  reetum  intlanied  and  softened. — AvI.  Atsx'l  Siiri/.  II.  ('.  Xiir- 
kirk,  Unci  hliind  Ilnnpitnl.  TV. 

Cask  71. — I'rivate  Warren  M.  I!nrtnn..('o.  K,28tli  .\la.;  age  H.S;  was  admitted  Dee.  7.  18tU,  with  ty]ilio-iiialai  ial 
fever.  He  had  lieeii  sick  for  four  weeks  with  diarrhiea  and  general  malaise.  On  admission  his  howels  were  slightly 
relaxed,  tongue  heavily  eoated  with  a  brown  era(died  fur.  skin  hot,  (iiilse  freiincnt  and  feeble,  eonntcnanee  shninkeu  : 
he  was  inelined  to  sleep,  vvhieh  lie  did  lieavily  and  w  ith  the  whites  of  his  eyes  exposed.  Hiceough  sjieedily  eame  on 
and  he  died  on  the  Stli.  Pont-mortim  examination  ten  hours  after  death:  The  lower  i)ortioii  of  the  right  pleura  w.is 
intlanied.  The  heart  euntained  white  elots.  The  peritoneum  was  much  injected  and  tinged  throughout  of  a  yellow 
color.  The  spleen  was  soft  and  friable.  The  stomach  contained  about  a  pint  of  dark  liiiuid  with  detached  shreds 
of  its  niueous  membrane  floating  in  it;  the  lining  ineuibraues  of  the  oeso])hagns  and  duodenum  were  also  softened 
and  disintegrated.  The  mucous  coat  of  the  boweLs  \vas  much  congested  throughout:  fa'cal  matter  iu  the  reetniii  was. 
of  normal  consistence  but  white  and  fetid. — Art.  Ans't  Siirr;.  J.  />'.  Voinifi,  Uocl-  I.ihnid  llospilal,  III. 

Ca.se  72. — I'rivate  .James  liozeman.  Co.  I,  40th  Ala.:  age  81:  .-idmitted  liee.  22.  IStU;  typho-malarial  fever. 
This  man  enlisted  in  .Ajiril,  lSfi2;  he  had  measles  soon  after  and  since  then  has  had  diarrlnea  ahiiost  constantly  and 
freiinent  attacks  of  fever.  He  was  cai)tiired  in  Jtine,  1S(U.  His  present  attack  comnienced  Hecember  IS,  with  iiain 
ill  the  head  and  breast  and  chilly  .sensations  t'ollowed  by  fever.  When  admitted  his  tongue  was  coated  brown  with  red 
margins;  bowels  hiose;  pulse  120;  cough  and  slight  expectoration:  anorexia  an<l  thirst.  He  died  on  the  2Sd. 
I'dnt-iiiorlfiii  examination  twelve  hours  after  death;  Great  emaciation.  The  low<'r  lobe  of  the  left  lung  was  congested. 
'I'he  liver  was  pale.  The  intestinal  mneons  membrane  was  congested,  and  in  the  rectum  softened. — .let.  A-is't  Sunj. 
H.  r.  .\(irkirK-,  Rod-  Island  Hn^piiitl ,  III. 

Case  7;^. — Rell field  W.  Ferguson,  a  citizen  of  Mo.;  age  63;  typho-malarial  fever.  Died  Dec.  20,  18t)l.  I'dxl- 
xiofdm  examination:  The  body  was  greatly  emaciated.  Tlie  posterior  part  of  the  left  lung  was  congested  and  ils 
pleura  inflamed.  The  intestines  showed  some  congestion  with  disorganization  of  the  solitary  glands:  the  inesen- 
terie glands  were  enlarged. — Ait.  Asa'l  Siirij.  -T.  M,  ll'illi<rtr<ix.  Hock  hliuul  Ilotpiial,  III. 

Case  71. — James  tUise,  citizen  id'  .\Io.  Typho-malarial  fever.  Admitted  Dec.  1, 1864;  died  2()th.  Onllie,  day 
of  his  death  he  had  a  dry  furred  tmigne  which  he  was  uiialde  to  protrude;  he  sjioke  with  diflicrilty;  respiratiiui  was 
qtiick  and  labored:  the  surface  dry  and  cold  and  the  pulse  imperceptible.  He  h.id  a  slight  erysipelatous  swelling  of 
the  left  ear.  Posl-iiiortnn  examination;  The  lungs  were  dark  and  congested  jiosteriorly;  the  liver  was  enlargi'd. 
''There  were  commencing  ulcerations  of  the  intestines,  with  general  indications  of  internal  congestion." — Act.  .Is.sV 
Surg.  J.  M.  JVithrrwiix,  Hock  Ishniil  Hospital,  III. 

Case  7;").— Stockton  M.  Hayne,  Co.  H,  3d  Ga.  Cav.;  admitted  Dec.  3,  18f)4:  typho-malarial  fever.  Die.l  21th. 
Post-mortem  exaininatiou:  Right  lung  normal;  lower  lobe  of  left  lung  hepatized  gray;  four  ounces  of  dark  yiUow 
serum  in  pericardium:  heart  flaccid,  both  sides  containing  thrcunbi  extending  into  the  vessels.  Liver  normal;  gall- 
bladder <listended;  sjdeen  enlarged,  congested  and  softened;  mesenteric  glands  greatly  enlarged.  Mucous  mem- 
brane of  small  intestine  ulcerated  in  various  parts,  and  that  of  colon  and  rectum  highly  congested  and  disintegrated. — 
Act.  Ass't  Surf/.  J.  M.  Withiriras,  Rock  Island  Hospital,  III. 

Case  76. — William  C.  Norton,  Co.  A,  Wood's  Missouri  battery.  Typho-malarial  fever.  Died  .Ian.  20,  1865. 
Post-mortem  examination:  The  heart,  lungs  and  liver  were  normal.  The  spleen  was  slightly  enlarged ;  the  small 
intestine  congested;  the  mesenteric  glands  enlarged;  the  rectum  ulcerated  in  jiatehes  through  the  mucous  and  mus- 
cular coat.s,  some  portions  appearing  gangreimus. — Act.  Ass't  Siirfi.  ■!.  M.  Withiricax,  Hack  Island  Hospital,  III. 

(,'ase  77. — Jes.se  Eaton,  citizen ;  admitted  Dec.  21,  1861:  typho-malarial  fever.  Died  31st.  He  snflered  from 
sore  throat,  chills,  a  slight  swelling  of  the  right  cheek  of  an  erysipelatous  character,  and  had  "many  symiitonis  id'  a 
typhoid  condition."  Post-murtrm  examination  six  hours  after  death:  Lungs  liealthy;  heart  contained  wliite  clots  in 
right  side;  liver  and  spleen  somewhat  congested:  lower  portion  of  ileum  presenting  numerous  small  ulcers:  descend- 
ing colon  strictured  for  six  inches  of  its  length,  so  that  an  ordinary  lead-pencil  could  scarcely  be  passed. — Act. 
Ass't  Snrij.  ir.  Mattlicirs,  Hock  Island  Hospital,  III. 

Case  78. — Private  Francis  Scott,  Co.  K,  41st  N.  Y.;  age  .So:  admitted  Feb.  13,  1865;  typho-malarial  fever  anil 
chronic  diarrluea.  He  was  treated  withqninia,  alcoholic  stimulants  and  turpentine.  In  the  progress  of  the  case,  the 
lower  extremities  became  (edematous  and  signs  of  valvular  disease  were  discovered.  He  died  March  21.  I'ost-morlrm 
examination:  Body  much  emaciated:  lower  extremities  (edematous.  The  heart  was  slightly  hypertrophied,  itHaortie 
valves  thickened.  'I'he  liver  was  enlarged  and  deei)ly  bronzed.  The  mucous  membrane  of  the  intestines  was  soft- 
ened tliroughout. —  Third  Dir'tsinn  Hospital,  Alexandria.  Va. 

Case  7!».— Private  Abraham  J.  Coo|)er,  Co.  A,  186tli  N.  Y.:  age  20;  adinitt(^d  Nov.  30,  IHtil;  typlmid  fever.  |  I  lie 
diagnosis  at  the  Ninth  Army  Corps  Field  Hosiiital,  on  the  24tli,  was  tyjiho-iiialarial  l'ev(^r,  and  at  the  Depot  Field 
Hospital,  City  Point,  Va.,  on  the  26th,  renuttent  fever.]  Symptoms  on  admission:  Pulse  varying  from  !M)  to  110. 
feeble  and  thready ;  skin  hot  and  dry;  tongue  dry,  extrenudy  red  and  gashed;  teeth,  gums  and  lips  inerusted  with 


THE    ruNTlNUKD    KKVERS.  lUO 

Sdidi-s:  (U'iifucs.s :  stii|>()i-;  low  (Ujliiium.  Wlieu  undistnrlifil  lie  Iny  with  his  oves  half  closed  iniitteriii^  ludki'ii  and 
iiucomieeted  .seiiteiiees;  when  aiou.sed  he  had  a  vaeant  expicssion  anil  was  unable  to  answer  eoneetly.  Duiinfj  the 
lii-st  t  wenty-tbiii-  houis  after  admission  he  had  foui'  ]iassajies  fnnii  the  liowi-ls;  the  alidoiiien  was  tyinpaiiitie,  vefv 
tendei-  over  the  small  intestine  and  eaeum,  and  marked  with  a  lew  peteehia-  and  siidandna.  'I'liipeiitine  eniul 
slon.  landaMiini  anil  milk-imneh  were  administered.  Xexl  day  tlien-  was  a  slight  impiovement :  I'he  jpiilse  lieianie 
sonuMV  hat  stron,<;er,  the  tongue  less  tremulous  and  jirotruded  with  mole  ease;  the  patient  was  aide  to  answer  a  feu 
quest  ions  eoneetly,  but  the  abdomiinil  syin]iloins  eon  tinned  and  there  was  some  e]iistaxis.  On  lleeemlier  1'  the  pnl.-e 
beeame  somewhat  stronger  and  less  freiinent,  the  tongue  ipiite  moist,  the  soriles  part  ially  removed  and  the  diarrhiea 
eheeked:  but  at  !i  P.  M.  the  diarrhiea  returned,  several  involuntary  stools  were  passed  and  the  patient  fell  into  a 
stn]ior  from  which  he  never  aroused.  He  diinl  at  3  A.  M.  of  the  'M.  I'(i/il-iiiiirltiii  examination  eight  hours  after  death : 
Lungs  eiepitant  throughout :  liver  pale,  with  well  marked  nutmeg  ajpiiearaiiee:  spleen  of  full  si/e  and  softeiwd  :  kid- 
neys full  of  blood,  the  jiy  ramiils  of  a  dai  k-red  color:  luesenteric  glauils  i'norun)Usly  enlarged  :  lolon  pale  ami  without 
ulceration;   ileum  injected. — Art.  Axi't  Siir;/.  II'.  ('.  Millar,  Third  IHri-iiiiii  Ilnnjiiliil.  Aluiiiidrin,  I'li. 

t'.\SE  80.— Private  AlbiMt  Mathews,  Co.  A,  ITltli  Ohio:  age  V.l;  was  admitted  .Ian.  L'S.  ISli."..  with  lypho-iuala- 
rial  fever.  When  admitted  his  bowels  were  loose,  skin  hot  and  dry,  tongue  dry  and  red,  pulse  lIHl  and  feel>lc. 
On  February  5  the  lUarrhiea  became  [irofuse.  A  chill  followed  liy  fever  and  sweating  occuned  on  the  lUlh  aiid- 
again  next  day.  yuinine  was  fieely  adiuinistereil  without  app;irent  lienelit.  lie  died  on  the  27lh.  I\n<l-iiinrliiii 
examination  three  hours  after  death:  ISody  much  emaciated.  Membranes  of  brain  much  injected:  cerebral  hernif- 
plieres  coated  with  coagulable  lymph:  substance  of  brain  much  injected  and  softeneil:  lateral  \eutricles  eont;Mning 
serum  and  a  deposit  of  lymph.  Heart  healthy;  liver  and  spleen  adherent  to  dia]diriigni :  gallbladder  distended  w  It  h 
dark  bile;  omentum  congested:  intestinal  nnicous  membrane  extensively  diseased  and  portions  of  ileum  gangien- 
ous. — Act.  Ain't  Surg.  Saiiiplf  I'unl,  Ciiiiilnrland  llufijiitiil,  Md. 

t'.\SE  81.— Private  William  Henry  Clay,  Co.  D,  2Wh  V.  S.  Colored  troops;  age  21  :  was  admitted  .July  L'l,  ISlil, 
on  account  of  inguinal  hernia  on  the  right  side  and  enlaiged  inguinal  glands.  On  .Vpril  (!.  lS('i.">.  the  records  present 
him  as  feverish  and  jaundiced,  without  giving  infornuition  as  to  the  period  of  on.sct.  His  pulse  was  !••">,  tongue 
coated  with  a  yellowish  fur,  skin  dry;  In^  had  thirst,  anorexia,  nausea,  tenderness  in  the  right  jliae  region  and  con- 
stipated I>ow(ds;  there  was  some  mental  torpor  and  considerable  muscular  debility.  On  the  Sth  his  pulse  was 
small  and  frei|uent:  he  hail  a  cough  and  complaitu'd  of  pain  in  the  right  wide  of  the  chest.  He  died  next  da\.  .\ 
mercurial  purge  oiierated  well  on  the  tith:  subsei|uenlly  the  bowels  were  so  loose  that  opium  was  employed.  (,iui- 
nine  and  stimulants  were  freely  administered.  The  case  is  recorded  by  the  .'ittcnding  jihysician  as  one  of  lypho- 
uuihirial  fever.  I'o.il-iiiiirtcm  examination:  The  thoracic  viscera  were  normal.  'I'he  liver  was  very  light-coloicd  :ind 
soft:  the  s|ilecn  ami  kidneys  softened  and  eougestcd.  The  whole  of  the  intestinal  canal  was  iullanud  :  I  lie  niisin- 
teiic  glands  enlarged.  The  iieritoneum  was  inllameil  ami  the  sac  contained  about  half  a  pint  of  sero-pm  iilent 
liiiuid. — .hi.  .Isn't  Stiri/.  I'raiik  Uinhland,  L'Oiirrvtiire  Jlonjiilul,  Aliiandriii.  In. 

Cask  X2. — I'rivate  N.  Henry  IJowning,  Co.  A,  «th  111.  Cav.,  was  admitted  June  IS,  IMil,  with  typho-mahu  iai 
fever.  He  had  not  been  in  his  u.sual  vigorous  health  for  several,  weeks,  but  had  continued  on  duty  until  aduiission, 
when  he  was  suffering  from  pyrexia,  severe  headache  referred  to  the  temples,  diarrhu'a  and  dull  pain  in  the  lower 
extremities;  his  eyes  were  sutt'used  and  painful  and  his  tongue  heavily  coated  with  a  dark-yellow  fur,  the  edges 
being  of  a  livid  hue.  tininine,  tweuty-tive  grains  in  the  twenty-four  hours,  and  chlorate  of  jiotassa  were  adminis- 
tered. Next  day  he  aiipeared  improved, — pulse  W),  headache  decreased,  tongue  less  dark:  but  a  little  ])ain  and  ten- 
derness had  developed  in  the  ileo-ca^cal  and  hypogastric  regions  and  there  was  slight  epistaxis.  The  i|uiniiu>  was 
continued  with  a  saline,  diuretic  and  diaphoretic  mixture.  He  remained  In  this  condition  until  the  21th,  when  his 
countenance  beeame  bright  and  pleasant  and  he  was  free  from  pain  :  pulse  12(1  and  full :  coating  of  the  tongue  lighter 
and  the  edges  pale;  he  vomited  a  little  greenish  liquid  in  the  morning  and  h;id  an  exacerbation  of  fever  in  the  aftci- 
noon.  Twenty-eight  grains  of  quinine  with  chlorate  of  potassa  were  ordereil  to  be  taken  in  the  twenty-four  hours. 
Next  day  his  skin  was  moist  and  cool,  pulse  96,  but  there  remained  a  little  pain  in  the  bowels,  which  afterwaids 
l)ecanie  a  feeling  of  fulness  and  was  relieved  by  castor  oil  and  tomcutations.  On  the  evening  of  the  27th  he  was 
suddenly  seized  w  ith  a  sharp  pain  in  the  bladder  and  penis  and  inability  to  void  his  urine;  the  catheter  showed  his 
bladder  to  be  empty.  Hy  next  morning  the  pain  had  extended  over  the  whole  abdomen,  w  hieh  was  very  tender:  his 
countenance  was  anxious;  pulse  120  and  small:  tongue  moist  but  with  the  light-colored  fur  and  pale  edges;  he  hiy 
on  the  right  side  with  his  thighs  llexed.  On  .July  1  he  became  some  easier  under  the  continued  use  of  morphine,  but 
later  in  the  day  the  pain  again  became  intense  and  he  died  at  2  a.  m.  of  the  2d.  I'mt-mortnu  examination  ten  hours 
after  death:  The  liver,  spleen  and  kidneys  were  healthy.  The  ileum  was  perforated  about  four  inches  from  the  ileo- 
ciecal  valve  and  there  was  extensive  peritoneal  inllammation.  [Sj«'cimt«  324,  Med.  Sect.,  Army  Medical  Museum,  is 
from  this  ease.] — Sitnj.  A.  Hard,  Sth  III.  Car.,  Regimental  Huspital. 

Cask  83. — Private  Daniel  Hare,  Co.  D,  175th  Ohio;  age  18;  was  admitted  Oct.  15,  181)1,  with  quotidian  inter- 
mittent fever,  which  passed  into  typhoid  fever.  He  was  weak  aiul  much  cnuiciated  from  chronic  diarrhiea,  but  !iis 
bowels  were  now  regular.  He  had  a  chill  and  fever  daily,  for  which  quinine  was  freely  given  w  ith  bi-nelici:il  etVect : 
but  on  the  19tli  diarrhiea  set  in  and  fever  was  developed  in  the  evening.  The  bowels  remained  nuider;itely  checked 
by  astringents  until  the  21th,  when,  as  they  becanu!  looser,  the  tongue  blackened.  Turpentiiu-  was  given.  Three  days 
later  retention  of  urine  required  ridief  by  catheter  and  tenderness  over  the  pubes  called  for  foiucnt:itifins.  The 
suprapuliic  tenderness  continued  until  the  30th,  when  a  violent  chill  occurred,  lasting  for  an  hour,  and  followed  by 
liigh  fever,  profuse  jierspiration,  great  abdominal  tenderness,  coldness  of  the  extremities  and  death,     ruit-inurtnit 


350  post-M()i;tkm  REConDs  of 

exiuiiiiiiitioii  twenty-oiM'  Ikhiis  iiCliT  diMtli :  I  Icurl  ikhiikiI  :  liiiij^s  coiinrstcd  imstri  iurly.     Alxlimiiiiiil  vi.sctTii  f,^MU'iully 
iiitfrailliert'iit ;  iiciitimciiiii  connr.stod  and  foutuiiiiiij;  li(iuid  firci's:  iletiiu  ulcerated  in  iiatrlius  toi'  thioc  and  a  halt' 
feet  above  the  ileo-eaeal  valve,  some  of  the  ukeis  having  reached  the  iieiitoneuiii,  and  two,  ahout  two  feet  from 
the  valve,  haviuj;  iHuforated  this  membrane.     Other  organs  not  examined. —  Ilnspihil  Xo.  X,  \ii-sltrillc,  Tcnn. 
(D.)  Condition  of  Pnjer^s  pulclim  nii-ioimlii  stilted,  tint  not  iilci'i-atcd;  intcxtinis  inoi-c  or  lens  iifficted,  Inil  no  ulccrulion  of  the 

ill  iini — 9  cd.scs. 

Case  81.— Serg't  John  II.  I'eters,  Co.  E,  120th  I'a.;  admitted  April  20,  IWii?.  Diagnosis— typho-malarial  fever. 
Died  30th.  rost-inortini  examination  nine  hours  after  death:  Some  rigor  mortis.  Brain  weighed  forty-six  onnees 
and  a  half.  Mucous  membrane  of  trachea  jialc.  Right  lung  litteen  ounces  and  a  half,  healthy;  left  lung  thir- 
teen ounces  and  three-quarters,  dark  l)lue,  its  apex  luirplt  Heart  normal;  soft  black  clot  in  right  ventricle: 
small  narrow  clot  in  left  ventricle.  Liver  forty  nine  ounces  and  a  half,  dark  purple  eNt(  in.illy.  paler  on  section. 
rather  soft ;  eai)sule  of  (ilisson  readily  torn.  Spleen  eight  ounces  and  a  ([uarter,  soft,  dark  mulberry  color.  tral>ecuhe 
conspicuous.  I'aucreas  four  ounces  and  one-(iuarter,  natural.  Stonuich  mottled  dark  and  pale  red.  Mucous  mem- 
brane of  small  intestine  generally  pale,  with  irregular  patches  of  conges titui;  I'eycr's  patches  pale;  solitary  follicles, 
especially  in  lower  part,  dark  puri>le  in  color,  enlarged  and  ulcerated:  mucous  membrane  of  vermiform  a]ipenilix 
dark-colored  and  presenting  two  ulcerated  patches  one-eighth  of  an  inch  in  length.  Large  intestine  gray  through- 
out; solitary  glands  consjiicuous;  three  ulcers  in  the  lower  part  of  the  bowel — the  lir.st,  one  inch  in  diameter,  in  the 
signmid  tiexure,  the  others,  smaller,  in  the  middle  porticm  of  the  rectum.  Kidneys  congested. — Axi't  Siinj.  lliirrixoii 
Allen,  U.  S.  J.,  Lincoln  JJonpitul,  U'ushinyion,  D.  C. 

Case  85. — Private  A.  C.  Starker,  Co.  D,  15th  N.  J.,  was  admitted  Nov.  23,  181)3,  as  a  case  of  typho-malarial 
fever:  Pulse  115  to  130,  irritable;  tongue  dry  as  a  pine  shaving,  glossy  and  red  on  its  edges;  sordes  on  teeth  and 
gums;  urine  scanty,  densely  loaded  and  very  fetid;  stools  involuntary;  friction-sound  on  right  side  of  chest.  In 
answer  to  (|nestioiis  he  talked  incoherently  for  a  few  seconds  and  then  relapsed  into  stujior;  he  picked  at  the  bed- 
clothes, and  drawing  his  legs  up  would  suddeuly  straighten  them  iu  an  aiiparent  etiort  to  kick  olf  the  covering. 
Subnitrate  of  bisnnttli  controlled  the  diarrluea;  stimulants  were  freely  adndnistered.  He  died  on  the  28tli.  I'lixt- 
mortnn  examination  ten  hours  after  death:  Right  lung  adherent  to  costal  pleura  by  a  strong  and  dense  false  mem- 
brane; left  lung  distended  with  a  black  tluid,  nnailherent:  heart  normal.  Liver  very  pale,  much  enlarged  and 
softened;  spleen  larger  than  usual  and  softened:  kidneys  one-fourth  larger  than  normal  and  indurated,  especially 
in  their  lower  fourth,  where  their  .substance  ciuild  not  be  crushed  between  the  thumb  and  linger.  Peyer's  patches 
distinct  and  elevated,  their  edges  ragged  ;ind  raised  one-tenth  inch  above  the  surrounding  surfacis:  solitary  glands 
of  large  intestine  ulcerated;  lymphatic  glands  enlarged — one,  as  large  us  a  walnut,  was  on  section  much  like  the 
spleen. — Act.  Jss'l  Snrij.  II'.  II.  Lcttcnnun,  llouijlas  Hoapitul,  ll'imhini/ton,  D.  C. 

Cask  8t). — Private  Patrick  Conlin,  Co.  E,  25tli  Mass.;  age  3(i;  was  admitted  March  11,  1805,  with  symptoms  of 
typho-nuilarial  fever.  He  had  decided  fever  with  fre(iuent,  compressible  pulse,  hurried  breathing,  hot  dry  skin, 
furred  ilry  tongue,  severe  headache  and  costive  bowels;  his  countenance  was  dusky,  his  eyes  injected,  and  there  was 
great  i)rostration  with  considerable  mental  confusion  and  hebetude.  Numerous  red  spots,  a  line  in  diameter  or  less, 
were  observed  chietly  on  the  chest  and  abdomen;  they  were  somewhat  elevated  and  did  not  disappear  comj)letcly 
on  pressure.  On  the  I3th  the  tongue  was  uu>re  thickly  coated  and  brown,  the  teeth  and  gums  covered  with  sordes, 
the  urine  scanty  anil  high-colored,  the  abdonuMi  tender  and  painful ;  no  abnormal  condition  of  tlie  lungs  was  delected 
by  auscultation  or  percussion.  On  the  15th  the  headache  was  succeeded  by  delirium  and  occasional  stnpor,  with 
contracted  pupils,  drooping  of  the  lids  and  subsultus  tendinum  ;  the  bowels  wore  constipated.  Later  the  spots  on 
the  skin  became  of  a  dusky  crimson  and  quite  nnatl'ected  by  pressure.  He  died  comatose  on  the  17th.  I'oxt-niovtint 
examination  nineteen  hours  after  death:  A  large  (luantity  of  serum  was  found  in  the  subarachnoid  space  and  a 
smaller  quantity  in  the  ventricles;  the  membranes  and  substance  of  the  brain  were  congested.  The  heart  contained 
some  imperfectly  formed  clots  and  fluid  blood.  The  lung.s  were  congested;  the  lower  ixirtion  of  the  right  lung  was 
iu  a  condition  of  gray  heiiatization ;  the  left  lung  weighed  twenty-one  ounces,  the  right  thirty-two  ounces.  The 
liver  was  soft,  well  tilled  with  blood  and  weighed  sixty-eight  ounces;  the  gall-bladder  contaiued  very  black  bile; 
the  spleen  was  tlaccid  and  slightly  enlarged;  the  pancreas  was  reddened  and  weighed  seven  ounces.  The  intestines 
generally  were  dark  and  congested;  the  glands  of  Peyer  conspicuous  and  dark-colored.  The  kidneys  were  appar- 
ently normal. — -Ifn't  fiiirg.  Gcorijc  M.  McGill,  U.  S.  A.,  Xiitional  Hospital,  Baltimore,  Md. 

Cask  87. — Private  Niles  Ivors,  Co.  F,  lith  Wis.,  was  admitted  April  21,  18t)4,  with  typho-malarial  fever.  He 
stated  that  he  had  been  sick  for  a  week  with  fever,  w  Inch  began  with  chills.  He  was  much  prostrated;  his  bowels 
were  loose  and  his  tongue  dry  and  brown  with  red  edges.  Quinine,  stimulants  and  nutriment  were  ordered.  In  a 
few  days  his  respiration  became  accelerated  and  he  complained  of  cough  and  pain  in  the  side,  for  which  he  was 
blistered.  Under  this  treatment  he  gradually  improved,  the  fever  subsiding,  but  a  considerable  quantity  of  li(iuid 
remained  in  the  ph'ural  cavity,  for  the  removal  of  which  iodide  of  potassium  was  given  in  free  doses  and  an  occa- 
sional bli.stei'was  applied,  but  without  much  benetit;  the  etfusion  did  not  embarra.ss  his  breathing.  Convalescence 
was  slow  and  he  was  unable  to  leave  his  lied,  when,  about  ,June  1,  symptoms  of  hectic  apjieared.  lie,  failed  gr;i<l- 
ually  and  died  on  the  23d.  I'ost-mortini  examination  twenty-four  hours  afti;r  death:  liody  much  emaciated;  rigor 
mortis  nu)derate.  The  left  pleural  cavity  contained  about  a  pint  and  a  half  of  purulent  li([uid  which  compressed 
the  lung  against  the  spinal  column;  the  right  cavity  contained  about  six  ounces  of  serum;  the  right  lung  was 
healthy.  The  intestines  were  distended  with  gas;  the  mucous  coat  of  the  stomach  and  of  the  intestinal  canal  wa.s 
thickened  and  softened:  the  glands  of  Briinncr  and  the  solitary  glands  of  the  ileum  were  enlarged  and  prominent 
but  not  ulcerated;  the  patches  of  Peyer  presented  the  shaven-beard  appearance.     The  liver  was  about  one-third 


THK    roNTlM'KH    FKVKKS.  351 

larger  than  iioniial  aud  contained  a  number  of  minute  abscosses;  the  spleen  was  enlaij;eil  to  tlirei'  timeH  its  normal 
size  and  also  contained  abscesses;  the  kidneys  were  healthy.  [SjiiciiiK iix  liiVd,  Med.  Sect..  Army  Medical  Museum, 
are  from  the  spleen  of  this  case.] — .hx't  Sid-tj.  dm.  J.  MiiiKnk,  I'.  S.  /'.,  Sluiilnii  llosjiilal,  ll'(i«hiiiiil<iii,  l>.  ('. 

O.vsE  ><«. — Private  (ieorge  Pitcher,  Co.  11,  23(1  Mich.;  afje  'M>:  was  admitted  Kel).  II,  ISiif),  with  cliioMie  rheuma- 
tism. AVliile  under  treat nu'ut  he  became  attacked.  March  18,  with  symjitoms  of  typho-malarial  fever,  lie  iM<ii;icsse(l 
favorably  until  the  23d,  when  abdominal  pains  set  in;  next  day  he  became  semi-couialose  and  died.  He  was  treated 
with  turpentine  emulsion  and  carl)onato  of  annnonia.  I'ottt-mortcin  examination  twilve  hours  after  ilealli:  l.i\er 
miich  enlarged,  bronzed;  intestines  congested,  small  intestine  showing  shaven-beard  appearauci'  of  I'l  yei's  paiclus 
and  four  intussusceptions  from  four  to  si.x  inches  long. — Third  Division  Ilo^pilal,  Aluaiiilrid.  I'li. 

Cask  ><i(. — Private  Lewis  Sage,  Co.  A,  IStJtli  N.  V.,  was  admitted  Nov.  3(»,  IStil,  from  City  Point,  \'a..  wlu're  he 
had  been  under  treatment  for  typho-malarial  fever.  On  admission  he  was  in  an  unconscious  condition,  with  low 
<lelirium,  troublesome  diarrluea  and  a  harassing  cough;  pulse  1(K),  soil,  lie  was  treat4>d  with  milk-puudi  ami 
ammonia,  expectorants  and  turpentine  emulsion  with  laudanum;  but  he  sank  gradually  ami  died  l)i'c<'ml»i  Id. 
7'os/-wior/cni  examination :  All  the  viscera  appeared  to  bo  healthy  except  the  intestines.  The  mucous  memluaue  of 
the  ileum  was  deeply  inji-cted  throughout  and  of  a  dark  jmrplc  color:  its  solitary  follicles  were  enlarge<l  aud  some 
near  the  ileo-cacal  valve  were  ulcerated;  Peycr's  pati'hes,  which  were  slightly  lliickened,  presented  the  shaven-beard 
aiipearance.  The  colon  jirescnted  a  number  of  deep  ulcers,  es|i<'cially  at  its  extremities;  In  the  transver.se  colon  sev- 
eral of  the  ulcers  were  cicatrizing.  An  Intestinal  diverticulum,  two  inches  aud  a^half  long,  was  foulul  in  the  ileum 
about  three  feet  and  a  half  from  the  ileo-cacal  valve.  [N'os.  I(i,")  aud  Ititi,  .Med.  Sect.,  Army  Medi<al  .Museum,  an' 
from  this  case.] — Act.  Auk'I  Siiry.  IV.  C.  Minor,  Third  IHrisioii  llimpiltil,  .lltjaiidrin,  l'<i. 

Case  90. — Private  J.  T.  Pierce,  Co.  (J,  33d  Mass.,  was  admitted  .lune  1(1,  MV.i,  with  typho-malarial  fever,  lb- 
bad  frei|uently  suffered  from  intermittent  fever.  When  admitted  he  had  been  sick  for  some  time  aud  was  greatly 
euuiciated;  he  had  Sonus  diarrhu'a;  his  tonguts  was  coated  In  the  middle,  dry  aud  cracked;  pulse  132.  Afli'r  this  his 
breathing  became  hurried,  ami  coarse  nuK'ons  rales  were  heard  ovtu'  both  lungs;  Ihere  was  also  uuirked  uer\  ous 
prostration.  Ho  died  on  the  21st.  rosl-mortiiii  examination  twenty-six  hours  alter  death:  Hody  emaciated  ;  rigiu- 
mortis  slight.  The  brain  was  nornuil.  The  unicous  nn'mluane  of  I  hi'  o'sophagus  was  of  a  ])ale  purple  cohu'.  Thi' 
trachea  contained  nineh  bronchial  secretion  ;  its  mucous  mi'mluane  was  pur]>lish.  The  ni)]ier  ami  lulddle  lobcsof  the 
right  lung  were  solidilied  except  their  anterior  free  borders,  which  were  ])ale  aud  healthy;  the  lower  lobe  was  con- 
gested hypostatlcally  but  not  soliditied.  The  posterior  jiortiou  of  tins  h'fl  lung  was  In  a  state  of  gray  hepati/ation, 
the  anterior  part  healthy.  The  right  lung  weighed  twenty-seven  oumcs  and  a  <|uarler,  iIh'  lel'l  iliirly  se\  I'li  oiuiiis; 
the  bronchial  glands  were  large,  one  of  them  softened.  The  pi'ricaidlum  was  liiu'd  by  rcccnl  lymi)h  nmghencd  by 
papillary  elevations;  it  contained  six  drachms  of  llaky  serum-  The  right  cavities  of  the  heart  coutalucil  a  large 
venous  clot,  tins  li'ft  cavities  a  mixed  clot  which  extended  into  the  aorta.  The  livi'r  weighed  lil'ly-si'vcn  ouiuts,  it 
was  ]iale  and  slightly  softened;  the  gall-blaibler  contained  a  drachm  of  greenish-brown  viscid  bile.  Tlu>  spleen  was 
firm  ami  weighed  threi'  ounces  and  three-(|narters.  The  paiureas  was  firm  and  white,  it  weighed  two  ounces  and  a 
half.  The  right  kidney  weighed  live  ounces  and  a  quarter,  the  left  five  ami  a  half,  both  were  pale  and  flabby.  .No 
prominent  lesion  was  observed  in  the  intestines;  the  lower  i>art  of  the  jejunum  was  contracted  and  its  mucous 
nH'mbraue  pale;  Peyer's  patches  were  rather  jiale  ami  dotted  with  iioints  of  bla(!k  jiigment;  the  large  intestine  was 
contracted  and  its  mucous  membrane  of  a  pale  bluish  color. — J»«'(  tiiirij.  Harrison  Alien,  V.  S.  A.,  Lincoln  Honpilnl, 
Wnshinyton,  I).  C. 

C.vsK  ill.— Private  Willard  liock,  Co.  E,  16th  N.  Y.;  age  19;  was  admitted  Aug.  10,  18(i2.  lie  was  convalescing 
from  Chickahominy  fever  and  diarrlnea;  but  afterwards,  from  im))rudence,  was  again  attacked  with  diarrh<ea  and 
died  October  5.  I'oxt-moriim  examination  next  ilay:  .Slight  emaciation.  The  heart  and  lungs  were  nornuil.  There 
were  old  adhesions  of  the  right  half  of  the  right  lobe  of  the  liver  to  the  diai>liragm,  but  the  organ  was  sound;  the 
spleen  was  very  small  but  otherwise  natural;  the  kidneys  pale.  There  was  nuxlerate  inllannuation  along  the  great 
curvature  of  the  stomach.  In  the  ileum  were  three  large  patches,  about  fourteen  inelu'S  long,  of  intense  inflam- 
mation, with  the  intervals  lietween  them  moderately  inflamed;  these  patches  presented  many  suuifl  eccliyuu)ses. 
The  colon  was  much  contracted,  intensely  inthuned  at  its  counnencement  and  moderately  iullanu'd  throughout,  with 
here  and  there  small  ecehynmses.  The  agminated  and  solitary  glands  of  the  small  aud  largo  intestines  contained 
black  pigment. — Act.  Aaa't  Siiry.  J.  Lcidy,  Sattcrlec  Ilonpital,  I'hiludelphiii,  I'a. 

Cask  92 Lewis  G.  Baker;  age  37;  a  citizen  of  Mo.,  was  admitted  Dec.  15,  1X(>1,  with  typho-malarial  fever. 

He  stated  that  he  had  taken  cold  in  November  while  nniking  his  escape  from  the  rebel  service.  On  admission  his 
tongue  was  slightly  coated,  bowels  loose,  pulse  1(X),  respiration  nornuil,  cough  and  exjiectoration  slight,  ajiiH-lilcs 
small  ,and  thirst  notable.  Diarrluea  and  increasing  prostration  were  the  luomlnent  symptoms  during  the  ])rogress 
of  the  case.  He  died  on  the  23d.  I'o^t-mortcm  examination  twelve  hours  aftir  death:  Kniiiclation.  tiray  liejiatlza- 
tion  of  right  lung;  distention  of  gall-bladder;  congestion  of  bowels  and  disorganization  of  the  glands. — Act.  .Inn't 
Sunj.  II.  C.  Kcwkirk,  Hock  Island  Hospital,  III. 

Cases  entehed  as  Tyi'iioid,  iu't  the  clinical  histohiks  sfiiUKsnvE  ok  .viai.auiai.  comi'mcation.s — 21  case.s. 
(A.)  I'cijir's patches  ulcerated  and  the  ileum  or  small  intestine  onlij  affected — ~>  cases. 
Ca.se  93. —  Private  Daniel  Plumnu'r,  Co.  H,  33d  Pa.;  age  23;  was  admitted  Oct.  2,  1861,  with  headache,  diar- 
rhcea,  loss  of  appetite  and  strength.  He  had  been  sick  five  days,  having  had  a  chill  and  fever  on  each  day.  A  bath 
was  given,  with  nuiuiue  at  night.  Next  day  his  face  was  flushed,  eyes  injected,  skin  hot,  dry  ami  rough,  tongue 
coated  whitish-gray,  i)ulse  10-1,  full;  he  had  pain  in  the  head  and  back,  slight  deafness,  tinnitus  auriuni,  insomnia, 


352  POsT-MuiirivM   i;t;ri_)i;i)s  of 

coiit'iiHiidi  1)1'  tlioii^ht  and.  iiiiil  trriiii;' :  liis  IkiucIs  won-  ti-iiiU'i'  and  had  licrn  nui\cd  t'liuv  tiniivs.  'I'n'alincnl — Dovcr'n 
powder  and  qiiinini;.  Durinj;  tlie  live  I'ollowiiiji'  davs  his  tou,i;iic-  liccaim-  di.\  and  hiciwn,  imlsc  less  tVeiiiicnl,  )St, 
couutoiiance  moll'  anxious  and  in-oslral  ion  mnidi  iniicased:  his  houils  were  uio\i-d  ahonl  i  w  ire  daily.  On  tlit^Sth 
the  treatment  was  (hanj^fd  lo  turpentine,  Dover's  ]io\\(lor  ami  \vliiske\ -punch.  A  liallon  id'  siion^iy  acid  urine, 
sp.  gr.  1009,  was  jiassed  on  the  0th,  but  later  in  the  disease  ihe  urine  hecame  alkaline.  .\  Idister  was  ajildied  to  the 
aliddiueii  on  the  lltli.  (hi  the  Kith  he  craved  api)les,  and  ni'xt  day  had  some  apjielite:  the  liowels  wereciuiet, 
having  lieeu  moved  hut  once  daily  for  several  days  liaek.  On  the  ^^ith  gangrenous  spots  appeared  on  the  blistered 
surface,  which  was  <lressed  with  chlorinated  soda  sidiition.  Three  days  later  an  erysipelatous  redne.ss  exti'iuled 
downward  to  the  thigh  and  the  p.itieut  was  in  extremely  low  condition,  lying  on  his  liack  with  his  month  and  eyes 
open,  unable  to  protrude  his  tongue,  his  lips  aiul  teeth  covered  with  sordes  and  his  body  generally,  except  tlu^  face 
and  ne(d<,  with  \  ildees.  The  gangrenous  l>listered  surface  was  treated  with  a  solution  of  one  drachm  of  nitrate  of 
silver  in  one  ounce  of  water,  but  without  benefit.  His  throat  became  sore  on  the  23d,  anil  he  died  on  the  uiorning 
of  the  24tli.  I'oal-morliin  examination:  The  lungs  were  congested:  the  heart,  liver,  spleen  and  pancreas  healthy: 
the  kidneys  intlauie<l  and  suj)purating.  The  iieritonenm  was  inllamed  ;  the  mucous  membrane  of  tlu^  stomach  uuiisn- 
ally  corrugated;  the  uu'seutery  and  its  glands  inllamed — of  the  lat<er  some  wore  ulcerated;  the  glands  of  I'eyer  in 
the  ileum  showed  cicatrizing  ulcerations. — Stniiiitiri/  Hanpital,  Giorijitown,  D,  C. 

C'.\SK  94. — William  L.  Layne,  Co.  G,  2d  Ky.;  age  2)«l;  was  admitted  Sept.  8,  1801.  having  been  sick  one  w  (■(  k 
with  feverishness,  increased  at  night,  anorexia,  great  thirst,  headache,  pain  in  the  back  and  limbs,  somewhat  I'le- 
(liient  l)nt  small  stools,  scanty  urine,  occasional  epistaxis  and  increasing  debility.  On  admission  the  hcadacdie  was 
intense;  he  was  listless  and  disposed  to  stupor,  his  sleep  dreamful  and  uniefreshing,  eyes  congested,  complexion 
venous,  breathing  slow,  pulse  Oti.  tongue  brown  with  red  nntrgius,  stools  freiiuent,  wati'ry  and  fetid;  there  was  lym- 
jianites,  iliac  ami  umbilical  tenderness  and  perspirations,  with  siulanuna  on  the  chest  and  abdomen,  lie  died  com- 
atose on  the  llith.  I'lisl-iiiurtcni  exaiidnation:  Colon  much  distended  with  air;  snuill  intestine  congested;  Peyer's 
glands  greatly  coiigi'sted.  enlarged  and  i:i  two  patches  imniediatidy  above  the  ileo-ca'cal  Jnnctiou  ulcerated;  liver 
dark-colored:  gall-bla<lder  distended. — .Id.  .Ixn't  ^di-y.  .U.  K.  (;/((Im;h,  Itock  InUnid  ILisjiiliil,  III. 

C.v.sK  05. — Private  Thomas  U.  Xewcomb,  Co.M,  Uth  \t.  Art.;  age  20;  was  admitted  Sept  8,  181)4,  fromhospital  at 
Frederick.  Md.,  where  his  case  was  recorded  on  September  0  as  one  of  coup-de-soleil.  He  stated  that  he  had  bi'cii 
very  sick  with  constant  nausea,  voiniting  and  general  i)ain  for  several  tlays.  He  wtis  treated  with  hydrocyaiiii^  acid 
and  morphine,  and  on  the  lltli  blue-pill,  podophyllin  and  compound  extract  ol'  colocynth  were  given  on  account  of 
constipation.  ( >n  the  lUth  he  had  occasional  spasms,  apjiarently  of  a  hysterical  eluiracler,  and  his  skin  ami  i-yes 
assutned  a  yellow  litic.  Thiee  <lays  later  he  became  much  jaundiced,  his  tongite  dry,  face  llitshed  and  pulse  OO,  w  hile 
he  had  frecjuent  attemi)ts  at  alvine  evacuations  but  passed  little  each  time.  The  Jaundice  disa|)peared  on  tlie  2i)th 
and  well-marked  typhoid  symptoms  set  in,  but  with  no  ilitirrhcea  nor  abdouunal  tymiianites.  His  strength  failed, 
his  tongue  becoming  dry  and  cracked.  He  complained  of  much  pain  over  the  region  of  the  stouuich  and  transverse 
colon,  and  his  abdomen,  on  the  20th,  became  tympanitic.  (Jn  the  supervention  of  the  tyi>hoid  coinlition  he  wa.s 
treated  with  turi)entine,  chlorate  of  potash  and  Dover's  powder,  with  hot  fometitations  and  siiiiipisms.  He  died 
()ctol)er4.  /'()«/-Hioc/('(/i  examination  :  Lungs  healthy;  libriuous  (dots  in  both  sides  of  heart  ;  intestines  nearstomach 
and  liver  yellow-colored:  gall-bladder  disorganized,  iierforated  and  with  light  green  hile  in  and  around  it;  two  or 
three  feet  of  mucous  membrane  of  jejunum  and  whole  of  ileum  congested;  Peyer's  glands  ulcerated  and  in  some 
places  nearly  perforated. — Act.  Ans't  Siirtj.  Geo.  W.  Fay,  Ifonpitul  Ptittcrson  I'arli,  Sullimorf,  Mil. 

C.vsjE  96. — Private  Charles  Perkins,  Co.  I,  1st  Mich.  Eng'rs;  age  53;  was  admitted  into  Hospital  No.  (!,  Xash- 
ville,  Tenn.,  in  September,  1802.  Etforts  were  made  to  restrain  the  dehilitatiug  diarrlnea  with  pari'goric,  Dover's 
powder,  mercury  w  ith  chalk,  blue  mass,  ipecacuanha  and  opium,  nitrate  of  silveraiid opium,  etc.;  during  tins  exacer- 
bations of  the  fever  neutral  mixture  with  sweet  spirit  of  nitre  was  given;  during  the  apyrexia  ([iiinia  and  iron:  oil 
of  turpentine  wiis  tried,  hut  it  disagreed  and  was  discontinued.  The  patient  improved  gradually  under  this  treat- 
ment conjoined  w  ith  a  bland  and  nourishing  diet,  and  convalescence  seemed  to  be  well  established.  Tonics  and 
the  milder  stimulants  had  been  administered  for  several  days,  when,  all  at  once,  diarrhiea  recurred  with  some  tym- 
panites, the  tongue  became  glos.sy,  the  pulse  130  to  140,  the  skin  yellowish,  and  sudamina  appeared  in  great  jiro- 
fusion  on  the  neck,  l]reast  and  groin  ;  he  bad  a  hacking  cough,  low  delirium  and  subsultus  tenilinum  :  his  eounteiianco 
became  bippocratic  and  be  died  October  20,  I'ost-mortcm  examination:  Uody  considerably  enuiciated.  The  peri- 
cardium contained  two  ounces  of  serum.  The  right  lung  was  collai)sed  and  pale,  its  lower  portion  hypostatically 
congested:  the  left  lung  was  emphysematous.  The  heart  was  large;  the  right  ventricle  contained  a  (tuantity  of 
nncoagulated  blood;  the  left  was  empty.  The  liver  was  large  but  normal  iu  texture  aud  color;  the  gall-bladder 
tilled  with  thin  watery  bile;  the  spleen  large  and  soft.  There  was  mtich  venous  congestion  of  the  peritoneal  coat  of 
the  stonuieh;  its  mucous  membrane  presented  a  number  of  soft  blackish  patches,  and  at  the  i)yloric  end  there  was 
some  ulceration,  which  extended  an  inch  and  a  half  into  the  duodenum.  The  mucous  membrane  of  the  jejunum  jiiid 
ileum  presented  nothing  renuirkable  excei)t  within  twenty  inches  of  the  ileo-ca-cal  valve,  where  Peyer's  pat<  he.s 
were  ulcerated;  most  of  the  ulcers  were  only  three  or  four  lines  in  diameter,  but  the  dark  tiimetled  patches  were  of 
considerable  size.  The  mucous  membrane  of  the  iIeo-ca'C;il  valve  was  ttimetied  and  the  vermiform  process  lilled  with 
pus;  the  mucous  meiid)rane  of  the  colon  was  normal.  The  kidneys  and  bladder  were  healthy.  The  blood  every- 
where was  in  a  fluid  state. — [_Fi-oni  Report  hi/  E.  Swift,  U.  S.  .(.,  Midicnl  Direclur  Department  Oltin  und  Citmlterlioid.'] 

Case  97. — Musician  William  lirandt,  17th  U.  S.  Inf.;  age  32;  was  a<lmitted  Dec.  11,  1803.  Diagnosis — tyi)hoid 
fever.  Ife  bad  been  sick  for  two  weeks  and  confined  to  bed  for  one  week:  Deliritim  at  night;  stupor;  tongue  dry 
and  coated;  skin  dry;  pulse  08;  thirst;  occasional  pains  iu  abdomen  ;  bowels  relaxed.     On  the  13th  the  right  parotid 


THF.    I'ONTIXl'K.ri    FK.VEns.  353 

}^laii(l  lii'i'.-iiiie  ])aiuriil  ami  iinicli  swollen  and  un  the  ITlli  typlHiid  syiiiiitoiiis  were  niaiiili'stcd  :  sordcs  apiicaii'il  on 
till-  Ku  Mis:  li  is  stupor  incTcasod  and  he  was  eonstantly  at  tempt  inj;  to  k<'*  <'"'  of  lied.  Tliorc  was  some  Inoncliitis  with 
a  little  painli'ss  exjieetoration.  A  red  painilar  eniiition  was  i|nite  distinct.  Dnrinj;  the  next  ten  davs  his  eon^h 
became  more  tidnldesome.  ;in<l  on  .Ian.  il.  1.n;|.  iann(li<c  and  conslijial  ion  wcic  added  to  I  lie  symptoms,  with  increasing 
stii|ior.  in  colic  rent  talkiiii;.  jrla/ed  e\  I's.  thick  and  ti'nacions  s)inta  w  hicli  he  was  inialde  to  e\pcclor;ite.  He  dicil  on 
tlieXtli.  ■■'I'lie  .iiilopsy  re\eale<!  pneiinionia  as  the  cause  of  death  and  I'oidiiiiicd  I  ln'  diiiiiiiosis  of  lyiilndd  fevi'r." — 
.III.  .Isk'I  Sing,  ('(iiiiit  CiirrnJlii,  DdikjIiix  Hiixpilnl.  llnxliiniiliiii,  I).  <'. 

(/)'.)    I'li/ir'x  jikIcIk'x  iiliTriiliil  mill  llir  hinii   iiilixtiiii  iihn  iiiijilinitiil — (i  viisix. 

Cash  !IS. — I'livate  Charles  K.  Mariner.  Co.  A,  rnrncU  I.e^'ion,  was  adiniltcd  .\ii^.  Iti,  IStili.  having  lieen  all'eeted 
with  sli^^ht  heailaidie  and  diarrlnea.  two  or  three  I'vaiiialions  daily,  for  sc\eial  clays.  There  was  no  fever  on  admis- 
sion, lint  his  toniiiie  was  <'oated  and  yellow  and  his  eyes  janmliced.  Caloiin  1  was  };iven  as  a  piirt;alive  and  small 
do.ses  of  (ininine.  On  the  IKtli  he  vomited  hile,  and  next  day  his  ton;j;m'  was  less  coaled  and  the  S(  lerolics  w  Idle.  On 
tho  20th  Hi;;ns  of  prostration  were  manifesteil.  Delirinni  oecnrrcd  on  theni;;ht  of  the  l-'-il,  after  which  he  faih'd 
rapidly  uinl  died  on  the  21th.  I'nst-miirli  iii  exaniinat  ion  ei<,r1ilccn  hours  niter  death:  The  iniieoim  coat  of  the  HtomiK'li 
was  softened  and  ahnost  disintcfjrated.  I'eyer's  pah  lies  wire  ulcerated  and  in  twd  jdaees  nearly  jierforated:  tho 
solitary  s''""''**  were  greatly  nieeraled  and  in  some  instances  Inoken  down:  tlie  ili'o-ca'cal  valve  was  disorganized, 
its  mncons  memhrane  lieini;  converted  into  a  I'lilpy  mass.  'I'he  rectnni  was  njcerati'd  in  Ihri'i'  [ilaees,  each  as  lar-;!'  as 
a  dime.  A  niimhor  <if  the  nu'senteric'  glands  were  eiilar'^ed  to  the  size  of  a  pigeon's  eg};.  The  livi'r  w  as  jiale;  tho 
Hjilecn  (uingesti'd  ;in<l  twice  its  normal  size.  The  left  side  of  the  neek  was  emphysemalons  and  its  lissio's  engorg««l, 
the  result,  proliahly,  of  an  iiiiti-morlnii  Idow. — .U:t.  .Ixx't  Siirn.  1).  //.  I.iltirmiiii,  DoiKjhix  Iliixjiiliil,  II  imliiiiiilnii,  I).  C. 

Ca.sk  !I9. — Private  .laeoh  lirewer,  Co.  I>,  l."ilh  Ohio:  agi>  lit:  was  adndtli'd  .\pril  12.  IKIII,  having  had,  as  rejxirted 
liy  himself,  a  severe  eliill  followed  hy  fever,  lie  was  at  lirst  legarded  as  siilfering  from  remittent  fever  and  <|iiinine 
was  given:  lint  as  ihr  disease  after  admission  seemed  of  ji  continued  type,  w  itii  iliac  lenderni'ss  ami  dry,  dark  an<l 
fi.ssnreil  tongne,  the  i|ninine  w  as  omit  led  and  slininlanls  administered,  lie  iliid  on  I  hi'  I7lh.  I'oxl-morlnii  examina- 
tion tliiity  horns  after  <leath:  Brain  snlist:ince  while  and  soflerthan  miglil,  he  i^xiieeli^d  from  mere  ea<laveric  •■Ininge; 
ineniuges  remaikalily  pale  and  an.emic;  lungs  and  heart  normal:  spleen  inlarged,  very  soft  and  rotten.  I'eyer's 
patches  and  solitary  glands  within  a  foot  of  tlie  ca'cnm  iiherati'd,  those  nearest  the  valve  most  allected,  lhi>  ulcers 
rai.sed  aliove  tin'  snrroniuling  snrface,  mii(h  tliickcncd  and  <ovcred  with  mnciisand  fa'ces.  Colon  nherati'd  in  small 
sp<its  in  its  nppcr  part. — Chatlanonija  lloxpilul,  'J'liiii. 

Casi:  KM). — I'rivate  Hiram  Cinder.  Co.  I!,  .")7th  I'a.:  age  17:  was  adniitteil  Nov.  2,  IKIll.  Ids  previons  history 
being  nnknowii.  lie  was  deaf  Init  not  delirious:  skin  yc  How,  checks  Unshed  and  nnirky,  respiration  hurried,  ]inlse 
110,  teeth  covered  with  sordes.  tongne.  lijis  anil  gnnis  dry,  cracked  and  oozing  blood.  On  the  Titli  some  eough  was 
noted  ;  the  respiiai  ion  liceame  more  embarrassed  and  the  elu'cks  darker.  Ho  died  on  tlu'  7th.  He  was  treated  with 
tnr]ientinc,  camphor  and  spirit  of  nitre,  eonntcr-irritation  to  chest,  beef-essenee  and  inilk-iinii(di.  I'oxl-mortcm 
ex.'imination  :  I'lenritie  adhesions  on  left  side:  fouronnces  of  dark  bloody  serum  in  right  jdenral  sac:  eongestioii  of 
Inngs  jiostcriorly  and  he)iatization  of  part  of  njiper  lobe  of  right  Inng;  heart  normal.  Mesenlerir  glands  enlarged 
and  tilled  with  dark  blood:  mncons  coat  of  ileum  ami  ca'cnm  thickened  and  inllamcd:  lifteen  I'eyer's  jialclMs,  from 
one-fonrth  inch  in  diameter  to  one  and  a  half  by  two  and  a  half  imdies,  thickened  and  some  show  ing  coinmcncing 
nlceration.  .'Spleen  large  and  soft;  liver  normal  in  size  lint  yellow;  gall-bladder  large,  containing  three  iinnees  of 
bile:  kidneys  normal. — .\rl.  Axs't  fiiiri/.  Thomas  Ilnwin,  Second  IHrhioii  HoKpital,  AUxiindria,  Va. 

Ca.se  101.— I'rivate  Michael  Mctiowan,  Co.  A,l."ilth  Ind.:  age  IH:  was  admitted  May  HO,  IXtio,  having  been  siek 
for  three  weeks  with  a  frequent  and  copious  diarrlnea  followed  by  chills  and  fever,  acute  jiain  In  chest  and  dry  congh 
with  very  little  expectoration.  On  admission  he  was  nnich  emaciated  and  very  feeble;  there  were  large  bed-sores 
over  the  sacrum,  trochanters  and  angles  of  the  ribs  on  the  right  side.  His  skin  was  dry  and  harsh,  tongne  dry,  red 
and  glazed  and  teeth  covered  with  sordes:  he  had  mnch  thirst,  no  ap]ietite,  pain  and  teinlerness  over  abdomen,  a 
profuse  diarrlnea  and  hurried  breathing".  He  died  on  the  7th.  VoRt-morlim  examination  fifteen  hours  after  deatli: 
The  mucous  membrane  of  the  trachea  was  inflamed  and  ulcerated.  The  lower  lobe  and  anterior  border  of  the  upper 
lobe  of  the  left  lung,  and  the  upper  and  lower  lobes  of  the  right  lung  were  congested  ;  the  middle  lobe  of  the  latter 
was  hepatized.  The  omentum  was  intlamed  and  adherent  to  the  abdominal  jiarietes.  The  spleen  weighed  twenty- 
four  ounces  and  was  dark  and  soft.  The  mncons  meinbiane  of  the  ileum  was  inflamed  and  I'eyer's  jiatches  were 
ulcerated;  there  was  also  some  ulceration  of  the  ca'cnm;  the  mesenteric  glands  were  enlarged. — .let.  Axh'i  Surg.  S.  H. 
West,  Cumberland  Honpital,  Md. 

Case  102. — I'rivate  Austin  Seeley,  Co.  C,  7M  Ohio,  was  admitted  Dec.  18,  1S62.  He  had  been  treated  for  inter- 
mittent fever  in  the  Harewood  hospital,  Washington.  D.  C,  from  N'ovember  li).  He  died  .Ian.  SO,  ISIiS.  I'oxl-morlim 
examination  tiext  day:  Age  about  21:  body  emaciated.  Lungs,  exce]iting  a  slight  bronchial  intlammation,  healthy; 
heart  contained  a  large  white  clot  in  its  right  cavities:  spleen  redder  than  natural  and  flabby:  liver  jiale  brown  anil 
on  section  pale  brown  with  darker  intralobular  spots;  stomach  and  upper  portion  of  small  intestine  apparently 
healthy;  agininated  glands  in  the  lower  five  feet  of  ileum  successively  and  gradually  increasing  in  enlargement; 
glands  in  the  terminal  foot  dark-red  and  bordered  by  intlamed  mniuius  membrane,  those  nearest  the  ileocolic  valve 
presenting  several  small  ulcerations;  solitary  glands  apjiarently  healthy;  colon  greatly  distended,  its  mucous  mem- 
brane redder  than  natural,  but  with  no  inflamed  spots,  streaks  or  patches,  and  with  no  visible  disease  of  solitary 
Mkd.  Hist.,  Pt.  111—45 


354  rosT-MoKTK>r   r,i;c()i;i>s  of 

glaiid.s;  lyiiiiihatic  jilaiids  of  mi'si'iitory  :niil  nirsocolnn  liluisli-lilnck,  wliiilMoIor  on  section  tbniiiMl  ii  circle  witliin  the 
))eii|pliel'.v,  and  nnder  the  niicrose()|ie  inesented  llie  :ij>iieiiiiince  of  exeeedin^ily  fine  |i:irticleH  siniil.ir  to  the  hhick 
del>osits  in  tile  inti'stinal  j;hinds  in  ChicUahoniiny  dianliiea  :  l<idneys  healthy. — [Spci-iiiii im  \os.  !lit-10].  Med.  Sect., 
Army  Medical  Mnsenni.  iilceiation  of  I'eyei'.s  jiatches,  are  from  thi.s  case.) — Jet.  Axx't  Sun/,  .lomph  Liidij,  S<iUerlei' 
f/ospitnl,  I'hilii(lilj)liiu,  I'll. 

Ca.se  103.— I'rivate  .lame,';  M.  FormfUi,C'o.  II,  HM  Pa.:  afje  21:  wa.s  admittiMl  Oct.  2,  ixdl,  having  been  sick  for 
nine  days  with.  ])ain  in  the  head,  hack  and  hones,  chills,  loss  of  appetite  and  strcnj;th.  diarrhiea.  ejpistaxis,  jiain  in 
the  stomach,  nau.sea  and  voniitinj;.  A  hath  was  ordi're<l  for  him  with  Dover's  powderat  iiiKht.  Next  morn inij  his 
face  wa.s  Unshed,  eyes  injected,  {(ul.se  il8,  fnll,  .skin  hot,  dry  and  roni^h,  ti>nj;ne  heavily  coated,  the  ceiiti<!  hrownish, 
the  tip  and  edfjcs  red  :  he  had  anorexia, great  thirst,  irritahility  of  stomach,  dlarrlnea,  the  howels  having  been  moved 
four  times,  tenderness  in  the  right  iliac  region  and  fonr  or  five  characteristic  rose-colored  spot.s,  Th<^  case  eontinned 
for  ten  days  without  nuich  change  under  treatment  by  astringents,  opiates  and  whiskey-puncli.  The  nausea  and 
vomiting  gradually  ceased;  some  degree  of  deafness  was  develo])ed:  there  was  occasional  tymp.anites,  and  hlood 
appeared  in  the  stools  for  several  days  and  on  th<^  Stli  in  large  qnantity.  Hut  on  the  12tli  the  diarrhcea  ceased,  the 
alxlominal  tenderness  was  les.sened.  the  tongue  became  moist  and  there  were  indications  of  icturning  a|i])etite, 
Al)ont  the  same  time,  however,  the  right  ])arotid  gland  became  intlamed  and  the  face  much  swolh  n.  'I'here  was  slight 
delirium  on  the  Itth.and  next  day  the  swelling,  which  had  liecome  erysipelatous,  extended  over  the  face,  nearly 
closing  both  eyes  and  iiresenting  a  small  gangrenous  spot  on  the  ear  and  another  on  the  cheek.  The  patient  walked 
about  the  ward  in  high  delirium,  but  towards  evening  became  more  (jiiiet.  At  10  r.  M.  he  s])rang  up  suddenly, 
knocked  the  pitcher  containing  his  punch  from  the  attendant's  hand  and  endeavored  to  get  down  stairs.  He  wa.s  got 
back  to  bed  with  someditliculty  and  innnediately  thereafter  began  to  fail.  At  midnight  his  pnl.se  was  rapid  and  almost 
im]>erceptible,  liis  extremities  cold,  eyes  fixed  ami  Jaws  locked:  he  took  no  notice  when  called  or  shaken  and  died 
at  1  A.  Ji,  of  the  Kith.  yo.^Z-mor/o/f  examination  :  Parotid  gland  in  a  stat<' of  siqipuration  ;  side  of  face  dark-colored  and 
with  snuill  jiatches  of  gangrene  in  front  of  the  ear.  The  mucous  membrane  of  the  stomach  was  congested  and  softened. 
The  liver  and  gall-blailder  were  large  but  healthy:  the  spleen  congested,  enlarged  ami  soft.  The  ileum  was  intlanu'cl ; 
its  solitary  and  agminated  glands  were  ulcerated  and  there  w.as  a  small  jierforation  in  one  of  tlw  ulcerated  patches. 
The  large  intestine,  from  the  valve  to  the  rectum,  was  very  much  ulcerated.  The  peritoneum  was  intlamed  :  t  he  mes- 
enteric glands  enlarged;  the  kidneys  and  bladder  healthy. — Seminary  Ho-'ipital,  GeorgHoirn,  D.  C. 
(C.)   CnnclitioM  of  Peyir's patclies  nut  stated;  the  intestines  variiiush/  affected — 7  eaue.i. 

Case  104. — .lohn  Freeman,  Co.  li,  12th  Tenn.  Cav.,  was  admitted  Hay  7,  1864,  in  a  semi-unconscious  state  ;  pulse 
feeble,  respiration  normal,  tongue  dry  and  dark,  teeth  covered  with  sordes,  skin  Jaundiced,  pupils  natural,  stools 
involuntary.  He  died  next  day.  I'ofit-mortem  examination  sixteen  hours  after  death  :  irnusual  injection  of  meningeal 
vessels;  hypostatic  congestion  of  lower  lobes  of  lungs:  congesti(Ui  and  discoloration  of  liver:  distention  of  gall- 
bladder :  much  congestion  of  spleen;  slight  congestion  of  ileum. — Jet.  Ass't  Surg.  George  E.  WaJton,  HoKpital  Xo.  8, 
Xashville,  Tenn. 

Ca.se  10."). — Private  A.  C.  Truman,  Co.  G,  152d  N.  Y.,  was  admitted  April  24,  l«(i3.  Diagnosis — typhoid  fever. 
Epigastric  pain  and  tenderness  but  no  diarrluea:  vomiting;  nuuked  febrile  action;  tongue  coated  dark  brown; 
sordes  on  teeth  and  lips:  pulse  125;  urine  scanty;  countenance  pinched;  tinnitus  aurium.  He  was  treated  with 
riuinine,  whiskey  and  turpentine  emulsion,  and  on  the  26th  was  improving.  On  the  29tli  blue  mass  and  colocynth 
were  given  for  constipation  and  on  May  14  suliihate  of  magnesia.  On  the  20th  he  was  seized  with  a  troublesome 
cough  and  dull  pain  in  the  left  side  of  the  chest.  A  few  days  later  diarrluea  set  in,  the  congh  continuing,  and  he 
died  on  ,Tune  ,'>.  I'ost-mortem  examination:  Kight  Inng  hepatized  in  its  lower  lobe:  left  lung  collapsed  and  contain- 
ing a  few  tubercles;  heart  luunuil.  Ileum  extensively  congested  but  not  ulcerated:  liver,  spleen  and  kidneys  nor- 
mal.— Act.  Ass't  Surg.  John  E.  Smith,  Douglas  Hospital,  Washington,  I>.  C. 

Ca.se  106.— Private  Pleasant  Willett,  Co.  E,  l.S.^th  Ind.;  age  28;  was  admitted  Aug.  19, 1864,  liaving  suffered  from 
diarrhoea  for  some  time.  His  pulse  was  106  and  his  tongue  dry  and  furred  but  not  glazed  or  cracked.  Next  day  a 
remission  was  noticed  and  on  the  following  day  nausea  and  vomiting  were  recorded.  The  diarrlnea  became  i)rofn.se, 
with  dysuria  and  much  ab<h)minal  tenderness.  He  died  on  thi^  2.'>th.  Post-mortem  examination  eight  hours  after 
death:  Hram  and  its  meninges  norinal.  Lungs  healthy:  heart  noiinal,  right  cavities  containing  a  firm  clot.  Liver 
much  engorged,  eighty  ounces;  spleen  intensely  engorged,  twenty-seven  ounces;  stoumch  distended  with  tlatus  and 
ficcal  matter;  peritoneal  cavity  containing  one  pint  of  purulent  serum;  colon  somewhat  thickened  and  softened; 
ileum  ulcerated  in  its  lower  three  feet  ant"  with  a  jierforation  six  inches  from  the  ileo-ca'cal  valve;  bladder  congested; 
kidneys  together  weighing  fifteen  ounces.— .1(7.  Asst  Surg.  I).  H'.  Flora,  Hospital,  Madison,  Ind. 

Ca.se  107. — Private  .Jasper  Kemp,  Co.  H,  lltli  N.  H.,  was  treated  in  the  Fifth  Army  Corps  Field  Hospital,  City 
Point,  Va.,  from  April  23.  IStiS,  for  malarial  fever,  and  transferred  May  1  to  hospital  transport  "State  of  Maine," 
where  his  case  was  diagnosed  typhoid  fever.  He  was  admitted  on  the  2d,  and  two  days  afterward  was  seized  with 
acute  abdominal  pain  which  increa.sed  in  .seviuify  until  he  died  on  the  5th.  I'ost-morti'in  examination:  General  ])eri- 
tonitis;  ulceration  of  small  intestine  with  sei  en  perfoiations. — ('aiiijilietl  Hospital,  Washington,  I).  ('. 

Case  lOS.— Private  Rrd.ert  Alexander,  Co.  E,  1  UHh  Pa.;  age  IS;  was  admitted  Dec.  7,  1X63,  as  a  fnlly  d<>vel- 
oped  case  of  typhoid  fever,  the  symptoms  stated  being  a  dry  aiul  red  tongue,  laboring  jvulse,  scanty  and  high-colored 
urine,  with  great  irritability  of  stomach  and  diarrlnea.  On  the  l>!th  there  were  involuntary  stools  and  more  or  less 
stupor  and  subsultns.  He  died  on  the  22d.  Post-mortem  examination  nine  hours  after  death:  .Softening  of  the  coats 
of  the  stomach;  thickening  and  softening  throughout  the  lower  course  of  the  colon,  but  no  ulceration  of  the  intes- 
tinal membrane.     Lungs  comparatively  healthy.     Liver  normal. — Third  Dirision  ftiispital,  Alexandria,  Va. 


THK    rdXTINTT.n    KKVKP.S.  8n5 

Case  lull.— Priviitr  Myidii  l'.:il<li.  Co.  H.  IHli  Midi.,  wns  :i(liMiltcil  .\])iil  2.  IStU,  with  a  IVvi'V  wliic-li  invseiili'il 
<li.st  inct  ii'iiiissiiiiis,  n\\t\  w  ,i.-  1  ic.ilcil  \i  il  li  trii  ,i;i.-iiii>-  of  c|ii  iiiiiic  iliniii;;  <-,-ich  icirii.ssidM  mil  il  I  lie  IHI  li.  \v  lirii  hr  lii'i'iiiiic 
(Iclii'ioM.s.  had  iliac  ifiKU'incss.  diarrliiiM  anil  licuion  liajiic  stiiols.  Stimulants  wimc  Kiviii  and  pcisiiliihatc  (pf  iron 
one  Kiaiii  ovciy  two  honis.  llr  died  on  thi'  Kith.  I'nsl-niiii-Uiii  ixaininal  ion  t  wi'iily-tbiir  honis  al'tci' di'ath:  liraiii 
and  its  ini'inliiancs  aiia'iTiic.  I'ostciiof  ihicc-l'omths  ot'  n]i|nT  hdir  of  li^'ht  Inni;  hi'ivati/rd  :  left  Inn;;  normal :  In'art 
uonnal,  small  wliiti'  clots  in  both  vciitiiclcs.  l.ivcr  fatty:  ileum  for  twelve  inches  ahove  the  ilco-ea'cal  valve,  nli-er- 
ated  in  ] latches  vai>  ini,'  from  the  si/i'  of  a  |iea  to  that  of  a  dollar,  the  lai};est  liiMiifX  ncari'st  the  \  al\c:  colon  injected 
and  ulcerated  in  its  ii|>-)icr  ]iait. — .i<l.  .Ikh'I  Siir<i.  C  /■'.  I.illli.  ('litiilniiiiiKin  llnxjiilnl,  Tiiiii. 

C.vsE  110.— I'lixatc  1>.  F.  McLaclilaii.  Co.  C.  1  Itli  \.  '\'..  was  admitted  .Sept.  L'n.  l.siil.  lie  had  heeii  taken  sick 
with  a  (diill  followed  liy  seven'  |iain  in  the  hi'ad.  hai'k  and  sides,  with  loss  of  a)ipet  ite  and  stri'iii^th.  (Mi  ailmissi<in  his 
skin  was  warm  and  iieispirini;:  pnlse  ill.'.  i|iiick  and  strotii;:  toiif;ue  ■;h)ssy  and  pale,  sli;;htly  colored  lirown  in  the 
centre  and  at  the  li.ise;  howcK  moved  eij;ht  times  in  the  twenly-fonr  lionis:  there  was  tenderness  in  the  iliac  and 
p]>ijiastric  regions,  wit  11  nietiiirism.  hoilioiyf;nins,  eiiista\is  and  rose-coloicd  sjiots  (from  twenty  to  lliiily)oii  the 
alidonieli  and  chest,  lie  was  trcalcd  with  tiirpentiiie  emulsion,  liliie  pill  and  opium,  anil  Dosci's  powder  at  nij;ht. 
Next  ihiy  there  w  as  .\lii;lit  mental  confusion  Avit  li  i  iny;inu  in  t  he  ears,  and  his  tonj;iic  was  coveted  with  a  ;;rayisli  fur. 
All  eif;ht-LClain  dose  of  i  pi  i  nine  was  added  to  the  t  real  meiit .  1  )iitini;  the  week  \v  liicli  followed  his  conilit  ion  was  iiiio 
of  i;radiial  im)>i(i\  emetit  :  the  ]inlse  did  not  rise  ahove  !tO.  the  meleorism  di.sappeaied.  his  appetite  h<'i;an  to  leliirn 
and  his  tonj^ne  lost  its  fnr.  Iiecomin;;  moist  and  pa'h',  lint  his  liowels  eoni  inned  slij;lil  ly  relaxed  not  withstanding;  the 
ii.se  of  opiates  and  ;ist  rinji'en  ts.  ,\t'ter  this  his  proi;ress  was  nni'ettain:  at  times  he  fell  pretty  widl.  Hi'  was  tiealed 
mainly  with  wine  and  (|niiiiiie  in  I  wo  ;;rain  dosi>s  three  times  daily,  hnl  on  ()clolic>r  Hi  the  Ihro.at  and  larynx  liecame 
colii;esled  ,'ilid  he  had  some  lildlicdiillc  eoiljjh.  I  !1  is  I  els  were  applied  to  I  he  sides  of  I  he  neck,  I  he  throat  w;is  sw  aldieil 
with  a  stronj;  solution  of  nit  rati'  of  silver  and  live  f^raiiis  each  of  calomel  and  Jala])  were  f;i  veil.  lie  did  not  test  well 
(lurlii;;  the  iii<;ht  and  next  d.iy  was  |iale  and  weak,  lio.iise  and  somewh.il  deaf;  his  liowels  were  moved  three  tiiiicH 
;ind  there  w;is  teiiiletiiess  with  lyiii]ianites  and  liorlioryiiinns.  Diiiiii;;  tlic  day  the  howels  were  .leain  moved  three 
times,  lie  continued  thus  for  three  days.  On  the  L'Ist  whiskey  piincli  was  sniistilnled  for  wine.  On  the  l.'lid  hJH 
expression    liecame   .inx  ions,  ]inlsc  111,  skin    hot    and  dry,lll(^  loiiLjiie  coiit  inn  in:;  pale  anil  llahliy:   lie   had  six    thill 

evaiiiat  ions  from   the  howels;  coiifih  was  I  roiihlesonie  and  the  llii'oal   symptoms  had  li me  so  at;i;ra\,iled  that  he 

swallowed  with  diflicnlly  and  could  not  sjieak  ahove  a  vv  liis]ier.  'I'hc  Ireatment  consisled  at  this  lime  of  idilorale 
of  ]iotash,  mniiate  of  iron,  lieef-tea  and  wlii.ikey-|)nncli.  Diiiint;  Ihe  followini;  nif^lit  his  |iiilse  rose  to  llll.  and  next 
day  sordes  apjicared  on  t  he  lec-tli.  Soon  ,i tier  I  his  he  hecjime  delirious,  imajiin in. n  thai  some  lar^i'  animal  was  in  lied 
with  him:  that  he  was  in  camp,  etc.  (In  t  he  -7th,  havinjf  jiassed  ji  hetter  nielli,  lii^  was  not  so  ilelirioiis,  hut  he 
looked  p.'ile  ,11  111  anxious:  his  jnilse  was  weak  and  small.  !U  ;  skin  warm  and  soft :  t online  pale,  moist  and  t  rem il Ions; 
his  liowels  vv  ere  moved  in  v  oiniit  at  ily .  At  this  time  t  here  was  noted  on  tile  skill  ilark,  almost  Mack  ,  slii;lil  ly  ele\  iited 
spots  so  mew  hat  lai  i;ei  t  liaii  split  -pi'as,  wit  lion  I  accom])aiiyiii;;  iiillammatioii :  those  vvliiidi  had  arisen  more  recently 
were  vv h i t  is li  yellow,  lieinj;  full  of  |nirnleiit  matter.  On  the  2X1  h  he  was  almost  niiconscious  ;  his  pulse  weak,  small 
and  irrilahle,  12(1:  skin  warm  and  soft:  toiii;ne  heavily  coated;  mouth  moist  and  its  whole  surface  coveted  with 
white  sticky  mucus;  ;;iiiiis  covered  with  Hordes;  one  sid<^  of  the  face  Hushed  very  dark  red;  his  howels  had  heeii 
i|iiiet  since  an  injection  j;iven  on  the  jircvioiis  <^veiiinf,',  hut  there  was  tenilerness  on  holli  sides;  suhmiKoiis  and 
sibilant  rales  were  heard  in  both  liinjis.  On  the  (tveninj;  of  this  day  he  was  i|uite  nnconseioim,  his  eyes  and  month 
ojii'ii.  jiiiLse  i:ill.  lesjiiiation  ."lO,  Duriiij;  the  iiif;ht  heinori  ha};e  JVom  the  bowels  took  place  and  recurred  on  the  after- 
noon of  the  nexl  day,  his  |itil.se  nieunwhile  heeoiiiiii};  weaker  and  hrciitliiiiK  more  rapid.  On  the  yOtli  his  uxti'eniitie« 
became  cold  and  at  2  f.  .M.  lie  died.  I'oKt-miirtcm  (>xainination  :  'I'lie  brain,  )iliaiyiix  and  u>sophaf;iis  were  not  examined. 
The  liinjis  wire  much  eonj^ested  and  hepatized.  The  Jieiirt  ciintaincd  librinons  clots  in  both  ventricles,  'I'lie  liver 
and  iiancreas  were  normal;  the  spleen  soft  and  somewlnit  eiilari;ed.  The  rifjlit  kidney  was  small  and  transformed 
into  a  thin-walled  cyst  (^oiitainiii};  a  yellowish  linuid;  the  left  kidney  ]H'e,sented  several  lari;e  cavities  eontainin^ 
piis,  '"'I'lie  small  intestine  showed  that  inllammation  had  been  rife  there  some  time  a^o,  hut  no  iilecrs  were  seen 
that  had  been  formed  lately:  there  were  ]ilaces  w  hero  lar;;e  and  recently  healed  sores  were  evidently  indicated," 
The  niucoiis  iiienibiane  of  the  colon  was  broken  by  several  large  ulcers,  Jlio  meseiitery  was  i|nitc  healthy. — Siiiii- 
nary  Umpitnl,  Ceiiriiiiown,  I).  C. 

(I).)  f'i)ii(lilioii  of  Pvycr's  patches  rarioiiiih/  uluhtl,  hut  not  iilnralrd;  tntfutints  rnorr  or  hsu  nffvctid — Ti  c(i.sr». 
Cask  111, — Private  Charles  Lew  is,  Co.  (;,23ilTT,  S.  Colored  troops;  a<re2I;  was  admitted  Oct.  2(1,  l.Hli.'i.on  which 
day  he  had  a  ehill  followed  by  fever,  Dover's  jiowderwas  given  in  the  eveniu};,  but  the  chill  recurriiif;  next  day 
quinine  in  live-.<;rain  doses  was  administered.  There  was  no  chill  on  the  following  day:  hut  the  febrile  uetion  con- 
tinued and  increased  so  that  on  the  2Uli  his  pulse  was  120,  quick  and  full,  respiration  60,  skin  hot  and  dry,  tongue 
furred;  and  he  was  weaker,  sleepless  and  slightly  delirious.  Small  doses  of  eggiiog,  chlorate  of  potash  and  tur- 
pentine with  Dover's  powder  were  administered.  Xext  day  his  condition  was  unchanged:  castor  oil  was  given  to 
move  the  bowels.  On  the  2(ith  the  insomnia  and  dtdiriiim  continued ;  the  tongue  was  dry,  brown  and  coated  :  the 
eyes  jaundiced;  the  urine  jiassed  involuntarily,  staining  the  linen  yellow;  the  abdomen  tender  and  tymiianitie:  a 
thin  yellow -colored  discharge  was  procured  by  the  oil.  Next  day  the  pnkse  was  not  so  strong,  the  tongue  continued 
dry  and  brown,  but  the  skin  became  somewhat  moist  and  the  patient  slept  a  little.  One  grain  of  calomel  and  two 
of  ipecacuanha  were  given  every  hour  for  six  hours,  with  mustard  to  the  back  of  the  neck  and  cliest.  He  died  on 
the  28th.  Post-mortem  examination  thirty  hours  after  death:  The  arachnoid  over  the  interpeduncular  space  was 
thickened  and  opaque  and  there  was  serous  cft'usiou  in  the  cerebral  ventricles.  The  Iniigs  and  heart  were  normal, 
but  there  wa.s  effusion  in  the  left  thoracic  cavity.     The  liverwas  large,  its  right  lobo  liouey-conibed,  full  of  air  and 


35G  POST-MORTKM    RECORDS    OF 

of  a  very  pociilinr  ainipnranro,  and  its  left  lot)(>  noiinal  in  trxtnii'  l>iit  uC  a  yellow  eolor.  The  fiaiiereas  was  lar<;e; 
the  kidneys  normal:  tlie  .si)li'i'n  larf^c,  soft  and  <larl<; -colored.  Thr  colon  and  nictuiii  were  normal;  I'eyer's  patehes 
were  enlarjjed,  as  weie  also  lln'  niesenti'rie  jjlands.  [Siicchin)!  (i.'iSt,  Med.  5eet.,  Army  Medical  Museum,  from  this  ease, 
shows  the  honey-eoml)iuf;  of  the  liver  hy  dilated  jjall-duets.] — S'hiv/.  A'.  Jtnitleii,  V.  S.  ('.,  (iliiiii/li  Ilanpildl,  Ahxundria,  In. 
C.\SE  112. — Private  F.  Hinder,  Co.  (i,  Kilst  I'a.:  ajje  '21:  was  admitted  Dec.  30,  lS(i2,  with  <;an<j;rene  of  hoth  feet 
after  tyi>h<)id  fever.  About  eifj;ht  weeks  jirior  to  admission  ho  wa.s  attacked  with  chill.s  and  fever,  bnt  the  disease 
afterwards  .assumed  the  character  of  tyjihoid  fever."  Tlie  condition  of  his  foet  was  supposed  to  he  due  to  frost-hite 
whihf  sick  in  ('amp.  On  .Ian,  7,  lS(iS,  the  skin  of  hoth  feet  was  reiairted  as  blue  from  the  toes  to  above  the  ankles, 
where  was  an  irrefjular  border  of  redness  ;  below  the  malleoli  the  parts  were  cohl  and  a  ])in  could  be  inserted  without 
beinfj  felt.  Lines  of  demarcation  were  formed  on  the  9th  just  ab<iv(<  the  malleoli;  at  this  time  the  patient's  ai>iietit(^ 
was  improvinji  and  his  tongue  looking  well,  but  his  skin  was  slightly  yellow  and  he  complained  of  much  jiain,  which 
he  referred  to  his  feet.  On  the  22d  his  bowels  liecame  loose,  there  having  been  five  stools  during  the  day,  and  m-xt 
day  the  tongue  was  somewhat  diy.  He  slept  well  at  night  and  had  no  niglit-sweats,  but  he  lost  flesh  and  continued 
to  suffer  from  pain  in  the  feet.  The  right  foot  se|)arated  at  the  ankle-joint  on  tlie  2t)th,  tlie  stump  having  bled  quite 
freely.  Next  day  both  legs  were  amputated  by  "LeXoir's"  operation,  after  which  the  patient  reacted  fairly  and 
rested  well.  On  the  30th  the  stumps  looke<l  badl.y  and  discharged  a  grayish  pus,  while  vomiting,  hiccough  and  extreme 
depression  were  d(!veloped.  Death  took  jilace  Feliruary  2.  rdKl-iiiorlem  examination  twenty-four  hours  after  death: 
There  were  clots  in  all  the  arteries  of  the  8tum))s  exce])t  the  right  anterior  tibial.  On  pressing  the  medulla  of  the 
left  tibia  a  yellowish  li(iuid  exuded  from  the  vascular  foramina  in  the  conijiact  substance  of  the  bone.  'I'lie  brain 
w.as  healthy.  'I'he  right  lung  weighed  thirty-three  ounces  and  three-quarters;  in  its  lower  lobe  was  a  circumscribed, 
light-colored,  consolidated  nia.ss  and  numerous  light-colored  points,  about  the  size  of  pinheads,  surrounded  by  irregular 
areas  of  congestion;  a  portion  of  this  lobe  was  in  the  state  of  gray  hepatization.  The  left  lung  weighed  eighteen 
ounces  and  a  quarter;  on  the  posterior  surface  of  its  lower  lobe  and  in  the  substance  of  the  upper  lobe  were  a  nnniber 
of  discolored  spots  beneath  which  the  lung-tissue  was  infiltrated  with  serum.  The  heart  was  pale  and  contaiiu'd  a 
small  fibrinous  clot  in  the  right  ventricle.  The  liver  was  pale  and  firm;  the  gall-bladder  small  ;  the  spleen  weighed 
seven  ounces  and  a  half  and  was  very  soft:  the  ])ancr<'as  was  of  a  grayish  color;  both  kidneys  were  small  and  light- 
colored.  The  stomach  was  large,  its  muccuis  membrane  slightly  softened;  the  iipjier  part  of  the  jejnnnm  was  slate- 
colored;  the  whole  of  the  ileum  congested  and  its  valvuhe  conniventes  indistinct ;  Peyer's  patchi's  were  slightly 
thickened  and  some  of  them  congested.  The  large  intestine  was  congested, — Ass't  Surg.  George  M.  .McGill,  I'.  S.  ./,, 
Lincoln  Hospital,  Washingtoti,  I).  C. 

Case  113.— Private  ,John  Frink,  Co.  K,  lOtli  N.  J.;  age  If);  admitted  .Tunc  4,  1865,  Typhoid  fever.  Severe 
diarrhoea,  gastric  irritability  and  nervous  disorder  were  the  prominent  i)heiioiiieiia.  Died  23d,  /V).v/-Hior(('«i  examina- 
tion twenty-four  hours  after  death:  The  lungs  were  enipliysematous :  the  small  intestine  much  intlamed;  the  glands 
of  Peyer  congested;  the  spleen  norinal. Thiid  Divhion  Hoxpiltih  Alej'uudria,  I'li. 

C.vSK  lit, — Private  Benjamin  Brady,  Co,  I,  24th  X,  Y.  Cav.;  age  23:  was  admitted  June  5,  ISti.'i,  with  chronic 
diarrhu'a  and  intermittent  fever.  Typhoid  symptoms  soon  became  ajijiarent,  including  delirium  and  petechial  spots 
on  the  abdomen.  He  died  on  the  14tli,  I'ont-mortem  examination  nine  hours  after  death:  Body  much  emaciati'il. 
Lungs  normal:  siileeii  enlargeil  and  softened:  small  intestine  ulcerated;  Peyer's  patches  much  infiamed  and  corn-s- 
ponding  mesenteric  glands  enlarged  and  indurated, — Slouijh  Honjiitnl.  .ihrdiidria,  fa. 

Ca.se  115, — Private  David  E,  Martin,  Co,  K,  137th  Pa,;  age  32;  w  as  admitted  May  17, 1863,  with  irregular  chills 
"followed  by  fever  from  which  he  had  suffered  for  some  weeks,  A  chill  followed  by  fever  and  perspiration  oceui  n-d 
on  the  evening  of  his  admission,  but  next  day  he  was  feeling  pretty  well.  This  was  repeated  on  the  followingevening, 
but  on  the  third  day  there  was  no  recurrence,  quinine  having  been  administered  meanwhile.  On  the  21st  he  was 
found  for  the  first  time  with  hot  skin,  active  jnilse  and  headache,  his  tongue  remaining  as  heretofore,  yellow-furred 
but  comjiarativel.v  clean  at  the  tip.  Signs  of  nervous  agitation  were  also  observed,  as  tremulousness  of  the  lower 
lip  and  twitching  of  the  hands.  Neutral  mixture,  cold  drinks  and  low  diet  were  substitued  for  the  quinine.  He 
continued  in  this  condition,  some  diarrhffia  meanwhile  appearing,  until  the  2.5tli,  when,  having  thrown  off  the  bed- 
clothes during  the  night,  an  oppression  of  the  breathing  was  developed,  with  sonorous  and  sibilant  rales  and  some 
sluggishness  of  mind.  Acetate  of  ammonia  and  wine-whey  were  given  with  sinapisms  to  the  chest,  A  blister  was' 
applied  next  day,  and  on  the  day  following  infusion  of  scrpentaria  and  carbonate  of  ammonia  were  given.  On  the 
28th,  in  view  of  the  continued  cerebral  disturbance,  indicated  by  heat  of  head,  some  confusion  of  ideas,  and  injection 
of  the  right  conjunctiva,  a  blister  was  applied  to  the  back  of  the  neck,  Xext  day  two  or  three  rose-colored  sjiots  of 
doubtful  character  were  noticed  and  there  was  slight  abdominal  distention.  Perspirations  were  added  to  the  list  of 
symptoms  on  the  30tli  and  involuntary  discharges  on  the  31st.  He  died  .June  3.  I'i>nt-niortem  examination  next  day: 
Body  somewhat  emaciated.  Heart  normal:  mucous  membrane  of  trachea  and  bronchi  iufiamed,  the  inflammation 
extending  to  the  smaller  tubes  and  in  several  instances  to  the  pulmonary  lobules.  About  four  feet  of  lower  portion 
of  ileum  showing  slight  irregularly  diffused  infianimation  ;  glands  of  Peyer  generally  healthy,  but  a  few  of  the  lower 
ones  containing  some  black  deposit :  ileum,  for  eight  inches  above  ileo-ca'cal  valve,  and  ca-cum  intensely  inflamed, 
the  mucous  membrane  livir-colored,  thickeneil  and  in  many  places  ulcerated,  the  ulcers  varying  from  the  size  of  a 
pea  to  that  of  the  thumb-nail  and  the  largest  extending  through  to  the  muscular  coat ;  C(doii  distended  witli  air 
and  its  mucous  membrane  here  and  there  slightly  intlamed  and  presenting  a  few  scattered  ulcers  about  the  si/e  of 
pepper-corns;  rectum  more  intensely  inflamed  and  with  large  and  numerous  ulcers.  Liver  large  an<l  rather  soft; 
spleen  soft  and  flabby;  kidneys  darker  than  usual,  their  pelves  somewhat  injected;  suprarenal  bodies  and  j)an<reas 
healthy.  The  muscular  system  and  blood  appeared  to  be  in  sound  condition;  a  large  translucent  clot  occupied  the 
right  cavities  of  the  heart. — Aet.  Ass't  Surg.  Joseph  Leidy,  Satterlee  Uunpital,  I'hiladeJphUi,  I'a. 


THE    CU.N  ITN;rK|i    KKVKKS.  357 

Case  UO. — I'livate  Darius  (irfcnlaw  .  Cu.  I.  Till  Me.,  wa.s  admUU'il  .\in;.  10,  IStit'.  llf  icjccti-d  all  iKiiiii.^liiui'iit, 
and  wa.-)  sustained  liy  injections  of  milk,  liiandy  ami  beet-tea.  lie  vimiileil  freiiuenrly  a  dai  U-v;ieenisli,  fetid  liiiuid; 
there  was  no  fever  niir  dianinea:  tlM'  alvine  evaeuatu>ns  were  slifjlit  and  infi('i|Ment.  He  dii'd  Septenilier  1.  I'oiit- 
/HOc/eHi  examination  :  Hodynotmueli  wasted;  aiijiaiently  alMiUt  1.'0  years  of  a:;e.  In  eonse(|nence  <d' the  j)atient  ha\  inj; 
had  a  swoilen  eye  and  bleedinj;  at  tlie  lars  th<>  brain  and  skull  w<'re  examined,  bin  both  aii]i<'are(l  to  be  normal. 
Lniijjs  and  heart  normal.  Stomach  mneh  eontraeted  and  em]ity:  its  mucous  nieULbrane  inllanu'd  from  it',so]ilia;;eal 
orifice  in^^  ciil-de-sac  and  a  short  distance  alouf;  greater  cnrvalnr<- :  rUL;;e  <d'  stomacli  and  summits  of  valvnhr  eoii- 
ni\  ent<'s  of  duodenum  also  iiitiame(l.  Ileum  iiri'sentin.i;  lour  small  iiillamed  pa  I  dies  :  upper  ajiminalcd  j;lands  healthy, 
lower  >;lauds  thickened  and  containiiifX  black  iiif;meut.  several  of  the  laller,  from  one  to  two  inclu's  liMi;;,  presi'nling 
two  or  three  little  ulcers  not  more  than  one  or  two  lines  in  diameter;  lower  solitary  f;lands  enlarfji'd  and  containing; 
black  ]ii;;ment.  Mucous  membrane  oi  ca'cum  and  of  part  id'asci'ndinn  I'olou  inllanu'd  and,  in  a  h'ss  de};re<',  that  of  iho 
desceiidinj;  colon  ;  solitary  j^lands  blackened. — Act.  .I.v.s'(  Siir;!.  .Iumjih  I.t'uhi,  SnllirUi  lla^pilal,  I'liilaili  liihiii,  I'd. 

Ainoni.r  the  one  liunJivd  aiiJ  .'sixti.'t.'n  ca.^os  suluiiitti'il  almvo  there  iU'r  lil'tv  tli;it,  in 
view  of  their  cliniral  liisiurv,  aiul  tlie  iiilunnatinii  ahvady  n'iitlieivd  eiuieei-iiino-  the  svmp- 
tomatokjgy  of  the  continued  levers,  must  he  reg;irded  as  cases  of  uiidnuhtiMl  typhoid.  The 
post-mortem  observations  in  some  of  thesr  instanei's  were  iiL-^ullieieiit  and  h)osely  expressed, 
but,  as  in  others  they  were  more  extensive  and  entered  with  precision  on  the  record,  there  is 
no  difficulty  in  appreciating  tlio  associated  anafomieal  cli;nioes.  Tlie  brain  and  its  membranes 
were  oltentimes  found  in  a  nornud  condition;  the  thoraeic  \'is(!era  were  U'eipieiitK'  atlected, 
but  in  manv  cases  no  morbid  alteration  was  discovei'ed  in  them;  the  abdoniiind  contents 
were  variously  changed  from  the  liealthv  state.  The  character  of  these  changes  will  be 
examined  hereafter  on  presentation  of  the  remainder  of  the  post-viorfcia  records.  It  is 
sufficient  for  the  present  to  point  out  that  an  ulcerated  condition  of  the  small  intestine, 
particularly  of  its  lower  |iart,  and  perhaps  specifically  of  that  ]>art  ot  its  twtent  which 
corresponds  to  the  position  of  the  agminated  ghmds,  was  the  only  constant  anatomical 
lesion.  In  s(dne  instances  the  stomach  and  upper  part  of  the  iiitestiibd  tract  presented 
traces  of  inllammation,  in  others  the  large  intestine  bore  similar  marks;  but  all  these  had 
at  the  same  time  an  ulct'iation  of  some  part  of  the  lower  portion  of  the  small  intestine. 
Of  the  fifty  cases  Peyer's  glands  were  ulcer:ited  in  thirty-tliree;  and  in  seventeen,  in 
whii'li  the  condition  of  these  jiatches  is  not  stated,  the  ileum  or  small  intestine  was  said  to 
have  Keen  ulcerated. 

Had  the  typho-malarial  cases  reported  by  our  medical  officers  consisted  of  typhoid 
fever  modified  by  the  activity  of  a  malai'ial  element,  there  should  have  been  dLscovered  in 
all  fatal  cases  the  constant  anatomical  lesion  of  ty[)hoid  fever  with  such  changes  in  the 
cadaver  as  are  known  to  be  occasioned  by  the  presence  of  the  malarial  poi.son.  It  has  been 
seen  in  a  previous  chapter  tliat  fatal  cases  of  malarial  fever  presented  no  constant  or  cliar- 
acteristic  lesion.  Inflammatory  conditions,  observed  perhaps  more  frequently  in  the  small 
than  in  the  large  intestine,  were  noted,  and  these  had  often  progressed  to  ulceration;  but 
as  in  some  cases  the  intestinal  canal  was  apparently  healthy,  such  coiulitions  c(_)uld  not  be 
regarded  as  pathognomonic.  Ulceration  of  the  intestines,  of  the  small  intestine  especially, 
is  therefore  to  be  expected  in  the  ty})ho-malanal  cases  as  the  constant  accompaniment  of 
their  typhoid  essential  and  as  an  occasional  result  of  their  malarial  complication. 

Nevertheless,  of  forty-two  cases  recorded  as  typho-malarial,  there  were  nine  in  which 
the  [latches  of  Peyer  WL'ie  reported  as  having  been  found  in  various  conditions,  but  not 
ulcerated,  and  in  which  the  intestines  were  more  or  less  aflfected,  but  without  ulceration  of 
the  ileum,  except  perhaps  in  two  instances.  Moreover,  of  the  forty-two  cases  there  were 
fifteen  in  which,  while  the  condition  of  the  patches  was  not  stated,  the  inti.'stines  were 
variously  affected,  but  in  only  one-third  of  these  is  it  stated  in  terms  or  inferentially  that 


OD 


8  rO.'^T-MORTEM    RECORDS   OF 


ulceration  was  i)vesent.     The  reinaiiiiiiif  eiichteen  eases  were  characterized  hv  ulceration  of 
tlie  patches  ol'   I'cver. 

or  the  nine  eases,  S4;-92,  in  which  tlic  condition  of  the  agminated  glands  was  vari- 
ously roporttMJ,  case  81  had  the  ellipitical  patches  pale,  the  solitary  glands  and  the  rectum 
ulcerated.  These  are  not  the  generally  accepted  lesions  of  typhoid.  ]n  .So  the  [lalchcs 
were  distinct  and  elevateil  and  the  solitary  glands  of  the  lai'ge  intestine  uleeratod,  wliih' 
in  8C)  the  patches  were  dark-colored  and  conspicuous  and  the  mueous  lining  ot  the  small 
intestine  contiested.  Tliese  mav  Ijc  set  aside  as  indicating  hv  the  ulamlular  tumefaction 
the  possibility  of  a  tvphoid  element.  In  >S7-lH  the  i)atches  presented  the  sliaven-hi^ai'd 
appearance;  in  87  the  solitary  glands  were  prominent;  in  89  these  glands,  near  the  ileu- 
cpecal  valve,  were  ulcerated,  as  was  also  the  colon;  in  88  the  intestines  were  congested,  and 
in  90,  according  to  Dr.  Harrison  Allen,  they  presented  no  special  lesion  otlu/r  than  pig- 
mentatioii  of  the  patches.  In  Dr.  Leidy'.s  cast',  91,  there  was,  in  addition  to  deposits  of 
pigment  in  the  agminated  and  solitary  glands,  laig-e  inflamed  and  ecchymosed  ])atches  in 
the  small  intestine  and  similar  but  more  diffused  conditions  in  the  large  intestine.  In  case 
92  the  record  is  indefinite;  the  expression  "congestion  of  the  bowels  and  disorganization  of 
the  alands"  leaves  an  uncertaintv  as  to  whether  the  glands  (d'  the  mesentery  or  the  dosed 
glands  of  the  intestinal  mucous  membrane  were  thus  afiected.  8i.\  of  the  nine  cases  pre- 
sumed by  the  diagnosis  to  have  both  a  typhoid  and  a  malarial  element  may  thus  be  regarded 
as  having  offered  uo  post-viortera  evidence  of  the  existence  of  a  typhoid  factor. 

Of  the  fifteen  cases,  69-83,  in  which  the  condition  of  Peyer's  patches  was  not  stated, 
the  small  intestine  was  ulcerated  in  five  instances:  In  case  74,  the  patient  having  been  undei- 
treatment  in  hospital  for  twenty-six  days  before  death,  there  was  congestion  and  commencing 
ulceration  of  the  intestines;  in  75  the  mucous  membrane  of  the  small  intestine  was  ulcer- 
ated in  various  parts  and  that  of  the  large  intestine  congested  and  disintegrated;  in  77  there 
were  small  ulcerations  in  the  lower  part  of  the  ileum,  and  in  82  and  8:)  this  part  of  the  intes- 
tine was  perforated.  Allowing  the  uh.-ei'ation  in  tiiese  cases  to  repi'esent  the  enteric  lesion 
of  tvphoid  fever,  there  remain  ten  cases  in  which  the  small  intestine  was  not  ulcerated.  In 
71,  72,  73,  78  and  81  the  intestinal  mucous  membrane  was  congested,  inflamed  i^r  softeiie(l; 
in  the  tlrst-mentioned  case  the  (csojiliagus,  stomach  and  duodenum  participated  in  the  inflam- 
matory action;  in  73  the  solitary  glands  were  disorganized  and  in  81  there  was  also  peri- 
toneal inflammation.  In  76  the  small  intestine  was  congested  and  the  rectum  ulcerated  and 
gangrenous.  In  79  the  ileum  was  injected  and  in  80  gangrenous.  In  70  the  solitary  glands 
were  disorganized  and  the  mucous  coat  of  the  rectum  inflamed  and  softened.  In  69  nothing 
is  said  of  the  condition  of  the  small  intestine,  possibly  because  it  presented  notiiing  of  impor- 
tance. Negative,  as  contradistinguished  from  jiositive,  testimony  has  its  value :  The  record  (d' 
case  76  of  the  {)aroxysmal  fevers  does  not  take  cognizance  of  the  condition  of  the  small 
intestine;  but  as  the  diagnosis  was  remittent  fever,  few  pathologists  would  doubt  its  nega- 
tive testimony  as  t(^  the  absence  of  ulceration  of  the  ileum.  In  69  of  the  ])resent  series  the 
diagn(j.-is  tvpho-malarial  sustains  rather  than  invalidates  a  similar  negative  evidence.  That 
typhoid  symptoms  may  be  present  without  the  co-existence  of  an  enteric  lesion  is  evident 
from  the  following  case  of  mistaken  diagnosis: 

Private  William  McMillan,  Co.  I,  15th  III.  Cav.:  age  16;  was  admitted  from  Washington  .stivtt  piisou  Fcli.  9, 
1865,  with  typhoid  fever.  He  complained  of  frontal  licadache  and  was  delirious  at  limes;  his  tongue  was  dry  and 
coated  with  dark-hrown  fur,  teeth  covered  with  sordes,  skin  hot,  dry  and  sallow,  pulsi!  120  and  weak,  l)owels  tym- 
panitic aud  tender.     He  died  on  the  13th.     I'onl-mortcm  examination  twenty-one  hours  after  death:  The  pericardium 


THK    rO.M'LNL'Kl)    l-KVKKS.  359 

was  full  of  senuii  and  llakcs  uf  lyniiih.  TIk-  k-fl  liiii^  was  coati-d  with  icconl  deposits  of  lyiiipli:  similar  deposits 
glued  togetlier  tlu;  intestines  and  other  alidiiininal  viseera.  The  liver  was  pale.  The  mueoiis  nanihrane  of  the  ileum 
was  (juite  normal. — Third  Diriision  lliixjiitu!.  JIuuiHlrid,  I'li. 

But  even  were  case  69  tliniwn  out  ;i>  iiK.lctiuitf  in  its  uviJence,  tliei'O  woultl  he  no  mod- 
ification of  tlie  general  conclusion  drawn  iVma  this  si/rics  of  eases,  to  wit:  that  anion;:;  tln'ni 
are  to  be  found  cases  in  which  the  svniiitoins  warranted  a  t vjiho-nialarial  diaLinosis  in  the 
absence  of  tlie  lesion  considered  pathognomonic  of  tvphdid  fever. 

This  conclusion  is  sustained  by  an  examination  of  the  jiDxt-morfcin  rtn-ords  of  those 
cases  wdiich,  though  recorded  as  tvphoid  iV'Vur,  showed  by  their  clinical  history  that  their 
course  was  probably  niodified  by  the  c<.ineui'rent  action  of  the  malarial  poison.  I'weiitv- 
four  such  cases  have  been  submitted/^'  in  eleven  of  whicli  the  patches  of  Pcvcr  were  referi'i'd 
to  definitely  as  ulcerated.  In  six  of  the  twenty-ibur  cases.  111-1  ](>,  the  condition  of  these 
glands  was  mentioned,  and  if  the  enlargement  in  111,  the  tlnekening  and  congestion  in  112, 
the  iuflanied  condition  with  ulceration  of  the  small  intestine  in  111  and  the  eonnnencing 
ulceration  of  the  piiiincnted  u'lands  in  116  l)e  rcLrarded  as  reiiresentiuir  the  aiiiitomical  lesions 
of  typhoid  fever,  there  remain  two  cases  in  wliich  those  lesions  cannot  be  recognized.  Tliese 
are  113,  in  which,  although  the  patient  was  under  treatment  in  hospital  for  twenty  days 
prior  to  death,  the  patches  of  Peyer  present<xl  no  other  characteristic  than  ;i  participation 
in  the  general  congestion  of  the  small  intestine,  and  11;"),  in  which,  although,  according  to 
the  testimony  of  Dr.  Lkidy,  the  ileum  near  the  valve  and  the  ctecum  hevond  it  were  intensely 
inflamed,  the  patches  were  healthy  except  that  a  i'^^w  of  the  lower  ones  contaiiieil  some 
black  pigment.  The  condition  of  the  agminated  glands  was  not  stated  in  seven,  101-110, 
of  the  twenty-four  cases.  Four  of  tlicse  may  Ik-  set  aside  as  presenting  prol)able  typhoid 
lesions,  but  the  remaining  three  cannot  be  so  regarded.  In  101  the  ileum  was  Imt  slightly 
congested;  in  105  it  was  extensively  congested  but  not  ulcerated;  ami  in  lOS  tlu'  mucous 
membrane  of  the  stomach  was  reported  softened,  of  the  lower  part  of  the  colon  thickened 
and  softened,  but  no  mention  is  made  of  the  condition  of  the  ileum  oi-  small  intestiiu^,  and 
it  is  hardly  admissible  to  su{)pose  that  the  characteristic  lesion,  in  a  case  admitted  :is  fully 
developed  typhoid  fever,  would  have  been  omitted  from  the  record  while  details  were  given 
of  other  and  a])parently  less  important  lesions. 

It  is  evident  from  these  records  that  among  the  fatal  cases  reported  as  typho-inalarial 
were  some  which,  while  presenting  the  inllannnatory  conditions  recognized  as  the  freipieiit 

*  Aiiiuii;;  tin-  lurt.v-two  ca.scs  filtered  na  tyi)hu-ii)iilariul  iiml  tlif  twi-nty-ttMir  wliii-li,  :iltli<m;^li  Hlicwiii^  in  tlu'ir  4-liiii<aI  liihtory  »  iir<il»aMr  malarial 
complkatiiiu,  were  iicviMtticU'w  rcjjanliil  as  ty|phiiiil,  ari'  ti>  In-  I'miTiil  tlhiM'of  wiiiih  Dr.  Wciiiiiwakd  «|»iki' as  IcpIIijui!  in  his  nniurks  cm  Tiiyh-iiuihiri'd 
Fner,  hrftm  IJir  Miruali'mid  Mcdiail  (V,i,,/r,««,  I'hila.,  IS'O,  paiiililcli't,  pawl's  :H-;t."> :  "In  tlii' KMaiiiof  rasfs  ill  wliiili  tlii' malarial  |.h<'m>mi'lia  luiiloiliiliali'tl 
tbf  (ii6t"a.st'  la-piu  as  a  simplr  intrrniittfiit  i>r  n-niittt-iit  fcviT,  »»('  ({iioticliali,  tertian  or  iiuartan  typi-,  the  most  IVccim-iit  Inrm  iK-inj;  a  siniplr  i>r  duulilo 

tiTtian  ;  but  al'tt^r  a  week  ipr  ton  days  the  IVviT  assunii'd  a  more  iir  leas  ciiniiilcli'ly  lontinnctl  type,  wit! iliy  ot  lln'  pliiicnmcna  ilianirtiTi.stii-  of  lyplmid 

fever,  sueli  as  diarrlnea,  alnluminal  teiiilerness,  mctenrisin,  miitlerin;;  delirium,  suhsultus  tendiiinm,  dry,  limwii  t<in;;ne  and  the  like.  Hut  even  when 
the  typlioid  j>lii-ninnena  were  most  pronouneed  some  of  tin-  most  charaeterislie  of  them  were  often  wanting;.  Thus,  sometimes  there  was  no  diarrho-a  at 
all,  lint  eonstiliatioLi  instead.     The  rlianieteristie  taehe  rouKe,  or  rose-iolt.nil  erupliipu,  was  j-enerally  entirely  alisi'nl  ;  (la^trie  disturliame,  he|iatic-  ten- 

dernes-sand  an  ieteroi.l  hue  of  the  eonntenanee  »c  re h  n-neiiiTally  present  than  in  simple  typhoi.l  fever.     Kow,  a  lar;;!'  pn.porticiTi  of  these  eases 

tcruiinated  favorahly,  especially,  a.s  I  think,  btn-ause  ipiinine  was  so  freely  useil  in  their  treat lit  ;  the  oeeurreiire  of  ordinary  imroxysms  of  iij;ue  was  a 

frequent  aeeident  dlirin;;  the  eolivaleseeliee.  .\nd,  just  beeallse  of  the  freipleney  with  wllieb  they  ri-eovenil,  I  sllplH.se,  the  nillllher  of  allto|w;ies  ill  eaw-s 
of  this  kind  whieh  I  have  been  aide  to  e(dli-it  is  iiineh  less  than  in  eases  of  the  seeoiid  t'lonp,  of  wliieli  I  shall  pies.ntly  speak.  Still,  I  have  eolleetiila 
nniiiber  td'  autopsies  id" eases  of  this  kind,  in  whieh  iliariho-;i  had  been  present  dnrilii;  the  fever  and  in  whieh,  att.'r  it  had  assumed  a  e,.iitiniioiis  type,  it 
had  strikiii^'ly  resenibUil  typhoid  fever,  but  in  whieh  disseition  showed  no  other  lesion  in  the  alimentary eiuial  than  a  Sliiart  intestinal  eatarrb.  I*at>  lies 
of  iiitlainmation,  seattered  irregularly  throiijxhoiit  tioth  small  and  lar};e  intivtiiieH,  and  enlar;reineiit  of  the  elosinl  j^lands,  often  assoeiatisl  \.  itli  pii;in'ut 
deposits,  were  the  ehanieteristic  lesions.  The  solitary  ^rlalids  of  the  small  intestine  appeared  as  little  proji^itinj;  tumors  the  si/e  of  pinbeads,  whieh  often 
had  eonstricttHi  lun-ks,  so  that  they  resembled  tiny  polypi.  The  agminated  ifiaiids  of  IN-yer,  sli;;litly  promiin-nt,  were  often  the  scat  of  pijjnieiit  deisisit, 
whieh  t;ave  tbem  the  so-ealled  shaven-beard  appearance.  Sonietiiiies  the  villi  td'  tin-  siiiati  inti-stines  were  hypertropliied  ;  .soiiietime.s  they  hail  pi^rnieiit 
deposits  at  their  apices.  In  the  large  intestine  the  slightly  swollen  solitary  glands  were  often  the  seat  of  pigment  ileiiosiLs,  seateil  either  in  the  glands 
alone  or  sometimes  also  in  the  surrounding  mucosa,  in  which  caiie  the  <-entral  dot  of  iiignieiit  was  siuToniuled  by  a  little  idgnientary  ring.  When  the 
fever  had  supervened,  as  often  hapix'ned,  njion  a  chronic  flux,  or  where  dysentery  had  been  devekiped  during  the  <-ourse  of  the  fever  or  of  the  conva- 
lescence and  had  been  the  imnuHliate  caU8<^  of  death,  the  characteristic  follicular  ulcerations  of  the  colon  or  the  jibenoniena  of  tin'  dipbtberitie  iirocess 
complicated  the  picture.    Great  enlargement  of  the  spleen  and  congestion  of  the  Uver»  with  or  without  fatty  degeuemtion,  were  frequent  concomitants." 


360 


POST-MOKTKM    RECORDS    OF 


attendant  of  acute  malarial  poisoninsi,  did  iiut  have  associated  with  them  the  morbid  condi- 
tion which  daily  exjicrience  shows  to  be  the  invariable  accomj)animent  of  t\'|ihoid  fever. 
Certain  cases  of  the  paroxysmal  fevers,  as  for  instance  58,  (i3,  81  and  82,  indicaU'd  that  a  clin- 
ical history  suggestive  of  ty})h(iid  fever  might  lx>  prcsenteti  witluiut  the  discovery  u(  lyjihoid 
lesions  on  pod-morteiii  examination.  This  indication  lias  been  fully  sustained  by  the  I'ccords 
just  submitted.  They  demonstrate  that  there  were  sometimes  developed  in  the  progress  of 
a  malarial  fever,  and  in  the  absence  of  the  local  intestinal  lesions  characteristic  of  ty[)lioid, 
certain  symptoms  which  are  so  generally  the  manifestations  of  typhoid  fever  that  tliey  are 
technically  known  as  typhoid  symptoms.  As  these  cases  are  too  numerous  and  well  authen- 
ticated to  be  disposed  of  by  the  assum]ition  that  they  were  exceptional  cases  of  mistaken 
diagnosis,  it  follows  that  our  medical  officers  applied  tlie  term  typho-malarial  to  cases  which 
Dr.  WooDWARj)  did  not  have  in  view  on  its  introduction.  Adynamic  malarial  remittents 
swelled  the  list  of  febrile  cases  reported  as  tv[>ho-malarial,  and  to  a  greater  extent  than  would 
be  supposed  from  the  small  number  o'i post-nwrtoii  records  that  support  this  statement.  Most 
of  the  recorded  cases  presented  the  characteristic  lesion  of  typhoid,  or  such  ulcerative  changes 
in  the  mucous  membrane  of  the  small  intestine  as  might  be  claimed  to  represent  the  typhoid 
lesion,  although  malarial  fevers  are  also  productive  of  such  changes.  But  it  has  already 
been  sliown  that  malarial  cases  rarely  reached  the  general  hospitals  in  the  rear,  w^here  facil- 
ities existed  i'ov  pod-viorf em  observation  ami  record.  Huch  cases  occurring  at  the  front  recov- 
ered under  the  influence  of  quinine,  or  died,  if  the  disease  was  pernicious,  before  reaching 
the  general  hospitals.  Hence  the  paucity  of  malarial  changes  as  compared  witli  the  fre- 
quency of  typhoid  lesions  in  the  recorded  cases.  Had  the  pod-hiortem  records  of  typho- 
midarial  fever  been  ])reserved  in  the  Held-books  of  the  regimental  surgeons  as  in  the  case- 
books of  the  general  hospitals,  it  is  higlily  prubable  that  the  number  of  cases  presenting 
lesions  not  definitely  typhoid  would  have  been  largely  increased. 

When  anomalous  febrile  cases  were  Hrst  observed  in  the  autumn  of  18(31  they  were 
viewed  by  our  medical  officers  as  remittent  fevers  which,  owing  to  depi'essing  iuHuences 
operating  on  the  newly  levied  troo})s,  tended  to  assume  a  continued  type  and  adynamic 
character.  This  is  expressed  in  a  large  number  of  sanitary  repoiis  furnished  at  that  early 
period  of  the  war,  a  few  of  which  are  herewith  submitted: 

Siiryton  J.  M.  Crvi.Ki!,  U.  S.  A.,  t'Ortresa  Afiniroc,  fa.,  Auijunl  17,  IXIil. — C'oiitiiiiud  fover  of  miliaria]  ()ri;;in,  liy 
many  lieie  called  "typhoid,"  is  the  most  formidable  disease  we  have  to  contend  with;  the  number  of  fatal  cases 
has  as  yet  been  comparatively  few,  but  patients  are  lung  in  recovering  tlicir  strength. 

Surgeon  Isaac  J.  C'i.auk,  12th  Pa.  Scotrnti. — Our  camj)  at  Teunallytown,  Md.,  in  August,  IXIil,  was  on  a  hill- 
side with  a  gravelly  surface  but  a  wet  clayey  subsoil,  near  a  piece  of  low  ground  suitable  for  the  generation  of 
malaria.  The  prevailing  disease  was  remittent  fever,  w  hich  almost  invariably  in  a  few  days  changed  to  a  mild 
typhoid  fever;  most  of  the  cases  recovered,  but  convalesced  (juite  slowly. 

Surfifon  A.  P.  Fhick,  lO'Sd  Pa. — During  our  sojourn  at  White  Oak  Swaiuii,  June  1W2,  there  was  much  and 
serious  sickness,  principally  typhoid  fever,  or  we  may  more  jproperly  say  remittent  fever  of  a  typhoid  form.  The 
prolonged  exposure,  continued  watching  and  great  mental  depression  after  tlie  battle  (Fair  Oaks),  united  with  the 
malarial  influences  of  the  region  in  giving  a  low  form  to  disease  and  in  making  cases  alaniiingly  fatal.  Stimu- 
lants, quinine,  chlorate  of  potash  and  opium  were  the  remedies  chiefly  relied  on. 

Siirycon  Sa.mukl  G.  Lane,  5th  Pa.  Reserves. — Disease  during  the  winter  18t)l-il2  was  of  a  decitlidly  tyi)hoi(l 
type,  death  being  usually  sudden  and  from  local  inflammatory  conijilications.  We  had  but  few  cases  of  enteric 
fever;  all  others  were  purely  miasmatic.  The  treatment  was  simple:  Depiction,  even  local,  was  pernicious;  i|uiiiine 
in  full  and  rejjeated  doses,  stinnilants,  nutritious  diet  aiul  cleanliness  constituted  the  general  treatment,  with  oil  of 
turpentine,  nitrate  of  silver,  acetate  of  lead  and  opiates  for  diarrho-'a,  which  was  a  usual  aecomi)animeut,  and  dry 
cupping,  blistering  aud  counter-irritants  to  subdue  inflammatory  action. 

Surgeon  S.  N.  Sherman,  3ith  X.  Y.,  Seiievu  Mills,  Mil.,  Sept.  30,  18(>]. — The  34th  N.  Y.  was  mustered  into  service 
June  15  at  Albany,  N.  Y.    It  reached  Washington  July  C  aud  went  into  camp  on  Kalorama  heights.    There  it  remained 


THK    COXTIM-ED    FKVERS.  361 

until  the  30tb,\vlK'ii  tlie  sick  were  ordered  to  the  (ieori^etoAvii  liospital  and  the  re<{imeut  to  Seneca  Mills,  Md..  where 
it  arrived  on  An^iiist  2.  While  eneaniped  at  Kalorauia  tlie  diseases  were  almost  exclusively  diarrh(ea  and  rheuniatisni, 
but  since  it  occupied  its  pri'sent  location  there  have  l>eeu  .superadded  interuiittent  ami  remittent  fevers,  which  in  a 
few  cases  have  assun\ed  atyplioiil  type.  I  was  detained  at  Washini^ton  and  did  not  rejoin  my  regiment  until  August 
11,  when  I  found  it  encamped  in  the  .Seneca  liottoui,  half  a  mile  from  the  rotouiac  humi'diatcly  the  camp  was 
removed  to  an  idevation  half  a  mile  from  and  one  hundred  and  (ifty  iVct  aliuve  the  creek  and  alMUit  the  same  distance 
from  and  heiglrt  above  the  Potomac.  All  possible  attention  has  been  |iaiil  lo  polici'  regulations.  The  location  hs  airy 
and  descends  in  all  directions.  The  water  from  a  spring  adjaceni  is  both  pure  ami  abundant.  The  rations  furnished 
are  sufticieut  in  (|uantity  and  of  nnexce)>tio!iable  i|Uality.  Ardent  spirits  are  excluded.  Among  the  duties  assigned 
the  regiuu'Ut  is  that  of  guarding  the  river  for  four  miles  above  aiul  below  the  cainii:  this  has  rei|uired  tlu'  constant 
services  of  two  companies,  with  geneially  four  on  picket  on  the  banks  of  the  river  or  the  tow-path  of  the  canal. 
Chills  and  fever  have  resulted,  but  only  auuing  those  tlidug  guard  duty  on  the  river;  and  of  those  attacked  few  fail 
of  a  rapid  recovery  when  (luiuiue  is  liberally  used  and  strict  coutinement  to  camp  enjoined.  As  the  frosts  of  autumn 
approach  the  number  of  attacks  decr«'ase  and  the  recoveries  are  more  si)eedy. 

.Iss't  tSiirij.  S.  COMPTON  Sjimii,  Mil  (li-s-.  Ciir.,  lUiiuj  Homo,  Md.,  Si]}l.  ;«),  IMtil. — We  had  been  in  our  present 
encampment  but  a  few  days  when  fevers  of  a  remittent  and  tygihoid  ty|ie  supervened,  three  )iatients  having  died  of 
the  last-named  <liseasc.  Until  the  [iresent  time  these  fevers,  accompanied  with  the,  various  forms  <d'  intermittent, 
have  been  attendant  ujiou  us,  latterly,  however,  assuming  m<ire  the  forms  of  remittiiil  and  tertian.  They  are  gen- 
erally controlled  by  the  suli)liate  of  i[uinia  a<lministereil  early  iu  from  ten  to  twenty-giain  doses  at  intervals  of  two 
or  three  hours  and  preceded  by  the  u.snal  cathartics.  At  this  date  our  hospital  wards  are  tilled  with  ]>atients 
laboring  under  the  two  last-named  forms  of  fever  with  a  few  cases  of  dysentery. 

Hiirijmn  D.  WADSWOinil  WAlNWmcillT,  \tli  .V.  1'.,  Harrndv  Grace,  Md.,  •Sept.  30,  IStil. — On  August  13  the  ri'gimeut 
was  ordered  to  guard  the  bridges  on  the  Phihulelpliia,  Wilmington  and  Haltiinoic  IJailroad:  Company  II  at  I  tack  river, 
H  and  1  at  (iuu))owder  river,  E  and  I)  at  Mush  river,  K  at  I'ei  lyuuinville,  A,  C  and  (J  at  Havre  de  (irace  and  K  at  I'erry- 
ville.  We  have  had  many  cases  (d'  uuilarial  fever,  uio.stly  from  Hack,  (iunpowder  and  Hush  rivers;  some  of  these 
were  interiuittent,  others  remittent ,  and  all  had  a  tendency  to  a  typhoid  state.  Most  of  them  yielded  readily  to  treat- 
ment, ten  grains  of  calomel  with  castor  oil  followed  by  <iuinine,  twenty-four  grains  in  twenty-four  hours. 

.inis't  Siiri/.  He.nhv  S.  Sciiki.i,,  ('.  <S'.  A.,  on  Ihr  niudilUtn  of  llii-  IjijUl  liatlirhn  iif  I'ilc-Joliii  Vorlir's  l>iri«'\ii»,  Hull's 
Hill,  /'((.,  .S'fj;?.  30,  IWil. — Fort  Corcoran  is  situated  about  ou(;-fourth  of  a  mile  fr(MU  tht^  l'ot<uuac  river  on  ihr  \'irgiuia 
side,  opi)Osite  (Jeorgelown,  I).  C.  It  is  upon  Ihe  brow  of  the  first  hill  from  the  river,  and  is  a  recently  constnnted 
earthwork  exixising  a  large  amount  of  freshly  upturned  and  moist  soil  to  llu'  action  of  tlu'  sun.  liesidi's  this,  the 
woo<ls  which  at  one  time  intervened  between  its  site  and  the  marsh  below  wi're  felled  during  the  suiuiuer  iu  the  con- 
st ruction  of  abatis.     Hence  miasmatic  disea.sesare  prevalent  and  characteri/ed  to  sonu'  extent  by  a  typhoid  teiulency. 

Siii-ycoii  N.  F.  M.vl!.sil,  ilk  I'a.  Cav.,  Wasliiiii/toii,  l>.  C,  Die.  30,  1801. — ^Diiriug  the  past  two  months  the  ti'iidc^ney 
of  every  disease  has  been  to  iissiime  a  typhoid  character;  a  simple  attack  of  diarrlnea  woubl  in  twenty-four  hours 
render  a  vigorous  man  perfectly  prostrate,  and  lie  would  then  |)re.sent  all  the  incipient  sympti>ins  of  typhoid  fever. 

Siirijviin  .J()Si;i'ii  1".  Cui.(i.\x,  .W//i  A'.  1'.,  i'oiiqi  Sliirmun,  Ftn-t  Hood  llupt,  l>.  (!.,.finiiiiirii,  IXOli. — The  weather  for  the 
season  of  the  year  has  been  favoiable,  yet  the  temi)eiatiire  is  variable  and  t  hi'  transitions  i|uii-k.  which  is  productive 
perhaps  of  more  respiratory  disease  than  a  colder  and  less  variable  season  might  be.  Coughs  .•md  c.-itairhal  atfections 
have  prevailed  to  a  considerable  extent  in  couse(|Ueuce.  Another  cause  of  the  iirevalence  of  such  complaints  is  found 
in  the  fact  that  the  Sibley  tents  in  which  the  men  sleep  are  furnished  with  small  sheet-iron  stoves  of  |ioor  i|uality, 
easily  ami  quickly  heated  and  as  <iniekly  cooled  again,  and  unless  they  are  constantly  supplied  with  fuel  the  tem- 
jierature  s])eedily  falls  to  a  low  iioiut,  so  that  it  is  all  the  time  too  hot  or  too  cold.  I'revious  to  ilay-broak,  when 
the  niercury  ordinarily  falls  lower  than  at  any  other  hour  and  the  men  are  all  asleep,  the  tires  die  out,  and  as  Ihe  top 
of  the  tent  is  open  to  the  atmosphere,  dew,  frost,  snow  or  rain,  as  the  ease  may  be,  causes  surgeon's  call  to  be  well 
attended  with  invalids  comiilainiug  of  pains,  coughs,  colds,  fevers,  etc.  Some  of  the  stoves  have  pipes  reaching 
out  at  the  top,  but  others,  and  these  the  majority,  have  pipes  reaching  but  half  way  u]),  so  that  the  smoke  ascending 
deposits  soot  on  the  slope  of  the  canvas  from  which  at  every  blast  of  the  wind  it  is  shaken  off,  covering  the  faires 
and  hands  of  the  men,  adhering  to  their  clothes  and  giving  them,  previous  to  ablution  in  the  morning,  a  dirty  and 
unbecoming  ajipeaiance.  This  is,  however,  unavoidable  when  troops  have  to  take  U])  winter  quarters  in  tents, 
sleeping  on  the  ground.  I  may  as  well  say  here  that  men  so  situated  are  too  scantily  supjilied  with  covering,  each 
man  being  provided  with  but  a  single  blanket  for  covering  and  ]irotectiou  from  the  cold  and  damp  ground.  This 
scanty  covering  compels  them  always  to  sleep  in  their  clothes,  the  overcoat  being  the  only  garment  removed,  and 
this  only  to  be  converted  into  a  bedcover  or  quilt.  It  must  not  be  forgotten  that  when  they  retire  to  their  canvas 
quarters  their  clothes  are  often  wet.  There  can  be  no  question  as  to  the  conseiiuence  of  men  sleei>ing  in  garments 
and  in  such  quaiters,  huddled  together  iu  crowds  of  twenty  to  a  tent;  that  it  tends  lo  demoralize  them  to  a  certain 
extent  I  entertain  no  doubt,  and  think  it  should  be  practiced  only  when  unavoidable.  As  a  consequence  of  these 
conditions  our  prevailing  diseases  are  afl'ections  of  the  respiratory  organs  and  fevers.  Intermitteuts  are  seldom 
well  marked,  but  remittents  are  frequent  and  various  iu  their  character  from  the  most  simple  to  the  uiost  compli- 
cated, some  soon  assuming  the  typhoid  type;  for  which  reason  they  have  been  bj'  many  surgeons  named  "typhoid 
fevers,"  so  that  nearly  all  have  been  compelled  to  adopt  the  nomenclature,  while  many  are  of  the  opinion  that  the 
disease  is  "bilious  remittent,"  which  sometimes,  of  course,  runs  into  continued  and  congestive  fevers.  The  patho- 
Med.  Hist.,  Ft.  Ill— 46 


362  ]>OST-MOnTKM    RKCORDS    OF 

loj^iciil  comlitious  are  so  various  that  no  organ  escapes  being  involved  in  all  eases.  (Quinine  autl  stimulants  are 
necessary  and  in  very  large  doses;  in  a  lew  instances  the  disease  refused  to  yield  to  these  remedies  until  the  system 
was  brought  slightly  under  the  influence  of  calomel. 

.let.  .tss't  Snrij.  ICnwARD  T.  WiiirriNGHAM,  on  the  coiiditmii  of  the  Artillery  Briijuile  of  Kearitij'n  DirixUm,  near  Hiir- 
rixon'x  Landhi;/,  I'd.,  June  30,  18t)2. — I  joinod  the  couuuand  May  17,  at  Cumberland  Landing  on  the  I'amunkey 
river.  Since  that  time  we  have  been  constantly  exposed  to  the  fatigue  of  marching  and  the  emanations  from  swamps 
lying  on  our  route.  We  have  also  be?n  obliged  to  use  water  so  muddy  and  impure  a.s  to  be  unfit  for  drinking.  These 
causes,  in  conjunction  with  the  previous  exi)osure  of  the  troops  in  the  marshes  about  Vorktown,  jiroduced  a  general 
tendency  to  malarial  fevers  and  dysenteric  atl'ections  severe  in  their  type  and  exceedingly  unmanagoalile.  (Quinine  in 
very  large  doses  and  opium  have  been  the  remedies  employed.  Though  the  mortality  lias  not  been  large,  yet  the 
average  duration  of  sickness  has  been  extremely  long. 

Suryeon  J.  M.  Boisnot,  Z7.  S.  V.,  Gaines'  Mill  Hospital,  near  Mechanicsrille,  I'a.,  June,  1862. — The  seven  cases  of 
typhoid  fever  which  we  report  were  of  unusual  severity,  four  of  them  original  and  three  seciuences  of  remittent  fever. 
All  diseases  in  tlie  army,  of  the  class  of  fevers  particularly,  have  a  typhoid  tendency.  I  believe  that  circumstances 
producing  freiiuent  and  rapid  changes  in  the  temperature  of  the  body,  as  a  rapid  march  and  then  a  halt,  a  hot  and 
(juickly  eaten  nu'al  of  soup  and  cotfee,  etc.,  then  lying  down  on  the  cool  ground,  have  nuiinly  to  do  in  bringing  about 
this  condition.  My  plan  of  treatment  in  the  seven  eases  treated  in  this  hospital  was  to  give  strong  but  digestible 
food  and  stimulants  in  small  quantities,  administered  nearly  every  hour:  six  recovered  and  one  died. 

Siinjeon  David  Mkeuitt,  5oth  I'a.,  Edisto  Island,  S.  C.,Junc  30,  1)<(52. — Edisto  Island,  upon  which  this  regiment 
is  stationed,  abonn<ls  in  swamps  or  salt-water  marshes.  The  climate  is  warm  and  generally  sultry,  but  moiUtied  by 
a  cool  sea-breeze  in  the  afternoon  from  North  Edisto  river.  The  prevalent  diseases  are  bilious  remittent  fever,  which 
tends  to  assume  a  typhoid  character,  and  dysentery,  bilious  in  character  and  mild,  easily  managed  by  the  prompt 
use  of  mercurials  followed  l)y  full  doses  of  saline  cathartics.  The  duties  of  the  troops  are  light;  they  are  ([uartered  in 
tents  and  the  sick  in  hospital  tents.  The  diet,  clothing  and  general  habits  of  the  nu'U  as  to  cleanliness,  temperance, 
etc.,  are  good.     The  water,  however,  is  bad,  being  generally  sulphurous. 

Siir(jeon  \.  H.  Sxow,  ^'.  1'.  Engineers,  Hilton  Head,  S.  C,  June  30,  1802. — During  the  winter  the  fevers  were  of  an 
intermittent  character,  but  since  the  warm  weather  has  set  in  they  have  assumed  more  of  a  bilious  typhoid  type. 

Surijeon  Ai.exaxdkk  M.  Stkek,  1th  Pa.  Car.,  liard-itoirn,  Ky.,  Feb.  3.  1862. — The  diseases  to  which  the  men  were 
most  susceptible  were  a  remittent  form  of  fever  with  a  strong  tendency  to  assume  a  typhoid  character,  diarrhoeas 
arising  from  change  of  food  and  water,  and  mild  bronchial  affections,  which  hav(?  been,  however,  witli  a  few  excep- 
tions, amenable  to  treatment. 

Suryeon  \V.  ,1.  CllK.NOWllll,  3.")//)  III.,  near  Holla,  Mo.,  Dec.  1,  1861. — Here  also  [OtlervlUe.  Mo.]  was  our  largest 
list  of  intermittcnts  and  remittents,  and  to  aild  to  our  trouble  we  had  no  (|uiuine  nor  could  we  procure  any.  Ereiiueut 
reiiuisitions  were  made  on  8t.  Louis,  and  in  the  space  of  two  weeks  as  many  as  live  messengers  were  dispatclu^d  for  it ; 
but  as  the  medicine  had  been  forwarded  to  us  by  the  purveyor  it  was  supposed  we  would  receive  it.  This  supply, 
however,  was  lost,  and  we  were  compidled  to  resort  to  arsenite  of  potash  and  other  antiperiodics,  but  our  sick-list 
steadily  increased  from  tifty  a  day  uji  to  one  hundred  and  titty.  Many  ca.ses  assuuu'd  a  typhoid  type,  and  two  men 
died.  A  marked  case,  showing  the  efficacy  of  i|uiiiine  in  the  arrest  of  the  disease,  was  exhibited  in  the  iierson  of 
Lowery.  Co.  K:  One  of  our  officers  on  rejoining  tlu-  regimi'Ut  brought  with  him  a  .solution  of  <|uinine.  This  we  con- 
cluded to  give  to  any  of  the  graver  cases  that  slill  showed  a  reuiission.  Lowery  had  a  dry  cracked  tongue,  fre(iuent 
pulse,  and  his  fever  manifested  every  indication  of  falling,  as  in  other  cases,  into  the  continued  form.  We  gave  him 
twenty  grains  of  i|uinine  and  repeated  the  dose  (Uuing  the  next  remi.ssion,  with  the  result  of  arresting  the  disease. 

Suryion  ,J  a.mks  L.  Kieunan,  6</(  Mo.  Car.,  June  30, 1862. — The  prevailing  diseases  in  the  Southw  est  are  bronchial 
and  thoracic  affections,  typhoid  fever  in  the  low  alluvial  (li.stricts,  .ind  in  the  army,  amongst  those  w  ho  have  seen 
service,  that  peculiar  train  of  syuii)toms,  induced  by  malaria,  exposure  and  privations  and  characterized  by  lassi- 
tude, emaciation  and  a  low  irritative  fever,  which  can  scarcely  beclassilied.  I  observed  the  same  phenomena  amongst 
the  troops  comprising  the  Army  of  the  I'otomac  last  year,  but  not  to  the  .same  extent. 

Typhoid  i'ev(_'r  of  undoubted  character  broke  out  in  uiuiiy  of  the  regiments  soon  after 
their  organization,  and  it  is  highly  probable  that  many  cases  of  this  disease  were  mistaken 
lor  adyntimic  developments  in  malarial  cases  where  remittents  ami  intermittents  were  the 
prevailing  fevers.  It  is  equally  probtible  that  during  these  regimenttd  epidemics  adynamic 
remittents  were  occasionally  chissed  with  the  j)revailing  ffVL'r.  After  the  {iresentation  of 
so  many  cases  of  undoubted  typhoid  from  the  case-books  of  tliu  Seminary  hospitul  and  the 
pofst-mortcvL  records  of  various  general  hospitals  it  is  nc(xllcss  to  occupy  space  with  a  selec- 
tion of  reports  indicating  the  ])re.scnce  of  this  fever.  Some  extracts  showing  its  prevalence 
will  be  embraced  in  the  section  di.scussing  the  etiology  of  the  continued  fevers.*  Brigade 
Surgeon  David  Peince,  under  the  impression  that  the  Army  Medical  IJoard  of  which  Surgeon 

*  See  iitj'ra,  p.  -180  ei  tu:^. 


THE    CONTINUED    FEVEKS.  363 

McLakex  was  president  had  concluded,  ai>  the  result  of  its  investigations,  that  there  was 
no  typhoid  fever  in  tlie  arniv.*  tiled,  in  ju'otest  at  the  otBce  of  the  Surgeon  General,  a  detailed 
account  of  cases  of  this  fever  thai  h;id  been  treated  in  his  cc^.imnand. 

But  although  tvphdid  fever  was  recognized  liv  so  inanv  regimental  nii'dical  dtlieers,  it  w.as 
iu)t  held  by  them  to  constitute  the  [U'evailiiiij;  armv  lever.  Surgeon  Zknas  [•'.  lli.iss,  I  .  S. 
v.,  ajipears  to  have  been  the  oulv  oliici-r  whose  recorded  experienec>  was  opposed  to  the 
ireneral  view.  While  on  dutv  with  the  .'ul  Mich,  at  ^'orktown,  in  1S()2.  he  had  a  I'ew  cases 
of  intermittent  and  remittent  fever  and  about  fortv  cases  of  tvphoid.  These  wert'  tr<'ated 
at  a  hospital  where  were  also  maiiv  feVer  cases  from  other  regiments,  and  nearly  all  were 
reirarded  bv  Dr.  Bi.[,ss  as  cases  of  tvphoid,  althoue;h  some  of  them  miiiht  easilv  have  l)een 
classed  as  low  remittents.  Death  was  caused  bv  hemorrhage  in  many  instances,  and  in  six 
cases  in  which  fi)i.s/-iiiiu'fcin  observations  were  made  the  glands  ol  I'eyer  were  ulcerated.-j- 

Eveii  at  this  t'arlv  date,  however,  cases  of  true  tv]iho-malana,l  I'ever  wii'e  obsi>rved 
and  reported  in  general  terms.  Wdieii  the  troops  had  been  exposed — using  the  language 
of  the  acce})ted  theory  of  a  distinct  pathogenesis  for  the  typhoid  and  remitttuit  fevers — to 
the  causes  of  both  these  morbid  conditions  the  resulting  epidemic  pri'seiited  such  a  com- 
plexity and  variability  of  sym|)toms  that  an  accurate  diagnosis  eould  not  be  expressed  by 
a  term  in  whieh  but  one  of  the  etiological  I'adoi-s  was  ri'pn'seiiled.  Surgeon  .I.WlKs  IxiNu, 
IsL  Jirigade  i'a.  iieserves,  in  a^  published  article, :{;  dated  T^ee.  2;>,  ISdl.oii  the  sanitary 
condition  of  the  troops  in  his  command,  savs  that  it,  was  impossible  toelassily  either  as  |iiire 
malarial  or  pure  tvphoid  all  the  cases  of  fever  that  (jcciirreil.  Jle  regarde<l  lluni  as  mixed 
affections,  combining  in  varying  degrees  the  eharacteristics  of  both  the  diseases  named;  In 
some  the  diagnostic  svmptoms  of  malarial  fever  predominated,  in  others  those  ol  the  typhoid 
afTection,  while  in  others  again  there  was  such  a  blending  of  symptoms  that  it  was  ditlicult 
to  sav  which  was  the  prominent  dise.-tse. 

Similar  views  had  already  been  expressed  by  some  regimental  medical  ollicei's  in  their 
sanitarv  reports. 

Si(i<i<(>n  .l.xMKS  ('i)l.l.lNS,  .'!(/  /'«/.  /;<.Mri(»,  Ctmii  Tciiiinllii,  Id.,  Ihr.  iil,  INU.— Dining'  llir  iii.MHli  of  OftolxT  the 
lit-altli  of  tin-  ie;jiiiu-iit  (■oiitiiiiuil  toil  riilil.v  f^ood.  Tlicii- w  :is,  however,  ii  Hiijilit  and  neiieial  iiiereaNi-  of  Ki<  kiiess,  and 
tlie  tyiieof  disease  .sei'iiied  to  indieatia  malarial  origin.  Early  in  Novenihei- diseases  of  an  iindoulited  malarial  nature 
lief^an  to  assnmi'  a  more  malignant  type  Ihan  had  heon  notic-ed  sinee  the  re^'iment  had  heen  organized.  The  previi- 
knl  diseases  were  remittent  and  tyidioid  fever,  ealarrh  and  aeut«-  bronchitis.  Ca.se.s  of  typhoid  fever  have  without 
doiiht  many  if  not  all  the  symptoms  of  th<-  same  disease  a.s  seen  in  New  Enfjland  and  renn.sylvania:  yet,  as  seen 
in  thiseanip,  malarial  inHuence  exercises  a  modifying  tendency  njmn  the  disease.  In  some  cases  the  line  between 
intermittent  and  typhoid  eoiUd  not  be  sharply  drawn.  In  all  cases  <|uinia  has  been  ijiven  with  ailvantaj^e;  it  has 
seemed  to  produce  peculiarly  happy  etlects  even  in  those  of  a  nnirked  typhoid  type. 

SiiniioiiW.  !I.Tii()HNE,12f/i  /'(/.  I!<;s(rr<n,Camp  rUrjioiiil,  Vii.,  \ur.l,  18til.— The  cairip  of  this  regiment  is  located 
on  the  sh>pe  of  a  hill  well  adapted  for  .surface  drainage;  u  streamlet  drains  the  bottom  of  all  snii.'rlluons  water  and 
carries  oti'  the  refuse  matter  of  the  camp.  The  soil  is  clay  mixed  with  ].ebbles  and  does  not  retain  moistnr.'  to  any 
fireat  extent.  The  prevailing  disea.ses  are  remittent  and  typhoid  fevers,  with  som<>  dysentery,  but  almost  no  diarrhoea. 
The  former  fever  scarcely  ever  occurs  as  pure  remittent,  being  rather  of  the  asthenic  type  and  not  so  amenable  to 
antiperiodics. 

Siiniani  Wm.  F.\ri.KNKK,  H3d  I'a..  Ilnlfs  Hill,  Va.,  lire.  :U,  IStU.— It  was  during  the  first  d.lys  of  Noveud.er  that 
typhoid  and  remittent  fevers  began  to  .show  them.selves,  and  indicated  a  most  important  change  in  the  type  and 
character  of  di.sease.  The  worst  cases  were  compliealed  with  extensive  di.sease  of  th.>  mucous  mc'Uil.iane.  which  called 
for  the  early  and  free  iiseof  .iiiinine  and  alcoludic  stimulants.  They  weredoubtlessof  a  malarial  origin  and  contracted 
perhajiH  when  in  camp  near  the  river  in  tlie  latter  i)art  of  Seiiteinber. 

tiuniiui,  1  ).\vu.  Ml.Nis,  Mh  Pa.,  (ami,  H'ih/;  W,  .V.  C  Inc.  31,  1861.— The  1st  of  ( ictober.  IStil,  found  us  encamped 
at  Camp  ilamiltou,  near  Fortress  Monroe,  and  laboring  under  the  usual  e^iideniic  of  diarrbo-a  and  dysentery  to  which 

»  Fur  ri'iiort  i.f  this  Biwini,  M-e  iii/rn,  iMge  Mi5. 

t  See  his  report,  \>.  S(l  iif  the  .\|)iKndi.\  to  the  first  |i4irt  of  this  volume. 

X  McJiaUau,lSi<r,jkal  K.j".;*r,  l'hil:idel|il]ia,  Pa.,  Vol.  VII,  p.  :iW. 


864 


i'OST-MUKTEM    KKl-()KUS    OF 


new  troops  are  liiilile.  These  (Uncases  were  at  this  time  almost  universal  but  mauageable,  uo  ease  torniiiiatiiig  fatally. 
After  their  subsidenee  the  liealtli  of  the  troops  was  excetleut  and  contiuueil  so  until  tlie  last  week  in  October,  when 
an  epidemic  of  catarrh  set  in,  havinj;  its  origin  in  the  ex]iosnre  incident  to  the  service  during  inclement  weather. 
This  disease,  although  very  general  in  its  manifestations  and  exceedingly  painful  in  its  symptoms,  yielded  readily  to 
treatment.  During  the  first  week  of  November  typhoid  fever  made  its  appearance,  following  immediately  in  the  foot- 
steps of  the  epidemic  catarrh,  many  cases  of  the  latter  appearing  to  glide  by  almost  imperceptible  gradations  into  a 
typhoid  condition  with  all  the  physical  signs  of  the  specific  fever.  On  the  11th  the  regiment  left  Caniji  Hamilton  and 
next  day  encamjicd  at  Fort  Clark,  near  Hatteras  Inlet.  Immediately  after  our  arrival  numerous  cases  of  tyi)hoid  fever, 
which  had  been  in  their  inci|;icnt  stage  on  leaving  Camp  Hamilton,  became  fully  developed,  and  being  modifie<l  by  the 
miasm  of  the  island  ;issumed  a  malignant  and  unmanageable  aspect  such  as  I  had  never  witnessed  in  any  cases  of  the 
disease  jirevionsly  falling  under  my  oliservation.  In  fact  in  these  cases  typhoid  fever,  epidemic  catarrh,  remittent 
and  intermittent  fevers  were  so  commingled  and  mutually  comjilicated  one  another  as  to  n'nder  the  diagnosis  obscure, 
the  treatment  unsatisfactory  and  the  prognosis  unfavorable.  The  most  striking  characteristic  of  this  ejiideniic  has 
been,  in  the  graver  cases,  the  almost  total  absence  of  tongue-symptoms.  In  some,  and  those  terminating  fatally  in  a 
few  days  after  the  access  of  the  disease,  there  was  no  abnormal  appearance  of  the  tongue  during  the  whole  progress 
of  the  attack:  while  those  cases  in  which  the  tongue  became  heavily  coated,  dry  and  red,  made  good  recoveries.  Hetweeu 
the  1st  and  20th  of  December  the  regiment  was  removed  from  Fort  Clark  to  this  station,  Cami)  Winfield,  aliout  four 
miles  north  of  Fort  Clark.  The  general  health  of  the  regiment  is  good  at  jiresent.  Either  from  the  jirevalence  of  cool 
weather  for  the  last  two  weeks  or  because  the  troops  are  becoming  acclimated,  diseases  having  a  malarious  origin 
Lave  almost  disappeared.     We  have  but  few  cases  of  severe  aspect  now  under  treatment. 

No  doubt  the  opinion  that  the  fevers  then  prevaiUug  in  the  army  were  adynamic  remit- 
tents was  based  primarily  on  etiological  and  clinical  considerations, — the  absence  of  a  special 
typhoid  infection  and  of  symptoms  indicative  of  a  typhoid  lesion,  the  presence  of  malarial 
influences,  the  sequence  of  the  adynamic  or  so-called  typhoid  symptoms  to  an  intermittent 
or  remittent  attack  and  in  many  instances  the  notable  efficacy  of  quinine.  But  since  death's 
were  unfortunately  of  frequent  occurrence  it  must  be  concluded  that  the  general  opinion  did 
not  continue  long  without  supj)ort  from  post-morteiii  observations. 

The  only  ofEcial  investigation  into  the  nature  of  the  fevers  which  prevailed  in  our 
camj)S  was  made  when  the  Seminary  hospital  was  receiving  and  treating  the  typhoid  cases 
that  have  been  presented  in  a  previous  section,  i.  e.,  at  a  time  when  typhoid  fever  was  unusu- 
ally prevalent  among  the  troops.  A  Board  specially  instituted  to  ascertain  whether  the 
existing  fever  was  to  be  considered  "an  intermittent  or  bilious  remittent  fever  in  its  incep- 
tion assuming  in  its  course  a  tvphoid  type,  or  a  typhoid  fever  primarily,"  proceeded  to  the 
field,  and  as  the  result  of  personal  observation  and  inquiry  concluded  that,  although  a  cer- 
tain number  of  cases  of  ordinary  typhoid  existed  in  the  army,  the  large  majority  of  the  cases 
were  bilious  remittent  fevers  which  "had  assumed  that  adynamic  type  whicli  is  present  in 
enteric  lever." 

The  I'eport  of  this  Board  is  as  follows:* 

♦Sonif  official  diK-intn-uts  iK'iirin;;  on  tlir  nature  (jf  tin-  fevers  that  itrevaile«l  in  tlie  lloo^lilj-  Di.strict  ilurlnj;  the  yeai-H  ls7)l-7;i  have  i.een  puhlisheil 
in  the  luitiini  M'-tt.  fUizrttt',  Vol.  IX,  1H74,  p.  74  H  seq.  Thewe  are  of  interest,  as  the  question  at  issue  was  similar  to  tluit  suhniltted  to  the  lioani  inen- 
tituuni  in  tije  text.  Wlioh;  families,  we  are  toltl,  were  iirostrated  at  the  isame  time  h.v  the  Hoo-^hly  fever ;  from  twelve  to  eiglite(;ii  or  more  niemhers  of 
joint  families  would  he  lairl  up  at  the  sanu^  time,  tliou;;li  not  all  sufferinj^  from  the  same  type  of  fever.  For  instance,  of  eighteen  eases  three  would 
present  the  symptoms  of  tyjihoid,  four  or  five  of  remittent,  tivc?  or  six  of  intermittent  and  the  renuiiuder  of  common  continued  fever.  J.\mes  A.  fJiiKENF., 
t'ivil  Medical  <  ifficer,  Seraiupore,  having  seen  anil  treatid  at  h-ast  2,lHlli  cases  duriri;,'  the  epidemic  in  the  tipwu  auci  suhurhs  under  his  care,  arriveij  at  the 
conclusion  that  ''the  fever  we  have  to  ileal  with  is  tyjdioid,  complicated,  no  douht,  with  malaria,  hut  the  first  outhurst  in  any  place  is  typhidd,  and  this 
is  the  foruudahle  fever  which  kills  or  leaves  its  victims  so  prostrated  that  they  suiter  thereafter  for  months  and  years  from  fcdapses  of  malarious  fever 
ending  in  enlargement  of  the  spleen,  liver,  etc."  Unfortunately  in  Dr.  ("Jkkf.xk's  i)ractice  p'i»l-in"i-ffni  examination  was  never  allowed  owinj;  to  caste 
prejudice.     His  reports  on  these  fevers  were  sent  to  .SurKeon-3Iajor  Norman  Chkvkks,  with  a  request  for  his  oidiiitui  on  the  suhji'ct.     In  reply  this  tdiicer 

refers  to  the  want  of  precision  involved  in  the  use  of  the  word  tyjilioid.     "Ilavirifr  [raid  consideraldi'  attention  to  the  recent  discu.ssiiu»  n| typhoid 

fever  in  India,  it  has  api>»'are<l  clear  that  much  confusion  and  vain  dispute  would  he  avoiiletl  if  we  strictly  confined  ourstrlves  to  the  designations  '{taluilal 
fever*  and  'enteric  fever,'  never  a^aiu  nsinjr  the  word  'typhoid.'  Kvery  practitioner  is  aware  that,  in  Ben;ial,  cases  of  chidera  and  rennttent  fevirr  fre- 
qtiently  take  on  a  condition  so  'typhoid'  or  typhus-like  in  its  character  that  no  physician,  se4'in^  a  ca.se  t'ur  tin-  first  time,  could  inuuediately  detf-runue, 
hy  the  symptoms  alone,  whether  it  was  one  of  true  typhus  or  (when,  as  frequently  luip]«'ns  in  the  cou;restive,  paludal,  remittent  of  the  cold  si-ason,  there 
is  bowel  comidicatiiuii  one  of  the  true  enterii'  fever  as  described  by  ,rK,NNRR."  Dr.  Cukvkks  then  tliscusses  tier  ty[»ical  casi-s  a'w'vn  in  the  rejiorts,  showing; 
that  the  "patients  may  have  been  the  subjects  of  'typhoid' — that  is,  true  enteric  fever,  but  Dr.  CiltF.KNE  has  init  at  all  pnjved  that  they  were."  He 
acknowledges  that  enteric  fever  has  taken  a  defined  posititm  among  the  disea-ses  of  IJengal,  but  claims  that  this  nutlady  has  never  during  the  last  eleven 
years  become  at  all  extremely  prevalent  in  Calcutta,  although  a  tyiihus-like  fever  (often  attended  with  diarrhreai,  demoustnibly  iif  paludal  tu'igin  and 
amenable  to  the  antidotal  action  of  quinine  in  nearly  all  but  the  moribund  cases,  has  been  almost  daily  aueuig  the  chii-f  subjects  of  his  clinical  practice. 
*'Dr.  Greenk  has  shown  that  cases  somewhat  resendiling  enteric  fever  occur  in  these  tlistricts  [Burdv\ati,  Iloughly  and  Seranqiore],  hut  sucli  castas  also 
occur  in  Calcutta,  where  these  causative  elements  are  nearly  equally  rife.     Still,  when  thoroughly  sifteii,  very  few  of  the  multitude  of  grave  Calcutta  fever 


SrEciAi.  Okders.    ) 
No.  -.iXi.  S 


THE    rOMTNUED    KEVEKS.  3G5 

IIKAIXJIAHTKHS   (II      IMK    AKMV,    AlMlTAM    (iKNKUAI.'S   OlTICE, 

Washhiijloii,  ;>(('.  Glh,  18(il. 


G.  A  ]')i)aiil  111  consist  of  Suif^foii  A.  \.  .MiI-aukn.  T.  S.  A.,  llriiiudi-  Siiij;roii  (i.  II.  I.v.man,  l'.  S.  Ndlmitrfr 
•service  anil  Ass't  Siii;;.  M.  .1.  Ascii,  l'.  S.  .\niiy.  is  liiTcliy  inslinuid  I'oi  tlie  t'ollowin;;  olijiil :  I'o  visit  as  many 
of  the  camjis  in  the  vieinity  of  WasUiiigton  as  tln'y  may  consider  necessary  to  olilain  snllicii'nl  ilala  to  make  a 
report  to  the  Snr^;con  (ieneral  on  tlie  character  of  the  disease  termed  hy  llie  Medical  Otlicers  of  i  hi-  liriy;ades  and 
KejiimentN  ''Tyidioid  Fever,"  and  as  far  as  piacticalile  tin'  cansi's  of  its  adynamii-  ty|)e  and  wliitluM-  it  is  to  lie 
considered  an  intermittent  or  hilioits  remiltcnl  feviT  in  its  iniTplion.  assnminL;  in  its  conrse  llic  lyphoidal  type  or 
a  tyi>hoid  fever  ])rimarlly. 

The  l{oar<l  will  he  refjiilated  in  its  sessions  and  niovcmenls  liy  its  I'resident  so  aw  least  to  interfere  with  llie 
other  o])erations  of  the  service.     The  jnnior  meniher  will  act  as  ii'corder. 

,^  .V  *  .»  ,¥  •  -  V  ■  *  Jf  #  #  #  * 

By  CD.M.MAsn  ov  Ma.i.  (;kn"i,  M(  (1.1.1.1. ..n. 

(Signed)     1..  THOMAS, 

Ailjiitdtit  <iitural. 

In  ohedience  to  the  ahove  order  the  Hoard  convened  on  Monday  tlie  l(;th  day  of  Decemher,  ISlil,  at  the  (|narter8 
of  lirigaile  Snrgeon  Lyman  and  proceeded  to  examine  the  hiigade  and  regimental  hospitals  of  the  division  coiii- 
iinmded  hy  Hrigadier  (ieneral  Fit/.lohn  I'orter  with  a  view  to  tln^  ohsi-rvation  cd' snidi  <ases  as  might  exist,  and 
to  the  comparison  of  such  symptoms  and  tendencies  of  the  di.sease  as  at  present  prevailing  with  a  similar  alfcction 
that  had  already  occurred  and  had  heeii  reported  as  typhi>i<l  fever. 

The  regimental  hosidtals  of  tlui  171  h  and  2."itli  New  York,  the  S:id  Pennsylvania,  the  \M\  MassachiiHctts  and 
the  2(1  Maine  regiments  were  oliserved,  together  with  the  hrigadi^  hospital  coniieeted  with  (ieneral  MorelTs  lirigade: 
lint  few  cases  were  discovered  which  con  Id  he  designated  coirectly  as  of  a  tyjdioitl  eliariicter.  ( tf  the  cases  so  marked 
the  majority  had  lieoii  received  into  hospital  as  sntiering  I'ldin  liilioiis  r(tiiiltteiit  finer  which  in  its  progress  a.ssiiined 
the  tyiihoid  type  .so  well  known  to  tho.si^  whose  experience  in  m:ilarial  fev(MS  has  lieen  gleaned  in  the  South.  No 
ease  of  enteric  fever  was  oliserved.  'i'he  disease  was  evidently  of  malarial  origin  and  was  so  considered  liy  the 
medical  olheer.s.  As  a  general  rule  in  this  division,  (|ninine  given  in  large  doses  in  the  remission,  with  mercurials  as 
ie(inired,  had  the  ell'ect  of  checking  the  levers.  The  typhoid  state  only  aiipeared  as  .a  result  of  a  continuous  neglect 
of  hygienic  jirecautions  when  in  health  or  in  those  jiensons  who  had  lieeii  cxposiid  to  unusually  s«^vere  and  prolonged 
duty.  In  the  cases  assuming  the  typhoid  type  which  the  Hoard  examined,  although  .syniptouis  of  prostration  and 
sinking  were  present,  together  with  the  dry  glazed  tongue,  collection  of  «orde»  on  tlie  teeth  and  gums  and  milisultns 
tendinum  which  characterize  the  state,  still  the  ahsence  of  any  enteric  symptoms  and  of  the  laches  rongcs,  which  are 
the  almost  invariahly  constant  symptoms  in  true  typluiid  fever,  as  well  as  of  any  jinlmonary  complication,  was  sulli- 
cieut  to  warrant  the  lioard  in  concluding  that  the  cases  hefore  them  wore  not  of  the  enteric  fever  so  c(imui(in  in  the 
Northern  States  and  generally  known  as  typhoid  fever,  while  the  jirevioiis  location  of  the  regiments  in  regions 
notoriously  malarious  Justified  them  in  attrihnting  malarial  origin  in  the  fehrile  cases  hroughl  to  their  notice.  The 
can.ps  and  hospitals  of  this  division  with  one  exception  were  remarkahly  neat  and  clean  and  iire  deserving  of  the 
highest  encomium.  It  mnst  he  noticed  as  a  medical  curiosity,  which  it  would  lie  scarcely  safe  to  take  as  a  precedent 
for  any  similar  rule  of  action,  that  tln^  cam))  in  which  police  regulations  had  not  lieen  enforced  and  which,  in  coii- 
8e(|neuce,  was  in  an  eminently  filthy  condition,  was  in  the  most  satistiK^tory  sanitary  state  and,  at  the  period  of  the 
visit  of  the  Hoard,  had  not  a  seriously  ill  patient  in  its  hos])ital.  It  is  hut  just  to  the  surgtMiu  of  this  regiment  to 
state  that  he  had  already  instituted  nu\asiires  which  in  a  very  hrief  period  would  eaus<!  his  camp  to  compare  favor- 
alily  with  any  other  in  the  division.  There  was  ohserved  in  one  of  the  regimental  hospitals  a  nnndierof  cases  of 
superlicial  gangrene  of  the  toes  resulting  in  some  cases  from  fever,  although  present  in  others  where  no  such  primary 
cause  existed  lint  where  the  pati('nt  was  in  an  adynamic  condition. 

On  the  18th  of  Decemher  the  Hoard  again  convened  and  visited  the  divisions  commanded  hy  (ien!ls  McCall  and 
Smith.  Here  were  found  some  cases  of  tyjihoid  fever  with  the  enteric  and  ]iulnu)nary  symptoms  which  distinguish 
it  in  the  North,  but  hy  far  the  majority  of  the  cases  were  of  bilious  remittent  fever  resulting  from  the  encampment 

eases  turn  out  to  lie  instances  of  true  enteric  fever.  The  true  naturo  of  many  of  tlie  eases  which  iH-cur  in  the  Semnipore  di.strict  nrny  In-  iiiferreti  fnim  the 
fact  nienlitinetl  by  T>r.  Ghki'.nf.  that,  when  patients  strujrjrle  thron^li  the  first  vlitleiice  of  tln^  nialaily.  they  ultimately  fall  victims  ti>  ileliility,  eiilariieuietit 
of  tlie  siiieeii  and  liver,  aiia-niia  ami  ilropsy.  Tliese  are  iiut  tlie  proper  ^eipielie  i»f  eiiterie  or  of  reiapsinjf  fever,  ami  they  dearly  iwiiiit  to  a  ]ja)iiilal  cause. 
Hence,  I  submit,  our  tirst  course  is  t(»  ascertain,  by  at  least  some  half  ilo/eii  carefully  perfttrmetl  jii,nt-tintrttnn  examinations  in  well-*-hosen  cases,  whether 
tlie  (iisi'ase  is,  ill  reality,  true  enteric  fever  or  a  typhus-like  fever  of  {laliiilal  orit^in,  coniplicateil  in  some  cases  with  diarrloea.  which  symptom,  I  net'd 
scarcely  say,  is  very  common  in  the  true  marsh  fevers  of  India  whenever,  as  in  very  cidd  weatlier,  the  state  of  the  skin  does  not  allow  of  free  critical 
sweat  in  j^."  Here  Dr.  Cuf.vkks  attaches  the  followinj;  note  :  "Since  I  w  rote  this  a  very  characteristic  casi-  of  this  type  of  uialarioiis  fever  has  terminated 
fatiilly  in  my  ward.  \  khaiKsiniah.  of  Toltolah.  was  attended  on  the  4th  instant,  complaitiiiii:  that  he  had  suffered  from  intermittent  fever  for  alumt  !.'• 
days.  Tongue  moist  anil  clean,  temperature  1(1.5°,  splenic  fulness,  a  little  coui;h  and  hroncliitic  rales,  (hi  the  next  day  there  was  jaundice  with  consti- 
liation.  On  the  day  after  that  ]deuropneunionia  of  the  rinht  Iuuk  set  in.  Some  niijiht  consider  this  a  primary  featuii"  in  the  case,  I  recoKiiizeil  it  as  a 
wx-oiidary  lesion  common  in  the  severe  malarious  fever  of  this  cold  weather.  The  daily  eveiiiti^  teiniM'rature  was  l(l.'» ;  l(i;l ;  KKl ;  1(12  :  '.(tl ;  Idl  ;  1(10,  s<irdes 
on  tonjjue  and  lips;  OS  ni.. '.I'.l  e ;  lIU  ;  1H2;  l(l2;  KH.l ;  1(11,  rather  consti|iated ;  '.111  m.,  KNI.S  e.;  Idl  ni..llMle..  toniine,  ligis  and  tisdh  dr)-,  lo.weycdhiw  stools: 
1112  m.  and  e.,  tongue  moist  and  clean,  three  stools  of  the  consistence  and  api»earanee  of  thick  dai,  no  gnrKlinf;  in  the  iliac  f«»ssa  ;  lli2  ;  thris^  stiails  ;  1)8  ni., 
KlO  e.;  97.8  m.,  tongue  moist  and  clean,  three  diarrhoeal  stools,  101  e.,  frequent  diarxineal  stools,  incoherence,  death,  lien*  the  stools  had  very  much  the 
apiiearance  of  tliose  in  enteric  fever,  hut  they  did  not  contain  blood  or  mucus.  The  character  of  the  mislerate  head  symptoms,  the  range  of  the  tcni- 
peniture  and  the  state  of  the  tongue,  except  for  a  time,  did  not  indicate  enteric  fever;  and  yet  I  could  not  feid  <iuite  sjitistied  on  this  piint  until  I  had 
aw-ertained  that  the  small  intestine  was  isTfectly  healthy." 


3G6  i'ost-M(»i;tkm    iikcokps  ok 

of  tlic  ifKiiiifiits  (liiiiiif;  tlic  uiitmiiii  iiKiiillis  in  a  iiialiirioiis  district.  In  (icii'l  Smith's  division  ncaily  all  diseases 
assumed  a  t.vi>lioid  l,V|i<s,  wliicli  was  attiilnited  by  thi'  sMij;euns  to  oelilesis  or  eio\vil-]ioisoniiiij  iiroilnecd  liy  the  ovei-- 
crowdinj;  of  men  in  llii'ir  ([naiteis,  and  also  to  the  latiL,nie  indneed  I)y  excessiv(>  (hillinjj;  and  t  he  nnneeessaiy  lenj;lli 
of  t  inn'  \vhi<'h  the  iinMi  aii'  oeeasionally  iei|niicd  lo  pass  on  dnty ,  as  well  as  the  dt>|ii'essinK  in  thin 'nee  of  eamji  lite  on 
persons  not  lial)itn;iled  to  it.  In  (ien'l  llaiH'oek's  lirij;ade  a  niimliei  of  eases  of  tyiihoid  fever  had  oeeiirii'd  whiidt 
lirifjade  Siirjjeon  II.\vi:n  att  ri hilled  to  causes  helonninj;  to  the  men  themscdves  and  not  to  the  condition  of  the  cam ]i. 
This  hri}j;ade  is  eom](osed  of  N'erinoiit  troo|is.  who  are  the  most  thoroii<;hly  provincial  of  any  in  the  service,  and  who, 
aeenstomed  to  their  native  mountains,  feel  aontidy  the  deiiressinj;  inlliienci!  of  nostals^ia  and  nnilaria  when  absent 
from  thiMii  anil  on  this  aeeinint.  probaldy,  are  more  liabhi  to  disease  of  an  ailynamic  type  than  those  from  other  local- 
ities. The  same  fact  is  noticed  ainon<;  those  Pennsylvania  troojis  eomiiif;  IVom  the  moiintainons  re;j;ion  of  the  Alle- 
gh.'inies.  In  the  division  commanded  hy  (ien'l  MeCall  a  nnmlier  <d'  ea.ses  of  typhoid  fever  were  rejiorted,  but,  as  in 
Gen'l  .Smith's  division,  the  majority  of  the  jiatients  were  labor! nj;  under  bilious  riMiiittent  fever;  some  eases  of  fjastro- 
ent.eric  fever  were  found.  As  want  of  time  |)reelndcd  the  Hoard  from  exainininir  thoroiijihly  all  the  hospitals  ol'this 
division,  the  ftillowjni;  interroijations  were  propounded  to  the  various  medical  oltlccrs.  the  answers  to  which  will  be 
founil  appended,  viz: 

1.  What  nninbi'r  of  cases  of  billons  remittent  and  of  ty|dioiil  fever  have  occurred  in  yonr  renimeut  ? 

2.  Is  the  so-called  typhoid  fever  the  ty)dioid  fever  of  the  Xorth  or  is  it  of  malarial  oriii;in  ? 
•i.  What  do  you  eonsi<ler  to  be  its  cause? 

4.  Describe  the  symjitoms  of  the  fever  oecurrinj;  under  your  care? 

5.  The  treatment  adopteil  ? 

6.  The  locality  of  the  re.fjiment  before  the  ap])earance  of  the  disease? 

7.  The  percentage  of  the  disease? 

S.   Have  any  eases  of  gangnMie  of  the  toes  been  observed  as  tlie  result  of  Xever  or  otherwise? 

From  the  information  alforded  by  the  answers  to  these  questions  the  Hoard  found  nothing  to  Justify  an  oi)iiiion 
that  typhoid  fever  existed  as  au  epideiuii'  or  otherwise  than  in  a  very  small  ])ro|>ortion  in  this  ]>art  of  th<^  army.  The 
majority  of  eases  of  fever  were  clearly  of  nialarial  origin  and  in  some  eases  from  the  causes  above  enumerated  they 
assumed  a  typhoid  type.  The  gangrene  of  the  toes  w  liicli  had  been  observed  in  other  divisions  was  found  liere  also 
from  the  same  supposed  cause  and  in  but  small  ratio.  In  Ileintzleman's  division  the  brigades  of  Sedgwick  and 
Jamison  were  examined:  In  the  former  no  ca.se  of  enteric  fever  was  found  and  but  few  of  bilious  remittent:  in 
the  latter  there  were  a  few  cases  i)resenting  the  appearance  of  typhoid  fever  in  which  were  the  taclies  rouges  and 
intestinal  sym]itonis.  pathognomonic  of  the  disease,  aecompaiiied  w  ith  pulmonary  and  cerebral  disturbances,  but  the 
cases  wiM'e  convalescing  and  no  new  ones  were  a]ipearing. 

From  the  data  furnished  by  the  investigations  stated  above  the  Hoard  fi'td  Justitied  in  eoiKduding: 

First,  'i'liat  the  large  majority  of  febrile  diseases  which  have  been  reported  as  "typhoid  fever"  are  not  cases 
of  that  fever  w  hicli  is  characteri/ed  by  the  eruption  of  rose-colored  sjtots  about  the  seventh  day  and  has  for  its  ])ecu- 
liar  lesion  intlaniiiiatiou  and  ulceration  of  the  glands  of  Peyer  and  is  known  in  the  Northern  States  as  typhoid  or 
gastro-enteric  fi'ver,  but  they  are  bilious  remittent  fever.s,  which, not  having  been  controlled  in  their  primary  stage 
have  assumed  that  ailynamic  tyi)e  whiidi  is  |)re.sent  in  enteric  fever,  on  which  account  they  have  been  errouooiisly 
termed  "  tyidioid."  whereas  in  reality  those  lesions  which  invariably  aceompany  true  "typhoid  fever''  have  been 
wanting.  There  is  undoubtedly  present  in  some  ]);itients  low  delirium,  sulisnltiis  tendiiiuni,  sor<les  on  the  teeth  and 
gums  with  occasionally  a  black,  dry  and  glazed  tmigue,  but  the  tender  and  tympanitic  abdomen,  the  taelies  rouges 
and  the  diarrlnea,  which  are  almost  constant  symptoms  iu  enteric,fe\  fr,  are  absent.  Cases  of  tyi)hoid  fever  certainly 
exist  in  the  army,  but  it  is  so  far  from  being  epidemic  tliat  the  ratio  of  its  occurrence  is  less  than  it  wonld  be  in  civil 
life  amongst  the  sanu'  number  of  individuals. 

Secondly.  The  cause  of  the  bilious  roinittent  fever  that  exists  in  the  Army  of  the  Potomac  is  undoubtedly  the 
malaria  generated  in  the  vicinity  of  the  river  to  which  it  has  been  exposed  during  the  late  summer  and  autumn 
months,  but  the  causes  of  the  typhoid  condition  that  it  takes  on  are  different  and  probably  within  our  reach  to  be 
guarded  against.  The  hygienic  measures  instituted  by  the  Medical  Director  of  the  Army  of  the  Potomac  are  proving 
effectual  in  lessening  the  number  of  cases  of  malarial  fever,  and  it  is  possible  t,liat  measures  may  be  ailopted  which 
will  lessen  the  tendency  of  di.seases  to  take  on  the  low  forms  that  they  have  lately  assumed.  This  tendeni-y  may 
originate  from  blood-])oisoniug  induced  by  the  crowding  together  of  men  in  close  and  illy  ventilated  quarters,  from 
fatigue  occasioned  by  excessive  drilling,  from  over-exertion  resulting  from  a  too  protracted  tonr  of  duty,  from  nos- 
talgia and  from  a  want  of  attention  to  personal  cleanliness.  If  it  occur  from  these  causes,  and  in  the  opinion  of  the 
Hoard  it  does,  the  prevention  is  in  the  hands  of  the  proper  authorities.  Sutiieient  space  should  be  given  for  quarters; 
a  proper  discretion  exercised  in  the  allotment  of  time  for  drill :  consideration  should  be  shown  for  those  engaged  in 
labori(uis  and  fatiguing  duty;  ele:inliness  should  be  rigidly  enforced  and  nostalgia  avoided  by  diversion  of  mind 
Inoiight  alxMit  by  projjcr  gymnastic  ami  other  sports,  ami  it  may  be  that  the  depressing  influences  now  operating 
will  be  obviated  and  as  a  necessary  result  the  adynamic  tyjie  of  disease  will  be  changed. 

The  Hoard  takes  this  occasion  to  remark  that  the  sanitary  condition  of  the  army  generally  is  eminently  satis- 
factory as  far  as  it  has  come  under  observation,  the  number  of  cases  of  disease  lieing  proportionally  few  and  of  these 
but  a  small  ratio  are  of  a  serious  character. 

Papers  appended  lo  the  Iteport  of  the  Board. 

Brigade  Siirgeoji  Jame.s  King,  U.  S.  T'oh. — 1st.  The  last  three  monthly  reports  of  the  surgeons  show  in  the 
four  regiments  of  the  brigade  .5.39  cases  of  remittent  fever  and  37  of  typhoid  fever,  the  mean  strength  of  the  brigade 
being  about  3.2f)0.  otiiccns  and  men.     3fl.  The  surgeons  represent  two  forms  of  fever  as  prevailing — one,  bilious 


THE    CONTLNTKI)    FFVF.RS. 


367 


remittent,  a  fever  of  iiialariiil  ori^nii.  the  other  tyiihoid.  ■■  thr  t,v|ilioiil  <,f  tin'  \orth."  In  my  opinion  it  is  iinim.ssil.lo 
to  ihiiw  smli  a  lino  of  (list  iiiet  ion  respeitiii-;  tliese  fevi-rs  as  to  divide  tlie  eases  into  two  \\  ell  ilrlini'd  elasses,  one 
exhibitiiii;  in  its  j;roiip  of  s.viii)itoni.s  tin'  ordinarv  <liaj;noslie  marks  of  typhoid  and  the  oilnr  of  ii'mitlent  fever. 
I>n  the  eontrary,  there  is  a  eertain  tnul  disi  iiihh  or  fieneral  form  lieloiifjinK  to  all  tiy  «  liicli  we  rero^'ni/e  one  atfeelion, 
thotigh  varyin};  in  its  features  in  dilferrnt  eas.'s.jnsi  as  we  know  the  idiysiof;nomy  ol'  man  in  all  its  iliversilied 
modes  of  expression.  I  have  ohsi^rved  tin'  following'  characters  or  so-ealli-il  diaKHoslic  si;;ns  of  the  twii  diseases 
a])parently  exjiiessed  and  varionsly  coexisting  in  the  sanu'  suli.ject.  It  would  he  easy  to  arran^T''  tin'  facts  oliser\e<l 
in  a  talinlar  .statement  showing;  in  one  column  the  distini;nisliini;  marks  of  lhi>  ■'  malarial "  ami  in  the  other  of  the 
••  ty])hoid''  disease,  bnt  the  facts  an'  so  conMnin;;led  and  united  in  many  cases  thai  if  re<|nired  to  ilassify  them  w  illi 
one  or  the  other  disease  it  would  In'  dillicnlt  to  s.iy  to  w  liicli  tluy  hcloni;.  I'Im'  following;  facts,  for  example,  I  have 
observed  as  variously  cocxistini;  in  many  ea.ses: 


KrUh'iicin  of  riiiiitlnit  J'l  lur  or  disdixr  nf  ■■  mdldiinl  ny'niiii." 

1st.  The  disense  niaile  its  ap)>i'aiam'e  in  autumn  and  on 
the  I'otomae  (malarial  rc;;i(Mi). 

2d.  Many  (d'  the  suhji'ets  have  the  disease  dcvclopi'd 
suddenly. 

;!d.   Ivari'  cases  hcj;in  w  itli  cpislaxis. 

■1th.  .No  special  tendency  lodiarrhiea  manifcstid,  al  least 
I  .have  m)t  oliscrvi'd  this. 

"itli.   We  v<'ry  selihun  see  mucli  lympaniles,  id'li'U  none. 

r>th.  The  fever  has  distinct  ri'inissiiuis  anil  is  found  in 
company  with  true  intermitti'lits. 

7lh.  In  the  first  staj;es  the  lon;;ue  is  fnncil  while  or 
yellow,  enlai'ficd  anil  indenle.l  at   the  cmI^cs. 

Xtli.  NnnnMons  cases  of  ot  her  m.alarial  disi'asc  ociun  iuL;. 
as  neuralj;ia  ami  .iauiidice,  fcvc-i' pal  ienis  showini;  .janii 
(lieeil  niiiu'. 

!Uh.  Certain  marked  i-lfccls  of  (|ninine  in  reliev in;;  licad- 
ache,  stupor  and  dcliiiuin  in  Ihecaily  sla^'es.  in  ciillin;; 
some  cases  slicui  and  <n-casjon:illy  in  aH'ordilie;  sp<'ed\  hen- 
elit  when  the  cases  ate  cliaraclei  ized  hy  dry  lcin;i;ne.  riise 
s]tots  and  other  si;;ns  of  I  hi-  lyphoiil  eondil  ion 

loth.  Certain  /msV-iioo/i /»  appearances,  as  hiss  of  color 
in  the  liver  and  distention  of  the  ^jalUldadder:  the  livi-r 
was  very  pale  in  two  ea.ses  examined. 


l^riiliniin  of  lijjihitiil,  lli<"liii>liiiiiII'iriTol'  llii'  S'lnlh." 

1st.  It  eontinnes  to  prevail  after  the  heavy  frosts  and 
in  winter. 

I'd.  .Most  cases  have  a  prolracled  con  v  alesecnee  thiui<;h 
tlii'y  havi'iiid  liecn  allacked  with  [lai  I  icnlar  violence. 

'M.  Many  show  rose  ((dorcd  spots. 

Ilh.  I'cw  cases,  none  thai  I  have  known,  have  shown 
lunch  nausea  and  hilioiis  viuniliu;;. 

Tilh.  Many  (d' the  eases  havi'  snlfusion  id' the  eyes,  dusky 
coiinlciiani'c  anil  mental  hclielude. 

tith.  Tim  ilnraliou  of  the  dise.isi'  when  fully  marked 
mostly  runs  on  to  the  Ihiid  or  fourth  week. 

Till.  In  till'  last  slatJi's  the  tony;iie  is  dry  and  f;la/ed, 
iillcii  cracked  and  covered  wilh  sordes. 

.s^lli.  file  oeeiiireiiec  cd'  1 1  iiulilesome  suppiil.al  iims,  as 
ahseiss  aliiMil  I  Ik'  parol  id  ;;lanils,  tollowin^'  I  In'  fevi't  in  a 
niiiiilter  of  cases. 

lull.  Cellaiii  ;;ood  cllecls  of  lurpeuline  in  cases  with 
^la/eil  ton;;ue  and  lympanil  ic  ahdiuiien.  the  ilcildcd  ad- 
van  I  a^e  of  niilril  ions  si  i  inula  Ills,  as  lirandy -punch,  in  all 
cases,  aii<l  I  he  a|i)iareul  necessity  id'  suppc:it  iii'j;  pica  us  to 
relieve  I  he  ally  iiainic  si  a  lea  lid  resist  the  teiicleiic,  lo  dcalll 
by  asl  heiiia. 

loth.  Ceilain  jinKl-iiiiirli  m  appearanccH,  as  I  liiekenin;;, 
iiillamiiiation  and  iilceraliou  of  I'eycr's  ;jlaiids  in  three 
cases  examined,  and  ailed  ion  of  meseiileric  nl.'inds.  I'leer- 
iition  of  the  elli))lical  plates  was  noticed  where  there  was 
no  i;aseons  distent  ion  of  the  bowids. 

lull.  Previous  erovvdin;;  of  men  in  badly  veiilil.iled 
tents  In  filthy  c.inips,  for  .is  yet  it  has  been  impossible  to 
enforce  )iro|ier  police  regulations. 

I  cannot  pursue  this  analysis  further  in  tin'  ]ireseiit  re])ort,  luil  I  will  ask.  are  we  .just died  in  rejiarilin;;  all  the 
facts  above  noted  as  entitled  to  weight,  as  I  think  we  aie,  and  in  determiniuK  fioiu  the  com  Id  iia  I  ion  in  the  same  casi-s 
of  many  of  thi-se  characterisl  ics  of  t  wo  diseases  that  we  have  a  mixed  alfectioii  f  Or.  if  not,  shall  we  take  the  "  rose- 
colored  erui>tion  '"  and  atleel  ion  of  IVyer's  fjlaiids  as  palho^uoinonic  of  the  disease  and  s.iy  it  is  typhoid  fever,  or  take 
the  intluence  of  (luinine  in  the  treatiniuit  as  specilic  for  the  malarial  )ioison  or  some  such  characteristic  and-say  the 
fever  is  a  "bilious  remittent  J"  In  my  .jnd;;iuent  it  is  only  by  carefully  eollectin;;  the  facts  noted  by  resiinental  and 
hospital  snrsjeons  who  have  made  dili<;ent  idiservation  of  their  cases  that  we  can  arrive  at  .just  eonelusions  on  this 
subject,  the  i n vest iffat ion  of  which,  by  a  eonipetent  olHcer  detailed  for  the  purpose,  would  not  he  w  itliout  its  uses 
to  the  public  .service.  3<l.  As  to  treatment,  I  haveobserved  most  salislaetory  results  from  the  use  of  i|iiinine,  begin- 
ning with  a  dose  of  sixteen  or  twenty  ^I'^ii'is  in  the  moiiiin^  and  the  remedy  conliiiued  in  smaller  doses  for  several 
successive  mornings  in  the  early  stages  of  the  disease,  the  occasional  use  of  bine  mass,  febrifuge  mixtures  w  hen  indi- 
cated, the  earl.v  resort  to  nutritious  stimulants  and  tluid  iioiii  isliineiil  with  nitrale  of  silver,  sugar  of  lead  and  spirit 
of  turpentine  administered  for  certain  enteric  syiu]>touis  when  particularly  indicated.  The  iiillaiiimatory  and  con- 
gestive com])licat  ions  are  treated  successfully  in  the  usual  way  by  sinapisms  and  cniiping.  4(1|  and  ot  li.  As  to  the 
symptoms  and  cause  of  the  fever,  I  have  no  other  report  than  that  given  above  to  indicate  its  character.  Olll.  As 
to  the  localities  of  regiineiits,  I  have  to  refer  to  the  reports  of  the  regimental  surgeons.  7tll.  As  to  percentage  of  sick, 
I  suppose  that  is  sutHcieutl.v  answered  with  the  1st  point.  Stll.  As  to  gangrene  of  the  toes:  This  I  observed  in  one 
case;  in  another  great  ])ain  was  coni]d,iined  of,  but  I  oliserved  no  discoloration  or  sloughing  of  the  skin.  In  both 
the  fever  was  protracted,  but  as  I  had  not  the  opportunity  of  watching  the  progress  of  the  disease  in  the  first  case 
I  have  no  further  remarks  on  the  subject. 

Surijeon  H.  K.  Xkkf,  StA  Pa. — 1st.  This  regiment  has  at  the  present  tinu'  ten  or  twelve  cases  of  bilious  remit- 
tent and  typhoid  fever  under  treatment.     2d.  The  so-called  tyi>hoid  fever  here  is  not  the  same  in  all  particulars 


lltli.  Kxposure  to  uiglit-.air  before  the  attack  in  locali- 
ties where  intermil  tents  arise,  as  on  night  niarehes,  picket 
duty,  etc. 


36S  ?0.<T-M()RTKNr    KKCORDS    OF 

as  tliiit  Dl'tlir  North.  1  iMiusider  it  oiMiili:itic-:illy  of  nialaiiul  (irif;in,  ;J<1.  'ririUincnl  !i:is  ln-i-n  in  all  <"isfs  aiili- 
periiidic,  tunic  and  stiiinilant.  Lais"'  di)scs  of  (luiiiinc  arc.  f^ivi'ii  at  tlio  outset  and  I'oUowod  liy  di-<: leased  doses 
tlii<iiif;liout  the  coiiise  of  the  attack,  lihie  mass  is  also  fi-e(|uently  ^iveli  in  conibination  with  the  ijiuniiie  when 
indicated.  ( trdinaiily  after  tlio  fifst  dose,  whieli  is  usually  from  lift<'en  to  twenty  grains,  tlw  Ji'ifi^'tit  fjets  the  ([uinine 
in  divided  dosi's  so  as  to  ieceiv<^  from  ten  to  twelvt^  ijraiiis  in  L'l  honrs.  In  addition  to  this  he  i^ets  tonics  snch  as  the 
tincture  of  iion  and.  when  iMdi(ated,  iliiirel  ies,  fclirifuj;es.  etc.  The  nsnal  ]ilan  of  treatment  is  that  puisned  in  the 
Noitli  in  like  cases  except  the  ([ninine  and  stimiilatits  dminj;  the  caily  stai;es.  4th.  The  symiitoms  aie  similar  to 
those  of  ordiiiaiy  fevers.  The  toii}j;iie.  however,  is  llahhy,  watery  an<l  ]iale.  reniaininf;  so,  exeejit  in  the  most  malig- 
nant cases,  tliroiijiliont  the  whole  c<n^iise  of  the  disease:  when  the  fever  i.s  of  the  mali;;naiit  ty]ii5  the  toii};iie  is  dark, 
dry  and  in  some  ca,ses  tissnred.  The  pulse  is  fiencrally  feehle  tVom  the  start.  In  many  cases  for  several  ilays  after  its 
ous(d  thi^  disease  assumes  a  decided  remittent  and  in  some  cases  iut<'rmittent  form:  hut  in  nu)st  instaiu'(>s  it  after- 
wards heeomes  continued.  *>tll.  The  sniil>osed  cjiuse  is  malaria.  Excitinu;  causes:  Kxposure,  irreijularities  in  diet, 
di  ink,  etc..  ami  an  imlitlercuce  ti)  the  estalilished  rules  of  hyjjiene  };<'ni'i'ally.  (itll.  Last  locality:  A  northern  slojie 
near  the  I'otomac  on  the  Virjiiuia  side,  Fairfax  Co.  Present  locality:  S(Hithern  slope  of  opposite  hill  faeinjj  former 
location.     7tll.  I'crccntage  of  sick:   I.}..     Stll.  (iangrene  of  toes:  no  remarks. 

Ash'I.  Surg.  I).  McKinnky,  1I)//i  I'd. —  1st.  'i'he  numlier  of  cases  of  bilious  remittent  fever  treated  in  our  hosi)ital 
has  been  HS,  of  which  13  ix^curred  at  C';\mp  Tenniilly  and  25  at  l'ier|iont;  w<^  had  three  cases  of  ty))hoid  fever.  li<l. 
From  my  (diservation  I  am  led  to  believe  that  the  army  typhoid  is  of  malarious  orijjirj.  Our  first  ease  had  Just 
recovered  from  an  attack  of  bilious  remittent  feverand  the  two  other  cases  showed  decided  remissions  at  first,  (^uite 
a  number  of  our  bilions  remittent  fevers  exliibited  for  a  time  a  typhoid  character,  a.lthoui;h  yieldinf;  readily  to  larj^e 
doses  of  quinine.  3cl.  In  the  treatment  of  tyidioid  fever  (iniuine,  solution  of  the  acetate  of  Iea<l,  mucilage  of  tur- 
pentine, wine  and  brandy  w  ere  used.  4  ( li.  I'he  early  symptoms  were  those  of  remittent  fever,  l)ut  after  a  few  day.s 
decided  symptoms  of  tyidioiil  fever  were  displayed.  The  disease  yields  miu'h  earlier  to  treatment  than  the  tyjihoiil 
fever  of  the  North.  .'>tll.  Malaria  is  the  siip])Osed  cause,  aided  by  the  entire  change  of  habits  of  the  volunteer  from 
the  comforts  of  home  to  ex(utemeut,  exposure,  badly  prepared  food  and  crowded  tents  incident  to  camp  life.  Gtll, 
Camp  ■fenn;illy,  two  cases;  Camp  I'icrpont,  one  case.     7tll,   Four  ]ier  cent,  for  the  past  thirty  days. 

Surgeon  S.  ().  Lank.  ')IIi  /'«. — 1st.  \Vc  have  had  from  December  1  to  date  21  cases  of  remittent  ami  one  of  typhoid 
fever.  2d.  The  tyjdioid  reported  is  properly  so  called,  and  is  the  typhoid  or  enteric  fever  of  the  North.  3<1.  Our 
t*reatment  consists  of  i|niniue,  };<'ntl(^  i>uri;atives  when  needed,  alteratives,  turpentine,  lutiirishmenl,  stimulants  and 
cleanliness:  local  <-omplications  are  treated  as  tlu'ir  character  demands.  The  hufje  and  repeated  doses  of  quiniile, 
so  highly  landed  by  numy  authorities,  have  failed  in  our  haiuls  to  (dfcct  the  promised  good  results,  and,  I  believe, 
when  fjiveu  thus  heroically,  it  is  apt  to  oi)press  tlu^  ucrvou.s  powers,  mask  the  symi)toiu8  and  aj^ravate  local  cony;e,»i- 
tions  into  inllaramations.  4th.  The  syuii)toms  vary  as  the  case  may  be  remittent  or  enteric  fever.  In  the  remittent 
the  disease  usually  nnikes  its  appearance  suddenly  with  a  chill,  followed  by  fever  and  perspiration;  sometimes  the 
patient  has  a  sallow,  sickly  appearance,  with  impaired  ajipetite,  nausea,  diarrhoea  and  the  tongue  covered  with  yel- 
lowish or  whitish  fur.  This  di.seased  coiulition  iutcnsilies  and  breaks  into  adistiuct  remittent,  or  an  intermittent  nmy 
pa.s8  into  a  remittent.  When  the  fever  is  fully  formed  the  jiatieiit  has  slight  n^missions,  ciuiek  pul.se,  hot  skin,  head- 
ache, tenderness  of  alidomen  and  mort^  or  less  delirium :  the  tongue  soon  becou»\s  dry  and  cracked,  the  bowels  relaxed 
and  the  stools  various.  Many  cases  jiass  early  into  a  low  or  ty])hoid  condition  with  the  usual  symjiloms.  The  local 
affef^tious  are  nunu'roiis,  occurring  in  the  he<id,  chest  and  abdomen.  Usually  tln^  enteric  eases  Ix^gin  insidicuisly : 
Nervous  derangement  is  an  early  sym]itom;  fever,  sometimes  at  first  remittent;  ejiistaxis;  pulse  ([iiick  and  feeble; 
headache,  confusion  of  mind  and  dulness  of  hearing;  stools  eliaracteristic ;  dry  glazed  tongue:  sordes  on  teeth: 
appetite  often  not  affected;  lieniorrliage  from  bowels;  rose-colored  eruption  on  abdomen;  tymiiauites  not  always 
))resent;  slow  and  tedious  recovery;  patients  generally  young  men;  deaths  sudden;  ulcerations  of  glands  of  intes- 
tines discovered  on  post-mortem  examination;  strong  tendency  to  local  inflammations.  5th.  The  supposed  causes  of 
remittent  fever  are  miasmata,  but  as  our  cases  teiul  so  rapidly  to  the  typhoid  condition  I  believe  them  also  inllnenccd 
by  the  causes  which  develop  enteric  fever.  Our  cani]>  is  located  on  a  narrow  tongue  of  land  until  within  a  short 
time  densely  wooded  and  surrounded  by  woods.  A  slow,  boggy  spring,  in  which  four  regiments  wash,  runs  along  one 
side,  and  at  the  point  of  the  strip  ujion  which  we  are  encainiied  it  meets  another  imrer  stream  running  along  our 
otherside.  The  tents  are  crowded  together,  preventing  proper  drainage.  Six  men  sleep  in  one  A  tent.  They  have  no 
straw,  iusutlicient  blankets,  sleep  in  their  clothes,  which  tliej-  can  seldom  change,  disregard  cleanliness,  cook  badl.v, 
take  no  gymnastic  exercise  and  are  liiscouraged.  Log  houses  are  being  built  by  the  men,  but  they  are  close  and 
crowded.  Hero  is  a  process  of  impairing  the  vital  forces  which  must  make  our  diseases  adynamic.  Oth.  These  dis- 
eases have  prevailed  in  this  regiment  since  September  (when  I  joined),  but  are  now  more  severe.  7th.  Percentage 
of  sick  of  aggregate  force  to-day  13.11.     8th.  Have  had  no  gangrene  of  toes. 

Surg(on  L.  W.  Kkad,  Ixt  I'ti.  —  1st.  Number  of  fever  ca.ses  from  August  to  December  inclusive:  Kemittent  526, 
typhoid  7.  2<l.  Many  of  the  cases  treated  were  well  defined  remittent  fever,  but  the  majority  presented  various 
grades  of  complication,  manifested  by  a  sense  of  great  weakness,  exhaustion  or  prostration  indicating  the  presence 
of  some  depressing  or  epidemic  intliience;  and  as  they  did  not  present  the  characteristics  of  genuine  typhoid  they 
were  regarded  aud  treated  as  remittent  fever.  Only  seven  ca.ses.  two  of  which  died,  gave  evidence  of  pure  typhoid 
fever.  3cl.  The  great  change  in  the  habits  of  the  men,  such  as  cxi)osure  to  rain  and  night-air  in  the  performance 
of  picket  and  guard  duty,  lying  on  the  ground,  sleeping  in  wet  clothes,  etc.  4th.  Many  of  the  cases  were  uslu^red 
in  without  any  luenionition,  but  the  majority  were  preceded  for  one  or  two  days  by  a  feeling  of  great  fatigue  or  dis- 
inclination to  exertion,  with  pain  in  the  head  and  back;  tongue  coated  and  the  circulation  accelerated;  about  the 


TllK    C()KT1.NI:K1)    b'KVKKf- 


369 


third  (liiy  tlicrc  w:is  a  drcidi'il  cliill  and  l'i-\  er  w  iili  an  a,i;.L;i'avatii)ii  (if  all  llu^  syiniifoiiiH.  Tliero  was  };i"iierall.v  a  coiii- 
liiiiatioii  oftlu'se  coiulitioii.s  in  the  uioiiiiuf;.  A  uiimher  of  the  i-asi's  yielded  readily  to  tieatnieiit  and  were  conva- 
lescent in  five  or  six  days.  Those  that  iiiTsi>fe<l  wcie  eharacti'ri/ed  liy  a  fi^elini;  of  exhanstion  or  prostration,  heavily 
coated  or  dry  tonj;ne,  pain  in  the  head  and  liack.  loss  of  a|i|iet  lie.  occasionally  nausea  and  diarrhiea  with  slij;ht 
tynijianites.  Tlie  urine  was  tnrliid  or  hif^lily  colored,  with  a  siruni;-  aiiinioniacal  odor.  nth.  When  the  case  was  seen 
dnrinji  the  reniissiou  ([uiiiiue  was  freely  ^Mven.  and  dnrini;'  the  day  lduc-|iill  lollowed  hy  castor  or  croton  oil  was 
administered.  When  seen  during  the  iireseuco  of  fever,  ([uiuine  was  jircceded  liy  |)ur,i;atives;  as  a  lelirifu.ire  neutral 
mixture  or  muriate  of  ammonia  was  given;  when  the  tongue  was  dry  tur|ienline  was  used,  and  when  there  was 
much  depression  an  emulsion  of  oarhonate  of  anniumia,  Inandy-pnneh  and  Uei-f-tea:  restlessness  was  tri'ated  with 
anodynes.  6tll.  The  locality  of  the  regiment  lietViro  the  breaking  out  of  the  disease  was  Cam])  Wayne,  West 
Chester,  Pa.  7th.  Percentage:  Kemitt<-nt  fever  5l-'ti,  typhoid  7.  Stll.  1  have  had  no  casi',  of  gangrene  of  the  toes 
but  have  treated  a  uumlier  of  cases  in  which  there  was  great  pain  ami  acute  si'Usiliility  of  the  toes,  several  of 
wliicdi  have  persisteil  for  more  than  three  months. 

BrUjailc  Siir(j. W.ij.  Low.M.vx,  U.S.  V. — 1st.  I  amofo|iinion  that  all  thi^  cases  of  fever  in  my  brigade  are  bilious 
remittents.  2<1.  The  typhoid  fever  hero  is  not  the  typhoid  of  the  North.  Although  there  are  nuiiiy  of  the  symptoms, 
as  slight  diarrluea  and  tymiianites.  roso-spots,  ihdirinm,  etc.,  the  <lisease  conu's  on  too  rapidly  for  typhoid  and  there  is 
not  that  liebi'tnde  of  lioily  and  mind,  tendi'tness  or  tympanites  of  tin'  bowels,  nor  the  red  poiuli'd  tongue  that  we 
havi!  in  the  North.  The  disease  assumes  a  typhoid  type  in  cases  t  hat  run  oti  for  ten  days  or  two  w  •■<d<s,  and  ill  consti- 
tutions that  have  been  broken  down  by  ])revioiis  disease,  in  drunkards,  etc.  I  am  of  o]iinion  that  if  the  use  of  (jni- 
uine  be  commenced  early  the  disease  will  be  broken  up  in  lidiii  tliiec  days  to  a  week,  at  least  in  the  majority  of 
cases.  Those  of  my  surgeons  who  use  (iiiiiiiiie  early  and  freely  have  few  cases  of  the  so-called  typhoid, — it  is  almost 
always  cut  short.  Hence  1  look  upon  the  disease  as  remittent  in  character  and  caused  by  malaria.  Indeed  all 
diseases  here  are,  I  think,  inllueneed  more  or  less  by  malaria.  If  a  man  takes  a  bad  cold,  sullieieiit  to  produce  a 
little  fever,  icterus  shows  ilsidf  and  he  will  in  all  pr(diability  lia\e  [■cmittent  fever.  ;{«l.  The  treatmt^nt  is  bhie-iiill 
and  (|uiuiiie;  and  those  who  give  thesis  fivcly  have  the  best  success.  When  the  disease  runs  on  for  ten  days  or  two 
weeks  and  the  tongue  becomes  red,  dry  and  chappi'd,  the  treatmeul  consiMs  of  stimulants  ami  alteratives,  as  turpen- 
tine, brandy,  wine-whey,  punch,  etc.  The  turpentine  acts  admiiably  on  t  lui  dry,  chappi'il  tongue.  4tll.  The  symp- 
toms generally  come  on  rapidly  with  chilliness  or  rigors  followed  by  heat,  full  juilse,  dry  timgue,  slightly  furred  and 
soon  becoming  brown,  constipated  bowels,  tenderness  in  epigastric  region.  fre(|uenl  vomiting,  .jaundiced  skin  often 
preceding  the  attack.  Hushed  eyes  and  face  and  eongestid  surface:  and  in  all  these  cases  the  patient  is  (piite  didir- 
ions.  The  remission  is  well  marked  in  scmie  ca.ses,  but  in  others  it  is  not — in  either  event  (|uiiiiiie  generally  acts 
well  :  but  if  tin'  disease  be  not  arrested  in  the  course^  of  a  week,  typhoid  symptoms  make  their  a]i|iearance.  I  siijiposo 
llu'  cause  of  the  disease  to  be  malaria.  6th.  Tlie  location  of  the  brigadi'  at  the  breaking  out  of  the  disease  was 
Camp  Tennally.  8th.  1  have  not  seen  any  gangrenous  toes  in  my  brigade.  Permit  me  further  to  state  that  the 
prevailing  di.sea.se  at  present  is  a  catarrh  of  a  ]ieeuliar  character.  There  is  seldom  any  coryza  or  lachrvmation.  It 
commences  with  a  dry,  tickling  cough  with  little  expectoration,  no  fever  or  loss  of  appetite  except  in  a  few  cases 
which  run  into  bronchitis.  The  patient  feels  well  gener.ally,  but  coughs  almost  incessantly.  The  disease  began  about 
a  mouth  ago  after  a  few  foggy  nights  followed  by  hard  frosts.  Since  the  frost  otir  remittent  fever  (or  so-called 
typhoid)  has  decreased  very  much.  There  has  not  been  a  new  case  in  my  brigade  for  about  three  weeks,  which  is 
additional  evidence  to  my  mind  that  it   is  caused  by  malaria  and  is  not  typhoid. 

Siiri/coit  W.  II.  TiioiiNK,  l'2^/i  /'((. — 1st.  Of  bilious  fever  we  have  hail  but  one  case  in  our  regiment;  of  tyjihoid 
we  have  had  tour,  in  all  of  which  tJiere  was  more  or  less  tendency  to  inllanimatiou  of  the  lungs.  Jid.  This  typhoid 
is  the  same  as  that  of  the  North;  it  is  not  malarial  and  does  not  yield  to  antii>eriodics.  A  sjuirioUH  typhoid,  which 
prevailed  during  the  summer  .and  fall,  presented  many  of  the  symptoms  of  true  typhoid,  but  there  was  a  marked 
remission  generally  in  the  forenoon,  and  although  the  tongue  indicated  more  or  less  intestinal  irritation  in  some  of 
the  eases,  the  bowels  were  mostly  constipated.  This  disease  was  of  malarial  origin  and  yielded  readily  to  alteratives 
and  antiperiodie.s — bine  mass  and  i|uinine;  none  of  the  cases  were  fatal.  JJrt.  The  treatment  of  typhoid  has  been 
alterative,  snjiporting  and  stimnlant:  turpentine  was  given  in  nearly  every  case  and  with  marked  benetit.  4th. 
Symptoms:  More  or  less  nervous  derangement,  headache,  furred  tongne  ami  diarrho'a;  in  some  cases  epistaxis,  tympa- 
nites, sordes  on  the  teeth  and  delirium;  the  taclies  rouges  were  mostly  inesent.  5th.  Cause:  Impure  and  contined 
air.  cold  and  dami),and  irregularities  in  diet  added  to  an  inipropi'r  location.  tJth.  Locality:  Near  the  bottom  of  a 
hill  w  ith  a  marsh  on  one  side  and  low.  damp  ground  on  the  other.  7th.  Now  sick,  10  per  cent,  of  the  command, 
the  majority  being  catarrhal  aft'ections.     8th.  We  have  had  several  ca.ses  of  wounds  of  toes,  but  no  gangrene. 

Suyycoti  .J.  A.  PiiiLi^ii'S,  i>th  Pa.  lifserrcs. — l.st.  During  the  last  three  months  I  have  treated  HO  cases  of  remittent 
and  It  of  typhoid  fever.  U<1.  The  majority  of  the  idiopathic  fevers  which  have  come  under  my  observation  were  of 
the  remittent  tyjie  and  ditfered  from  the  enteric  or  typhoid  fever  of  the  North  in  these  particulars:  The  disease  was 
not  often  preceded  by  headache,  dulness  or  feelings  of  malaise,  but  began  abruptly,  nor  was  it  preceded  by  epistaxis 
or  diarrluea ;  the  bowels  were  generally  constipated  during  the  cinirse  of  the  ;ittack ;  in  most  cases  rose-colored  spots 
and  sudamina  were  not  developed;  there  were  distinct  remissions  though  not  at  any  particular  time  in  the  day; 
lastly,  the  fever  could  often  be  checked  in  a  few  days  by  the  free  use  of  (|uinine,  I'atieiits  were  generally  conva- 
lescent in  ten  or  twelve  days;  but  if  the  disease  was  not  subdued  within  two  weeks,  it  often  ran  into  an  adynamic 
form  resembling  typhoid  in  some  resjiects,  3d.  A  mercurial  cathartic  was  fust  administered  followed  in  a  few  hours 
by  tifteen,  twenty  or  thirty  grains  of  (|uinia.  Kefrigerant  diai)lioretics  were  freely  given  during  tlie  fever.  I  was 
not  deterred  from  the  liberal  exhibition  of  iiuiuine  by  the  absence  of  a  <listinct  remission  nor  by  symptoms  of  gastric 
Med.  Hi«t.,  Ft.  111—47 


370  POyT-MORTKM    RKC'OKDS    OF 

or  corcbiul  (listiiiliaiic-e.  If  tlio  disciiso  assiiinrd  ii  low  form  (Hiiniiii-.  nnimoiiia,  inilk-]»iiii(h  and  tlif  iiuist  nutritioiiH 
diet,  Ix^Ld'-tua  and  hiM'I'-esBoucc,  wimt  givrn.  It  may  l>o  proiicr  to  add  that  I  have  often  mih-ii  a  dry,  brown  tonj^ut) 
bi'uonie  clean  and  moist  in  twenty-tour  Injurs  after  the  administration  of  what  would  bi;  called  in  the  Northern  States 
U,  heroic  dose  of  i|uinine.  4:tll.  In  a  few  instances  the  attack  was  iircccded  by  languor,  loss  of  a|)l)etito,  etc.,  but  in 
most  cases  it  began  with  a  chill  an<l  pain  in  the  head,  back  and  limbs,  followed  by  smart  febrile  excitement.  There  was 
generally  a  remission  of  the  fever  daily,  som(^time»  twice  a  day;  the  tongue  covered  with  a  pasty  fur  such  as  I  have 
seen  accom]ianyiug  yellow  fever;  bowels  constipated;  skin  dry  and  pungent  except  during  the  remissions;  conjunc- 
tiv.e  of  a  yellow  tinge;  pain  in  epigastric  and  hypochondriac  regions;  urine  highly  colored.  Stll.  The  etfects  of 
miasmata.  Three  months  ago  the  regiment  for  strategic  reasons  was  encamped  in  its  present  position.  The  tents 
were  i)itched  on  low  ground  with  liills  rising  on  eitht^r  side.  The  camp,  from  the  nature  of  its  site,  cannot  be  proji- 
erly  drained  and  policed.  6th.  Tennallytown,  D.  C.  7tll.  The  monthly  reports  show  an  average  of  21  per  cent. 
§tll.  I  have  not  seen  a  case  of  gangiene  of  the  toes;  ccnivalcscents  from  remittent  fever  have  complaineil  occasion- 
ally of  stiftness  and  soreness  of  the  toes,  but  these  symptoms  yielded  j)romptly  to  emollient  applications. 

Brigade  Surg.  A.  E.  Stock?:u,  U.  S.  V. — 1st.  In  answer  to  the  first  query,  as  the  cases  I  have  seen,  although 
numerous,  have  been  only  in  consultation  with  the  regimental  surgeons,  I  can  give  no  additional  information. 
2d,  Such  of  the  cases  as  I  have  examined  and  designated  as  typhoid  fever  were  clearly  cases  of  the  true  typhoid 
fever  of  the  North,  characterized  by  all  the  usual  symiitouis  and  phenomena  of  that  disease  as  it  there  exists. 
There  have,  however,  been  a  great  number  of  cases  which  in  their  commencement  and  progress  were  true  bilious 
remittent  fevers, although  they  subsei|Uently  put  on  a  low  or  typhoid  type;  these  were  undoubtedly  due  to  malarious 
influences.  3d.  I  have  advised  quinine  and  iron,  the  former  in  doses  of  two  or  three  grains  every  two  lionrs,  with 
milk-punch  and  strong  essence  of  beef;  when  the  tongue  became  dry,  brown  and  cracked,  turpentine  was  used  with 
excellent  effect,  ^tll.  The  cases  I  have  designated  as  typhoid  have  had,  in  addition  to  the  usual  symptoms  of  febrile 
disease,  the  low  compressible  pulse,  extiuguishable  by  pressure,  so  characteristic  of  this  fever,  with  epistaxis,  deaf- 
ness, tlushed  and  besotted  appearance,  diarrhiea  and  taelies  rouges.  If  I  shouhl  say  one  symptom  of  tyjihoid  was 
less  marked  than  those  usually  found  in  this  disease  it  would  be  the  want  of  special  tenderness  and  gurgling  in  the 
right  iliac  fossa,  while  in  many  cases  the  tenderness  on  pressure  seemeil  to  be  equally  diffused  over  the  abdominal 
cavity.  5tll.  The  cause  of  the  disease  is  yet  undi^terminei^.  I  am  not  prepared  to  say  that  there  is  even  a  greater 
number  of  cases  of  this  disease  in  the  camjis  of  this  division  than  would  exist  were  the  same  number  of  men  placed 
under  the  care  of  one  or  two  physicians  in  any  city  of  the  North.  Otll.  As  the  manifestation  of  the  disease  does  not 
seem  to  have  been  sudden  at  any  time  in  my  experience  here,  it  would  he  impossible  for  me  to  designate  the  locality 
of  the  regiments  when  it  broke  out.  7tli.  As  no  time  has  been  specified  for  the  calculation  of  the  number  of  cases 
the  regimental  reports  cannot  be  expected  to  approach  uniformity  in  their  calculation  of  the  percentage  of  typhoid 
cases.  Stil.  I  have  seen  two  eases  of  gangrene  of  the  toes  in  the  regiments  under  my  charge.  They  were  conse- 
quent upon  attacks  of  typhoid  fever:  the  issue  of  them  I  cannot  tell  as  they  were  removed  to  general  hospital  before 
entire  convalescence  had  taken  place. 

Surgeon  D.  Stanton,  1»^  Pa.  Car. — 1st.  We  have  now  five  cases  of  remittent  fever,  all  mild  and  amenable  to 
quinine  in  five-grain  doses  three  times  daily;  of  typhoid  fever  we  have  one  case  now  convalescent  and  one  case  in 
division  hospital.  3(1.  With  perhaps  one  or  two  exceptions  the  typhoid  cases  we  have  had  this  fall  have  been 
clearly  of  a  malarious  origin.  3d.  A  mihl  purgative  and  ([uinine  in  tive-grain  doses  every  three  hours  during  the 
remission;  during  the  febrile  paroxysm  sweet  spirit  of  nitre  with  acetate  of  ammonia.  When  about  the  eighth  or 
tenth  day  the  remissions  become  less  marked  and  typhoid  symptoms  api)ear,  the  (|uinine  is  continued  in  doses  of  two 
or  three  grains  i^very  four  hours,  w  ith  brandy,  beef-tea  and  wine-whey,  and  when  the  tongue  becomes  dry  and  parched 
and  the  bowels  tympanitic  I  give  castor  oil  and  turiieutiue  every  four  hours.  I  have  found  blisters  upon  the  abdomen 
to  be  of  great  advantage  in  the  second  stage  of  the  disease.  4:tll.  Nearly  all  of  our  cases  have  been  of  a  remittent 
character  at  first.  About  the  sixth  or  eighth  day  the  fever  became  of  a  more  continued  form,  with  more  or  less 
delirium  and  subsultus,  tympanites,  hot  skin,  compressible  pulse,  tongue  at  first  furred  and  afterwards  smooth  or 
cracked  ami  dry,  and  on  the  ninth  or  tenth  day  the  characteristic  eruption  of  rose-spots  would  appear  on  the  body. 
About  the  end  of  the  second  week,  in  favorable  cases,  the  tongue  becomes  moist  and  clean  at  the  tip  and  edges;  in 
more  protracted  cases  it  cleans  off  from  the  centre,  becoming  dry.  parched  and  cracked.  Diarrhcea  occnrred  in  most 
of  the  cases,  but  was  not  attended  with  hemorrhage.  The  mortality  of  the  eases  treated  in  the  regimental  hospital 
has  been  about  twenty  per  cent.  Stb.  and  6tll  may  be  conjoined,  for  the  locality  of  our  camp  was  certainly  the  cause 
of  two-thirds  of  our  typhoid  cases.  We  were  located  at  first  on  damp,  low  ground,  not  susceptible  of  drainage. 
Two  weeks  after  this  our  sick-list  was  doubled,  and  ten  or  twelve  of  our  typhoid  cases  originated.  The  camping 
ground  was  certainly  pregnant  with  causes  of  malarial  and  typhoid  fevers.  In  addition  to  this  cause  there  were  also 
those  resulting  from  the  mode  of  life  in  cam]),  and  especially  in  the  camps  of  recruits  who  have  not  yet  learned  an<l 
practiced  the  most  salutary  police  regulations.  Bad  cooking  and  want  of  cleanliness  in  their  persons,  clothes  and 
quarters,  the  change  and  irregularity  of  diet,  exposure,  etc.,  nuty  be  named  amongst  the  causes  of  typhoid  fever  and 
diseases  in  general.  7tli.  .Sick  84,  mean  strength  ilUH,  giving  about  it. 2.")  per  cent.,  including  about  25  who  have  been 
reconnneuded  for  discharge,  and  al.so  those  injured  by  horses,  gunshot  wounds,  etc.  Stll.  But  one  case  of  gangrene 
of  the  toes  has  oceurre<l, — in  a  severe  and  tedious  case  of  typhoid  fever.  The  predisposing  cause  was,  I  think,  the 
low  vital  powers  of  the  system  and  the  exciting  cause  the  pressure  of  bed-clothes.  As  this  was  the  only  case  we  were 
not  suffii-iently  on  the  alert;  perhaps  had  more  care  lieen  taken  the  gangrene  might  have  been  prevented.  Bathing 
in  warm  water  or  with  hot  whiskey  and  the  application  of  artificial  heat  might  prevent  this  trouble  in  a  measure,  if 
not  altogether. 


THE    Co:JTiiMi;ED    KKVKRS. 


371 


Siiryeuii  J.  Collins,  'dd  I'a. — 1st.  Cases  uf  bilious  lomittfut  51',  of  typlioiil  lover  16,  talvoii  sick  diiiiug  the 
moiitli  of  November.  2d.  Tliere  lias  been  a  stiikiu};  similarity  between  the  feliiile  eases  observed  in  camp  anil  those 
I  have  seen  in  IVnnsylvania  and  New  England.  Afew  cases  have  begun  as  well-marked  remittents  and  ended  as 
typhoid  fever  of  a  malignant  tyjie.  Moreover,  the  fact  that  ciuinine  is  well  borne  ill  all  typhoid  cases  woulil  seem  to 
indicate  that  malarial  intluences  opeiated  in  tlieni.  3<l.  The  treatment  has  not  been  uniform.  As  a  rule  in  a 
case  of  remittent  fever  a  mercurial  jiurge  is  given,  followed  liy  oil  or  a  saline  and  afterwards  by  ijuinine  and  tincture 
of  irou.  Should  the  case  prove  persistent,  alterative  doses  of  blue-pill  are  given.  During  the  paroxysm  great  relief 
is  afforded  by  neutral  mixture  or  acetate  of  ammonia.  Ilortniann's  anodyne  is  valuable,  and  in  the  later  stages  good 
milk-punch  plays  an  impoitant  part.  The  seijuehe  of  the  disease,  dcViility,  diarrluea  and  Jaundice,  need  i)artic- 
ular  attention.  'I'yidioid  cases  re<iuire  strict  watching  as  the  sym])toms  are  in  many  cases  insidious  and  deceptive. 
After  the  first  stage  these  bear  stimulants  and  ([uinia  i|uite  well;  in  fact  stiuuilants  are  absolutely  necessary. 
Carbonate  of  annnonia,  milk-juinch  with  geucrons  diet  of  beef-tea  and  animal  broths,  and  in  certain  cases  turpen- 
tine emulsion,  are  given  w  ith  great  advantage.  In  the  olistinate  and  tlebilitating  diarrhcea  of  typhoid  I  havi>  found 
catechu  most  efficient.  4:tll.  In  remittent  fever,  li<-sides  the  ordinary  felirile  symptoms,  may  bo  noted  a  peculiar 
brown  or  bluish-black  coating  of  the  tongue.  This  peculiar  shade  I  have  never  noticed  before.  In  other  cases  the 
conjuntiva!  are  injected,  often  yellow  and  the  tongue  of  a  reildish  tint.  The  iiaroxysm  generally  occnrs  towards 
evening.  In  typhoid  cases  there  is  generally  a  greater  tenderness  or  gurgling  in  the  line  of  the  colon;  the  dis- 
charges are  dark  or  watery;  tlie  pulse  has  a  hollow  vanishing  beat;  the  tongue  is  dry;  tlie  fever  continued;  rose- 
colored  spots,  etc.  ntll.  The  supposed  cau.se  is  concealed  in  tlie  two  terms  used  with  scientific  llipiiancy,  viz:  jire- 
disposition  and  malaria.  Ctb.  The  regiment  has  never  been  quite  free  from  the  disease.  I  think  the  violent  and 
malignant  form  assumed  iu  November  due  to  locatiiui  in  the  swaiui)  Just  in  advaiu^e  of  our  presi^nt  encamimient. 
7tll.  During  the  month  1)2  per  <'ent.  of  the  whole  leginuuit  were  sick  at  one  period  or  another.  8tll.  One  case  of 
gangrene  of  the  toes  was  sent  to  division  hospital.  Another,  a  jiatii'iit  sutl'ering  from  a  violent  attack  of  typhoid 
fever,  occurred  in  tlio  regimental  hospital:  On  the  morning  of  the  tenth  day  he  complained  of  intense  pain  in  the 
toes.  The  feet  were  cold,  tlie  toes  (|uite  blue  <ir  liluisli-black.  1  immediately  ordered  stimulation,  and  heat  to  be 
applied  externally,  with  largo  doses  of  tincture  of  iron,  niilk-punch  and  good  diet.  In  a  few  days  the  patient  ceased 
to  complain  and  the  symptoms  yielded. 

Siii'in'oii  J.  S.  De  Hennevi'lle,  11(/i  Fa. — 1st.  From  August  to  December  inclusive  we  have  had  '20  cases  of  remit- 
tent fever  and  19  of  typhoid.  3cl,  The  cases  of  typhoid  were  similar  to  those  called  typhoid  or  enteric  fever  at  tlie 
North.  3(1.  Treatment  was  by  gentle  purgatives  when  necessary  and  diaphoretics  of  neutral  mixture  or  acetate  of 
amiuoiiia  combined  with  sweet  spirit  of  nitre,  tartrate  of  antimony  or  ipecacuanha  iu  the  lirst  stage.  Meeurials  com- 
bined with  diaphoretics  were  used  as  the  secretions  diminished  and  the  tongue  became  furred  and  dry;  cold  apidica- 
ti(uis  to  the  head,  dry  cups  to  the  temples  and  back  of  the  neck  and  blisters  to  the  temples  or  scalp  when  fever  and 
delirium  were  present.  In  the  advanced  stages,  when  the  tongue  became  dry  and  fissured  and  the  abdomen  tynijia- 
uitic,  turpentine  was  emploj'od  with  advantage.  Dry  cujiping,  mustard  poultices  and  stimulating  liniments  to  the 
chest  were  used  in  treating  bronchitis  and  ]nilmonary  complications.  The  diet  was  at  tirst  arrow-root  gruel,  farina 
and  barley,  but  as  the  disease  advanced  beef-tea,  essence  of  beef,  milk-punch  and  wine-whey  were  given  with  cinchona 
or  (|uiiiine.  4tll,  The  patient  usually  suffered  from  a  feeling  of  general  uneasiness  and  discomfort,  headaclie,  alter- 
nate sensations  of  heat  and  chilliness,  diarrluea,  iu  some  cases  epistaxis,  furred  tongue,  etc.  These  symptoms  became 
aggravated  with  dry  skin  and  tongue,  pain  in  the  iliac  region,  tympanites,  bronchitis  or  pneumonia.  Kose-colored 
spots  and  sudamina  were  found  in  nearly  all  cases;  marked  cerebral  disorder  with  delirium  occurred  in  many.  5tll. 
It  is  probably  the  endemic  fever  of  this  region,  its  increase  being  favored  by  overcrowding  in  small  tents  and  neglect 
of  cleanliness.  6tll.  The  tlrst  case  occurred  while  the  troops  were  at  Camp  Tennally,  about  a  month  after  they  had 
removed  from  a  camp  one  mile  north  of  Washington.  7tll,  The  number  of  sick  daily  averaged  5.0  per  cent,  in  July 
and  August,  4.5  iu  September,  5.0  in  Octolicr,  5.75  in  November  and  0.75  iu  December.  8tll.  The  only  case  of  gan- 
grene that  came  under  my  notice  was  at  the  division  hospital.  The  patient  had  been  sick  in  this  regiment  for  seven- 
teen days  with  a  low  form  of  remittent  fever  iu  which  the  prominent  symptoms  were  cerebral;  the  lower  limbs 
became  cedematous  and  the  gangrenous  condition  ajipeared  soon  after  his  entrance  into  hospital. 

Siiryeon  S.  D.  Freeman,  ISth  Pa.  Reserves. — 1st.  Daring  the  last  three  mouths  we  have  had  91  cases  of  liilious 
remittent  and  9  cases  of  typhoid  fever.  3d.  The  typhoid  fever  is  not  the  typhoid  of  the  North,  but  originates  in 
bilious  remittent,  attributed  to  malaria.  3d.  Treatment  is  alterative,  tonic  and  stimulating  by  blue  mass,  carbonate 
of  ammonia,  turpentine,  quinine  and  brandy.  The  disease  does  not  yield  to  quinine,  ^tll.  Headache,  with  chills, 
backache,  general  malaise,  tongue  coated,  at  first  yellow  then  dark,  crusting  and  cracking  in  the  centre — in  short, 
the  usual  symptoms.  5tll.  The  cause  is  supposed  to  be  the  change  from  a  high  and  dry  to  a  low  and  moist  climate, 
as  that  portion  of  the  regiment  coming  from  the  Alleghany  inountaius  suffers  most.  6tll.  The  regiment  was  encamped 
at  Harrisburg,  Pa.;  Cumberland,  Md.;  New  Creek,  Va.;  then  again  at  Harrisbnrg,  Sandy  Hook,  Buckeyestown  and 
Hyattstown,  where  fevers  first  made  their  appearance.  Ttll.  The  percentage  of  sick  from  all  causes  is  at  present 
7.25.     8tll.  There  is  no  gangrene  of  the  toes. 

Stirt/eoii  A.  W.  GliUKs.  7th  I'a.  Heserres. — 1st.  Six  jases  for  the  present  month.  3d.  I  do  not  consider  it  the 
same  as  the  typhoid  fever  of  the  North:  it  commences  as  a  bilious  remittent,  running  rapidly  into  a  typhoid  condi- 
tion, and  almost  invariably  with  strongly  marked  cerebral  symptoms.  I  think  the  heavy  fogs  overhanging  us  almost 
every  night,  the  nature  of  the  soil,  vegetable  mould  with  clay  siilisoil,  and  the  constant  digging  connected  with 
camp  improvements  serve  to  indicate  a  malarial  origin.  3d.  (Quinine  in  doses  of  three  to  ten  grains  every  two 
hours  generally  succeeds  in  breaking  up  the  fever;  but  at  this  time  we  have  to  be  exceedingly  careful,  else  the  disease 


r)72  rnsT-M(ii;rKM   i;Kcnj;i)s  ny 

will  iissuiiio  llie  tyiihoid  fdriii.  The  trciitnunt  in  this  cvoiit  cuusi.st.s  of  tui'iieiitino  emulsion,  opium  or  Dover's  pow- 
der, beef-tea,  luilk-iiuneh,  brandy,  eailiouute  of  aninionia,  etc.  -Itll.  Chilliuess,  restlessness,  fever,  lieadaelie,  [laiu  in 
l)iiek  anil  liones,  geueial  uneasiness,  t(irpor  of  the  bowels,  pain  in  bowels,  tenderness  on  pressure,  tympanites,  diar- 
rliiea,  liemorrhafie.  dilated  jiupils,  entire  ailytiamic  condition,  death.  Stll.  The  snpi>osed  causes  are  miasm  and 
exi)osure.  Ctll.  (.'amp  Tennally.  7th.  Three  and  one-half  per  cent.  Stll.  Convalescents  complain  very  much  of 
their  feet,  but  I  have  not  met  with  a  case  of  j;angrene. 

Biifjadv  Surg.  S.  E.  Haven,  l'.  .S.  I'. — The  rei)ort  of  sick  aud  wounded  shows  in  October  1,794  cases  of  diseasi. 
and  in  November  2,918  cases.  Most  of  those  included  iu  the  report  for  October  have  been  of  a  distinctly  malarial 
type:  Kemittent,  intermittent  and  eoirtinued  fevers;  also  a  larf^e  number  of  cases  of  measles. 

Cami)  Advance  is  situated  on  the  blutis  forminjj;  the  southwest  bank  of  the  Potonnte  at  Chain  bridj;e.  These 
bluffs  vary  from  IHi)  to  200  feet  in  height.  The  Potomac  at  this  ))oint  and  for  a  considerable  distance  above  and  1>elo\v 
Hows  over  a  rocky  bed  with  steep  banks  on  both  shores,  e.\tendinij;  back  in  rollin;^  hills  with  shai'p  gulches  inter- 
vening. The  region  is,  therefori'.  apparently  non-malarious.  The  intermittent  and  remittent  fevers  that  have  pre- 
vailed here  during  the  last  month  are  attributable,  I  think,  to  the  extensive  felling  of  timber  and  clearing  ii|)  of  a  new 
country  required  by  the  military  necessities  of  the  camp.  This  division  was  moved  to  its  present  camp  October  10. 
Its  topograpliy  is  not  unlike  that  of  Camp  Advance  except  that  it  is  four  miles  distant  from  the  Potomac.  It  will 
bo  observed  that  the  diseases  reported  indicate  a  gradual  deepening  into  more  serious  forms  as  the  sotison  advances. 
These  forms,  I  think,  are  not  correctly  designated  typhoid,  the  coinlition  being  rather  that  of  a  low  form  of  bilious 
remittent  incident  to  the  depressing  iuHuence  of  camp  life  upon  those  wholly  unaccustomed  to  it. 

Ilriyddc  Snry.  J.  H.  W.\Kiii:N',  U.  S.  J'. — As  far  as  I  have  visited  the  various  camps  in  this  divisi(m  I  have  not 
been  able  to  find  more  than  si.\:  or  eight  cases  of  true  typhoid  fever  as  I  have  been  accustomed  to  .see  it  at  the  Xortli. 
These  cases  were,  I  think,  lironght  with  the  troops  from  the  North  here.  We  have  a  great  nuiiiy  cases  of  Itilious  remit- 
tent fever  assuming  the  typhoid  tyi)e.  Quinine,  oi)ium  aud  camphor  seem  to  be  the  best  agents  for  the  treatment  of 
this  fin-iu  of  fever.  The  surgeons  unite  in  this  statement,  that  all  cases  begin  with  the  usual  form  of  remittent  fever 
and  end  with  the  typhoid  type.  The  common  diagnostic  signs  of  typhoid  fever  as  we  see  it  farther  North  are  wanting 
in  the  incipient  stage  ot  the  disea.se. 

Ill  tlie  t'iU'c  of  litis  testimony  tickiiuwlcdging  the  existence  ot'  typlioid  fever  in  our  camps, 
but  pruinnuicing  the  pivvuiling  ciinip-fever  to  be  es-sentially  a  malarial  fever  of  an  ailynamic 
character,  it  is  ditiicult  to  conceive  that  the  insertion  of  the  term  tyj^lio-malarial  in  the 
monthlv  sirk  reports,  witlmnt  n  word  of  I'.xphmation  as  to  it.s  scope,  could  liave  so  influenced 
medical  oiiii-cr.s  in  the  held  as  to  cause  tliem  to  change  their  views  and  reirard  these  fevers  as 
typhoid  modified  by  active  malarial  phenomena.  As  a  matter  of  tact  their  opinions  remained 
unchanged.  This  is  fullv  evidenced  by  the  sanitary  reports  that  were  filed  subsequent  to 
June  30,  1S62,  the  d;\te  of  tlie  introduction  of  tlie  new  term.  Thus,  Burgeon  Jonath.vn 
Lettekman,  U.  8.  A.,  ^kleilical  Director  <>(  tlic  Army  of  the  Potomac,  in  a  report  covering 
the  first  six  montlis  after  the  date  stateil,  referred  the  prevailing  typhoid  type  of  fevers  to 
the  action  of  the  deadly  malarial  poison.*  His  successor.  Surgeon  Thomas  A.  McPaki.in,  U. 
8.  A.,  makes  use  of  tlie  new  term,  but  docs  not  explain  the  value  attached  to  it  when  lie  say.s^- 
that  "  during  tlie  ailvaiici;  from  tlir  l'a|iidan  to  Petersburg  malaritd  and  typlio- malarial  t'evers 
and  diarrhoea  were  the  prevailing  diseases,"  and  he  is  equally  indefinite,  so  far  tis  the  use  of 
the  new  term  is  concerned,  when  later  in  the  same  report  he  mentions  "fevers  of  the  inter- 
mittent and  typhoid  type"  among  the  diseases  prevalent  during  the  siege- of  Petersburg. 

The  large  number  of  cases,  23,846,  reported  as  typho-malarial  during  the  year  following 
the  introduction  of  this  term,  shows  how  generally  it  was  accepted  by  medical  officers  in 
the  field;  but  it  has  no  bearing  on  their  views  as  to  the  essential  nature  of  the  fevers 
thus  reported. J  Tlie  term,  when  used  outside  of  the  monthly  reports  of  sick  and  wounded, 
was  seldom  accompanied  by  any  data  indicating  whether  a  modified  typhoid  or  an  a<lynamic 
remittent  was  intended.  There  is  on  the  files  of  the  Surgeon  General's  Office  but  one  report 
which  attaches  to  typho-malarial  the  value  which  Dr.  Woodwaed  had  in  view  on  its  official 
introduction.     It  reads  as  follows: 


*  p.  03,  .\p|>™Jix  to  the  First  Part  of  tliis  vrilnme.  t  ^•'"'-  "'•.  !•■  !''■•■ 

+  "-^s  it  \va^,  tlif  tf-rm  went  iipou  tlie  side  ri'iiurt  without  any  explanation  or  a  wont  of  cointncnt.  Rut  even  itinler  tht'sf  circiinistann-s  ^i'-.^UG  cR-ma 
were  reportcil  as  t.vpho-nialivrial  ft-ver  during'  tin-  folluwinpr  y<'ar,  sliowinp  lio^v  -wiil.-ly  tito  opinions  I  Iniil  fornit'il  wito  slian-d  liy  tie-  nii'dical  otlict-rs  of 
thu -Vrmy." — Dr.  Woodwaku's  pajwr  uu  Ti/pliu-malnri'd  Fa-a;  Sirdivmi/ Midkiui;  lulcruativmU  Maliad  C'uiij/rew,  Philactilphia,  ls7ii,  (i.  1:;.  - 


TIIK    COXTTXT-KP    FKVKT^f!.  373 

Siirii'itit  \Vm.  O'Meagiikii.  ;>7//(  .V.  Y..  F.du-ard'^  Firrii.  Mil..  Sijit.  ISO.  1X02. — But  ii()t\ritli>;f:in(linfr  :ill  nnr  cfVovts, 
aided  by  aluuidance  of  iKiurisliiiicm  aud  stimiilalils.  sovrinl  died  of  a  iiiixi'<l  discasi'  wliicli  is,  to  iiiy  iiiiTid,  accurattdy 
naiut'd  ill  tin:  new  moiitlily  i'i'|Mivts  of  sirlc  and  wonndi'd  as  tyiiliii-maUirial  fevi'V.  The  two  cases  of  tli  is  iiatiiri'  r»Tordi'<l 
in  my  report  for  Anf;;ust  cxliiliitcd  vory  iiiarki-d  ex  idcncr  o1'  t  \  phoid  fi'vor  and  tniasniatic  poison  inn',  and  tlic  treatment 
was  adajjted  accordingly.  In  one  case  tlie  delirium  was  so  violent  as  to  apjiroacli  the  character  of  mania:  cerebro- 
spinal meninj;itis  was  tbe  jironiinent  condition,  and  to  this  the  tri^atnuMit  was  mainly  directed,  t!ie  remote  and  excit  in;; 
canse  beinj;,  however,  kept  in  view.  l!nt  tbe  patit'iit  died  exliausted  in  a  few  days.  'I'lie  second  ease  partook  more 
of  the  typhoid  conilition  and  the  delirium  was  of  the  nsiial  character.  He  also  died  in  an  i'i|iially  short  s])ace.  A 
third  man  recovered,  Imt  I  am  satisfied  his  constitution  is  permanently  hri]iaired.  He  is  still  in  the  reirimeni  and 
tinder  observation,  being  on  lisht  duty  only.  I  should  have  mentioned  that  the  daily  exacerbations  in  each  case, 
varied  considerably.  In  the  first  there  was  violent  didiiinm.  almost  maniacal;  in  the  second  a-men^  shudder  with 
low  mntterinir;  and  iu  the  third  a  convulsive  tremor,  with  };nrj;linj;  in  the  throat  and  a  hissini;  expiration  accom- 
panied by  the  expulsion  of  some  frothy  niucns  between  the  teeth. 

On  the  other  hand  Ass't  Surg.  J.  T.  Caliku-.v,  U.  S.  A.,  1)c'heved  the  fevers  of  the 
Peninsula  to  be  not  enteric  but  niiasniatic,  tiiiJ  appropriately  denominated  ty}iho-inahx- 
riah*  "The  form  of  fever  tei'med  by  tlie  negroes  swamp  fever,  but  whielt  should  be  hnown, 
perhaps,  in  scientific  nosoloifv  as  tvpho-malarial  ['wcv.  was  vory  frequent. "f  Dr.  Cal- 
houn bore  testimony  also  to  the  absence  of  intestinal  glandular  lesions  in  certtiin  tidviiivmic 
fevers.  J 

Siirjiroii  J.  M.  Kick,  2'>th  Mass.,  ycir  i:ir)ii\  \.  ('..  Mari'li  10.  llSCili. — 'I'he  intermittents,  unless  controlled  by  the 
administration  of  ciiiclionii  or  other  anf  ipi'i  IimIIcs,  passi'd  into  ninilleiit,  .'iiid  the  remittents  fre(inently  assnnu'd 
that  tyjie  of  disease  now  mimed  in  our  reports  ty|dio-inalaiial.  In  the  ((iiMmenccment  there  was  usually  cepliill- 
alfjia;  pain  in  the  eyes;  severe  achiiif;  (lain  in  tbe  back  :\'\i\  limbs,  very  noticeable  ev(Mi  in  the  milder  cases;  soino- 
times  nan.sea  !ind  vomitinj;:  S''"i''''ill.v  slii;hl  ilesire  for  food.  The  cMuidition  of  tlie  bowels  was  variable — diarrhiea 
when  present  beiiifj  reaiUl.v  controlled.  Diirini;  the  remissions  the  debility  wa.s  i|uile  marked,  with  iiKUsjiosition  to 
the  slijibtest  exertion.  In  a  number  of  cases  I  had  the  most  satisfactory  evidence  th.'it  the  production  of  cinchonism 
cut  short  the  disease  in  its  early  staj^es,  and,  as  it  apjipared  to  nie,  without  causiii^i  any  unsatisfactory  result  when 
this  was  not  accomplished.  In  some  cases  there  was  a  tendency  to  the  congestive^  form,  anil  this,  when  occiirrinj]; 
in  those  debilitated  i»y  ffei|ueiit  attacks  of  intermittent  or  by  recent  rernittenis,  w;is  always  daiifjerous  and  in  some 
instances  fatal.  Xearly  all  were  remarkable  for  the  loii^  and  unsatisfactory  period  of  cinivalescence.  Treatiiiont 
consisted  of  meiciiiials  eoniblneil  with  other  cathartics;  sometimes  emetics:  counter-irritation  when  re(|iiired:  the 
exhibition  ol  liuiiiine  in  tiill  doses  in  the  early  reinissioiis;  diaphoretics  dnriiij;  tlie  febrile  paroxysms,  accompanied 
with  a  dry  skin,  and  later  in  the  disease  (juinine  in  sniall  doses,  with  stimulants  when  needed. 

V>\\t  jierliaps  the  strongest  evidence  of  the  undetermined  value  attached  to  the  term 
typho-malaritd  bv  our  medical  officers  is  afforded  by  a  report  of  Surgeon  George  A.  Otis, 
afterwttrds  Ibr  manv  years  the  colleiigue  of  Dr.  ^Voodward  iu  tlie  preparation  of  this  history: 

Hiiiiurks  on  1hc  Moiithhi  Hijwi-t  of  Siiryivii  Of.ohce  A.  Oris,  2~th  .Vii.w.,  JN'cic  licnw,  X.  C.,June,  18(!.'i. — There  were 
three  cases  of  typho-malarial  fever  (so-called) — cases  in  which  it  was  impracticable  for  mo  to  decide  whether  the 
disease  should  bo  pronounced  remittent  or  typhoid  fever.  One  (Hall)  entered  on  the  2l8t  instant  with  liijjh  fever, 
deliriiiiu,  excessive  prostration.  He  had  been  reported  at  surgeon's  call  for  ten  or  twelve  days  previously  with  diar- 
rhiea, but  his  bowels  were  confined  when  he  was  admitted.  There  was  abdominal  tenderness,  especially  near  the 
ca'ciim.  There  was  no  remission  in  his  fever,  and  the  administration  of  (juinine  was  not  ventured  upon,  for  signs  of 
rapid  sinking  were  sjieedily  noticed.  He  died  three  days  after  admission.  It  was  not  practicable  to  make  an  autopsy. 
The  other  fatal  case  was  similar  in  many  respects,  save  that  the  cerebral  complications  were  less  prominent.  Although 
a  remission  was  anxiously  looked  for,  none  could  be  detected.  At  last  tentative  doses  of  quinine  were  given.  They 
did  not  apparently  aggriivatc  the  symptoms,  but  they  failed  to  relieve  any  of  them  appreciably.  In  the  third  case, 
the  only  one  of  recovery,  quinine  was  administered  before  an  absolute  remission  was  observed.  The  next  day  there 
was  a  fair  remission,  and  the  antiperiodic  was  given  immediately  in  full  doses  with  the  happiest  eft'ect. 

Tliis  al)lo  officer  made  use  of  the  term  one  year  after  its  introduction,  not  as  embodying 
his  views  of  the  pathology  of  the  febrile  cases,  but  as  indicating  his  inability  to  discriminate 
betweena  typhoid  modified  by  malarial  manifestations  and  a  remittent  with  typhoid  symptoms. 

The  general  acceptance  of  the  term  typho-malarial  fever,  as  indicated  by  the  large  number 
of  cases  reported  under  it,  shows  niiinifestly  that  it  filled  a  nosonomial  want  which  had  been 
sorely  felt.     It  may  be  fairly  claimed  that  it  was  made  use  of  in  all  febrile  cases  not  purely 

*  In  Ills  roiinrt,  p.  'Jl,  .\piwndix,  Part  1st.  f  Oi).  cU.,  p.  02, 

X  In  tlio  ^f^^ll.  and  Sur/j.  I2'-pi>rtiT,  Vol.  X.  Philu.,  tStvi,  p.  (17,  lif  siiTS  tliiit  licsiiU'S  I'ast^rt  i)f  pinv  i-nt'-ri.'  fi-vi-r  wlik-li  ilitTtTfil  in  nn  inaniur  fruin  tliusi^ 
seen  in  civil  life,  tliere  frequently  oei-iirrcil  ejisi-a  uf  an  jiiiynjimir  fever  in  wliieli  tliero  were  inp  enterii:  syin])t(inis,  im  ruse-enlureil  sputy  and  iiu  epistaxin; 
ami  ill  tUot*c poiU-}iu>r(e}ii  e.xamiluition  fuili^il  to  reveal  any  uleeratiuu  itr  cliun^e  nf  wtruetlire  in  the  glanits  ui  IVyer. 


0/-i  POST-MOKTEM    RFX'OKPR    OF 

enteric,  wliicli  presented  tlie  so-calk'J  ty})lioi(l  svmjitonH,  liv  tli^se  wlio  regarded  sueli  symp- 
toms as  indicative  of  enteric  fever,  by  those  wlio  ix'garded  tlimi  as  developed  during  tlie 
porsistence  of  a  malarial  fever  irrespective  of  the  })res(Mice  of  iyplmld,  and  lastly,  l)y  those 
who,  in  the  absence  of  post-mnrtcm  investigation  in  individual  cases,  were  ready,  like  Dr. 
Otis,  to  confess  their  inability  to  determine  whether  a  specific  typlioid  element  was  or  was 
not  present. 

From  the  frequency  wdth  wdiich  ulceration  of  Peyer's  patches  was  found  in  the  posf- 
viortem  researches  conducted  at  the  gciKM-al  hospitals,  tlic  officers  forming  the  stafT  of  these 
institutions  verv  generally  concluded  that  tlie  prevailing  fevers  of  the  Army  were  essentially 
typhoid.  The  cases  which  occasionally  presented  an  unaltered  intestinal  uuicous  membrane, 
or  one  changed  only  by  an  apparently  unspecific  congestion,  were  accepted  as  showing  that 
death  had  resulted  from  the  malarial  influences  to  which  our  troops  were  almost  constantly 
exposed.  I>ut  these  cases,  as  has  already  been  explained,  seldom  lived  to  reach  the  gen- 
eral hospitals,  or  if  they  did  so  died  subsequently,  not  from  tlie  primary  fever,  but  from 
secondary  pneumonic  or  intestinal  complications,  the  latter  of  which  offered  to  view  exten- 
sive ulcerations  of  the  intestines  simulating  the  appearances  of  typlioid  fever.  Typho-mala- 
rial  fever,  therefore,  to  the  medical  officers  of  these  hospitals  generallv,  implied  an  enteric 
lesion.  Positive  results  were  obtained  at  the  neerripsies,  and  specimens  were  fi>i'warded  to 
the  Army  Medical  Museum  in  such  nunibers  as  seemed  to  the  pathological  anatomist  to 
leave  no  doubt  of  the  character  of  the  prevailing  fever. 

But  fatality  and  prevalence  are  not  synonymous.  Fevers  presenting  ulceration  of  the 
small  intestine,  and  particularly  of  its  closed  glands,  certainly  occasioned  more  deaths  than 
tliose  unassociated  with  such  anatomical  changes,  but  the  universal  testimony  of  the  medical 
men  who  treated  the  fever  cases  that  recovered  or  died  at  an  early  [ieri<xl  after  the  onset  of 
the  disease,  is  to  the  efTect  that  the  pi'evailing  fevers  were  essentially  paroxysmal.  The 
hospital  pathologists  did  not  give  due  weight  to  these  assertions.  They  found  that  the  field 
surgeons  re))orted  large  numbers  of  ty[)]io-malarial  cases,  and  assuming  that  these  cases  were 
characterized  by  pathological  conditions  similar  to  those  with  which  their  experience  had 
made  them  famdiar,  they  conceived  their  view  of  the  enteric  nature  of  the  fevers  reported 
as  typho-malarial  to  be  correct  because  based  upon  post-mortevi  research  instead  of  on  synip- 
tomatology  and  therapeusis. 

But,  as  has  been  indicated  by  certain  of  the post-nwrtcm  records  of  typho-malarial  cases, 
this  term  was  applied  by  the  field  surgeons  to  fevers  which  in  its  absence  would  have  been 
returned  as  malarial  remittents.  Inasmuch  as  no  instructions  had  been  issued  limiting  the 
applicability  of  the  term  to  enteric  fever  with  malarial  complications,  these  officers  were 
fully  justified  in  including  under  it  those  malarial  cases  which  had  typhoid,  i.  e.,  adynamic 
tendencies,  particularly  as  there  was  nothing  in  the  first  part  of  the  compouml  term  to  limit 
its  significance  to  one  specific  cause  of  typhoidal  syin[.)toms.  Undoubtedly,  also,  the  new 
term  was  accepted  by  many  as  enabling  them  to  dispose  of  their  anomalous  cases  without 
committing  themselves  to  certain  etiological  ami  pathological  doctrines. 

The  pathologists  were  therefore  in  error  in  supposing  that  enteric  fever  was  present  in 
all  the  cases  reported  as  typho-malarial  by  our  medical  officers.  This  view  is  sustained  by 
a  study  of  the  monthly  changes  in  the  curve  of  prevalence;  and  on  it  only  can  the  sin- 
gular death-rate  of  typho-malarial  fever  be  understood.  It  has  be(.'n  shown  by  the  records 
of  the  Seminary  hospital  that  the  fatality  of  typhoid  cases  which  were  complicated  witli 


TTIE    CONTTXT-KD    FF.Vr.r.>:.  375 


active  uiauil'rstatiniis  ul'  tlic  malarial  iriflueiire  was  niucli  u'reatcr  lliaii  (liaL  of  uiieoinpli- 
cateJ  ca^es:  ami  such  a  result  is  consistent  with  our  >j.viieral  expci'ieiictt  of  the  action  of 
laorhific  au'ciicies  on  the  system,  especially  when  these  ageiieies  have  similar  (.lestructive 
ten<lcin-i(.^;.  ]]nt  the  statistics  of  the  white  troojis  shuw  that  altluiugh  the  mortality  causeil  l>v 
typhuid  subsequent  to  the  introduction  of  the  new  terin  was  -10  per  cent,  of  the  cases,  the 
latality  of  the  cases  reported  as  typho-malai'ial  was  oidv  S  per  cent.  This  is  convim-iu^ 
proof  that  the  medical  ofHcers  who  placed  these  cases  on  the  monthlv  reports  did  not 
restrict  the  term  to  cases  in  which  there  was  a  coincidence  of  both  fevers.  Had  thev 
done  so  an  antagonism  between  the  action  of  the  typhoid  and  malarial  poisons  on  the  human 
system  would  have  been  immediately  established.  But  there  was  no  evidence  of  an  antag- 
onism of  this  character.  On  the  conti'ary,  typhoid  lever  was  deadly  in  jiroportion  to  it.s 
modilication  by  other  deteriorating  agencies,  chief  among  which  was  the  malarial  influence. ==' 

In  true  typho-malarial  fever  at  least  41.4  per  cent,  of  cases  among  the  white  troops 
should  have  terminated  fatally,  since  typhoid  gave  40  per  cent,  of  fatality  and  remittents 
1.4  per  cent,  from  June  30,  1862,  to  the  end  of  the  period  covered  by  the  statistics.  But 
as  tlie  cases  reported  under  the  term  typlio-malarial  were  fatal  at  the  rate  of  only  <S  per  cent., 
it  may  be  inferred  that  for  one  case  thus  reported  which  was  really  characterized  l>y  the 
specific  typhoid  element,  there  were  4.85  cases  which  could  not  have  been  typhoid  as  they 
lacked  its  gravity  and  were  so  amenable  to  specitic  treatment  that  they  furnished  only  the 
mortality  which  would  have  occurred  among  an  e(pial  number  of  malarial  remittents.  In 
other  Words,  83  per  cent,  of  the  cases  rejiorted  among  the  white  troops  as  typho-malarial 
were  remittents  or  febrile  attacks  attended  with  no  greater  mortality  than  the  remittents. 
Sjieaking  approximatively,  of  the  49,871  cases  thus  reported  more  than  41,393  were  remit- 
tent and  less  than  8,478  were  true  typho-malarial  cases. 

A  similar  calculation  on  corresponding  data  furnished  by  the  statistics  of  the  colored 
troops — to  wit:  Percentage  of  tvphoid  cases  whicli  ended  fatally  55.69,  of  remittents  3.27, 
of  cases  re|)orted  as  typho-malarial  17.27 — shows  that  73  p(_'r  cent,  of  the  cases  entered  on 
tin'  I'eports  under  the  new  term  were  remittents  or  febrile  attacks  whicli  had  no  larger 
mortality  than  the  malarial  remittents. 

Typhoid  fever,  including  typhus,  occasioned  daring  the  war  181  cases  of  sickness  and 
59.6  deaths  among  every  thousand  of  our  white  soldiers.  The  remittent-malarial  fevers 
caused  664  cases  and  8.2  deaths.  There  were  also  115  cases  and  8.6  deaths  attributed  to 
tvpho-malarial  fever.  But  the  cases  last  mentioned  have  been  seen  to  consist  of  one  truly 
typho-malarial  case  to  4.85  malarial  remittents.  Were  the  ty{)ho-malarial  figures  duly  dis- 
ti'ibuted  among  the  typhoid  and  the  remittent  fevers  the  former  would  number  200  per  thou- 
sand of  strength  with  67.16  deaths,  and  the  latter  759  per  thousand  with  9.24  deaths. 
There  were  thus  more  than  seven  deaths  attributable  to  tyjjhoiil  fever  for  every  death  caused 
bv  adynamic  remittent  or  other  low  fevers  not  specifically  typhoid  or  enteric.  In  other 
words,  seven  cases  of  fever  with  typhoid  sym})toms  presented  typlujid  ulcerations  for  one 
case  of  fever  with  typhoid  symptoms  which  had  no  ulceration  of  the  closed  glands.  Hence 
the  opinion  of  the  pathologists  that  a  specific  typhoid  was  the  prevalent  fever.  The  rela- 
tive prevalence  of  these  fevers  was,  however,  3.7  of  malarial  remittent  to  one  of  true 
ty[ih<'itl;   most  of  tlie  former  were  treated  in  e'ami>,  of  the  latter  in  general  hospitals.      ITen 


ce 


*  rir.  .Tas.  .1.  T.KViiK  ia  f]ir  ..iilv  ..l.sir\.i  wli...  «1iiU' cli'iiyhi^-  iiiiy  ;intaf;"Misni  I.iIm.'.mi  111.-  |...is..M  .,r  typlioid  aiM  that  nf  iiuilarial  fi-viT,  cMusiilcm 
that  th''  malarial  i'..niplii-ation  ,liil  i]<,t  acM  t..  llii>  Ki'avity  i.l'lhi-  ly|ih.iicl  siHirli"";  hut. . .11  tli.-  ..mlnirv.  it,  or  the  n'lllfdii-s  i-lii|ihi}-.-il  tiiculllrol  it,  m-c'Iiu-J 
to  riMuliT  Ihi' discas.'  nion-  tnictal.h'  ami  l.-as  fatal.— .l.u.nV,,,,  .l,„„,„il  .)?../.  S.J.,  lsi;l,  V..I.  \l.\  II,  |..  InT, 


37G 


rosT-MoirrF.M  kkcoktis  of 


tliG  opinion  of  tlio  field  surgeons  tliafc  tlie  prevailiiisj;  fevei'  was  a,  malarial  remitt(>n(.  Tliese 
figures  iiiehuli'  the  vast  luunlicr  of  tvplioiil  feVer  ciises  that  oecurreJ  after  tlio  organization 
of  tlie  volunteei'  armies.  JTail  thov  liocii  cxrluJi'il  hv  making  use  of  the  statistics  of  the 
third  year  of  th(!  war,  that  ending  June  'M).  l.S(U,  the  remittents  would  have  been  found  to 
have  oiitnumhercd  tlie  enteric  cases  in  tlie  proportion  of  (3.5  ;  1,  although  the  chances  of 
finding  typhoid  ulcerations  in  a  fatal  case  of  low  fever  would  vet  have  remained  as  high 
as  5.4  :  1.  '  ■ 

It  is  to  be  regretted  that  the  applicability  of  the  new  term  was  not  fully  explained  and 
limited  on  its  introduction.  Had  this  been  done,  the  attention  of  our  medical  officers  would 
have  been  directed  to  the  diftei'cntiation  of  typhoid  fever  with  malarial  complications  and 
remittents  with  adynamic  symptoms,  and  our  knowledge  of  this  clinically  obscure  sul)jcct 
would  have  been  materiallv  improved.  As  it  was,  the  new  term  was  productive  of  unde- 
sirable results.  It  dissociated  cases  of  typhoid  and  malarial  fevers  from  their  etiological, 
pathological  and  therapeutic  associates,  thus  injuring  the  totality  of  the  statistics  of  both 
the  classes,  and  massed  them  in  uncertain  proportions  in  a  separate  group  which  could  be 
analysed  only  at  the  close  of  the  war  on  tlie  presentation  of  all  the  materials  relating  to  it. 
Instead  of  conducing  to  disciimination  and  simplification  in  the  study  of  the  camp  fevers 
its  use  tended  to  admixture  and  confusion.  It  appears,  also,  to  have  been  responsible  for 
the  lack  of  material  illustrative  of  itself,  as  by  affording  a  local  habitation  and  a  name  to 
obscure  cases  it  relieved  medical  officers  from  the  official  necessity  of  maturely  conslilering 
them  prior  to  formulating  a  diagnosis  or  of  entering  into  the  details  of  their  peculiaritie's  and 
difficulties.  ^Moreover,  the  term  was  cariieil  by  our  medical  men  into  civil  practice  at  the 
close  of  the  war,  where  it  has  pei'petuated  the  uneeiiainties  atl;iching  to  tlie  castas  that  have 
been  classed  under  it.''' 

But  wliile  the  cases  reported  under  the  heading  typho-malarial  comprised  so  snudl  a 
proportion  of  such  as  Avere  really  typho-malarial  in  the  views  of  the  originator  of  the  term, 
it  by  no  means  follows  that  true  typho-malarial  fever  was  a  rare  occurrence  in  our  camps. 
On  the  contrary,  it  may  be  said  with  certainty  that  it  occurred  with  greater  frequencv  than 
unmodified  typhoid;  and  owing  to  its  tedious  and  uncertain  course,  the  typhoid  aftection 
being  often  prolonged  by  pn-ellniinary  malarial  attacks,  and  the  return  to  health  interrupted 
by  relapses  of  the  malarial  essential  or  prevented  by  the  development  of  diari'lueal,  dvsen- 
teric,  pneumonic  or  other  sequehe  common  to  botli  its  elements,  it  assumed  prominence 
among  the  fevers  of  our  camps  as  Ijeing  the  most  destructive  to  the  army  as  \vr]]  as  to  the 
life  of  the  individual,  although  by  no  means  the  most  prevalent  fever. 

In  the  early  months  of  the  war  typhoid  fever  was  to  be  expected  from  the  aggregation 
of  young  and  susceptible  subjects  under  unhygienic  conditions.  But  as  the  men  at  this 
time  had  not  become  so  thoroughly  aft'ected  by  the  malarial  poison  as  was  the  case  at  a  later 
date,  their  typhoid  e[iideinics  ought  to  have  been  of  a  conijiaratively  unmodified  character. 
Nevertheless  it  has  been  shown  liv  the  ehnical  records  of  the  Keminary  h(jspital  that  many 
of  the  cases  which  then  occurred  were  distinctly  impressed  by  the  malarial  poison  and  on 
that  account  entitled  to  be  ranked  as  typho-malarial  fevers.  Later  in  the  war  the  t're(|uency 
of  such  cases  undoubtedly  increased,  but  as  tlie  tvphoid  element  was  recognized  by  some 
symptom  regarded  as  pathognomonic  or  by  prM-niortem  observation  in  a  sample  case  of 
the  series,  the  fever  was  reported  as  typhoid  and  not  as  typho-malarial.     It  is  impossible  to 

*  Seo  page  .'iOfl,  mfra. 


THE   COXTINUKD   fkvj-:rs.  377 

say  liow  many  of  tlio>e  so  ropoi'ted  were  modll'ii'd  In'  malarial  iiilluences,  but  tlio  munlK/r 
must  liavi.'  lircn  vi-rv  lii'<;':U.  J^r.  Wmopwaimi  was  cdrrfct  in  nssiii-niui:;  iniportanco  i<i  tlio 
true  tvplio-malarial  trvrrs.  but  lie  eriiil  iu  ri^i'ar'linL;'  iIm'  numlu-rs  ropoiTcil  umltT  the  tv[>lio- 
malanal  licailiiii;' as  i^-ivuiij;  i'X]iri's>i(.n  t<i  tliat  imjM.i-iaiuH'.  Tlic  true  t\'[iliii malarial  casrs 
were  usually  rc}>ort(.'(.l  undrr  the  term  IvjiIimkI.  The  sanitary  ri'[)(irts  imlicalo  that  wluai 
tyiilioitl  liocamo  ojiiJemic  among-  men  on  ilutv  in  a  malarious  scrtion  the  diseaso  d\d  not 
present  the  characteristics  comnion  to  it  in  the  civil  jiojiulation  of  the  Northern  t^tates. 
Only  in  retiimonts  newlv  levied  and  as  vet  unexposed  to  malarial  intluences  was  the  tvphoid 
disease  similar  to  that  with  which  their  medical  olHcers  had  been  familiar  in  civil  life.  In 
tlie  first-mentioned  connnands  the  disease  was  alwavs  of  a  li'rave  character;  wlule  in  those 
last  referred  to  the  mortality  from  tvphoid  was  ^-enerall}-  light,  in  some  instances  a  hundred 
cases  having  been  i-e]iorted  with  oidv  a  few  deaths.  Corresp(,indingly  the  rate  of  I'atalitv  of 
tv}>hoid  was  only  18.8  per  cent,  among  the  while  troops  during  the  lirst  eight  months  of  the 
war,  while  it  rose  later,  as  the  disease  became  modified,  to  an  average  of  38.0  per  cent.  The 
greater  fatality  during  tlie  later  years  may  not  lie  wholly  attributed  to  the  malarial  iniliienee, 
1)ut  that  it  was  due  \n  part  to  this  is  obvious  from  the  evidence  already  presented.  These 
considerations  imjily  a  relative  paucity  of  cases  of  unmoililled  tvphoid  lever  and  a  large 
proportion  of  cases^which,  had  the  term  t v}iho-malai'ial  been  jiroperlv  applied,  would  have 
lioen  dropped  from  the  re]»orts  as  typhoid  and  recorded  as  typho-malarial. 

It  has  been  shown  that  the  cases  rejiorted  as  typho-malarial  were  chiefly  composed  of 
malarial  remittents  with  a  comparatively  small  percentage  of  true  tvpho-mahirial  cases.  It 
has  been  shown  also  that  of  the  ca<es  re]>orted  as  tyjihoid  the  majority  were  reallv  coiiipli- 
eated  with  malarial  phenomena,  and  were  thus  in  fict  typho-malarial  cases,  while  the  mil  ion  t  v 
Were  cases  (jf  unmodiiied  fvphoid.  \]\\\  among  those  re] >orted  as  typhoid  was  another  group 
in  which  typhoid  symptoms  wei'e  associated  with  no  anatomical  lesions  other  than  those 
attributable  to  the  action  of  the  mahu'ial  poison.  In  other  words,  adynamic  remittents  and 
malarial  levers  assuming  a  sulvcontinued  form  and  ty})lioiilal  tend(Micy.  while  forming  the 
mas>  ol  the  eases  reported  as  typho-malarial,  constituted  also  a  portion  of  those  fevers  reported 
as  typhoid.  The  f  illowing  series  of  cases  will  amply  sustain  the  latter  part  of  this  state- 
ment. In  most  of  these  there  is  no  clinical  history  to  show  wdiat  were  the  symptoms  during 
life,  but  the  diagnosis  presumes  the  existence  of  more  or  less  of  the  so-called  typhoid  symp- 
toms, wliih^  in  a  minority  of  the  cases  some  of  these  tvphoid  symptoms  are  spe<-iHtvl.  A 
certain  number  of  these  cases,  so  far  as  can  be  learned  from  tlie  yin-'^t-riiorteiii  records,  were 
instances  of  pure  typhoid;  others  were  instances  of  true  tvplio-malarial  fever;  but  a  third 
set,  comprising  no  inconsiderable  number,  were  cases  which  offered  to  view  no  other  lesion 
than  those  which  have  been  construed  as  indicating  the  presence  of  malarial  disease.  These 
cases,  like  those  which  preceded  them,  have  been  arranged  for  convenience  of  study  in 
accordance  with  tlu'  character  and  situation  of  the  chang(\s  in  the  intestinal  canal: 

Cases  keportkd  as  Typhoii)  Feveh,  the  clinical  iiistouy  ixst  ti-icient  ou  ahsent — ISi'  cases. 
(A.)  I'riio'ii patclus  iikcnilid  (tiid  tlu:  ilciiiii  or  miiall  hitisliiii'  onJij  tiffictvd — 13  cumn. 

Case  117. — Private  Lovi  St'liietz.  Co.  I,  ITtli  I'a..  was  adniitti'd  April  3,  18(il,  with  a  liot  ami  dry  .sl<iii.  brown, 
dry  and  craclctd  touitne  and  lips,  slijflitly  dilated  pupils,  <|uiok  pnlso,  112  to  VH),  and  inntterini;  ileliriuni.  Two  days 
thereafter,  under  the  inlhieiiee  of  small  doses  of  turpentine  and  laudanum,  the  delirium  subsidcil.  the  ton;;ue  became 
somewhat  moist  and  tlie  ])ulse  fell  to  10(1-112;  but  the  jni]iroveinent  was  only  temporary, — diarrlirea  set  in  and  the 
skin  over  the  sacrnm  beeame  painful  and  reddened.  He  died  ou  the  11th.  Post-niDiii m  examination  liffeeu  hours 
after  death:  "Slijrht  ulceration  but  e.\tensive  inllamniation  of  I'eyer's  patches;  also  a  slii;ht  de,i;ree  of  araclinitis.'' 
— Jet.  Jss't  Siirij.  Chttrhn  Ciirtir,  Turner's  Lane  llos})it(il,  I'hiUuh  Iphia,  I'd. 
Med.  Hlst.,  Pt.  Ill— 48 


378  POST-MORTEM    P.F.f'ORDP    Op 

Cask  1  IS. — I'i-is;ito  lli!iiry  H.  Wliitni'V,  Co.  D,  53(1  Muss.,  was  udiiiittcil  An^'.  1(5,  18ti;i,  hnviiif;  Ikmmi  sii'k  a  wook 
with  (liaiiliii-a,  f^roat  [irdstration.  <liy  and  i'liirt'd  tongue,  soidi.'.s  on  teeth,  siidaniina  on  abdomen  and  chest,  snll'iision 
of  face  and  t}'ini)anites  of  abdomen,  (i.ive  heef-tea  and  sherry  wine.  liUh:  Severe  chill.  20th:  Mnmiis;  pulse  110. 
([uieU  and  feeble.  21st:  (ireat  (irostiation ;  rusty  sputa;  creijitant  rales;  death.  /'DsZ-mor/cm  examination  ten  Iionrs 
after  deatli:  I'.otli  lunj;s  eonj;ested  posteriorly  and  ]iartly  adherent  to  thoracic  walls,  with  slight  effusion  into  eacli 
jileural  cavity;  heart  healthy;  stomach  much  <listended;  bowels  purple-spotted  on  their  serous  surface;  I'l'ver's 
]>atchcs  in  several  iiistaii<:es  proniiuent,  much  ccuigested  and  slightly  ulcerated. —  I'liion  Hospital,  .Urm/i// /•>.•,  '/'(»». 

Cask  U'.I. —  Private  .loliii  II.  Jieckwith,  Co.  C,  Tilth  N.  Y.;  age  33;  admitted  Juno  (!,  1805.  Diagnosis — ty|ihoid 
fever.  Died  2t>th.  The  only  symptoms  mentioned  are  delirium,  almost  constant,  and  uiucli  jactitation,  rdxl-iiiortcin 
examination  twelve  houis  after  death :  l.ungs  adlierent  to  pleur:e  by  til)rinou8  bands;  spleen  enlarged  and  8oftene<l: 
Peyer's  patches  ulcerated. — SU))i()li  IIi)n}iit<tl,  Ahxamlria,  I'd. 

Cask  120. — Private  Robert  liooth,  Co.  A,  MTth  Pa.;  age  21 ;  was  admitted  Xov.  I,  18t>3,  delirious,  witli  dry  tongue 
and  sordes,  and  on  the  second  day  after  admission  involuntary  discharges  from  the  bowels,  lie  died  on  the  13th. 
I'Dxt-mortcm  examination  showed  "  that  condition  of  the  intestinal  glands  usually  found  in  typhoid  eases." — .It/.  .ls«V 
Surij.  JamiH  Eohertiion,  1st  Divimon  Honpilul,  Alejcundriii,  I'a. 

Cask  121.— Private  Albert  Gratf,Co.D,4th  X.  Y.,  was  admitted  X'ov.  30, 1801,  with  typhoid  fever,  much  exhausted 
by  his  journey  from  City  I'oint,  Va.  His  tongue  was  dry  and  brown,  teeth  covered  with  sordes,  bowels  teinler;  lu^ 
was  affected  with  low  delirium  and  subsnltus.  Ife  died  December  3,  having  had  involuntary  fa'cal  pass:iges  and 
retention  of  urine  for  twenty-four  hours  before  death.  Post-murttm  examination:  Extensive  ulceration  of  Peyer's 
patches. — Third  DiviKion  IIonj)itul,  Alexandria,  I'a. 

Ca.se  122.— Private  Aaron  T.Ward, Co.  ]i,20thMe.;  age  25;  was  admitted  Oct.  29, 18t)2,  with  diarrlin-a  following 
typhoid  fever.  He  was  feeble  and  emaciated:  the  stools  were  generally  natural  in  color,  but  liquid  and  occasionally 
streaked  with  blood.  On  November  11,  the  diarrhoea  still  continuing,  he  was  attacked  with  diphtheria  characterized 
by  suffocative  paroxysms;  he  died  next  day.  I'dxt-mortrin  examination  eighteen  hours  aftc^r  death:  The  larynx  was 
(edematous  and  lined  with  pseudo-uu'nibrane.  The  lungs  were  congested.  The  heart  was  normal,  its  right  ventrieh^ 
fille(l  with  a  larg(^  firm  clot.  The  stomach,  liver  and  kidneys  were  normal.  The  glands  of  Uriinner  were  enlarged; 
Peyer's  glands  thickened  and  in  the  lower  portion  of  the  ileum  ulcerated.^ T/iirrf  l)irinioii  Hoxpital,  Alexandria,  Va. 

Ca.se  123.— Private  William  Martin,  Co.  M,  17th  Pa.;  age  23;  was  admitted  July  10,  1863,  delirious  and  with  a 
liot  and  dry  skin,  freijnent  and  feeble  pulse,  dry  and  brown  tongue,  tender  bowels  and  some  diarrlnea.  He  died  on 
the  21st.  1'ii.it-mortem  examination  twenty-fmir  hours  after  death :  Mucous  membrane  of  the  small  intestine  inflamed  : 
glands  of  Peyer  ulcerated ;  mcscfiteric  glands  etilarged ;  lower  lobes  of  both  lungs  congested ;  heart  and  liver  normal. 
— Aet.  Aas'l  Surg.  S.  Upnon,  Third  Divinion  Uospilal,  Alexandria,  I'a. 

Case  121.— Corp'l  Charles  S.  Benedict,  Co.  B,  144th  X.  Y  ,  was  admitted  April  14,  18G3,  moribund:  Pulse  130, 
very  feelile;  resjiiratiou  28;  tongue  dry,  brown,  cracked;  bowels  relaxed;  skin  moist;  extrenuties  cold,  clammy. 
He  died  next  day.  I'usi-iiinrUm  examination  twenty-four  hours  after  death:  Mucous  membrane  of  larger  bronchi 
abnoruuilly  red:  liver  and  si)leen  enlarged  and  softened:  stomach  injected;  nnicous  membrane  of  snuill  intestine 
much  injected:  Peyer's  patclies  enlarged,  some  deeply  ulcerated. — Third  Dirixion  Ili/xpifal,  Alexandria,  Va. 

Case  125. — Private  Anthony  Duchey,  Co.  C,  iy5th  Ohio;  age  18;  was  admitted  xipril  G,  1865,  much  emaciated 
and  very  weak,  his  mind  much  imjiaired.  A  number  of  small  abscesses  on  his  thighs  and  legs,  on  being  punctured, 
discharged  a  (luantity  of  thin  milky  pus.  Ho  had  a  large  deep  bedsore  over  the  sacrum  and  one  over  each  trochanter, 
great  thirst,  anorexia  and  a  red,  dry,  transvensely  fissured  tongue.  He  died  on  the  24th.  Post-mortem  examination 
four  hours  after  death:  Large  deposits  of  pus  were  found  beneath  the  skin  and  between  the  muscles  of  the  lower 
extremities;  the  right  parotid  gland  was  infiltrated  with  pus.  The  liver  adhered  to  the  diaphragm  and  the  abdom- 
inal parietes;  its  sulistance  was  soft(^ne(l;  the  gall-l)lad(ler  was  enormously  distended  with  bhKtk  bile;  the  spleen  was 
enlarged  and  softened.  The  st(Uiiach  was  contracted  and  its  mucous  nu'inbrane  inflamed;  the  ileum  inflamed  and 
Peyer's  patches  ulcerated. — Aet.  Ass't  Surg.  S.  B.  West,  Cnmberlund  Hospital,  Aid. 

Case  126.— Private  John  S.Hall,  17th  Ind.  Bat'y;  ago  18;  was  admitted  Nov.  10.  1862,  with  typhoid  fever,  and 
died  on  the  20th.  I'ost-mortem  examination:  The  only  lesion  found  was  an  extensive  inflammation  and  ulceration  of 
Peyer's  patches. — Ass't  Surg.  H.  Pierce,  I'jOth  X.  }'.,  Stewart's  Mansion  Hospital,  liultimore,  Md. 

Ca.sk  127. — Private  AVilliam  O'Brien,  Co.  D,  38th  Mass.;  age  19;  was  admitted  Nov.  5,  1862,  with  typhoid 
fever,  and  died  on  the  9th.  I'Dst-morteni  examination:  Heart,  lungs,  stomach,  liver  and  kidneys  normal;  inflamma- 
tion of  Peyer's  glands:  intu.ssusception  in  the  middle  third  of  the  ileum. — Act.  Ass't  Surg.  T.  F.  Murdoch,  Stewart's 
Mansion  Uospital,  Baltimore,  Md. 

Ca.se  128.— Private  Patrick  Farnu>r,  Co.  B,  38th  Mass,,  was  admitted  Oct.  7,  1864,  from  City  Point,  Va.,  with 
tyjihoid  fever,  and  died  next.  day.  Post-mortem  examination  sixteen  hours  after  death:  Ulceration  of  Peyer's  glands; 
nuicli  pleuritic  ctl'usion. — Aet,  Ass't  Surg.  John  T.  Myers,  Birerhj  Hospital,  X.  J. 

Cask  129.— Private  William  J.  Roberts,  26th  Ohio  Bat'y;  age  22;  was  admitted  Nov.  29,  IWil,  with  typhoid 
fever.  He  died  December  10.  Post-mortem  examination  twenty  hours  after  death:  The  spleen  weighed  thirty-four 
ounces;  Peyer's  glands  were  inflamed  and  ulcerated  throughout  the  ileum  and  for  .some  distance  up  in  the  j(>jununi. 
— Xatelie::  Hospital,  Miss. 

Cask  130.— Private  John  Prall,  Co.  K,  KiOth  Oliio;  age  22;  was  admitted  Aug.  29,  1864,  greatly  prostiated 
and  alnujst  unconscious.  He  died  next  day.  Post-mortem  examination:  Extensive  ulceration  of  Peyer's  patehtis  and 
ati  intussusception  of  one  portion  of  the  ileum. — Seminary  Hospital,  Columbus,  Ohio. 


TITK.CONTTNrKP    FKVKTtS.  379 

Case  im.— Privato  Joiiatliaii  Tloamaii,  Co.  IT.  r.Ttli  V:i.:  adniittnl  April  30.  18(!l.  Diod  Jfay  TO.  rnnt-mortnn 
oxaiiiiiiatioii  twi'iity  lioiirs  altrr  (leatli:  I^ody  iiuicli  I'liiaciatcd.  l,iiiij;s  and  sjdci'ii  ('(>iijj;csted ;  rpyci".s  glands  iik'er- 
atcd. — .((7.  Jk*'/  Siiry.  C.  fC.  FiUmorc,  Han  iniiid  JJoi]iil(il.  Il'dnliiiiiiloii.  1>.  ('. 

(ASF.  1Ml>.— rii\  ate  J.)seidi  J.  Koi'd,  Co.  I!.  Nth  111.  Cav.:  admitted  Ajiril  H!,  Ixiil.  Tviilioiil  IVver.  l>ifd  May  •!. 
I'lisliiiiiiltiii  fxaiiiiiiatidii  five.  Iiimi-s  al'tor  death:  liody  slightly  ciiiaciatcd.  The  Iciwei-  loin- <it"  the  left  lung  and  the 
lower  liorder  of  the  right  Iiiiig  were  much  congested  and  sank  in  \vat<'r.  The  heart  was  normal.  The  livi'r  was 
sliglitly  enlarged  :  the  gall-hladder  full;  the  spleen  much  congest eil,  weighing  tort y-one  ounces:  l'i>yer"s  patches  were 
enlarged  and  many  of  them  ulcerated:  the  mesenteric  glands  were  much  enlarged. — ./<•/.  ./»»'/  Siirij.  .1.  I>.  I.iiiloii.  llnn- 
wnttd  Unsjiitdl.  Wii^hhii/lnn.  1>.  C. 

Cask  lij:!. — Pri\  ate  Jno.  1  lender.  Co.  C,  tlTth  I'a.,  was  a<lmilted  May  10,  lsi;."i,  with  typhoid  Icmm',  and  died  mxt 
day.  /'().v/-(HO)-/cw  examination  Iweiity-eight  hours  after  death :  Knngs  normal ;  heart  pale;  liver  |)ale;  spleen  much 
enlarged  ;  IVyer's  patches  ulcerated  ;  kidiu'ys  normal. — Ihpol  F'lrhl  //d.vy/i/d/,  S'ulU  Aniiji  ('orin-,  Aniii/  n/  ruliiiiuu: 

Case  1;!1.— Private  James  Mcl.oon.  Co.  K.  lOlh  N.  .1.,  was  admillcd  May  II),  l.KCri,  with  tyidioid  fever,  and  died 
on  the  18tli.  I'onl-iniirloii  exauiimition  sevenly-two  hours  afti'r  death:  l.ungs,  he:irt.  liver,  s))leen  :inil  stomach  nor- 
nuil ;  mesenteric  ghmds  enlarged  ;   I'cycr's  jiatches  ulcerated. — Ih^ml  FiiUI  Ilii!<i)il<il,  Sixlli  Army  ('iii-ji.i,  Arm;/ 1;/'  I'otiHitiic. 

Casi-.  Ilia.— I'rivati'  William  D.  Khaugh.Co.  V.  :i!Hh  Ind.:  ;ige  IS:  was  admitted  I)..c.  II,  18(;:i,  with  lyi>hoid  fever. 
an<l  died  March  L'.  IsdI.  I'lixl-iiinrttiii  examinaliou  twenty -tour  hours  alter  <lealh:  Much  emaciation  :  i>leuiitic  adlie- 
sions  on  hoth  siiles:  right  lung  hepati/ed  red  and  gray,  lidl  lung  partly  hcpati/.cd;  heart  weighed  ten  ounces;  liver 
sixty-four  ounces,  fatty;  spleen  lift  ecu  ounces  and  a  half:  right  kidney  six  ouiu'cs,  left  six  ounces  and  a  half;  mucous 
mcmlirane  of  stomach  somewhat  conircsti'd;  lower  ileum  showing  a  few  large  cicatrizing  ulcers  in  I'eyer's  ]iatches; 
large  intestine  normal. —  IliispUal  Xd.  1,  XnxlirilJc,  Tmii. 

Cask  irifi. — Private  .Jacoli  Spangles,  Co.  M,  1st  Mich.  Kng'rs,  was  ailmitled  Dec.  .f,  ISOS,  with  typhoid  fever,  and 
died  on  Ihi'  nth.  rnxt-iiioi-liiii  examination  fourteen  hours  .-it'ter  death:  Pericardium  containing  six  to  I'ight  ounci's 
of  scrum  ;  licart  lilh-d  with  huge  cadaveric  clots;  lungs  hcpal  ized  jiostcriorly,  the  right  cont.iining  a  few  hard  isolated 
tulier(des;  liver  and  ki<lneys  noiinal ;  spleen  weighing  fourteen  ounces;  nu'senteri<' ghimls  enlarged;  I'eyer's  ]patches 
ilecply  ulciMated:  stonuuh  and  large  intestine  normal;  anterior  ahdouiinal  wall  nuiih  c(Uitused  inferiorly  and  |)re- 
senting  s(une  hlood-clots  heiu'ath  the  iicritoneum. —  llnxpiliil  Xii.  1,  \iixlirilh,  'I'liiii. 

C.\SK  l."7. — Private'  A\'.  H.  SI  in  gland.  C<i.  II.  1  Ith  II.  S.  Inf..  was  admitted  .lune  1"),  ISft!,  and  died  on  the  ITtli. 
Vi>«t-iiiiiiii  III  examination  twent.v-(uie  hours  after  de.'itli:  liody  not  enuiciated.  Hrain  healthy.  -Esophageal  mucous 
membiane  yellow-tinged  and  ])resenting  su]H'i  licial  ulcers  In  its  lower  portion,  the  ulcers  liiivlng  their  greatest  <liam- 
eter  ]i,irallel  to  tlu"  axis  of  the  tnlie.  Lymphatic  glands  at  lii furcation  of  trachea  much  softened  ami  blackish;  niijier 
and  middle  lolies  of  light  lung  and  upper  lolieof  left  lung  slightly  congested,  lower  hdies  intensely  congested.  Heart 
ll.ililiy,  containing  no  clots;  jicricardium  everywhere  tirml.y  attached  to  the  heart,  obliterating  the  sac.  Liver  very 
llaldiy.  dull  greenish  in  color,  evolving  a  jiecnliar  chicken-coop  odor  and  so  soft  that  the  linger  could  be  inserted  in 
every  direction;  gall-bladder  containing  eight  drachms  of  dark  oclire-colored  bih-;  spleen  dark,  soft,  pultaceous, 
weight  seven  (unices.  Lower  fifth  of  small  intestine  ulcerated,  the  ulcers  routined  to  I'eyer's  jiatches  and  presenting 
ragged  surfaces,  puri)!isli  walls  and  congestiim  of  the  surrounding  mucous  membrane — the  patches  higher  nj)  in  the 
intestine  being  pale  and  not  elevated  or  congested.  Kidneys  congested. — Asx'l  Sunj.  Harrison  Allen,  V.  S.  A.,  Lincoln 
lloxjiiliil,  Waahingion,  1).  C. 

Case  138.— Private  Stephen  Cornwright,  18th  N.  Y.;  ago  23;  was  admitted  Xov.  30,  1801,  with  fever  and  feet 
gangrenous  from  frost-bite.  He  died  December  20.  PoHt-tnortiin  examination  two  hours  after  death:  JJody  niiich 
emaciated.  Tlie  larynx,  trachea,  U'sophagus  and  heart  were  normal.  The  right  lung  weighed  twenty-two  onnci-s 
and  the  left  thirty  ounces;  the  lower  and  middle  lobes  of  the  right  lung  and  the  lower  lobe  and  lower  ]>ortion  of  the 
up|)er  lobe  of  the  left  lung  were  solidified  and  studded  with  small  abscesses.  The  liver  weighed  seventy-one  ounces 
and  a  half  and  the  sjdeen  seven  ounces  and  a  half;  Peycr's  patches  were  ulcerated;  the  kidneys  ajipcared  to  be  nor- 
mal. ['I'he  attending  physician  remarks:  "This  man  was  admitted  with  both  feet  in  a  gangrenous  c(Uidition. 
According  to  his  own  statement  ho  had  them  frozen;  but  my  oiiinion  is  that  their  condition  was  a  result  of  his 
fever."  This  opinion  is  supi)orted  by  the  register  of  the  ho.spital  at  Giesboro  Point,  Md.,  in  which  the  patient  appears 
as  admitted  Xovember  25  with  typhoid  fever,  and  as  sent  to  General  hospital  on  the  29th.  No  reference  is  made  to 
frost-bite.] — Lincoln  IToi<pital.  TFanhintiton,  I).  C. 

Cask  139.— Private  Xatlian  Upton,  Co.  H,  1st  D.  C.  Cav.;  age  32;  was  admitted  Sept.  fi,  1803,  with  typhoid  fever, 
and  died  on  the  19th.  Foat-mortini  exaniin.'ition  eight  liours  after  death:  Kigor  mortis  well  marked.  The  brain 
substance  was  healthy;  the  pia  mater  slightly  congested;  half  a  drachm  of  fluid  was  found  in  the  ventricles.  The 
right  lung  weighed  twent.v-four  ounces,  the  left  fifteen  ounces;  the  lower  lobes  of  both  were  much  congested.  The 
right  auricle  of  the  heart  contained  .a  venous  clot  which  extemled  into  the  ventricle;  the  left  auricle  contained  .a 
small  lilirinous  clot;  the  pericardium  was  everywhere  firmly  attached  to  the  heart,  so  that  its  separation  was  almost 
impossible  without  tearing  the  muscular  tissue,  'i'he  liver  was  healthy;  the  gall-bladder  contained  three  ounces  of 
.'V  thin  straw-colored  li(|uid  ;  the  spleen  was  firm  and  dark  jiurplo  on  secti(ui.  weight  thirteen  ounces  and  a  half.  The 
mucous  membrane  of  the  stomach  was  congested.  The  small  intestine  was  health.v  in  its  ujiper  portion,  but  in  its 
lower  part  the  solitary  glands  were  enlarged  and  Peyer's  patches  ulcerated.  The  large  intestine  was  healthy.  The 
kidneys  were  congested;  weight  of  right  six  ounces  and  a  half,  of  left  seven  ounces. — Afn't  Snrg.  Harrison  Allen,  U. 
S.  A.,  Lincoln  Hospital,  Washington,  D.  C. 


oiSO  POST-:\ro?.TKM  T;K^'o^,r)^;  of 

Cask  110.— rrivnti'  f'liailos  P,.  •Boaiiis,  Co.  li,  llOtli  X.  V.:  jiko  20:  admitted  Xov.  2.'!.  18^:1:  diid  27t1i.  PosU 
mortiiii  cxaiiiiiiatiiiii  iwclvi;  boius  after  di.Mtli:  Ki^or  iiiuitis  cxtroinL'ly  iiKirked;  body  inodiM'att-ly  riiuuiaicil.  The 
l)Vaiii  was  iiiiiisMally  tiiiii  and  wci^lied  f'orty-iiino  ounces;  its  ventrieles  contained  one  draelnn  and  a  lialt'  of  lliiid. 
The  larynx,  trachea  and  ies(i|ilia^ns  wvn;  natniiil.  The  liglit  lung  weighed  (deven  ounces  and  a  half  and  the  left 
twelve  ounces;  the  lower  lol)es  were  engorgecl,  softened,  friable  and  charged  with  frothy  bronchial  secretion.  The 
lieart  was  healthy  and  contained  a  large  lil)rinon.s  clot  in  its  right  cavities;  tlie  pericardial  li(inid  was  jiale  and  nieas- 
iiri'd  fonrtccn  drachms.  Thi'  liver  was  healthy,  weight  sixty-i'ight  ounces;  the  sidccii  firm,  natural  in  si/e  and  of 
normal  color.  The  small  intestine  was  much  distended  with  air;  within  five  feet  of  the  ih'o-ca>cal  valve  its  muccnis 
membrane  was  deeiily  congested,  the  solitary  and  agminated  glands  prominent,  and  the  latter  ulcerated  in  jiarts  of 
their  surface.     The  kidneys  were  congested. — An.i'l  Siiri/.  lI.AUoi,  I'.  S.  A.,  TAiicoIii  Hnniiititl,  U'lifih'nirildn,  I).  ('. 

Cas]-,  111. — Private  Thomas  Pintler,  Co.  I[,  lliTth  N.  Y.,  was  admitted  Jan.  11,  18G3,  with  typhoid  fever,  and 
died  during  the  night.  He  came  from  Fairfax  Court  House,  \'a.,  to  Washington  in  an  amluilance  w  ithoiit  covering, 
so  that  he  was  thoroughly  chilled.  tStimulaiit.s  were  employed  without  etfeet.  Pinst-mnriein  examination:  The  tho- 
racic vLseera,  the  liver,  spleen  and  kidneys  were  normal.  The  small  intestine  was  intlaiued;  Peyer's  patches  were 
thickened  and  ulcerated;  the  solitary  glands  were  mnch  swollen,  especially  in  the  Jejnnum,  where  they  stood  out 
from  the  mucous  membrane,  attaining  the  size  of  medium-sized  shot  and  having  their  apices  pigmented  or,  in  some 
cases,  ulcerated. — lAnioln  llospiidl,  Ji'uKhiiiijIoii,  V.  C. 

C!ase  142.— Private  Milton  .Striker,  Co.  C,  188th  N.  Y.,  was  admitted  Feb.  1,  IStri,  and  died  on  tht^  .'id.  I'nxt- 
morlcin  examination:  I'pper  lobe  of  riglit  lung  hejiatized,  middle  lobe  healthy,  lower  lobe  congested,  weight  of  lung 
filty-fonr  ounces;  np|ier  lobe  of  left  lung  healthy,  lower  lobe  congested,  weight  fourteen  ounces.  H(>iiil,  normal. 
Weight  of  liver  seventy  ounces;  of  sjileen  fourteen  ounces.  Stomacli  healthy;  Peyer's  patches  and  solitary  follicles 
nlceratetl;  mesenteric  glands  enlarged.     Kidneys  healthy. — Fiflh  Annii  Corps  Fkld  IJoxpilal,  Army  of  I'dIoiiikc. 

('ase  It:!. — Private  .James  Loveland,  Co.  C,  tth  Vt.,  was  admitted  Xov.  23, 1863,  moribund.  Vnxl-moricm  exami- 
nation: Toes  and  anterior  j)ortion  of  metatarsus  of  both  feet  gangrenous.  [5/)('oi»i((is  ?!•  and  f^il,  Med.  Sect..  ,\rmy 
Medical  Museum,  constitute  the  only  record:  7i),  a  portion  of  the  ujiper  part  of  the  ileum,  shows  a  single!  oblong  and 
thickened  Peyer's  patch;  80,  a  portion  of  the  lower  part,  presents  two  thickened  and  ulcerated  patches  and  two  small 
ulcers, corresponding  Jirobably  to  solitary  follicles.] — Asu^l  Sury.  W.  Tltomnon,  V.  S.  A.jDOKijIas  Hospital,  JVaslii)ii/toii,  I).  C. 

Cask  1 11.— Private  Michael  Kennedy,  Co.  I,  32d  N.  Y.;  age  21;  was  admitted  Aug.  10, 18(12,  and  died  on  the  11th. 
rost-morhm  examimition  next  <lay:  The  body  presented  a  vigorous  ajipearance,  with  but  slight  emaciation.  Thoracic 
organs  health.v.  Liver  cirrhosed,  much  enlarged,  of  a  yellowish-brown  color  and  granular,  the  granules  about  the 
size  of  jiepper-eorns;  S])leen  enlarged,  nine  by  five  and  a  half  by  two  and  a  half  inches,  but  natunil  in  c(dor  and  con- 
sistence. Mucous  membrane  of  ileum  reddened,  the  lower  agminated  glands  thickened  and  ulceraf  I'd,  1  he  upper  unaf- 
fected. Otlii'r  organs  a])|iareutly  healthy.  ISpcchiiiiifi  (iO,  til  and  02,  Med.  Sect.,  Army  Jb'<lieal  .\Iusenni,  ulcerated 
pat<dies  and  enlarged  spleen,  are  from  this  case.] — Act.  A»i't  Siirj/.  .tonvpk  Lcidy,  Suttirlce  Jlosjiiliil,  Philattelphia,  I'd. 

Case  11.">. — Private  .Joseph  Terry,  1st  N.  J.  Cav.;  age  li';  was  admitted  Jan.  11, 1804,  in  a  state  of  low  delirium 
from  typhoid  fevi-r.  He  died  on  the  lOtli.  /'ost-mortciH  examination:  Lungs  congested;  liver  softened;  Peyer's  patches 
ulcerated. — Third  Dirisioii  llonpitut,  AUxtimlria ,  V<i. 

Case  MO. — Private  X.  (;.  Carey,  1st  X.  J.  Cav.;  age  18;  admitted  Jan.  11,  ISOl.  Diagnosis — continued  fever. 
Died  18th.  I'ont-inortem  examination:  Lower  lobe  of  left  lung  hepati/.cd ;  Peyer's  patches  ulccrate^d;  one  inch  and  a 
half  of  ileum  gangrenous. — Third  J)iriiiion  lIoi<piia\,  Ahxandria,  J'a. 

Ca.se  117. — H.  Kussell,  citizen;  colored.  Died  June  24,  180.").  ro«t-iiiortnn  examination:  The  lungs  and  heart 
were  normal.  The  sjileen  was  largt^  and  hard;  the  mesenteric  glands  enlarged.  A  series  of  elevated  Peyer's  patches 
of  all  sizes,  honey-combed  and  with  constricted  bases,  extended  from  the  ileo-canal  valve  along  the  ileum;  the  soli- 
tary glands  for  eight  or  ten  inches  from  the  valve  w  en^  ele\  ated  and  had  softened  white  centres.  [Spirimcn  .5ti5,  Med. 
Sect.,  Army  Medical  .Museum,  taken  from  this  case,  shows  also  hypcrtrophied  villi,  giving  the  ileum  a  velvety  appear- 
ance, seen  in  plate  facing  this  page.] — .Ic^.  Akk'I  ><iirij.  J)'.  C.  Minor,  L'Oiirtrturi'  JJoi^pitiil,  Ah.rti)idri(i,  Vu. 

Case  148.— Private  William  T.  liarrett,  Co.  K,  3ilth  Mass.,  was  admitted  Dec.  24,  18G2,  with  typhoid  fevi^r. 
lironchitis  set  in  about  a  week  before  his  death,  w  hich  occurred  Jan.  29, 1803.  Post-mortem  ex.aniiuation  twelve  hours 
after  death  :  The  brain  w  as  pale,  firm  and  weighed  forty-three  ounces.  There  were  pleuritic  adhesions  on  both  sides. 
The  lungs  were  marked  by  black  pigment  in  the  course  of  the  ribs.  The  left  lung  weighed  nineteen  ounces  and  a 
half;  its  lower  lobe  was  much  congested  and  friable  and  its  bronchial  tubes  cong<vsted,  especially  iu  their  tiuer 
ramifications.  'I'he  right  lung  weighed  twenty-tiv(>  ounces  and  three-quarters;  there  was  a  mass  of  soliditie<l  tissue 
in  the  posterior  part  of  its  lower  lobe,  the  centre  of  which  was  occupied  by  lluid  and  opened  into  an  inllanied  bron- 
chial tube  of  the  third  magnitude;  several  condi'iised  pnlmomiry  lobules  were  found  also  in  the  upper  part  of  the 
lung;  the  bronchial  glands  were  mottled  black  anil  white  and  were  iiuite  lirm.  The  heart  was  llabby  and  contained 
clots.  The  liver,  seventy-four  ounces,  was  firm  and  of  a  light  browu  color,  its  acini  comparatively  distinct;  the 
spleen,  eleven  ounces  and  a  half,  was  soft  and  presented  inferiorly  a  cyst  containing  half  a  drachm  of  fluid;  the  left 
kidney,  live  ounces,  was  slightly  llald)y  and  full  of  blood;  the  right  kidney,  four  ounces  and  a  half,  was  normal. 
The  mucous  membrane  of  the  st(uuaeh  was  softened  and  free  from  folds.  There  were  jiatches  of  intense  congestion 
in  the  small  intestine;  some  of  Peyer's  pat(dies  were  ulcerated  in  the  centre,  some  were  neither  ulcerated  nor  tliiek- 
eiied  and  others  near  the  valve  contained  black  pigment  and  wert!  ulcerated  through  to  the  peritoueuui.  The  large 
intestine  was  <iiiite  thin. — Lincoln  UoxjiUal,  ll'anltiiigton,  I).  C. 


Am.  Fholo~Rthff  Printing  <A»., 


Il»ir»  Arrh  St.,  FhilcuUlphid. 


THICKENED    PEYER'S    PATCH  AND   ENLARGED  SOLITARY  FOLLICLES. 

No.  565       MEDICAL  SECTION. 


XJIE    C'UiSlTIiXUKl.)    FKVEiuS.  38l 

Cask  Hi*. — I'livjitc  (looii^c  Kiiilil,  Co.  V.  ;ii'th  N.  J.:  in;c  .'ili;  wa.s  admitted  .Jiiiu-  L>8,  IStif),  delirious  and  iiiiicli 

exhausted.  He  liad  lieeii  siek  ten  days.  The  tyinpanites,  wliieh  was  i)reseiit  on  admission,  diminished,  Init  was  suc- 
eeeded  bv  profnse  involuntary  stools,  with  extreme  i-xhaustion.  lie  died  .July  1*.  I'li.il-iiiorli in  examination  twelve 
hours  after  death:  The  solitary  Ibllioles  of  the  hiwer  ileum  were  enlartjed.  eoni;ested  and  in  sonu^  e,-ises  nleerated: 
I'eyer's  jiatehes  Avere  enlarged.  jiigniente<l  and  ulcerated.  The  remaining  viseera  wi'ri'  normal. — Art.  Anx'l  >'«(■;/.  deornc 
P.  JhaidWiill,  lloKf/hix  HoKjii/iil.  Wanhiiiiitoii,  I>.  C. 

C.\.SE  l.")(i. — l'rivat<-  David  ('line,  Co.  II,  lOlst  Ohio;  age  21  ;  was  ;idniitted  .lune  21,  l.'^l!.'),  in  a  state  of  eollapse, 
having  lieen  sick  about  ten  days  with  diarrluea.  His  mind  was  (ditnse:  his  pulse  slow  and  almost  imiierceiuible; 
tongue  dry  and  white:  skin  bathed  in  cold  clammy  sweat.  Stimulants  were  freely  administered  and  he  rallied  sonu'- 
what,  hut  nausea  and  hiccough  supervened,  and  lie  died  on  the  2:id.  I'usl-iiinrtim  examinati(Mi :  Heart  pale  and  llaldiy; 
blood  uneoagulated  and  very  thin  ;  peritinieun\  over  ileum  covered  with  a  dejiosit  of  coagulable  lymph  :  nuicous  mem- 
brane of  ili'um  iullamed:  glands  of  I'eyer  ulcerali'd;  corresponding  mesenteric  glamls  highly  intlamcd. — Act.  Ans't 
Siiri/.  II.  J.  ll'U'stl,  Cuinhi rliiiitt  llnsjiiliil,  lilil. 

Cask  1."i1. — I'rix  ate  Andrew  M.  llyland,Co.  1).  3!<tli  Mass.;  agi'  21 :  was  admitted  Nov.  (i.  18(12,  with  typhoid  fever, 
and  died  on  the  lOth.  ronl-iiiorUiii  examination  :  Purulent  elfnsion  within  the  sheath  of  the  rectus  abdominis;  <>xu- 
dat  ion  of  lymph  on  the  jieritoiienm,  gluing  the  intestines  toget  her:  ulceration  of  I'eyer's  patchi's;  distention  of  gall- 
bladder by  about  four  ounces  of  bile. — .l.v.sV  .S'h/v/.  If.  I'irn-r,  \'>()lli  .V.   )'.,  ,S/i  null's  Miiii-iiini  llnspihil,  ISnUiiihirf.  Mil. 

C-V.SE  ir)2. — I'rivate  William  N.  I'eake,  Co.  C,  I'Jtli  Wis.;  age  IS;  was  admitted  from  tht^  Army  of  th<i  I'otomao 
Sept.  y,  18G4,  having  been  siek  two  weeks  with  typhoid  fever.  On  the  llSth  a  pain,  which  had  developed  on  the  |ire- 
eeding  day  in  llu^  left  iliac^  region,  became  diffused  over  the  .abdomen  and  was  accompanied  with  much  tymi)anites. 
He  died  next  day.  l'ii«t-iiu)rtciii  examination  two  hours  after  di'ath:  The  intestines  were  adherent;  more  lluin  two 
((uarts  of  a  yellowish-colored  li(iuid,  which  had  escajied  in  part  from  the  inti'stinal  tul)e,  \vel<^  found  in  the  peritoneal 
cavity.  The  glands  of  I'eyer  near  the  ileo-ca'cal  valve  were  indurated  at  thl^  edges  and  soft  in  the  centre;  in  one  of 
these  pate  lies  t  he  ulceration  had  |icr  lb  rated  the  iieritonenm.  |  Sjiic'nnrii  Sill.  .Med.  Sect..  Army  Medical  Mnscum.  ] — .let. 
.I«n'l  Siiii/.  ./.  II.  Biitlcr,  M'l sl'.t  Hiiildiiiij  lltispiiiil,  Ilultiiiioic,  Mil. 

Ca-sk  l."i;i. — Privates.  Kmmoiis,  2(ith  Ohio  Uat'y:  age  111;  admitted  No\ .  II,  ISIil.with  lyplioid  fever.  Died  Dec. 
11.  I'lmt-iiiiii-triii  examination:  Body  nnicli  emaciated,  reyer's  patches  cxtensi\cl\  nleerated.  in  many  ida<'es  as  far 
as  the  peritonetim,  which  in  some  places  was  jierforated. — .irt..lsx't  Siiri/.  .1.   T.  Wiirinr.  Sntrhi:  IfoKjiital,  .1/i.v.s. 

CaSI-;  1."iI. — I'rivate. I.  C.  Morrow-,  Co.  E.  110th  Ohio:  admitted  Xov.  2:i.  ISli:!.  Died  2sth.  I'list-iiiiirh  in  exam- 
iimtion  thirty-nine  hours  after  death :  The  brain  was  liealthy.  The  lungs  were  somewhat  engorged  posteriorly.  The 
heart  was  llabliy  and  contained  a  small  clot  in  both  sides,  larger  in  the  right  than  in  the  h'fl.  Tlie  liver  was  lirm  and 
souu'what  congested,  its  surface  of  .in  intense  bluish-slate  C(dor.  which  coloration  extended  two  lines  into  the  ]iaren- 
ehyma  ;  the  gall-bladder  cinitaincd  an  ounce  of  dark-brown  bile;  the  spleen  was  of  a  purple  color  with  an  a<lniix- 
ture  of  ludwn  ami  wa.s  extremely  firm;  the  pancreas  wa.s  white  and  not  very  tirm.  The  ileum,  in  its  six  lower  feet, 
was  extensively  ulcerated;  about  two  feet  above  the  ileo-ca'cal  valve  was  a  I'eyer's  patch  of  an  irregular  circular 
shape,  presenting  three  distinct  ulcers  with  high  blackish  walls  and  stone-gray  bases,  in  one  of  which  was  a  small 
perforation  which  had  cau.sed  .some  exudation  of  lymph  on  the  pi'ritoneal  coat.  The  kidneys  were  healthy. — Ana'l 
Surg.  II.  AUin,  U.  S.  A.,  Lincoln  Jhisjiitid,  ll'niihiniitiin,  I).  ('. 

Case  155.— Sergeant  James  Ceddis,  Co.  L,  t>th  Mich.  Cav.;  age  33;  admitted  Aug.  IS,  1803.  Died  22d.  Pnxt- 
morttin  examination  nineteen  hours  after  death:  The  brain  was  tirm  and  healthy.  The  trachea  was  of  a  dark-purple 
color,  tinged  with  ochre  on  the  rings;  the  bronchial  tubes  contained  a  dark  grumons  secretion.  The  (Esophagus 
was  yellowish  throughout.  The  lungs  were  somewhat  (edematous,  the  right  weighing  twenty  ounces  and  the  left 
twenty-one  ()uiic('8.  The  heart  was  pushed  n))Wiir(Is  by  the  intestines;  the  right  ventricle  cont.ained  a  librinons  clot 
which  extended  some  distance  into  the  pulmonary  artery;  the  left  cavities  contained  a  soft  venous  clot :  the  aorta  was 
highly  colored.  The  liver  and  stomach  were  concealed  by  the  intestines:  the  liver  was  tirm:  the  galMdadder  con- 
tained twelve  drachms  of  dark-colored  bile  with  a  yellow  tlocculent  deposit;  the  s|ileen  was  e(mipact  and  of  a  dark- 
purple  color;  the  pancreas  was  dark-green  externally,  hard  and  white  iriternally.  The  intestines  were  much  dis- 
tended, evidently  from  cadaveric  changes;  the  lower  third  of  the  small  intestine  was  nleerated  in  several  places, 
in  one  of  which  there  was  a  circular  perforation  with  pale  white  edges,  and  the  peritoneum  surrounding  it  blackened 
to  the  extent  of  the  Peyer's  jiatch  affected  and  covered  with  tough  yellowish  lym|di  for  some  distance  beyond;  the 
large  intestine  was  healthy  except  that  its  solitary  glands  were  conspicuous.  The  kidneys  were  dark-|)uri)le  in  color. 
— -I.S.5'/  Siiri/.  n.  AJIvii,  V.  S,  A.,  Lincoln  Hon^iital,  IVaKliiniitiin,  I).  C. 

Case  l.M).— Private  W.  S.  Doyle,  Co.  H,  3d  Mich.  Cuv.;  admitted  Juiu'  11,  1863:  died  October  15.  rost-mortcm 
examination:  Sudaiiiina  were  observed,  especially  on  the  abdomen  and  arms.  The  brain-substance  was  very  tirm; 
the  lining  membrane  of  the  ventricles  was  roughened,  csiiecially  over  the  corpora  striata  and  the  descending  crura 
of  the  fornix,  where  the  roughness  .seemed  like  an  exudation  of  lymph,  but  it  could  not  be  detached  without  destroy- 
ing the  cerebral  substance:  there  was  no  meningitis.  The  trachea,  dark  purplish-red  in  color,  presented  nnuier- 
ous  minute  whitish  points  of  exudation  on  the  surface  of  the  mucous  memlirane  at  its  ujiper  part.  The  (esophagus 
was  of  a  pale  purple  C(dor  superiorly  and  of  a  luownisli  hue  below;  an  abscess  the  size  of  a  chestnut  was  found  in 
its  walls.  Both  lungs  were  congested;  the  right  weighing  sixteen  ounces  and  one-(iuarter,  the  left  twelve  ounces 
and  a  half.  The  heart  contained  tibrinous  clots  in  both  sides.  The  liver  was  tirm.  its  capsule  easily  torn,  its  acini 
distinct;  the  spleen  was  pnltaceous.  The  stomach  was  mottled  and  tilled  with  liiinid  greenish  fiecal-like  matter. 
The  iutestines  were  distended  with  air;  patches  of  the  peritoneal  surface  were  of  a  bright  crimson  color  and  the  coila 


3y2  P()Sr-.M()KTK.\L    KKCuKliS    uF 

of  the  siiiiiU  iutewliiie  were  glued  lof;i;tlier  with  leceiil  lymph;  the  duudeiiiiui  was  ol'  a  dark  tulur,  ils  villi  hiil'teiieil 
and  readily  delaclied;  the  ileum  was  iiassively  eimi;ested,  its  solitary  glauds  enlarged,  its  agminated  glands  elc\  ated 
and  whitish,  those  near  the  ilco-ciecal  valve  I'oriiiing  elliptieal  uleerated  patches  with  high  thickened  walls  and 
smooth  pale  bases,  in  many  insl;inces  covered  liy  a  whitish  adherent  exudation,  while  in  one  instance  the  i>erito- 
iieuni  fornu'd  the  base,  and  in  another  perforation  had  taken  ])lace;  the  large  intestine  was  healthy.  The'  kidneyrf 
were  normal. — Anx't  Sitnj.  11.  AUin,  l'.  S.J.,  Lincoln  JJospitcil,  Wa>iliiiiytoii,  I).  V. 

Ca.sk  1.")7. — Corporal  Cyrus  I!.  Clark,  Co.  li,  l.lth  Vt.;  admitted  Dec.  11,  IStJL',  with  continued  fever:  <lied  21st. 
l'u»l-murUm  examination:  I'eyer's  glands  were  nictated  and  one  of  the  ulcers  bad  perforated.  There  was  general 
lieritouitis  aiul  a  large  quantity  of  serum  in  the  abdominal  cavity.  The  recti  muscles,  in  their  lower  third,  contained 
much  extravasated  blood. — Third  llirisiun  IloajiituI,  Alcxundria,  Tit. 

Ca.sk  15!S. — Private  John  Clark,  Co.  E.  Kith  Va.;  age  21;  was  admitted  Nov.  Id,  l!S(i2,  presenting  a  hot  skin, 
frequent  feeble  pulse,  dry,  dark  and  furred  tongue,  diarrha'a,  tympanitic  and  tender  bowels  and  slight  dulness  on 
percussion  over  the  lower  l(d)es  of  the  lungs;  there  were  no  rose-spots  nor  sudamina.  The  patient  apjiarently  did 
well  <luring  the  day  and  .slept  couifortably  the  greater  part  of  the  night,  but  towards  morning  he  became  deliriou.s, 
after  which  he  sank  rapidly,  and  died  during  the  day.  Pust-mortim  examination:  The  middle  and  lower  lobes  of  the 
right  lung  wcnr  engorged;  the  left  lung  was  slightly  congested.  The  heart  was  normal.  The  peritoneal  cavity  con- 
tained a  large  (]uantity  of  serum  mingled  with  tiecal  matter;  the  great  omentum  was  engorged  and  the  mesenteric 
glan<ls  enlaiged.  The  small  intestine  was  greatly  discolored,  in  sonu)  places  nearly  black;  its  mucous  membrane 
was  reddened  and  engorged  w  ith  black  blood;  the  patches  of  Peyer  were  inHamed  and  ten  of  them  ulcerated,  two 
of  the  ulcers  having  perforate<l.  The  liver  and  spleen  were  enlarged  but  of  normal  consistence;  the  kidneys  were 
normal. — Third  Division  Ilonpitiil,  Ahxittidriii,  I'li. 

Cask  15!i. — Private  Martin  Ilogle,  Co.  B,  fith  X.  Y.  Cav.;  age  27;  was  admitted  Aug.  12, 1(^61,  with  wcll-markeil 
symptoms  of  tyjdioiil  fever.  He  was  delirious,  the  abdomen  tympanitic  and  tender,  thi^  tongue  furred  and  the  pulse 
accelerated.  He  tiled  on  the  2S)th.  There  w  as  no  diarrhica  until  within  four  days  of  death,  rusl-inurlmi  examina- 
tion on  thi^  day  of  death:  Kigor  mortis  well  marked;  body  moderately  emaciated.  The  trachea  was  lined  with 
frothy  simta  of  a  molasses  c(dor:  the  rij'.ht  lung  normal  externally,  was  studded  internally  willi  nudanic  spots 
about  the  size  of  peas,  it  weighed  twelve  ounces;  the  left  lung  was  healthy,  it  weighed  seven  ounces  and  a  half. 
The  right  side  of  the  heart  contained  a  large  (irm  black  clot.  A  considerable  nuantity  of  i)iis  was  observed  on  th(< 
onu'utum;  the  spleen,  fourteen  ounces  and  a  half,  was  lirui  iiud  of  a  bluish-slate  color;  the  liver,  seveuty-eight 
ounces,  appeared  to  be  noruuil;  tlie  kidneys  were  healthy.  I'eyer's  patches  were  extensively  ulcerated  and  the  ulcers 
had  perforated  in  five  places:  the  large  intestine  was  normal.  [See  Med.  .Sect.,  Army  Medical  Museum,  odit  to  HTI), 
audalso  plate  facing  this  ]iage.] — Act.  A-ss't  Siiry.  II.  M.  Dean,  IJiicohi  llospitaj,  Wiisliiiiijtvn,  D.  C. 

(I!.)   I'li/ir'.i  jKitcIict  iilcL'nttcd  and  tin  liiri/i  intcitinc  iilxo  iniplii'ittid— i.>  C(i.fin. 

Cask  Itlll. — Privati'  .James  Kilgore.  Co.  1.),  l.")Oth  Ind.;  age  30;  was  admitted  April  2ri,  IXllfi.  It  was  at  lirst 
supposed  that  this  man  was  crazy,  and  his  bed-card  was  nuirked  accordingly:  His  numner  was  strange,  his  face 
llushed,  his  breath  exceedingly  otiensivt^  and  his  hiibits  iilthy;  when  asked  his  age  he  answered  ''about  a  liundred.'' 
On  M:iy  1  his  pulsi^  and  respiration  became  frei|Uenl  and  he  jiresentcd  the  physical  signs  of  pneunu)nia.  He  died  on 
tin'  ;Jd.  I'lhtt-niurtcm  examination  four  hours  after  death;  Suggillation  on  the  chest  and  posteriorly;  sudamina  on 
the  skin.  There  was  sonu;  injection  of  the  meninges  and  a  moderate  (juantity  of  serum  at  the  ba.se  of  the  brain. 
The  riglit  lung  was  engorged  with  blood  and  adherent  to  the  thoracic  parietes.  The  tr.-msverse  colon  was  much  con. 
stricted,  not  nu'asuring  more  than  eight  lines  in  diameter:  the  mucous  mendiraiH'  of  the  ileum  was  inllamcd  and 
the  patches  of  Peyer  ulcerated.  The  spleen  was  very  soft  and  enlarged  to  three  times  its  ordinary  size. — Act.  Ass'/ 
Siir;/.  H.  ,/.  WicxcJ,  Ciimlurloiid  Hospital,  Md. 

Cask  1i>1. — Private  Xornum  Hoyd,  Co.  1$,  1st  Conn.  Heavy  Art.,  was  admitted  July  2"),  ISIU,  in  nu>ribuud  con- 
dition; tongue  dark  brown,  dry  and  cracked;  sordi-s  on  teeth;  involuntary  passages  from  bowels.  He  died  comatose 
next  day.  Voxt-mortem  exannnatiou  five  hours  after  <leath:  Body  not  much  enuiciated.  The  lungs  were  engorge  ', 
and  the  pleura'  adherent.  Peyer's  glands  were  slightly  ulcerated  for  tlit^  space  of  eight  inches  above  the  ileo-cacul 
valve,  and  extending  for  six  inchi's  below  it  were  twenty  or  thirty  ulcers,  several  of  which  nearly  perforated  the 
intestine;  the  rest  of  the  intestine  was  apparently  healthy. — ■Fiiirfux  Seminary  Uoapital,  i'a. 

Cask  162. — Private  Patrick  Lynch.  Co.  A,  65th  111.:  age  17:  was  admitted  July  20,  Viiiib,  with  diarrlnea  and 
constant  delirium;  he  (lie<I  on  the  27th.  runt-mortcm  examination:  There  was  about  an  ounce  of  clear  serum  in  each 
lateral  ventricle  and  two  ounces  in  the  sub-arachnoid  space.  The  posterior  portions  of  both  lungs  were  congested. 
Peyer's  patches  were  greatly  enlarged  and  ulcerated  and  the  solitary  glands  enlarged.  In  the  colon  minute  oval 
))ur]iura-like  spots  were  observed. — Ans't  Snry.  Gca.  M.  McdiJl,  C.  <S.  A.,  IIielx>i  Uonpitul,  Baltimore,  Md. 

C.\sK  Id;!. — Private  ().  .1.  Richardson,  Co.  C,  IDSth  N.  V..  was  admitted  Nov.  2H,  1863,  in  a  couuitosi'  condition  ; 
pulse  120. just  perceptible;  tonguediy  and  tissured;  breast  and  abdomen  covered  with  sudannna  and  feet  and  leg; 
C(dd.  Stimulants  were  t'reely  given  and  w.irmtli  .ipplied  to  the  feet.  He  died  on  the  '27tli.  I'ost-inorlcm  examination 
thirteen  hours  after  (h'ath:  Much  emaciation:  fiet  becoming  gangrenous.  Lungs,  heart  and  sjileen  normal;  Peyer's 
glands  enlarged  and  ulcerated  ;  .solitary  glamls  of  large  intestine  enhirgeil  and  nlcerated;  mesenteric  glands  enlarged. 
— Act.  .I.fs'l  Siiry.  U.  II.  Ijttcniuiii,  l>onyln-t  lliispital,  Wiinninyton,  1).  ('. 

Case  16.4. — Private  .lohn  Hutton,  Co.  H,  1st  \'t.  Cav.,  was  admitted  Nov.  2;i,  MV.i,  delirious,  lie  ndled  froio 
side  to  side  iu  bed  and  i)icked  at  the  bedclothes;  his  tongue  and  skin  were  dry,  his  jiulse  small  and  his  feet  eoldj 


Am.  Photo- Rtlief  Printing  Co., 


1002  Arch  St.,  Philadelphia. 


PERFORATING   ULCERS  OF  THE  ILEUM. 

No.  370,     MEDICAL  SECTION. 


THE    CONTINUED    FKVKRS.  383 

iuvoluiitaiy  Ntools  were  passed  fiv(|uently.  Stimulants  were  given  and  warnitli  and  mustard  applied  lo  liis  feet  and 
legs.  He  died  on  tlio  27tli.  I'ml-imn-Uiu  examination  twelve  hours  after  death  :  liod.v  not  emaciated  ;  both  feet  gan- 
grenous. Heart  and  lungs  healthy.  .Spleen  enlarged  and  of  a  dark-purple  color:  kidneys  healthy;  mesenteric  glands 
enlarged  ;  I'cyer's  glands  enlarged  and  ulcerated :  solitary  glands  of  large  intestine  ulcerated. — Aci.  .Isx't  Sur//.  11'.  Tt. 
lAihrmtui,  l)oii(/li(n  llimiyilaJ.  Viinliiiii/toii,  I>.  C. 

C'.v.sE  1()5. — Sergeant  Frank  Douohue,  Co.  A,  17th  Pa.  Cav.,  was  admitted  Feb.  19,  IMIk^.  having  lieen  sick  fortwo 
months  with  typhoid  fever.  He  was  comi)letely  deaf.  On  ilarch  1  he  had  sore  throat,  severe  headache  and  consti- 
pation. On  the  loth  his  stomach  became  irritable  and  tliere  was  soreness  in  the  bowels  with  diarrlnea.  Later  the 
stools  became  dark-looking  hut  less  fre(iuent.  He  died  on  the  L'oth.  I'lmi-morti'tn  examination  forty-eight  hours  after 
death:  liody  well  developed  and  not  emaciated.  The  tight  lung  weighed  sixteen  ounces  and  a  half  and  the  left 
twenty-one  ounces  and  a  ([uarter:  posteriorly  the  lower  lobe  of  the  right  lung  was  full  of  blackish-brown  thud,  which 
also  tilled  the  bronchi;  similar  apjiearances  were  found  in  spots  in  the  left  lung.  The  heart  weighed  nine  ouuces 
and  contained  no  clots;  the  aorta  was  somewhat  contracted,  deeply  congested,  and  three  inches  beyond  the  semilunar 
valves  was  a  cicatrix-like  puckering  with  intense  surronndiug  congestion.  The  liver  was  pale  and  weighed  lifty- 
eiglit  ouuces  and  a  half;  the  spleen  soft,  reddeued,  weighed  twelve  ounces  and  a  half:  the  jiancreas  natural,  three 
ounces  and  three-quarters;  the  stomach  healthy.  The  mucous  nieuibrane  of  the  up|ier  jiart  of  the  small  intestine  was 
y<'llowisli  and  presented  several  roundish  ulcers  with  well-defined  edges  in  I'eyer's  jiatehes  and  one  patch,  a  half  inch 
in  diameter,  enlarged  and  indurated :  lower  down  the  ulcers  were  more  ragged  and  ajjparently  did  not  involve  I'eyer's 
patches;  in  the  last  fifteen  inches  of  the  ileum  the  nnicous  membrane  was  of  a  reddish-slate  color,  the  solitary  glands 
brownish,  and  tliere  were  ragged  excoriating  ulcers  in  many  of  which  was  a  thick  yellowish  exudation.  The  nnicous 
membrane  of  the  large  intestine  was  of  a  dull  slate  color,  presenting  one  ulcer  on  the  ileo-ca'cal  valve,  one  at  the 
commencement  of  the  Ciceum  and  a  third  four  inches  beyond.  The  kidneys  were  llabby  and  much  congested. — Ann'l 
Siiiij.  Jlarfixiiii  Jlh'ii,  U.  S.  A.,  I.iiiculii  IIo«p\tal,  IVnsliitujlon,  I>.  C. 

(  AHE  Itili. — Private  .John  F.  Chapman,  Co.  I,H2d  lli^.;  age  'So;  was  admitted  July  2,  181)1,  with  some  irritability 
of  the  bowels,  soreness  of  abd(nnen,  slight  tympanites,  fever,  great  thirst,  a  dry  furred  tongue  and  a  pulse  of  110.  He 
became  afflicted  with  a  troublesome  cough  on  the  5th,  which  continued  for  some  days,  but  on  the  11th  he  was  rejiorted 
as  improving.  Two  days  later  the  stoinach  became  irritable  and  the  skin  showed  a  tendency  to  slough.  On  the  1  Ith 
he  refused  food  and  medicine,  and  next  day  he  died.  Pont-morliiii  examination  three  hours  after  death:  The  riglit  lung 
weighed  fourteen  ounces,  the  left  fourteen  ounces  and  a  half;  both  were  healthy  except  that  there  were  a  few  softened 
tubercles  in  the  upjier  lobe  of  each.  The  heart  weighed  eight  ounces:  its  right  ventricle  contained  a  small  filirinous 
clot.  The  stomach  was  healthy.  I'eyer's  patches  were  extensively  ulccrati'd;  the  solitary  glands  showed  many  ulcers; 
the  ileo-c;ecal  valve  was  much  congested:  the  ascending  ccdon  presenti-d  two  ulcer.s — the  upper  one,  about  the  size  of  a 
jiea.  was  superficial,  the  lower,  five-eighths  of  an  inch  in  diameter,  penetrated  to  the  peritoneum.  The  liver  weighed 
sixty-nine  ounces  and  was  slightly  congested;  the  gall-bladder  contained  five  or  six  ounces  of  thin  liile:  the  spleen 
weighed  thirteen  ounces. — Act.  Ass't  Surg.  James  T.  Logan,  Lincoln  Honpital.  Washington,  I).  C. 

Case  1(57. — Private  Everett  H.  Felton,  Co.  G,  187th  Pa.;  age  28;  was  admitted  .Vug.  :>(),  18(il,  with  an  apparently 
mild  attack  of  typhoid  fever;  but  on  .September  20  a  profuse  diarrlnea  supervened,  and  he  died  October  .">.  I'mtt-nidilim 
examination  ten  hours  after  death  :  Body  much  emaciated.  Hrain  aud  thoiticic  viscera  normal :  .a  filirinous  clot  in  each 
side  of  the  lii'art:  sjdeen  and  kidneys  normal;  several  Peyer's  ]iatches  aud  solitary  follicdes  ulcerated;  iiumeious 
small  ulcers  in  the  large  intestine. — Act.Ass't  Surg.  H.  M.  Dian.  Lincoln  HokjiHiiI,  ]y<i»liintilon,  l>.  ('. 

Case  1(38.— Private  Lewis  Weir,  Co.  A,  202d  Pa.;  age  18;  admitted  Nov.  2,  18ti4.  Typhoid  ft^ver.  Died  on  the 
7th.  I'oft-niiirtcni  examination  forty  hours  after  death:  Kigor  mortis  well  marked;  suggill.it  ion  posteriorly;  no  emacia- 
tion. On  the  upper  surface  of  the  cerebral  hemispheres,  anteriorly  along  fln^  course  of  the  large  liloodvessels,  there 
was  in  several  jilaces  a  gelatinous  subarachnoid  deposit:  the  subarachnoid  sjiace  contained  one  ounce  and  a  half  of 
.serniii.  The  right  jileural  cavity  eontaiued  two  ounces  and  the  left  four  ounces  of  dark  bloody  serum:  the  posterior 
part  of  the  right  lung  was  engorged  and  small  portions  of  its  upjier  and  middle  lobes  were  hepatized  ;  the  left  lung 
was  congested  posteriorly.  The  intestines  were  distended  with  air;  Peyer's  i>atclies  in  the  lower  jiart  of  the  ileum 
were  ulcerated  in  several  places;  the  solitary  follicles  of  the  ea'cuni  and  of  the  first  six  inches  of  the  colon  were 
ulcerated ;  the  remainder  of  the  large  intestine  was  normal ;  the  mesenteric  glands  adjacent  to  the  ulcerated  intestinal 
glands  were  enlarged  and  dark-colored.  The  spleen  was  enlarged  and  softened. — Act.  Axu't  Surg.  Thomas  Bowcn,  Second 
Dirifiion  Hospital,  Alexandria,  I'a. 

Case  169. — Private  .Jo.seph  Oilly,  Co.  D,  (ith  Pa.  Heavy  Art.:  age  47:  w.is  admitted  Oct.  30,  1861,  with  typhoid 
fever,  and  died  November  3.  Post-mortent  examination  nine  hours  after  deatli:  Marked  rigor  mortis;  slight  I'lnacia- 
tion;  suggillation  posteriorly.  Lungs  very  dark,  filled  with  blood;  l)rouchi  slightly  congested:  bronchial  glands 
normal;  ventricles  of  heart  dilated  and  containing  small  dark  clots;  liver  enlarged,  pale;  spleen  enlarged,  dark- 
ened, much  softened:  nniiiius  coat  of  stomach  and  jejunum  normal;  I'eyer's  patches  in  the  lower  two  feet  of  ileum 
an<l  solitary  follicli's  of  first  six  inches  of  colon  thickened  and  ulcerated;  mesenteric  glands  enlarged,  filled  with 
dark  matter,  especially  three  near  the  ciecum;  kidneys  cougesteil. — Second  Dirision  Hospital,  Alexandria,  I'li. 

Cash  170.— Private  .John  Verberson,  Co.  B,  ii.'ifh  Mass.:  age  33:  was  admitted  Nov.  30,  1864,  convalescing  from 
typhi>iil  fever.  He  was  much  debilitated  and  had  a  severe  diarrhcea.  He  died  Decemlier  16.  I'ost-niorteni  exami- 
nation ten  hours  alter  death:  Sndamina  on  legs  and  breast:  slight  suggillation  iiosteriorly.  Some  pleuritic  adhe- 
sions (Ui  the  right  side;  emphysema  of  both  lungs;  puckering  of  middle  lobi^  of  right  lung;  three  ounces  of  pale 
serum  in  pericardium;  enlargement  of  liver;  congestion  aud  in  some  i)laces  ulceration  of  Peyer's  patches;  conges- 
tion of  ciecum. —  Third  Division  Hospital,  Alexandria,  T'a. 


384 


l'(.>ST-.MUl;'IKM    KKCniUiS    oF 


Cask  171. — I'rivatf  (ic(irj;i'  Wduil,  Co.  1!,  l.si  l!:it'y,  I'd  Mo.  Li,i;lil  Art.;  aiii'  L'l:  was  admillcil  .liilv  l.'."i.  DSfil, 
ill  very  low  coiiditidn.  lli' ilifil  coiiiatDsc  on  tlio  tnllowiiig  day.  I'ii>:l-iiiiirtt  in  exaniin.il  inn  nvfiity-l  wn  linuis  al'icr 
Joatli:  liody  cxticiiicly  c'liiaciari'd.  Stomach  and  intestinal  canal  fii'i'atly  inHanicd  :  larjio  intestine  nincli  uleeialed; 
livef  fatty;  jiall-liladdcr  enormously  distended;  other  ovjj;aus  healthy.  [Spu-inini  I'M.  Med.  SimI..  .\i'my  Medical 
Museum,  which  is  from  this  case,  shows  several  larjje  tilcevs  of  Peyer's  [latclii's  Just  alio\c  the  ileo-ca'cal  \alve, 
pellet  rat  In  j;  in  .somo  jdaces  to  llie  iransvers.-  muscle  and  in  others  to  the  peritonenm.  as  also  some  enlarged  and 
ulcerated  solitary  follicles.] — Snnj.  J'J.  liciitlci/,  I'.  S.  ?".,  Third  Dichimi  llusjiilal.  Ahxdiidrid.   I'd. 

Cask  172. — I'rivatt^  Joseph  Swartz,  Co.  M,  I'd  U.  S.  Cav.;  ajie  L'L';  was  admitted  .Inne  IL'.  18(i)!.  for  a  <'ontnsioii 
of  the  chest.  On  .July  .j  he  was  placed  on  duty  as  nurse,  hut  on  the  2()tli  he  becauu'  attacked  with  tyidioid  fever 
which  jiroved  fatal  on  August  10.  roHt-iiiorfiiii  examination  seventeen  hours  after  death:  .slij^ht  emaciation;  coni- 
meuciug  decomposition.  Lnujis  slii^litly  coiif^ested;  heart  healthy,  a  tibrinous  clot  in  the  left  ventricle.  .Stoimich 
and  liver  healthy;  spleen  tirm  hut  nearly  iloulde  its  normal  size.  I'eyer's  patches  in  the  lower  part  of  the  ileum 
ulcerated,  the  surroundinj;  mucotis  memlirane  much  congested  and  the  corresponding  mesenteric  glands  enlarf,'ed. 
Ca'cum  prescntini;  one  ulcer:  the  remaiiuler  of  the  lavRe  intestine  healthy. — Act.  .{■■in't  Sunj.  J.  If.  Hiitchinwn,  ■'<at- 
terlee  llDHjiitiil.  I'liiladilphid,  I'd. 

Cas?;  17:1. — Private  J(din  Flowers,  Co.  M,  "ith  Pa.  Cav.,  was  admitted  .June  9,  ISIiL'.  with  rheumatism,  iind  died 
.July  2it  of  typhoi<l  fever.  ri)«t-iiidrtciii  examination  on  the  day  of  death:  Effusion  of  serum  into  the  ]iericar<lium, 
amountiiifj;  to  ahout  one-third  of  a  pint  or  more ;  no  evidence  of  pericarditis  except  a  more  than  usual  redness  of  the 
surface  of  the  left  ventricle :  indications  of  a  recent  pleurisy,  with  the  formation  of  pseudo-niemhrane  on  the  right 
side,  the  corresponding  pleural  cavity  filled  witli  serous  effusion.  The  mucous  membrane  of  the  large  intestine  pre- 
sented patches  of  inflammation  but  no  ulceration  ;  that  of  the  ileum  was  more  intensely  inflamed  and  all  the  agini- 
nated  glands  were  ulcerated,  in  most  instances  as  far  as  the  muscular  coat  and  in  two  instances  to  the  peritoneum, 
though  the  latter  was  not  inllamed. — Jet.  Jun't  Siirij.  Joseph  Lcidij,  Sdttirlcc  Hospital,  Vhiladdphiu,  I'd. 

Cask  174. — Private  George  Young,  Co.  aiul  Keg't  not  recorded,  was  admitted  Aug.  10,  I^Ol'.  and  died  on  the  13th. 
lie  was  delirious  from  the  time  of  his  admission,  ro.st-mortcm  examination  same  day:  Age  apparently  between  35  and 
■10;  body  much  enuiciated;  about  a  dozen  scattered  rose-colored  spots  on  thorax  and  abdomen.  The  organs  of  the 
chest,  the  stomacli,  liver,  spleen,  pancreas  and  kidneys  appeared  natural.  The  small  intestine  was  inflamed  through- 
out; its  agminated  glands  were  ulcerated,  the  ulceration  exposing  the  muscular  coat;  the  mucous  meml)raue  of  the 
lower  part  of  the  ileum  was  of  a  livid  ])uiple;  the  agminated  glands,  together  with  a  iiortiou  of  the  stirronnding 
mucotis  and  sub-mucous  tissue,  were  completely  destroyed,  leaving  patches  of  exposed  transverse  muscular  fibre 
inclosed  by  thickened  ridges  of  the  mucous  membrane,  [.^prcimcii  23SI,Med.  Sect.,  Army  Medical  Museum.  ]  The  lining 
memlirane  of  the  colon  was  slightly  inllamed  ami  of  a  slate-color.  The  solitary  glands  of  the  small  and  large  intes- 
tines were  not  conspicuously  diiseased. — Act..ls«'t  Sura.  Joseph  Lcidij,  Sdtterltc  Hoxpitdl,  I'hihitlelphid,  I'd. 

Case  17r>. — Private  lienjamin  Allen.  Co.  II.  1st  Ohio,  was  admitted  Dec.  23, 18(i2.  with  typhoid  fever  and  erysip- 
elas of  head  and  face;  he  died  on  the  2()th.  I'oxt-morti  in  examination  next  day:  Body  fat;  left  side  of  head  and  neck 
discolored  by  erysipelas.  Brain  healthy  but  pia  mater  somewhat  injected  ou  left  side  and  slight  elfusiou  iu  sub- 
arachnoid space.  Lungs  and  heart,  liver,  stomach,  pancreas  and  kidneys  healthy.  Spleen  enlarged,  seven  by  five 
by  two  and  a  half  inches,  very  tlahby,  bluish  on  the  surface  and  marked  with  dark  reticular  lines;  mucous  mem- 
brane of  ileum  and  colon  moderately  intiained;  intestinal  ghmds  healthy  except  in  tlie  lower  three  feet  of  the  ileum, 
where  the  agminated  glands  were  ninch  enlarged  and  ulcerated.  {^Specimens  112-11 1,  Med.  Sect.,  Army  Medical  Museum, 
are  from  this  ease.] — Act.  Asu't  Surfj.  Joseph  Leidy,  Sutterlee  Hospital,  rhiladelphia,  I'a. 

Cask  17t). — Private  Sidney  Church,  Co.  A,  189th  \.  Y.;  admitted  Jan.  17,  18IJ5:  died  21.st.  Post-mortem  exam- 
ination: Lungs  normal;  heart  llabby;  liver  healthy;  spleen  fourteen  ounces,  softened;  duodenum  and  jejunum  healthy; 
Peyer's  patches  of  ileum  ulcerated,  the  ulcers  cup-shaped  and  round;  ileo-ciecal  valve  much  thickened;  c(don  for 
eighteen  inches  filled  with  clotted  lilood,  lielow  which  the  solitary  follicles  were  not  enlarged. — Ass't  Sury.  U.  /.mir- 
eiithdl,  U.  S.  I'.,  Fifth  Army  Corps  Field  Hospildl,  Army  of  rotomae. 

Cask  177. — Private  Silas  X.  Peterson,  Co.  1),  38th  JIass.;  age  25;  was  admitted  Xov.  5,  18(52,  with  typhoid 
fever,  and  died  on  the  10th.  I'ost-iiiorteiii  examination:  Intlammation  and  ulceration  of  Peyer's  patches  and  of  the 
colon  near  the  caput:  much  enlargement  of  the  mesenteric  glands. — Act.  Ass't  Sitry.  T.  F.  Miirdoeli,  Steieart's  Man- 
sion Hospital,  Iliiltimore,  lid. 

Case  178.— Private  C.  M.  Kelsey,  Co.  M,  Uth  N.  Y.  Heavy  Art.,  was  admitted  .July  24,  18(;4,  having  been  siik 
since  the  7th  with  iliarrha'a  and  fever.  He  died  on  the  28tli.  rost-morlem  examination  on  day  of  death:  Lungs  and 
heart  healthy.  Peyer's  patches  were  inflamed  and  slightly  ulcerated;  several  ulcers  were  found  in  the  large  intes- 
tine; the  mesenteric  glands  were  much  enlarged  and  softened.  The  spleen  was  five  inches  long  by  three  broad  and 
rather  soft;  the  kidneys  were  large  and  fatty. — Fairfax  Seminary  Hospital,  Va. 

Cask  179. — Private  II.  Richardson,  Co.  (',  13th  E.  Tenn.  Cav.,  was  admitted  >Jan.  22,  l8t>4,  with  typhoid  fever, 
and  died  February  ti.  Posi-morteni  examination  forty-eight  hours  after  death:  Body  einaciateil;  rigor  well  marked. 
Till'  brain,  lungs,  heart  and  solid  abdominal  viscera  were  healthy.  4'lie  stomach  was  Injected;  Peyer's  patches  ulcer- 
ated throughout  the  entire  length  of  the  ileum;  the  mucous  iiieiubrane  of  the  large  inti'stine  intlamed  and  tliii'keiu'il : 
the  mesenteric  glands  eulargeil. — Act.  Ass't  Sury.  y.  ]!'.  Iloberts,  Hospital  .Vo.  19,  \iishrille,  Tenn. 

Cask  W). — Privati'  Robert  Traut,  Co.-\,  10th  E.  Tenn.  Cav.,  was  admitted  .Ian.  29,  lf<(il,  with  lyidioid  fever. 
He  died  Feliruary  tl.  I'ost-niortem  examination  twenty  hours  after  <leath:  Body  emaciate<l;  rigor  slight.  Tlie  mem- 
branes of  the  brain  were  slightly  injected.     The  lungs  weighed  sixty  ounces   and  the  iileural  cavities  contained 


TITK  roNTi  Ni;i;ti   ki-:vkt;s.  885 

Uvo  ouni'cs  1)1' li(|iiiil ;  IIh'  IhihI  \\  ;i^  lii'alili\.  'I'lic  liicr  \\:is  jimIc  liiit  scciiiiiisl.v  licahli.v:  (lie  splci'ii  (■iin;cf.stt'(l, 
wrifjliiiij;  tit'tfcii  oinii'i'r-:  ihi-  kiilnrN,-.  i's|iiTiull.\  tin'  lill,  coh^csIimI.  'I'Iic  iiiiicdiis  ijK'iiibraiui  of  llic,  stoiiiacli  was 
iiillMMii'il  ami  .s(it'lcMr(],  a^  \\  a>  I  hat  uT  t  In-  Miiall  iiil.-^l  iiir  amt  ((jIhh  :  l'r\  n's  ulaiids  wnc  iiliTiatcil  ami  llie  liicscntei'ic 
f;laiiils,  ill  siiini'  iii>laiici's,  as  lai;;r  a>  a  iliist  mil .  —  Ail.  .I.v.v'/  Sni-fi.  '.'.  /)  .  UhIhi-Ih.  IliispUdI  .No.  l!t,  SimliriUc,  Tctni. 

Cask  1X1.— rn\  air  I  la  .\.  Spi-n  \  .  Cn.  1).  1  ITtli  ,\,  \ .:  aL;r  iM  :  w  as  adiiiil  led  .Iiiiic  15,  ISt;.!,  with  t.vpliiiid  fcvi-r, 
anil  ilic'il  (III  t'lir  "-'I'll,  riixt-iiiiirli  <«  rxaiiiiiial  inn  I  wi'ii!.\  -li  \  i-  Ikhi  i  s  a  I'lrr  deal  li :  liody  mil  i-macialril.  lira  ill  Ileal  thy. 
.Mucous  iiiciiiliiam'  of  tiai-hcu  iiiilcli  ciilijirslrd :  iiiipiT  lidii'  of  ri^lil  liiii^  soiiH'what  I'oiiurstcd,  middle  l(di<^  more 
iialiual,  lowci-  lolie  cxticMiitdy  coiijiestcd,  wci^lil  of  liiiij;  sixici-ii  oiiiiics;  ii|i]iri-  lolic  of  Irl't  liiii^  rotiijesfi'd,  wcif^ht. 
of  liiiii;  lilU'cii  oiimcs  and  a  half.  l\i^ht cavities  of  lieail  eoiilaiiied  lilniiioiis  clots;  h'I'l  mixed  idots.  I>i\  er,  sixtv- 
li\e  ounces.  Ilaldiy,  iiiollled  ciini  itiiiils  and  deep  piuple;  aliont  the  middle  of  tin'  aiiti'iinr  siilface  of  the  ri^iht  lolie 
was  ii  lai-;;e  white  spot  eo.iled  with  l.viiiph.  indicative  iirohalily  id'  pn-vions  iiillammation.  (Ksophaffiis  normal; 
Kfomaeli  of  a  dull  fiiay  cojoi  ;  spli-cn  fmii.  dark  nialiouanv  coloied,  weij;ht  ideven  imnees  and  a  i|iiarler.  an  o]i:ii|iie 
spot  co\  iTcd  with  recent  lymph  on  its  ii|ipei'  surface:  pancreas  11  rm  and  while,  w  ciiilit  two  ounces  and  a  half.  Diio- 
deniini  somewhat  coiiifesled:  iejiiinim  and  iipjier  ]iail  of  ilcnni  iioniial:  mncoiis  memhrane  <d'  lower  part  of  iletllil 
t  liin,  jiale  and  easily  lorn  :  I'cyei's  |iat(dH's  i'le\  aled,  dark  slate-colored  ;  scdilaiy  <;lamlH  ]iroiiiinent  :  nleeratioii  prt'S- 
ent  l)Ut  nowhere  extensive,  l.aiiie  intestine  dull  j;reenish  in  lolor  lint  not  iileeraled,  Left  ki<lney  tialihy,  slifjhtly 
in.jected,  somewhat  friahlc  and  with  many  ee(diymiised  lilotidies  on  jielvis;  Madder  iniKdi  distended  with  urine, — Aim't 
Siir;/.  Hiirrixiiii  .lllcn,  I'.  >',  .1.,  Lincoln  llnxpilal.  H'liiliiiKiloii,  1>.  ('. 

t'.\si;  1X1',— Private  William  (iililiiiics,  (  o.  F,  ,",tli  .Mich.;  a^'e  W'l;  was  admitted  April  ■_'l,  ISIil,  with  typhoid 
fever,  and  died  May  12,  I'lixt-iimrli  in  examinalion  t  weiily-l  luce  lionrs  after  death:  The  brain  wei};lied  lifty  onne,os. 
The  iniieoiiM  inemlnane  of  the  larynx  and  trachea  was  K<miewhal  eonj^esled.  Th<i  ri;;hf  liinj;  wei};Iu'd  thirty-two 
ounces,  its  lower  lohe  lie])atized  red,  its  np)ier  lobe  •;i'ii,v  ii"<l  the  pleural  surfaces  adherent  ;  the  left  liiiif;  weij^hed 
nineteen  oiinees.  The  heart  was  flabby;  tlu^ro  were  three  draelims  of  lifrht-red  lliiid  in  tlni  peri<'ardinm.  The 
lesopliajjiis  was  healthy;  the  cardiac  end  of  the  stomach  reddish-brown  and  ninch  softened;  the  miieons  membrane 
of  the  dnodennm  miieh  eoiiiiestcd:  the  solitary  follicles  of  the  ileum  and  I'eyer's  jiati  lies  ulcerated,  some  of  the 
ulcers  pi^netratiiif,'  to  the  )ieriloneiiiii :  a  small  triangular  ]iieee  of  bone  was  found  in  the  aiipeiidix  vermiformis;  the 
mucous  menibrane  of  the  lar;;e  intestine  was  much  eon};ested  and  softened.  The  liver,  tifty-iiine  ounces  and  a  half, 
was  tialiby  and  ananiic:  theie  were  six  <lrachms  of  <;ainbojie-(ailored  lii|uid  in  the  fiall-bladder;  the  spleen  eleven 
oiinecs  and  a  half,  was  ]iiil|iy,  its  capsule  easily  se|iarated  and  preseutinjj;  on  its  superior  Hiirfiice  a  "round  white 
body  resemblinf;  b<ine,''  The  riirlit  kidney  weijjheil  live  ounces,  the  hd't  live  ounces  and  a  half;  both  were  soft  and 
llabby, —  Id.  Akx'I  Suri/.  A.  .Infill,  l.hiciiln  lliispilnl,  Wituhbifjton,  D.C. 

Case  lH:i,_l'rivatc  I'eter  "W,  Haekoveii,  Co.  (!,  Stli  N,  Y,  Cav,;  aj,'e  about  21;  admitted  Ann,  18,  IWiH;  died 
iTilli,  I'lisl-iitiiflcin  examination:  I'ody  not  much  emaciated;  ri^or  mortis  <i;r(^at.  The  brain  weighed  fifty-one  ounces 
and  a  half:  the  surface  of  the  eerebellnni  was  slifj;htly  red  and  the  vessels  of  the  l)ia  niatev  tilled  with  a  purplish 
lliiiil:  the  iiileiiiir  of  the  brain  was  normal.  The  larynx  and  trachea  were  jiale,  the  portions  between  the  riuj;s  of  a 
li^hl  purple  line.  Ihe  iiso]ihaj;eal  mueoiis  membtane  was  ])ale  gray  in  the  upper  part,  liecoiuinfj  tawny  or  ]>urplish 
further  down,  and  eonsidiiably  corrugated  both  longitudinally  and  transversely.  The  right  lung  weighed  eleven 
oimces  and  a  half,  the  left  twelve  ounces  and  a  half:  both  w  ere  somewhat  congested  in  their  lower  lobes.  The  heart 
was  healthy,  its  ri^;lit  ventricle  contained  a  librinous  clot;  the  liiini<l  of  tlie  iiericardinm  was  decidedly  reddish 
in  color  jiiid  measured  six  drachms.  The  liver  weighed  lifty-seveu  ounces,  its  surface  i>ur))Ie  with  a  few  scattered 
yellowish  niacuhe,  its  section  jialcr  than  usual  but  tirni;  the  mucous  membrane  of  the  stomach  near  the  ])ylorus  was 
somewhat  marbled;  the  spleen,  nineteen  ounces  and  a  half,  was  firm  and  of  a  chocolate  color;  the  jiancreas  was 
normal,  IN^yer's  patches  in  the  lower  part  of  the  ileum  were  elevat<'d,  white  and  covered  with  small  ulcerations, 
a  few  of  the  ]iatches  were  cinigested;  the  large  intestine  was  purple  in  its  upjier  part,  becoming  ]ialer  towards  tlio 
rectum.  The  kidneys  were  thin;  on  section  a  small  (|uautity  of  venous  blood  llowed  from  the  cut  edges  of  the  pyra- 
mids; the  right  suprarenal  capsule  was  yellow  ish-white  internally  and  did  not  contain  the  usual  brown  fluid;  the 
left  capsule  w  as  darker  in  color  and  contained  a  small  iiiiaiitity  of  brownish  fluid. —  Ih.i'I  Snry.  Jldrrixon  Alien,  U.S.  ./,, 
l.inciiln  Hunpitiil,  lyusliini/tiin,  I>.  C. 

Cask  ISI.— I'rivate  Abraiii  Fteeker,  Co.  II,  11th  V.  S.  Inf.;  age  3!l ;  was  admitted  May  11,  18111,  with  a  gunshot 
llesh  wdiuid  of  the  lift  heel,  lie  contracted  typhoid  fever  while  in  hospital,  but  had  ajiparently  convalesced;  his 
apjielite  iiiii>ioved,  and  lu^  gained  strength  during  the  last  two  days  of  his  life;  lie  was  walking  about  within  ten 
minutes  of  his  death  on  .July  ;J0,  l'(ist-ini>rtini  examination  seventeen  hours  after  death:  liody  wtdl  nourished.  The 
lungs  contained  much  frothy,  bloody  Iliiid;  the  right  weighed  nineteen  ounces  and  three-(|uarters,  the  left  nineteen 
ounces.  The  heart  was  flabby  and  contained  a  small  soft  fibi  inous  clot  in  the  right  ventricle.  The  liver  wa.s  flabby 
and  dark-colored;  the  spleen  weighed  tliirte<'n  ounces  and  three-ijuaiters.  In  the  ileum  I'eyer's  patches  werl^  con- 
gested, near  the  ileo-ca'cal  valve  ulcerated:  some  of  the  solitary  glands  also  were  ulcerated.  The  huo-e  intestine 
was  somewhat  congested  in  its  iijiper  ]iortion, — Avt.  Asi't  Snyij.  11.  il.  Iirun,  Liiiaiht  Ilnspital,  fVdnhington,  I).  C. 

Cask  IS,"..— Private  Jos.  S.  Xelson,  t!lli  Me,  liat'y;  age  !.">;  was  admitted  Oct.  10,  18()3,  with  typhoid  fever,  and 
ilied  Nov,  L'l,  I'oil-iiiiiitnn  examiniition  next  day:  liody  greatly  emaciated.  The  brain  was  healthy.  The  epiglottis 
was  lined  on  the  posterior  surfae<^  with  an  exudation  and  ulcerated  on  either  side  of  the  free  border,  the  ulceration 
being  confined  to  the  mucous  menibrane,  which  was  <if  a  palish  pink  color  and  thickened  around  the  edges  of  the 
ulcers;  an  irregular  nicer,  with  pinkish  walls,  was  seen  on  the  left  side  of  the  larynx  immediately  below  the  vocal 
cord  and  a  smaller  ulceration  of  Biiuilar  ajipearauce  in  tlie  angle  of  tbe  thyroid  cartilage,  The  posterior  portion  pf 
Mj.;d.  Hist.,  Pt.  Ill— 19 


386  POST-MOKTKM     i;KCt)i;l)S    OF 

the  iiliiiryiix  <)ii]«i,sitf  the  oi>i;;liitti.s  was  tlit!  scat  of  a  sii]>crfK:ial  iilcci':  t  lie  (i-s(ii)lia;;iis  wa.s  |iaic  and  (illcd  witli  a 
whitish  i-iuil-like  mass,  at  first  siiiiposnl  to  he  a  rotaiiicd  portion  of  iiif^osta,  hut  on  caiffiil  examination  found  to  be 
a  tine  exudation.  Tlie  ri;;lit  Innj;  weijjlu'd  tweuty-seven  ounees;  the  j)OSterioi'  )iart  of  its  upper  h)l>e  was  quite 
(edenuitous,  its  bronclii  pidniinent.  fceliiiff  li]<('  millcl-seed  nn(h'r  the  fiiijuevs.  and  llicir  mucous  lininjj;  everywliere 
of  a  (hark-]iur]>hj  color;  tlio  jiosterior  surface  at'  I  lie  lohe  was  coated  to  the  extent  of  an  inch  and  a  lialf  with  a  thick 
whitish  membrane;  tli<'  h>wer  lobe  iiosteiioily  was  iiiucli  coni])ressed  by  a  eirciniiscribed  |)leiiritic  effusion  measuring 
fourteen  ounees.  Th(^  weight  of  tlic  left  lun^  was  lliiity-two  ounces;  its  u]iper  lobe  presented  the  same  jieneral 
api>earance  as  tliat  of  the  ri;;lit  side:  the  bnuichial  tubes  were  everywhere  promini'nt .  in  some  parts  giving  tlie  fc<'l 
of  a  cirrbosed  liver:  the  lower  jpoitiou  of  tlic>  lunj;  was  of  a  durk-]iuri)le  Ib'sh-tolor.  friable  ami  heavier  than  water. 
The  heart  contained  but  litlle  clot  in  its  rifilit  side  and  none  in  its  left.  Tlu^  liver  was  dark  and  tolerably  tirni, 
weij;hin<;  lifly-sevcii  ounees;  the  };all-bhi(lder  was  very  iirominent  and  contained  twenty  drachms  of  thin  brown 
bile;  the  sj)leen  weif;lied  seven  ounces  and  was  of  a  dark  mahogany  color  and  (|iiite  firm.  I'eyers  patches  and  the 
lower  ]K)rtion  of  the  small  intestine  were  ulcerated;  the  larjje  intestine  was  also  ulcerated  and  of  a  stone-;;ray  liu<^ 
alternating  witli  patches  of  a  dull  larda<eous  aiipearanee:  the  iileeration  was  of  the  punctated  form.  A  large 
gangrenous  abscess  was  found  on  the  right  of  the  anus  extending  deeply  into  the  right  buttock;  its  external  opening 
was  small.  .Just  b(^fore  death  a  severe  hemorrhage  had  taken  jdaee  from  this  abscess;  several  very  large,  firm,  black- 
ish clots  were  found  in  its  cavity.  Il  was  supjiosed  from  the  examination  that  this  connnunicated  with  the  rectum, 
but  the  ]iassage  to  that  gut  was  olitained  with  some  diliiculty,  and  it  is  not  improbable  that  the  force  used  in  manip- 
ulation produced  the  comniiini<'ation.  No  tlatns  or  exeiementitious  matter  had  escaped  during  life. — .(.s.s'/  Hiiftj.  Hiir- 
rixoH  Alhn,  I'.  S.  A.,  lAiicolii  lloxjiititl,  WitxhiiKjUiii,  I).  ('. 

Came  186. — I'rivate  Martin  Stevens,  Co.  L),  7th  N.  ('.;  age  'i\i\  was  admitted  May  li(),  l«ti4,  w  itli  typhoid  fever, 
and  died  on  the  24th.  I'oxt -mortem  examination  sixteen  hours  after  <leatli :  Body  rather  spare.  Lungs  congested 
throughout;  left  ventricle  of  heart  dilated;  small  inti-stine  much  inflamed;  solitary  follicles  and  Peyer"s  patches 
ulcerated;  large  intestine  intlained;  mesenteric  glands  enlarged  and  softened:  liver  and  kidneys  normal;  spleen 
much  enlarged  and  congested. — Ijiiciihi  lloxpiidl,  Jl'dsliint/ton,  I).  V. 

Ca.sk  \Kl. — .Sergeant  .bilin  Link,  Co.  A,  lOTtli  Ohio,  was  admitted  .liini'  lo,  Ist;:;,  delirious,  and  died  on  tlu'  17tli. 
roxl-moflim  examination  ten  hours  alter  death:  The  brain  was  normal.  The  trachea  was  jiurple;  its  nuicous  mem- 
brane tirm;  the  bronchial  glands  at  its  bifurcation  large.  The  lower  part  of  the  (esophagus  was  of  a  ]iale  yellowish 
color  and  ])resented  ulcers  of  the  same  hue:  its  nineous  meinbiane  was  not  softened.  The  right  lung  weighed  nine- 
teen ounees  and  a  half  and  was  congested  in  its  lower  and  in  part  of  its  upjier  lobe;  the  lower  lobe  of  the  left  lung 
was  somewhat  engorged.  The  heart  was  normal  and  contained  a  librinoiis  clot  in  its  right  side.  The  liver  was  large 
and  dark-colored,  extending  entirely  across  the  body:  the  gall-bladdi'r  contained  three  ounces  and  six  drachms  of 
bile.  The  stomach  was  imniensely  distended  an<l  occupied  the  grealcr  |iortion  of  the  abdomen  in  an  oldic|ue  posi- 
tion ;  its  mucous  nienibrane  was  softened  and  presented  several  minute  black  spots  towards  the  iiylorus ;  l)etween  its 
superior  curvature  and  the  gall-bladder  was  a  small  ([uantity  of  reient  lymph.  The  small  intestine  was  contracted; 
its  mucous  membrane  was  softene<l  and  varied  in  color  from  light  pink  to  deep  purple:  the  jejunum  was  tilled  with  a 
glairy  tenacious  mass;  the  last  two  feet  of  the  ileum  presented  widl  defined  ulceration  of  Peyer's  patches,  the  ulcers 
being  mostly  circular  with  ragged  walls  au<l  an  irregular  base,  which  was  generally  stained  of  a  dull-ochre  color  by 
the  intestinal  contents:  near  the  ih'o-ira'cal  valve  seveial  of  the  ulcers  ran  together,  forming  a  large  ulcerated  area, 
which,  w  ith  its  fdack  indurateil  walls  and  yellowish  base,  stood  out  in  strong  lelief  against  the  i>iirple,  livid  and 
congested  mucous  membrane.  The  large  intestine  was  also  much  contracted,  its  ruga'  elevated  anil  coated  with  a 
tenacious  mucoid  secretion:  no  ulcers  were  found  in  it.  The  right  kidney  was  congested,  and  several  small  s))ots  of 
transuded  blood  were  noticed  on  its  external  surface;  the  pelvis  of  the  left  kidney  was  similarly  discolored. — JuxH 
Sury.  H.  AlUii,  U.  >S.  .1.,  Liiicolii  Hiixpilol,  lldxlihiiilDii,  I),  d 

Case  188. — I'rivate  John  Walford,  Co.  V.  2d  U.  S.  Colored  troops,  was  admitted  .Ian.  17,  18()<),  in  a  moribund 
condition;  tongue  parched;  teeth  and  lips  covered  with  sordes.  Stimulants  were  freely  used,  but  he  died  next  day. 
There  is  no  detailed  record  of  the  autopsy,  but  tlu?  whole  intestinal  canal  was  recreived  at  the  Museum.  The  ileum 
showed  hypertrophied  villi  and  progressive  thickening  and  ulceration  of  the  solitary  follicles  and  I'eyer's  patches; 
many  solitary  glands  in  the  colon  were  enlarged  to  the  size  of  peas  and  ulcerated  on  their  sumnuts.  [See  Mod.  Sect., 
Army  Medical  Museum,  707  and  708. j — Surg.  J!.  11.  liotittcou,  C.  S.  I'.,  Uiiriwood  Hoxpital,  Ifcwhlngtoti,  J).  C. 

Cask  18!).— Corporal  Walter  Angel,  Co.  K,  lOtli  X.  Y.  Cav.:  admitted  Aug.  17,  180;^,  with  typhoid  fever.  Died 
20th.  Post-morlnii  examination  ;  Body  slightly  emaciated.  The  lungs,  heart  and  pericardium  were  normal.  The  liver 
was  congested;  the  gall-bladder  somewhat  distended;  the  spleen  enlarged  and  congested,  weight  eleven  ounces. 
The  mesenteric  and  nie-so-colic  glands  were  much  enlarged  and  there  was  considerable  venous  congestion  of  the  intes- 
tinal peritoneum.  The  mucous  membrane  of  the  low er  je,junum  and  ileum  was  congested  in  patches,  the  congestion 
increasing  progressively  downwards,  the  last  two  feet  being  much  congested,  with,  in  the  last  six  inches,  several 
deep  circular  ulcers  having  yellow  bases  and  raised  edges;  Peyer's  patches  were  not  elsewhere  ulcerated.  The  colon 
was  of  a  deei)  mahogany  color,  especially  in  the  ascending  portion.  The  pyramids  of  the  kidneys  were  congested, 
the  cortical  siilistauce  pale. — Hdrcircuil  IJoxpittil,  ll'dxhiiiyfiiti,  11.  ('. 

Ca.se  190.— Private  H.  (i.  AV.  Stoner,  Co.  A,  1  Ith  U.  S.  Inf.;  admitted  Oct.  10, 1863,  with  typhoid  fever.  Die<l  13th. 
Post-morUm  examination:  Tlie  lungs  were  normal  excepting  a  slight  adhesion  to  the  pericardium  on  the  left  side. 
The  right  cavities  of  the  heart  were  dilated  and  tilled  with  fluid  lilood  ;  their  walls  were  thinned.  The  liver  weighed 
sixty-four  ounces ;  the  spleen  twelve  ounces.  The  stomach  and  the  upper  part  of  the  duodenum  were  much  congested. 
The  ileum  was  congested,  esiiecially  in  its  lower  part,  which  was  thickened  and  iutlamed  and  in  Peyer's  patches 


THK    CONTIM'KI)    KKVEES.  3S7 

iilcciati'(l;  (he  ilrii-c;i'c:il  \:il\<-  \v;i.^  iiiiicli  t  liicki-liicl  :inil  iilicl:itr<i.  T]\f  iiiiirdiis  intMiilinilio  of  tlio  colon  Wiis  roii- 
■icsti'd  uiid  soCti-iiril  a  ml  liiiiKlrcils  of  hs  soli  la  ly  follicli-s  were  iilcr  rated  ;  I  hi  reel  inn  also  wa.s  <'on};cstod  and  softened. 
'I'lie  kidneys  were  eonyi'sted. — llun  innid  [fuxjiihil,  lldxIiiii'ilDii,  l>.  ('. 

Cask  I'Jl. — l'ii\ale  Maitiii  Kiliy.  Co.  C,  iL'lM  I'a.:  adniitled  .\|iiil  L'l.  ISli.'i.  ConiinMcd  fever.  Died  May  L'l. 
I'dsl-iiiiirliiii  i-.\aininalioM  I  went y  liouis  aflei-  <leiil  li :  11  le  iioil,\  was  nineli  eiMa<'iati'd.  'i'lie  Innns  w<'ie  lieallhy,  liut  tim 
bi'oneliial  Inlies  eontaiiu'd  a  piiiiileiit  secret  ion.  flic  lira  it  was  softeneil  and  pale;  a  small  poini  of  ]iiis  was  foil  nil  at 
its  ape\:  tlie  mitral  valvis  was  tliieUeiied  and  sli};lilly  roiii;liened.  Tlie  stoiiiaeli  was  ni'arly  filled  with  Idle.  'I'lie 
liver  was  healthy:  the  KiiH-'iladder  nearly  eiiiiity.  'I'lie  ilnodeniim  and  .iejiiniim  were  normal;  the  ileiini  inllanied 
and  Tevi'l's  )ialehes  iileerated ;  the  ascending  eolon  eoiifiested  in  spots,  the  transverse  and  deseeiidiii;;  portions 
healthy.     The  kidneys  wi-re  normal.  —  Ait.    Us^t  Sin-;!.  A.  II.  Iliinii,  Udriiniml  lliLtjiilol,  ll'iislihinlini,  l>.  I'. 

Cask  l!tL'.~rrivale  .lolm  ll.iiise.Co.  11,  IT.'ilh  I'a.:  aue  :;.".;  admit  tiil  .Inly  ti,  ISC,:!.  Died  iL'th.  I'lisl-ninili  in  exani- 
i  II  at  ion  :  liody  sli;;litly  emaeiated.  J.iver  healthy;  e'al]-lil  adder  distemh'd  with  Idle:  spleen  some  what  enlarj;ed.  mneli 
eoniiested  and  very  soft ;  diiodeiiiim  and  jejiiniim  heallliy :  ileiun  niiieh  intlamed  and  its  at;minaled  and  solitary  f;lands 
iiieerated,  lint  some  of  the  n  lee  is  appealed  to  lie  lu'aliiif;:  .solitary  follieles  of  aseeiidinjj  eolon  eiilaineil  and  nici' rated. 
Kiilneys  healthy. — J<'l.  .l.sV/  Siii-i/.  I.Uijiil  Durmii.  Ildrnnidil  llnspUnl,   U'lialiDiiildii,  I).  ('. 

Cask  I'.i:;. ^Private  Frederiek  \\'olfaiJi;cr,  Co.  C.  Ii:'.d  N.  V.;  aije  i:i:  was  admitted  Oct.  21,  IMi:!,  and  died 
Ts'ovemlier  IS.  /'(i.s/mii/^oii  examiiiat  ion  thirty  lionrs  after  di'atli :  IJody  nin<di  emaeiated.  Hraiii  healthy.  I'he  left 
pai'otiil  };land  was  the  .seal  ot  siipinirat  i\  e  intlamniatioii ;  the  piKS  liad  dis(liai;;eil  froni  two  oiieiiin^s,  one  in  the 
nioiith,  1  let  ween  the  toiiji'ie  and  the  inferior  maxilla,  t  ho  other  externally,  lietween  the  niasloid  proeess  and  claviele. 
The  hd't  lolie  of  the  thyroid  ;;lanil  eontained  a  ealeaii'ons  nias.s  us  larf;<>  as  u  walnut,  and  in  Its  iipjier  poitioji  a  lysl 
the.  size  of  a  |iea,  tilled  with  a  dark-lirow  n  tluid  :  tln^  rij;lit  lobe  iiintained  !i  cyst  tlie  fiize  of  ii  small  ejiestniit,  ami  in 
its  lower  ))ortion  an  ii))oiilecli(^  extra\  asation  one  ineh  and  a  half  loiifj  liy  one  iin-li  in  width.  'J'lie  riffht  IiiiijJ  wei);lie<l 
forty-seven  oiiiiees  and  a  half;  its  lolies  weie  interadheKiit  lull  not  attaeliid  to  the  rilis:  tlie  lateral  anil  posterior 
]iart8  were  (edematous.  The  left  liinj;  resenililed  the  other,  lint  eontained  a  ;.{ieater  (|iiantity  of  lilood  In  many  places, 
the  parenchyma  beiiit;  of  a  ihirker  line.  The  liroin'hial  tnhes  were  tlii(d<ened  and  tliidr  miicoiiH  niemlirane  reddish; 
a  yidlow  tenacious  ninciis  was  contained  in  the  smaller  Inlies,  nivinj^  a  j;i.innlar  ap]ieaiaiici'  to  a  section  of  tin-  Inny:. 
Hotli  siili'S  i)(  the  heart  contained  mixed  lilirinons  and  dark  clots;  its  iniiscniar  tissue  was  nineli  softer  than  usual, 
'i'lie  liver  was  normal;  the  s|ileen  soft,  llaldiy  and  of  a  tiiiMd  piirjile  color.  'I'lie  intestines  were  of  a  dark  );rayish 
color;  I'eyer's  patches  were  ulcerated  in  places  Init  were  not  clevatt^d.  The  kidn<^}»  were  Mlif;htly  congested. — AxK't 
Siirij.  II.  Alli  II.  I'.  S.  ./.,  Lincoln  lliixi>iliil,  ll'iixliiiu/loii,  l)\  ('. 

Cask  1!I|.— Private  Walter  Wisner,  Co.  F,  titli  Mich.  Cav.;  a^e  2S;  was  admitted  ,Inly  'M>,  IXliS,  with  typhoid 
fc  \  er.  and  died  All  fiiist  )i.  I'lisl-iiinrliin  examinat  ion  eii;liteeu  hours  after  death:  The  Inain  wei^fhed  ti  ft  y -three  oiinees; 
liolh  lolies  of  the  ci'ieliiiim  were  hijilily  congested,  es|iecially  in  their  sii]ieriop  and  anterior  portions,  whiih  were  in 
|iart  of  a  Inilliaiit  crinison  color.  The  tracheal  niiicoiis  nienilirane  was  of  a  deep  diill-purjilish  hmI  ;  the  trachea  and 
liiciiiehi  eoiit.iined  a  thin  liloody  liiiiiid  instead  of  the  normal  secretion;  tlio  veins  under  tlio  mucous  niemlirane  of 
the  larynx  wcri^  distended;  the  lyni])hatie  jfliinds  at  tile  bifurcation  of  tlie  tradieawere  lar);e,  soft  and  eii^rorned 
with  black  blood.  The  liin<;s  were  of  a  delicate  pink  color;  the  external  and  lateral  ])ortioiis  of  the  ujiper  lobes 
and  the  u  hole  of  the  lower  lobes  were  doiifjliy,  seini-solidiliiMl  and  enfioiKi'd  with  dark  blood  mixed  with  u  frotliy 
broniliial  secretion:  the  riglit  Inns  weighed  twenty-live  ounces,  the  left  twenty-fonr  ounces.  Tlie  cavities  of  the 
heart  were  free  from  clots,  cxcejit  a  very  thin  wafer-liki^  formation  on  the  tricusjiid  valve.  The  liver  was  flabby  and 
somewhat  conf^esfed ;  the  s]ileen,  sixteen  ounces,  w  as  firiiyish-jiuriile  in  color  and  iiniisnajly  tlrin.  The  intestines  were 
diseased  throiijihont :  tlie  miicons  membrane  of  the  iipjier  portion  was  llaccid,  softened  and  easUy  torn,  the  vaJvnlai 
coiinivcnfes  of  an  orange-ochre  color;  I'eyer's  pat(dies  wmo  enlarged,  elevated  above  the  snixounding  inncons  niem- 
lirane, whitish  in  color  and  ulcerated,  none  of  the  ulcerated  points  being  larger  than  the  head  of  a  jiin:  the  scditary 
glands  were  al.so  afl'eeted  and,  in  the  neighborhood  of  the  valve,  the  mucous  nienibrano  was  completely  nodulated 
with  shot-like  eminences;  the  mucous  membrane  of  the  last  six  feet  of  the  ileum,  which  was  the  jiart  cliietl,v  involved, 
was  of  a  dark-red  color  and  its  veins  were  very  ]irominent.  The  kidneys  were  slightly  congested,  soft  and  llaccid. — 
Axfi't  Surg.  Harrison  AUin,  I'.  S.  A.,  Lincoln  lloxpitiil,  IViixhinijlon,  D.  C. 

Case  195. — Private  Vincent  Hogle,  Co.  E,  ,5tli  Mich.;  age  33;  was  admitted  March  24,  IHtU,  and  died  on  the 
'ititli.  I'ont-mortcm  examination:  Lungs  and  pleura'  inflamed;  much  etl'nsioii  in  right  cavity.  Intestines  intlamed 
nearly  throughout;  I'eyer's  patches  ulcerated. —  Third  Dirixion  Iloxpital,  Alexandria,  I'a. 

Case  liKi.— Private  .John  Sullivau,  Co.  15, 1st  Mass.  Cav.,  was  admitted  .Tiily  2,  IHti^l,  and  died  on  the  lllli.  /'"«(- 
mortem  examination:  Much  emaciation.  Lungs  extensively  intlamed;  heart,  liver  anil  spleen  healthy;  stomach  and 
intestines  much  inflamed;  I'eyer's  jiatches  slightly  ulcerated. —  I'liird  Dirixion  Jlo.sjiitnl,  Alexandria,  I'a. 

Case  1!I7. — Private  James  Foster,  Co.  I,  Hod  Pa.;  age  lit;  admitted  April  lit,  IXtil;  died  22d.  /'iw/-;H9Wrm  exam- 
ination twenty-four  hours  after  death:  The  lungs,  liver  and  spleen  weie  normal.  The  glands  of  the  intestines  were 
enlarged,  ulcerated  and  almost  disintegrated. —  Third  Dirixion  Iloxpilal ,  Alexandria,  Va. 

Case  lilS. — Private  Alonzo  Wilkinson,  Co.  A.  'JOtli  Me.,  was  admitted  Aug.  21.  IHtU.  having  about  five  or  six 
alvine  evacuations  daily,  with  some  pain  in  the  right  side  and  slight  dys]iiio-a;  pulse  120:  tongue  dry  and  covered 
with  a  brown  fur.  The  jiatient  continued  with  but  little  change  in  his  symptoms  other  than  a  temporary  abatement 
of  the  diarrliiea  and  aggravation  of  the  lung  trouble,  together  w  itli  increasing  ]irostration,  until  delirium  came  on, 
and  (loath  occurred  on  the  27th.    J'onl-tnorleni  examination  six  hours  after  death;  liody  not  emaciated;  riKOr  Uiortis 


0<S8  I'DST-MOinKM     I'J'll'OKliS    OF 

jji'ciif.  Till'  litjlit  liiHi;  Wiis  ijuiicinll.v  connrstcd  iiiid  ils  iiiiildlf  Icilic  lir)i:iti/c(l ;  tin-  Irfr  lung  was  coiigestcd  jKiste- 
riorly.  The  jxiric'iirdinin  cimtaiiiid  I  wn  niiiiccs  dC  li(niid;  the  i'ij{lit  cavitii's  of  the  licai't  were  tilled  with  a  liirKe  i)ar- 
tially  washi'd  riot.  The  livrr  was  ciilar-ucd  and  pale;  (he  f^all-Idaddci-  distended  with  viseid  liile;  the  S])leen  en  larked 
iiiid  soft.  The  stomach  was  inll.'ile<l  w  ilh  ii'as.  dilaicd  ajiil  Ihihliy,  and  its  iiniediis  nienilirane  was  ie<ldened  near  ihe. 
jiylonis.  In  tin'  lower  halt' of  the  ileum  the  aicminati'il  j;lands  were  congested,  enlarged  and  prominent,  and  those 
near  the  ileo-ca-eal  valve  showed  small  uleeis;  the  niueous  inenilirane  around  the  glands  was  more  or  less  eongested 
iieeordiiig  to  its  jiroximity  or  distane<'  from  the  valve;  the  solitary  I'ldlieli-s  were  enlarged  and  prominent.  No  ulcers 
were  found  in  the  large  intc'stine,  whieli,  liowever,  was  congested  throughout  and  dotte<i  with  hlack  (ligment,  ])ar- 
t  icularly  in  the  descending  e(don.  where  an  occasional  largo  Mack  spot  apiieareil.  [Sjiiciniiiit  .'illS  ami  :i!)lt,  Med.  Sect., 
Army  Medical  Museum,  were  taken  from  this  (-ase.  | — .1(7.  .ixs'l  Siirj/.  O.  I'.  <S'h'((7,  Cdrnr  Ifo«jiilal,  IVaxhiiifitoii,  I).  ('. 

Cask  lltll. — Private  Wm.  S.  Armstrong.  Co.  1!.  7th  .Me.;  age  2\ ;  was  admitted  .June  II,  If^ti.'i.  witli  high  fever  and 
delirium,  a  furred  and  fissured  tongue,  sordes  on  the  tcM'th,  frequent  retching  and  diarrhd'a,  the  stools  iiuuiliering 
about  twenty  daily.  Jle.  was  mu(  h  emaciated  and  so  weak  as  to  ho  unalde  to  sit  up.  During  the  ne.xt  few  days  his 
stools  hecanui  le.ss  frecjuent,  hut  on  the  lUth  the  ))assages  wert'  inv(duutary,  the  delirium  continued,  thi-  })nl.se,  which 
had  falh'U  from  120  to  80,  was  very  weak,  the  countenance  jiinched,  the  extremities  cool,  the  ])ers])iratioii  cold.  He 
died  on  the  2(lth.  I'lixi-miiriiiii  examination  fourteen  hours  after  death:  The  brain  was  healthy.  Tln^  mnious  meui- 
braae  of  the  (esophagus  was  of  a  bright-ochr(^  color  and  rather  softened:  the  trachea  was  of  a  (huk-]>ur]de  color,  its 
irnicons  menibranu  slightly  softened.  The  lower  lobe  of  t  he  right  lung  and  the  w  hole  of  t  he  left  lung  were  congested. 
The  endocardium  was  somewhat  darkened;  the  right  ventricle  contained  a  librinous  clot;  tins  aorta  wa.s  reddish. 
The  surface  of  tlio  liver  was  generally  of  a  grayisli-blue  color,  but  anteriorly  the  right  lobe  presented  a  more  healthy 
appearance;  minute  collections  of  air  wei'e  dissemiuated  tjiroughout  the  ])arenchyma  of  this  organ,  which  was  soft- 
ened, of  the  color  of  sanious  pus  iind  )iossessed  of  it  disagreeable  odor;  the  air-cavities  and  the  transverse  section  of 
the  portal  veins  gave  a  honey-condied  a])]>earance  to  thi'  interior;  (ilisson's  capsule  was  siimoth  and  easily  torn.  The 
mm'ous  lining  of  the  stoma(di  was  of  a  dark-slate  color  but  healthy.  The  spleen,  lifteen  ounces  and  a  half,  was  unusu- 
ally firm  and  of  a  deep  mulberry  color;  the  ]iancreas  was  healthy.  The  intestines  were  distended  w  ith  air;  the 
mucous  membrane  of  the  ui>per  ))ortion  of  the  small  intestine  was  of  a  light-yellow  color;  in  the  lower  third  I'eyer's 
patches  were  ulcerated  and  the  mucous  niemluane,  in  some  places  very  pale,  was  in  others  intensely  injected;  at  the 
ih^o-ca'cal  valve  it  was  indurated,  thickened  and  blackened  and  in  the  large  intestine  i)ale  and  irregularly  dotted 
with  blackish  spots.  A  cavity  containing  about  four  drachms  of  juis  was  found  betwei^n  the  i)eritoneum  and  tlu; 
ctdlular  tissue  on  the  right  side  of  the  abdomen,  about  two  inches  below  the  dia|>hragm;  the  omentum  was  healthy. 
The  kidneys  resembled  the,  liver  in  having  air-cavities  disseininatcd  through  their  parcnchyiua;  the  distinction 
lietwwn  the  cortical  and  pyramidal  portions  was  almost  obliterated,  the  latter  being  ]iur]dish;  the  organs  generally 
wpro  tunud  and  tlabby.  Two  largo  bed-sores  were  noted,  one  over  the  sacrum,  the  other  over  the  great  trochanter 
of  the  right  femur. — A.in't  fiurij.  lIiirrisDii  Jllvii,  U.  S.  A.,  Lincoln  lloxjiitol,  fl'ofilihiyioii,  I).  C. 

Ca.se  200.— Private  K.  L.  Tyler,  Co.  E,  17th  IT.  S.  Inf.;  age  2'A:  was  admitted  Aug.  lU,  1X(!2.  and  (Ued  on  the  16th. 
Post-moilim  examination:  The  mneous  membrane  of  the  ileum  was  not  generally  inllamed,  being  of  a  ]iinkisli-cream 
color:  there  were  twenty-two  agmimited  glands,  varying  in  size  from  half  an  inch  to  one  whi(di  was  four  inches  in 
length;  the  twidve  upjier  patches  were  healthy,  the  thirteenth  ulcerated,  the  fourteenth  healthy  and  the  icuuiinder 
ulcerated,  some  even  through  to  the  peritoutuim;  the  last  of  the  scries,  near  the  ileo-ca'Oal  valve,  formed  a  blackish- 
brown,  irregular  eschar  about  an  inch  and  a  (inarter  s(|uare  and  the  fourth  of  an  inch  thick  [see  plate  facing  this 
jiagej;  in  the  vicinity  of  Ihe  iLlcerated  glands  the  mucous  nu-nibrane  was  intlamed.  The  colon  was  intlamed  in 
patches,  and  its  solitary  glands  wcr(>  |)roniinent  and  contained  a  dc]iosit  of  black  pignuMit,  which  was  observed  also  in 
the  agrninated  ami  solitary  glands  of  the  ileum.  ISpcciiiiniK  210  and  211,  Med.  Sect.,  Army  Medical  Museum, are  from 
this  case.  ] — Act.  Ann't  Sury.  Jascjih  Lculy,  Sathrlce  Uo^pitul,  I'hiladclphia,  I'a. 

Cask  201. — Private  Lorenzo  II.  (lox,  C'o.  C,  tith  \'t.;  admitted  August  10,  18t;2.  Typhoid  fever.  Died  Sept.  7. 
Post-mortem  examination  next  day:  Age  about  2^  years;  emaciation  extrenu;  diffuse  ecchymosos  on  skin  of  body. 
Ijungs  healthy;  heart  natural,  containing  some  li(iiiid  blood  and  a  soft  black  clot  in  the  right  ventricle.  Spleen  sm.ill, 
lake-red  on  section;  liver  dull-brown  above,  slate-color  below  and  iiniforudy  brown  on  section.  Stomach  imxh'r- 
ately  distended,  its  mucous  membrane  dirty  gray  with  some  vascular  injection  ;  ileum  and  colon  inflamed  in  pat(diis ; 
agminated  glands  containing  black  deposit,  but  otherwise  healthy,  except  two  near  the  colon,  which  were  slightly 
ulcerated;  solitary  glands  everywhere  pigHU-nted. — Act.  Asu't  Surg.  J.  Leidy,  Satterlee  Hosxntal,  Philadilphia ,  Pa. 

Ca.se  202.— Sergeant  Samuel  Kelley,  Co.  E,  23d  N.  Y.,  was  admitted  Dec.  23,  1862,  with  a  gunshot  wound,  and 
died  .Ian.  1,">,  1863.  I'ont-mortem  examination  next  day:  Age  about  30  years;  no  emaciation  ;  a  few  faint  reddish  sjiots 
on  t  he  abdomen.  Vessels  of  brain  distended  with  blood.  Lungs  and  heart  healthy.  Liver  pale  Indian-red  on  surface 
and  on  section:  sple(>n  enlarged,  six  by  four  by  two  and  a  half  inches,  rather  soft  and  on  section  like  black  currant- 
jelly.  Colon  pale  gray  with  sliite-colored  streaks  and  reddish  spots,  its  solitary  ghinds  containing  black  nuitter; 
ileum  geuiaally  ]pale,  but  w  ith  streaks  and  jiatches  of  moderate  intlannnation,  its  solitary  glands  enlarged,  some  to 
the  .size  of  pejiper  grains,  and  its  agminated  glands  enlarged,  several  ulcerated  and  with  ochre-yellow  adherent  gran- 
ulations.— Act.  .[m't  Surij.  Jomph  I.iidij,  Sdttcrbc  IloxpHtil,  PhUudclphid,  Pa. 

Case  203.— Private  Mo.scs  liurkctf,  Co.  A,  12th  V.  S.  Inf.;  admitted  Aug.  ID,  1862.  Typhoid  fever.  Died  .'^ept.  !». 
Pont-morlrm  examination  sami'  day:  Age  alxnit  20  years;  emaciation  :  slight  petechial  nuirks  on  breast  and  abdonuMi. 
Kight  lung  with  old  pleuritic  adhesions  throughout;  left  with  adhesions  at  apex  of  upper  lobe;  small  tuljercles,  few 
in  number,  from  the  size  of  hempseed  to  that  of  a  pea,  deposited  in  the  pleura  pulmonalis,  pleura  costalis  and  superficial 
tissue  of  both  lungs.    Heart  llabbj ,  with  a  large,  transparent,  fibrinous  clot  in  the  left  ventricle  but  none  in  the  right. 


Am.  Plwta-Relitf  Printing  Co.,  1002  Arch  St.,  fhiladtlphia. 

SLOUGHING   PEYER'S  PATCH. 


No.  241.     MEDICAL  SECTION. 


THE  CONTINrEB  FEVERS.  389 

Ppritoneum  everywiicro  strewed  with  small  tnliercles  from  the  size  of  mnstarrt-seed  to  that  of  lieiiipseed,  in  ureatest 
aliuiulaiice  in  the  pelvis,  where  they  were  accoiniiaiiied  with  peritonitis,  the  l)owels  adherinj;  by  reei-nt  pseu<l()-mem- 
liranous  matter;  mesenteric  j^lands  and,  indeed,  all  the  alidominal  lymjihatic  inlands,  enlarged  but  not  tul)ercular. 
Liver  fatty,  the  acini  in  section  appearini;  large,  dull  yellowish  with  brown  centres;  spleen  natnral.  Stomach  moder- 
ately contracted  and  not  intlamcd.  Ileum  with  several  small  ])atehes  of  moderate  inllannnation  and  one  ecchyniosed 
patch;  agniinated  glands  slightly  thickened  and  the  lower  ones  sniierficially  ulcerated;  solitary  glands  enlarged. 
Moderate  inllannnation  in  the  Ciccnm  and  sigmoid  flexure  of  the  colon,  the  mucous  membrane  of  tlu^  latter  with  a 
blackish  blush,  apparently  from  deposits  of  line  black  ])tgnu-nt  in  the  ejiithelial  cells;  solitary  glands  healthy  and 
not  blackened. — Act.  As-i't  Siirij.  Jo^iph  Lddy,  Hattirhv  Iluxpiliil,  I'liUodcljih'Ki,  I'li. 

Case  20-1.— Thomas  James,  a  nurse  of  ward  7,  died  Oct.  SO,  181)8,  of  peritonitis.  P(i>:t-moi-li'iH  examination  eight 
hours  after  death:  Age  about  fifty  years;  body  well  nourished;  thyroid  body  enlarged  on  one  side  to  the  size  of  a 
hen's  egg.  Heart  and  lungs  healthy;  capacity  of  chest  diminished  by  pressure  of  alidominal  contents.  Peritoneal 
surface  everywhere  reddened  by  turgid  vessels  and  covered  by  thin,  recent,  cream-colored  pseudo-membrane,  with 
interstitial  sero-puruleut  liiiuid;  ab(fiiniinal  Iymphati<'  glands  not  paljiably  diseased.  Liver  large,  yellowish-brown, 
soft  and  somewhat  fatty:  gall-bladder  small  and  jiartially  collaiised;  spleen  liabby,  on  the  surface  bluish-white  and 
with  an  <dd  white  cicatrix-like  niark,  which,  together  with  the  sub-serous  tissue,  was  spotted  with  black  macuhe,  on 
section  light  Indian-rod,  lemarkably  bloodless  and  for  half  a  liim  from  tins  surfain^  black  frcuu  pigment  deposited  in 
molecular  granules  and  rounil  masses  th(^  sizi'  of  blood  eoriuiscles.  Stomach,  jiancreaB  and  kidneys  lu^althy.  Ileum 
and  colon  slightly  more  pink  than  normal:  upjier  agminated  glands  healthy;  glands  of  lower  three  feet  of  ileum 
ulcerated,  the  ulcers  occupying  only  ]>art  of  the  surface,  hut  extending  to  the.  muscular  and  serous  coats  and  in  one 
instance  perforating  the  latter,  the  hole  being  circular  and  about  a  lino  in  dianujter.  The  blood  contained,  if  any- 
thing, fewer  white  corpuscles  than  usual.  ISpvcimenn  2'M  to  230,  Med.  Sect.,  Army  Medical  Museum,  are  from  this  case.] 
— Act.  Ass'i  Surg.  Joneph  Lcidy,  Hattirttii  ffoxpilal,  I'hihi.,  I'd. 

(C)   I'onditioii  of  I'i'i/i'i-'k  piilclicK  not  stolni ;  llic  ileum  or  the  urn  all  iiilcxlinc  iilvfrolid — 22  ctmcK. 

Case  2(ir>. — I'rivate  lien.janiin  McCoy,  Co.  11.  llUh  I 'a.,  was  admitted  Sept.  16,  l«(i:!,  in  low  <(Uidition  and  cyan- 
otic. Next  day  he  became  <lelirious,  and  soon  afterwards  ccchymoses  ajipeared  on  the  chest  and  abdonuMi.  He  died 
on  the  22d.  Vont-morttm  examination:  Heart  sound;  parenchymatous  orgiuis  healthy;  a  portion  of  the  ileum 
ulcerated. — Ait.  Am't  Siirij.  It'.  Leon  llamnionil,  First  IHvinion  lloxpilal,  Alexandria,  I'li. 

Cask  2()(). — Private  Kicliard  lioyer,  Co.  F,  14i)th  Ohio  National  (iuard;  age  IS;  delirious  and  with  a  feeble 
intermitting  pulse;  diarrlnea.  jirofuse.  Died  August  HI,  IStiL  I'oxt-morit in  examiiuition  sixteen  hours  after  death: 
Lungs  soumwhat  euiphyseiuatous  on  their  peri]du'ry;  ])ericar(linm  thickened  and  containing  four  ounces  of  yellow 
liiiuiil :  lu'art  enlarged  bilt  with  no  valvulai'  derangement;  lower  third  of  ileum  ulcerated,  some  of  the  ulcers  nearly 
lierforat ing,  others  almost  cicatrized. — Scminari/  Hospital,  Colninliw.  Ohio. 

Cask  2(i7.— Private  Levi  Hentley,  Co.  K,  Itth  N.  Y.  Art.:  age  IX;  was  admitted  .lune  II.  1W>I,  with  typhoid 
fever,  niid  diiil  i>n  the  2.">tli.  Post-mortem  examination  twenty-four  hours  after  death:  Miliary  tubercles  in  both 
lungs;  uleer.ition  of  the,  ile()-c:ecal  valve  and  of  the  whole  of  the  ileum.  Heart,  liver,  spleen  and  kidneys  normal. — 
.!<■/.  Ass't  Snrij.  Jl.  Jl.  Miles,  ./arris  Hospital,  Jialtimore,  Mil. 

Cask  208.— Private  William  Park,  Co.  F,  llHtli  Ohio  National  (luards;  age  37;  was  admitted  May  30,  1864, 
ami  die<l  .Jum^  2(>.  I'ost-morlem  examination  twenty -four  hours  after  death:  A<lhesi(uis  of  the  meniliranes  of  the  brain 
and  slight  effusion  of  serum  uiuler  the  arachnoid.  Lungs  noruuil;  heart  natural,  but  the  pi'ricardinm  contained 
some  effusion;  liver  much  nuittled;  spleen  normal.  The  lower  part  of  the  ileum  was  much  congested  hut  showed 
only  01U5  ulcer. — Ael.  Ass'l  Siirij,  li.  li.  Miles,  ./arris  Hospital,  liiiltiniore,  Md. 

Cask  20!): — Private  .Janu's  M.  Cammell,  (!o.  (i,  Uth  \'a.;  age  22;  was  admitted  Aug.  31,  18(U,  with  typhoid 
fever,  and  died  Sejitember  10,  Post-mortem  examination  twenty-four  hours  after  death:  Klfusion  in  the  ventricles  of 
the  brain.  Twenty-five  ulcers  in  the  ileum,  which,  for  two  feet  above  the  ileo-cacal  valve,  was  intensely  intlamed; 
the  valve  was  one  mass  of  ulcers. — .lit.  .Iss'f  Snri/.  />.  /<'.  .Miles,  ./arris  Hospital,  Ballimore,  Md. 

Cask  210. — bdin  Henry,  contraband;  age  22;  was  admitted  Aug.  27, 18til,  with  typhoid  fever,  and  died  on  the 
30th.  /'(iNNMKr.'cw  examination:  Lungs  congested ;  heart,  liver  and  kidneys  normal;  spleen  softeneil:  small  intestine 
congested  and  extensively  ulcerated,  especially  near  the  ileo-ca'cal  val\  e. — Chuttiinooyii  Field  Hospital,  Tenn. 

Cask  211. — Spencer  Jonaijue,  contraband;  age  20;  was  admitted  Aug.  18,  18IU,  with  typhoid  fever,  and  died 
on  the  27tli.  Post-mortem  examination:  Lungs  congested;  heart,  liver  and  kidneys  normal;  spleen  softened;  snuill 
intestine  congested,  softened  and  showing  many  miiinti^  ulcers. — Chattanooga  Field  Hospital,  Tenn. 

Cask  212. — Private  .James  Lock,  Co.  K,  22d  Mich.;  age  10;  was  admitted  .\ug.  10,  18(>4,  with  typhoid  fever, 
and  died  on  the  10th.  I'ost-mortem  examination  on  day  of  death:  Lungs  congested  and  lower  lobe  of  left  lung  hep- 
atized;  heart  tlabliy;  liver  and  kidneys  imrmal;  spleen  large  and  softened;  mucous  nu^mbraiur  of  ileum  softened 
and  showing  many  ulcers  of  varions  sizes. — Chattanooga  Field  Hospital,  Tenn. 

V\!iK  213.— Private  David  Cantwell,  Co.  A,  42d  IT.  S.  Colored  troops;  age  37;  admitt.'d  Aug.  17,18W;  died  29th. 
I'osl-morteni  examination  on  the  day  of  de.-ith:  I,uugs  universally  iind  firudy  adherent :  lu'art,  liver  and  kidneys  uor- 
nuil;  spleen  oiu!  and  a  half  ounces;  mucous  memlirane  of  suuill  intestiiu'  thickened,  softened  and  showing  several 
ulcers  one-fourth  to  one-half  inch  in  diameter. — Chiittanooga  Field  Hospital,  Tenn. 

Cask  214.— I'rivate  Fielding  Childers,  Co.  D,  Kith  U.  S,  Colored  troops;  ago  22;  was  admitted  Sept.  2,  18&1, 
and  died  on  the  8th.     Pont-morti'm  examination  on  the  day  of  death:  'J'ho  lower  lobe  of  the  right  lung  and  part  of 


390  POST-MORTEM    RECORliS    OF 

the  upper  lol)e  were  Iiepatizcd;  tUe  lower  loin-  of  llu;  h-t't  liiiij;  was  coiijjtf.sted;  tlif  lii-iut  was  flabby.  The  liver 
WiiB  Hofteiieil;  tlii^  Nph3eii,  eij^htceii  oiliiceti,  wuh  Hoftened  and  had  two  l»r>;t!  eysts  on  its  siufaci'.  The  mucous  mem- 
brane of  the  small  intestine  was  softened,  coiif^ested  and  stu<hh5d  with  numerous  small  ulcers.  The  kidneys  were 
normal. — FiiUl  floxjiihil,  ('hdlhiiioni/n,  'I'niii. 

(;ask  215. — Private  Henry  \V.  Shedron,  Co.  E,  regiment  not  stated,  was  admitted  Oct.  14,  1K64,  as  a  conva- 
lescent from  typhoid  fever.  He  was  f;;reatly  emaciated  an<l  had  slifrht  chills  every  day  f(dlowed  by  hif;h  fever  and 
ni};ht-8weat8.  On  the  Kith  he  complained  of  ]),iiii  in  the  chest;  diarrluea  set  in  next  day,  ami  he  die<l  on  the  22d. 
/'()»(-moc((-w(  examimition  eight  hours  after  death:  Kight  lung  liepatized  throughout;  uh^ers  and  an  old  cicatrix  in 
the  small  intestine. — flo.ipital  Mo.  8,  Na»hrUle,  Tom. 

Case  21().— Private  Simeon  M.  Van  Horn,  Co.  F,  14l8t  Pa.;  admitted  Oct.  14, 1802;  died  24th.  Post-mortem  exam, 
iuatiou:  The  mucous  membrane  of  the  small  intestine  was  much  softened  and  presented  many  ulcerated  patches. 
The  mesentery  was  highly  congested  ;  the  mesenteric  glands  enlarged  :  the  spleen  twice  the  usual  size,  much  engorged 
and  easily  broken  down;  the  liver  enlarged  and  frialde. — Third  Ilirixioii  Ilosjntal,  AUjnnilrin,  la. 

Cask  217. — Recuuit  .lohn  11.  Skillington,  lilth  Pa.;  agi>  2ri;  was  admitted  .Sept.  9,  18H4,  with  typhidd  fever. 
He  fell  into  an  uneons<-ious  state,  and  died  on  the.  11th.  I'oat-inorttm  examination  one  hour  and  a  half  after  death: 
Slight  effusion  ben(vitli  ara<!hnoid  at  ape.x;  three  small.  Hat,  strong  dejiosits  in  anterior  part  of  posterior  commis- 
sure in  front  of  pini'al  gland;  a  dirty  looking  clot  in  the  heart;  gray  hepatization  of  jiosterior  i)art  of  upper  l(d)e  of 
right  lung  and  minute  red-lirown  interlobular  intiltrations  in  posterior  j)art  of  lower  lol)e;  liver  large;  sjileen  large, 
dark  and  hard;  kidneys  ])ale;  ileum,  near  ileo-ca-cal  valve,  show  ing  |)atches  of  congestion  and  ulcers  with  thickened 
and  re(hlened  bordius;  colon  normal. —  Third  Dirixiuii  Hospital,  Alexaiiilria,  fa. 

OsK  218.— Private  Benedict  Gehrich,  Co.  D,  67th  Pa.;  admitted  April  24,  18(i").  Typhoid  fever.  Died  29th. 
/'o«/-»«or<rm  (examination :  Rigor  nu)rtis  well  nuirked  ;  integuments  excoriated ;  patches  of  denuded  mus(de  here  ami 
there.  Lungs,  heart  iinil  stomach  healthy.  Sjdee.i  eiihugied  to  three  times  the  usual  size,  congested  :  small  intestine 
slightly  ulcerated  at  several  points. — Ihpot  Field  llo.'^pilitl,  Sixth  Ariiii/  Corps,  City  Point,  f'li. 

Ca.sk  2I!t. — Private  Frederick  Wombeyer,  Co.  F,  list  X.  Y.,  was  admitted  March  lo,  18ti."),  and  died  on  the  same 
day.  Posl-morlem  exaniinaticm  twenty-four  hours  after  death:  'i'he  lungs  were  lilled  with  blood  and  frothy  serum; 
there  were  adhesions  on  the  right  side,  ami  eight  ounces  of  serum  in  each  pleural  sac;  the  heart  was  pale  ami  con- 
tainetl  a  small  clot.  The  liver  was  normal;  the  lower  portion  of  the  ileum  was  entirely  denudiMl;  Ww.  kidiu'ys  were 
iutiatned  and  <'onl:uneil  pus. — Depol  I'iild  Hospital,  fiixlh  .irnii/  Cor/is,  Cili/  I'oiiil,  I'a. 

(!ase  220. — Private  .lolin  Fitzslmmons,  Co.  I),  l(l2d  Pa.;  admitted  March  15.  lSt;5.  Diagnosis — typhoid  fever. 
Died  28th.  Post-morlem  examination  forty-eight  hours  after  death:  The  lungs  were  healthy,  but  there  were  pleuritic 
adhesions  on  the  left  side;  the  heart  contained  large  (ibrinoiis  clots  in  all  its  (•aviti<^s.  The  liver  was  pale,  almost 
fatty;  the  spleen  normal.  1  he  Intestines  were  normal  exce])t  the  last  two  feet  of  the  ileum  ;  near  the  ileo-<'a'cal  valve 
the  gut  was  entirely  denuch-d  of  membraiu'  and  covi'red  with  greenish  slime.  'I'be  left  kidney  was  |>ale;  the  right 
contained  a  huge  abscess. — l>ei>ol  Fielil  llosjiilal.  Sixth  .h'lnji  Corps,  Cilji  I'oiiil,  I'li. 

Cask:  221.— Private  R'oImtI  K.  Sluiw,  Co.  K.  lllth  K.  V.:  age  2:{;  was  admitted  .lune  2t>,  18t;:i.  with  lyphoi<l 
fever,  and  died  .Vugust  Id.  .f'<).s/-/H())/'«i  examiniil  ion  t  weiity-live  hours  after  <leal  li :  Piody  rigi<l,  not  ennieialed.  Pungs 
normal  excejiting  eadaviMJc'  changes,  light  weighing  eighteen  ounces,  left  seveiileen  ounces:  right  cavities  of  heart 
containing  a.  huge  clot,  lilirinons  with  a  bloody  admixliire,  extending  a  long  dislanee  into  the  |iulmonary  artery. 
Liver  i)ale  and  llabby;  sple<'n  soft  ami  d<'C(imi>osing;  small  intestine  healthy  to  within  four  feet  of  the  ileo-ciecal 
valve,  below  this  point  extensivt^  typhoid  nleeraliou  existed,  the  uliers  being  snperliei;il  and  situ.ited  lor  the  most 
part  in  the  centre  of  huge  congested  patches:  large  intestine  healthy;  kidneys  very  soft  and  llabby,  congested  in 
their  cortical  substance. — Ass't  Siir;/.  II.  /Ilbii,  V.  S.  A.,  Lineoln  Ilosiiital,  U'lishini/loyi,  I).  C. 

C.\SK  222. — I'rivate  H.  Mortenson,  (.'o.  (i,  27th  Wis.;  age  ;i2;  was  admitti'd  May  1(1,  18t)3,  with  jiarotitis,  a 
sequel  of  fever.  An  infusion  of  frostw(Ut  ( lleliaiitheiiiiuii  Caiiadeiise)  was  given  and  the  atl'eceted  parts  painted  with 
tincture  of  iodine.  The  |)atient  would  not  ))ermil  any  poultices  or  other  appli<-atioiis  to  \>t'  used.  An  ichorish  nuit- 
ter  was  discharged  from  both  eais  until  death  on  the  18th.  ^•Aulojisij  revealed  softening  of  kidneys  and  a  cavity 
containing  tlnid  in  right  kidney;  intussusception  and  ulceration  of  small  intestine." — .1(7.  Ass't  Snrij.  \V.  A.  McMiir- 
ray,  City  (ieneral  llospildl,  St.  Louis,  Mo. 

C^ASK  22:1 — Private  Wendilin  (hiesbauni,  Co.  F,  Kith  111.  Cav.;  age  43;  was  admitted  Sept.  12,  18(i3,  having 
had  fever  for  ten  days.  As  he  was  unable  to  s]ieak  English  and  was  rather  dull  withal,  but  little  acc<uint  of  his 
case  could  be  obtained.  Simi)le  febrifuge  renu'dies  with  i|uinine  were  ordered.  Castor  oil  was  adnunistered  on  the 
15th,  as  the  bowels  weie  constipatiil,  painful,  somewhat  distended  and  Inird.  The  abdominal  symi>tom»  werce  aggra- 
vated on  the  Pith,  althimgh  t\w  bowels  had  been  moved  in  the  meantime ;  the  piil.se  was  KHI  and  feeble.  Ho  died  <ui 
the  evening  of  this  day.  Dr.  F.  K.  Haii.ky,  attending  surg(H)n,  reports  that  "on  inquiry  among  his  comrades  1  learn 
that  this  man  had  been  kicked,  some  six  or  eight  months  ago,  in  tlii!  abdomen  by  a  fellow-soldier,  and  that  he  has 
been  sick  ever  since."  Post-mortem  examination  fourteen  hours  aftir  death:  Pody  emaciated;  abdomen  hard  an<l 
very  much  distended;  large  quantities  of  bloody  lic]uid  oozing  from  mouth;  skin  in  dependent  regions  livid.  The 
thoracic  viscera  were  normal.  The  jieritoneal  cavity  contained  a  large  iiuantity  of  bloody  serum.  ]ius  and  fa-ces;  the 
omentum  was  livid  and  so  tender  as  to  scarcely  hold  together;  tht»  liver  was  twice  the  usual  size  and  could  be  easily 
broken  down  by  the  tinger;  the  spleen  was  discolored  but  not  enlaige<l.  The  stomach  was  distended  to  double  the 
normal  size;  the  ileum  perforated  near  its  union  with  the  large  intestine.  The  kidneys  were  healthy. — Hospital, 
Quincy,  III. 


M  ^«btr  piRv' 


F.Moras  ctiromoltrti  Phil* 


iPiKiFi^^TDKi©  EU^^  m^m  \iimm. 

TKe  righ[  hand  piece  shows  the  mucous, the  left  \\\e  peritoneal  surface. 


TIIK   rONTINUED    FEVERS.  391 

Case  224.— Private  Eli  W.  Whitiiif;.  'iili  Mo.  Bat"y,  was  admitted  Sci)t.  1,  1><62,  with  a  Kunsliot  wound  reet-ived 
at  the  liattle  of  Bull  Kuu.  Ho  was  sent  to  his  home  ou  furlough  Noveiuliei'  12,  and  wa.s  there  taken  very  siek.  He 
returned  to  hospital  Fehruary  tj,  IJidI?,  in  a  debilitated  condition.  On  .Mar<di  IX  he  was  attacked  by  fever  and  a 
severe  }iaiu  in  the  pneeordial  region.  On  the  iiuirninf;  of  the  21th  he  had  a  chill,  an<l  the  seat  of  the  pain  changed 
to  the  umhilical  and  hypogastric  regions:  he  lay  on  his  liack  with  his  knees  ilrawn  up  and  the  abdominal  walls 
motionless  in  respiration:  his  face  was  ))alc  and  coiitractcil.  showing  great  distress  ;ind  anxii'ty:  pulse  frequent  .-ind 
Biiiall:  tongue  red  at  the  tip  and  edges  anil  furred  with  yellow  in  the  centre;  thirst  extreme;  liowcls  constipated; 
he  had  much  nausea  and  vomited  a  greenish  offensive  imitter.  lie  was  lonscious  until  within  an  hour  of  his  ileatli, 
which  took  place  on  the  evening  of  the  2."ith.  PoKt-miivliiii  examination;  A  large  i|nautity  of  serum  and  pus  was 
found  in  the  peritoneal  cavity:  the  peritoneum  was  thickeiu>d  and  congested;  it  presented  a  lirilliant  rcil  appearance 
over  some  parts  of  the  small  intestine  and  a  deep-red,  almost  black,  appeaianue  over  other  parts.  The  ileum  for 
aliout  live  feet  from  the  ca-cum  was  more  or  less  ulcerated;  it  was  ))eiforated  by  a  large  ulcer  at  a  point  eighteen 
inches  froiri  the  ileo-ca>eal  valve.  [.'>ee  spiciiiini  1 17.  Meil.  Sect.,  Army  Medical  Museum,  and  i)late  facing  this  page.] 
— MciI.  Ci((lii  Ahuer  Tliiirp,  V.  S.  A.,  Ciihimhian  llospita],  ll'dnhiliiiUm,  I).  C. 

Case  22."). — Private  .Iose]>h  Fair,  Co.  L.  lltli  Pa.  Cav.;  age  .")2:  was  admitted  .Inly  2"),  IStiS,  witli  delirium, 
tremors  and  diarrlnea.  He  died  .\ugust  3.  I'o»l-iii(irlem  eKamiuation  ten  hours  after  death:  Lower  lobe  of  right 
lung  hepatized;  liver  hypertrojihied :  g:ill-bladder  enormously  enlarged,  six  to  eight  inches  long;  ileum  ulcerated 
and  perforated,  [(iall-bladder  forms  sjjcciHicii  :?7.  Med.  Sect.,  Aimy  Medical  Museum.] — Ass'l  Sitr;/.  IhWitI  C  I'llirt, 
V.  S.  A.,  Jarcix  [{ospilal,  Haltimorc,  Md. 

Case  22(5. — Corp'l  Paul  Grauvet,  Co.  I),  1st  N.  J.,  was  admitted  Aug.  !t,  1862,  having  sulfered  from  diarrhd'a 
and  fever  at  Harrison's  Landing.  After  his  admission  he  did  well,  recovered  his  appetite,  increased  in  llesli  and 
strength,  and  appeared  in  fact  entirely  convalescent;  but  during  the  afterno(Ui  of  the  iilst  he  was  suddenly  seized 
with  violent  pain  in  the  abdomen,  quick  pulse,  piostration  and  vomiting.  Under  the  use  of  opiates  and  restoratives 
he  was  relieved  from  ])ain,  but  the  abdomen  became  tumid.  He  continued  to  sink,  and  died  during  the  night.  On 
the  day  of  this  attack  the  patient  took  :in  unusually  large  uiciil  of  meat,  which  he  ilid  md  cliew  sutliciently,  and 
which  he  vomited  in  pieces  as  large  as  a  shellbark.  "The  (iiilopsji  rcv<>aled  thrci'  large  |);it(dies  of  ulceration,  two  of 
which  had  perforated  the  simill  intestine,  ])roducitig  intense  ])eritonitis." — SulirrUf  lloxjiilal.  Vliiloili)jihia,  I'll. 

(D.)  Condition  of  I'eijir'ii patches  not  stilted;  the  ileum  or  the  small  intestine  nlcentled  and  the  liirije  intestine  also  affected — 

1!)  cases. 

Case  227.— Prixate  Albert  Turner,  Co.  .\,  I2d  U.  S.  Colored  troops;  age  48;  was  admitted  Aug.  31,  1864, 
with  typhoid  fever,  and  died  September  2.  I'ost-morti  m  examination  on  day  of  death:  liight  lung  congested  and  at 
points  hepatized;  left  lung  normal;  heart  pale  and  tlabliy.  Liver  congested  and  somewhat  softened;  spleen  enlarge<l 
and  softened;  kidneys  enlarged  luit  tirni,  weight  of  each  nine  ounces,  l^ower  ileum  ulcerated  in  patches;  mucous 
membrane  of  ascending  and  transverse  colon  thickene<l  and  softtnicd. — Chiitlunooija  Field  Hospital,  Tenn. 

Case  228. — Charles  Lancaster,  contraliand;  age  28;  was  admitted  Sept.  2,  1861,  with  typhoiil  fever,  and  died 
on  the  10th.  J'ost-murtem  examination  next  day:  Left  lung  partly  he]>atized;  lower  hdte  of  right  lung  congested; 
heart  normal.  Liver  congested  and  softened;  spleen  weighing  two  ounces;  left  kidney  presenting  a  small  eyst  tilled 
with  jius.  Large  intestine  congested  and  softened;  ileum  ulcerated,  the  ulcers  measuring  two  to  three  inches  in 
their  long  diameter. — Chiittanooija  Field  Hiisjiilal,  Tenn. 

Ca.se  22!1. — Private  Ire  Campliell,  Co.  K.  16tli  U.  S.  Colored  troojis;  age  20;  was  admitted  Aug.  27,  1864,  with 
typhoid  fever,  and  died  on  the  30th.  Post-morlein  examination  lui  day  of  death:  Lungs  somewhat  ciuigested ;  heart 
normal.  Liver  congested  and  softened:  s]ileen  much  softened;  kidm\vs  normal.  Large  and  small  intestines  ulcerated, 
some  of  the  ulcers  being  one-fourth  inch  in  diameter. — Chiittanooija  Field  Hospital,  Tenn. 

Case  230.— Private  Kicliard  Weathorford,  Co.  D,  42d  11.  S.  Colored  troops,  was  adnntted  Aug.  II,  1864,  with 
typhoid  fever,  and  died  on  the  17th.  Post-mortem  examination:  Tilings  c(uigested:  heart  flabby.  Liver  and  kidneys 
normal;  si)leen  softened.     Intestines  congested  and  softened,  ileum  ulcerated. — Chattanooija  Field  Hospital,  Tenn. 

Ca.se  231.— Private  Frederick  H.  A.  Steel,  Co.  D,  lOth  Pa.  Cav.,  was  admitted  Aug.  16, 186-1,  with  typhoid  fever, 
and  died  on  the  18th.  Post-mortem  examination  next  day:  Lungs  much  congested;  heart  and  liver  nonaal;  spleen 
softened;  right  kidney  somewhat  congested,  left  kidney  longested  and  fatty:  mucous  meudirane  of  intestines  soft- 
ened and  congested,  that  of  ileum  presenting  ulcers,  some  small  and  others  with  a  long  diameter  of  two  inches  and  a 
half. — Chattanooga  Field  Hospital,  Tenn. 

Case  232.— Private  Samuel  Hurto,  Co.  B,  10th  IT.  S.  Inf.;  age  21;  was  admitted  .Inly  2,  18&1,  from  City  Point. 
Diagnosis — typhoid  fever.  Died  11th.  Post-mortem  examination  eleven  hours  after  death:  Extreme  emaciation. 
The  intestinal  canal  was  intlamed  and  presented  several  indurated  ulcers  in  the  c^ecnm,  colon,  rectum  and  ileum. 
The  other  organs  were  in  a  normal  condition,  [^flpetinien  421,  Med.  Sect.,  Army  Medical  Museum,  is  from  this  case.]— 
Surg.  F.  Bentley,  TJ.  S.  V.,  Third  Division  Hospital,  Alexandria,  }'a. 

('a.sb  233. — Private  George  Martin,  Co.  B,  110th  Ohio,  was  admitted  Aug.  10,  1864,  unconscious,  and  died  next 
day.  Post-mortem  examination  :  Much  emaciation.  Considerable  thickening  of  the  intestinal  mucous  membrane  and 
extensive  ulceration  of  the  ileum,  ca'cuiu  and  colon. —  Third  Dirision  Hospital,  Alexandria.  I'n. 

Case  234.— Corporal  William  Powell,  Co.  K,  10th  N.  Y.  Cav.;  age  43;  admitted  .July  13,  1864.  Diagnosis- 
typhoid  fever.  Died  24th.  Post-mortem  examination:  Great  emaciation.  Slight  adhesions  of  right  pleura  and  e.xten- 
sive  inflammation  of  lower  lobe  of  right  lung.     Numerous  and  large  ulcers  in  the  intestines,  extending  from  about 


392  POST-MORTE^r    RK(X)1:11S    (W 

two  feet  aliove  the  oicciirii  to  the  :11111s.  ami  two  iiitussusceptioiis  of  the  ih'Uin,  reeeiit  in  aiipearaiiee.     Liver  euhiiiied 
and  fatty;  spleen  very  much  enlai;j;e(l  and  congested. — ll'liii-d  IHi-i'^iiiii  Husjiilnl,  AUjundria,  lit. 

C'a.se  23."i. — Private  Georf^e  Fox,  (Jo.  K,  2d  N.  Y.  Mounted  K'illes:  admitted  July  L':i,  iJ^iil :  tyi)hoid  fever.  Tliis 
patient  was  delirious  on  admission,  and  continued  so  until  he  died  i-om.itose  on  tlie  2!itli :  vihices  aiiiieart^d  on  the  chest 
on  tlieiJTth  and  hecame  darker  and  more  extensixe  diirinj;  the  toUowinj;  day.  Viinl-innrt(  m  examination  twenty 
hours  after  death:  JIiuli  emaciation.  Intlamiiiation  and  ulceration  of  the  nincons  coat  of  the  ileum  anil  colon,  in 
some  places  nearly  perforating;  other  organs  not  seriously  diseased. — Third  Dirision  llospital,  Ahj-iiiiilrhi,  )'it. 

C.vSK23n.— Private  Frederick  Bingal,  Co.  I,  5th  IT.  S.  Cav.;  age  21:  was  admitted  June  20,  ISC.'^,  in  the  last 
stage  of  typhoid  fever — pulse  111)  to  110;  muttering  delirium,  with  sulisultiis.  I':>st-iiioiU  111  examination  twenty-four 
hours  after  death  showed  "  considerahle  hepatization  of  the  lungs,  with  extensive  soltening  of  the  nieseiitcric  glands 
and  ulceration  of  the  intestines." — Act.  Ana' t  Siiry.  A.  P.  Craftx,  Tltinl  Divixioii  Ilospitdl,  Alcrdudriit,  Va. 

Case  237. — Private  Isaac  F.  I'lasdale,  Co.  C,  l.MUh  Ind.;  age  18;  was  admitted  .Tune  lH,  ISH."),  in  an  extremely 
weak  and  exhausted  condition,  having  been  sick  in  camp  for  ten  days  before  admission.  His  tongue  and  lips  were 
pale  and  dry,  tlio  former  covered  with  a  white  fur;  he  had  great  thirst;  his  pul.se  was  very  ixuiek,  small  and  feeble; 
his  respiration  hurried,  and  his  dejections  small,  liquid  and  freiinent.  He  died  on  the  20tb.  rosi-mortem  examina- 
tion sixteen  hours  after  death:  The  sjileen  was  largi^,  soft  and  very  dark;  the  mucous  memhrane  of  the  ileum  and 
ciecum  was  intlained  and  ulcerated. — Act.  Ass't  Siiry.  S.  B.  West,  CiimlwrJaiid  Hospital,  .^fd. 

Casp:  288.— Private  AVilliam  Fowler,  Co.  D,91st  Ohio;  age  21;  was  admitted  Aug.  21,  1801,  with  typhoid  fever, 
and  died  September  22.  I'ost-inoitim  examination  twenty-four  hours  after  death:  Hypostatic  congestion  of  both 
lungs;  a  quantity  of  serum  in  the  left  pleural  cavity,  two  ounces  in  the  jjericardinm,  four  ounces  in  the  peritoneum. 
The  liver  was  large  and  light-brown  in  color  and  the  spleen  large  and  congested.  The  whole  of  the  large  intestine 
was  much  thickened  and  its  mucous  surface  covered  with  large  elevated,  hard  and  ragged  ulcers;  the  ileum  was 
softened,  thinned  and,  for  two  feet  from  the  ileo-ca'cal  valve,  intensely  congested,  showing  traces  of  uninerous  ulcers, 
some  of  which  were  healed. — Act.  .Iss't  Siiry.  J}.  B.  Miles,  Jta-ris  Hospitul,  Baltimoir,  Md. 

Case  239. — Private  Alson  lUeedlove,  Co.  J),  13th  E.  Tenn.  Cav.,  was  admitted  Jan.  22,  186f,  with  typhoid 
fever,  and  died  February  4.  I'ost-mortem  examination  twelve  hours  after  death:  Body  much  emaciated;  cadaveric 
rigidity  marked.  The  brain  was  healthy.  The  lungs  weighed  forty-one  ounces;  their  apices  were  emphysematous 
and  thin  ;  bronchial  tubes  inHamed;  heart  health.v.  The  stomach  contained  two  ounces  of  matter  like  cotfee-groiinds; 
its  mucous  membrano  was  inthiineil  iiud  softened.  The  up]ier  jiart  of  the  small  intestine  was  softened  and  ulcerated 
in  small  patches  and  contained  two  Ininhricoid  worms:  the  mucous  lueiuhrane  of  the  large  intestine  was  thickene<l 
and  softened  in  patclies;  the  mesenteric  glands  were  much  enlarged.  The  liver  was  somewhat  fatty;  tlie  spleen 
congested,  weighing  (ifteen  ounces;  the  kidneys  normal;  the  prostate  enlarged  and  containing  one  drachm  of  ]iiis. 
—Act.  Ass't  Surg.  G.  W.  Boberts,  Uoapitdl  Xo.  19,  XushviUe,  Tom. 

Cask  240.— Rerg't  H.  C.  Kogers,  Co.  C,  Kith  Pa.  Cav.;  age  28;  was  admitted  Aug.  18, 18t!3,  with  typhoid  fever, 
and  ilied  on  the  2()lli.  I'osl-mnrli-m  examination  fourteen  hours  after  death:  liody  hut  little  emaciated.  Tracliea 
slightly  congested,  piir])Iish  between  the  rings;  right  liiug  weighing  seventeen  ounces,  its  upper  lobe  gri'atly  con- 
gested and  its  lower  lobe  almost  solidilied  but  lighter  than  water;  Ictt  lung,  eighteen  ounces  and  a,  half,  congested 
generally,  eiuiihysematous  in  lower  part  of  u]iper  lobe;  right  ventricle  containing  a  librinous  clot  which  extended 
into  the  iiulmoiiaiy  artery.  Liver  dark  colorc<I,  its  ]iaien(  hyma  stained  around  the  portal  veins;  spleen  lirm,  purjile 
and  conspicuously  mottled  on  its  surface  witn  a  daiker  hue.  Ileum  congested  and  extensively  ulcerated,  the  upper 
ulcers  being  small,, blackish  and  with  depressiMl  c'entres,  while  those  near  the  ileo-(ta'cal  valve  had  a  long  diameter 
of  one  and  a  half  inches,  in  ojio  of  which  the  iiheiation  had  penetrated  to  the  muscular  coat;  cmcuiii  and  ascend- 
ing colon,  especially  between  the  longitudinal  bands,  studiled  with  sniierticial  ulcers  having  dark-bine  borders  and 
an  elliptic  form,  their  long  diameter,  one  to  live  lines,  at  light  angles  to  the  axis  of  the  bowel.  Kight  kidney  aua'niie 
and  firm;  left  somewhat  congested. — Ass't  Siirij.  II.  Allen,  C.  S.  A.,  Lincoln  Ilospitdl,  Vushinijloii,  I).  C. 

Cask  241.— Private  David  C.  Hollcnbei  k,  Co.  K,  188th  X.  V.;  age  37:  was  admitted  Jan.  31).  18ti,"i,  having  been 
under  treatment  for  fever  uilh  his  commaiHl  for  seven  days  befon^  adniission.  He  died  Fibriiary  o.  I'ost-niortem 
examination:  The  low<'r  lobe  of  each  lung  was  congested;  the  right  weighed  twenty-two  ounces,  the  left  fourteen 
ounces.  The  liver,  spleen  and  kidneys  were  healthy.  The  ineseuteric  glands  were  enlarged  and  congested.  The 
stomach  was  congested  and  contracted;  the  diuidenum  and  jejunum  health.v,  except  that  there  was  an  intussuscep- 
tion, two  inches  long,  about  seven  feet  and  a  half  from  the  stomach:  there  was  a  good  deal  of  ulceration  in  the 
neighliorhood  of  the  ilco-ca'cal  valve;  a  few  ulcers  were  scattered  thioiigh  the  colon. — Ass't  Siirrj.  M,  L.  Lord,  ItO/A 
N.  Y.,  Depot  T'ieUi  Hospital.  Fifth  Armij  Corps,  Citi/  Point,  I'o. 

Case  212.— Private  Charles  P.rown,  Co.  II,  9th  Pa.,  was  admitted  Sei)t.  28,  ]S(;2,  convalescing  from  typhoid 
fever.  The  patient  was  greatly  debilitated  with  diarrluea,  but  under  a  tonic  treatment  he  improved  slowly  until 
within  three  or  four  days  of  his  death,  when  he  began  to  coni]daiii  occasionally  of  t'aintness.  On  Oct(dii'r  17,  after 
visiting  the  water-closet,  he  lay  down  on  bed  and  expired  almost  immediiitely.  Vost-morlem  exaniination.  lirain, 
lungs  and  stomach  normal :  walls  <d'  right  venti  icle  of  heart  very  thin  and  s(dt ;  intestines  ulcerated  to  a  moderate 
extent  and  showing  signs  of  former  ulceration. —  ]\'((rd  Ilaspihil.  S<inirk.  S.  ./. 

Ca.se  213.— Private  Jeremiah  Thorndyke,  Co.  C.  12th  Mass.,  was  admitted  Xov.  4,  181)3,  having  been  sick  for 
some  time.  On  admission  his  bowels  were  loo.si!  and  he  had  pain  in  the  chest  and  abdomen.  J'ills  of  tannin  and 
opium  were  given,  with  oi)iate  enemata,  but  on  the  10th  nausea  and  vomiting  c.iiiie  on  and  continued  with  failing 
pulse,  dyspuffia  and  hiccough  until  death  on  the  l.'ith.     I'ost-mortem  exandnalion:  The  right  lung  was  congested, 


TUF.    COXTINTKO    FKVKRs.  393 

tli<>  left  liepatized  ;  tlit-  \v;ills  (if  tin-  iit;ht  vriitrii'le  of  the  licart  were  !is  lliiii  as  jilovc-leatlior.  The  rijjlit  lobe  of 
till'  liver,  iiiisii'iidily,  was  sufti'iicil.  and  ilie  (■iiini;,'iiiiiis  lirpalic  lirxiiii'  uf  lln'  (■oliiii  wan  gaiifti't'lidus.  'I'ln'  uiiu'iiiis 
liic'iiibrain'  of  tin-  .stouiaih  anil  nf  llir  iliiiMlriiuiii.  tVimi  llie  ]i\lorii-  orifice  to  the  \al\iila'  eonnivonles,  was  jiiilla- 
<'eiiu.s;  tile  ileum  was  iileeialed;  ilie  lower  end  of  llie  siij;iiioid  lle\iiie  i-oiist  rieled.  'I'lie  left  liidiiev  was  nonniil; 
tlieriiilit  kidiie\  and  sii|iiaieiial  eajisiile  slioweil  Iiaees  of  iiitlainiiial  ion  :  tlie  fundus  nt'  llie  Idadder  was  very  iiiiu'li 
tliicl<ened. — .1.7.  .Isx'l  Siirij.   II".  Luni  lldiiiiiiniiil.  /'i/.W  liiiisimi    l!nxj,\l,[l.  Ah jniidi'iii.   Id. 

Cask  211. — Corji'l  I'.  S.  Nottinf;liaiii.  Co.  1).  1  liHli  X.  Y.:  aL'e  :>'-:  was  adiiiitli'd  A])iil  L'L'.  \X{\;\,  with  a  jirofiiNe 
iliarrlio'a  wliieli  resisted  remedies,  intense  ]iain  and  swidliiij;  in  llie  liyjiojiastrie  ref;ion  and  dillieiiliy  of  mii'liu'itioii ; 
lie  was  in  low  eoiidition.  imNe  i:iii.  As  the  di-lenlion  of  llie  alidomeii  did  nol  (le|iend  on  aeeiimiiluled  urinn  hot 
fomentations  were  ajiplied,  and  on  llie  '-'."lli.  llminalioii  lieiiiii  a|i|ialenl.  an  alidominal  aliseess  was  o)iened.  jrivinfj 
issue  to  a  sero'iniriilelil  (liseliaii;e  w  liieli  eonliiiued  for  fi\e  days,  lie  died  M:  y  I  willi  symiifoms  of  )ieritoiiitis. 
I'lifit-iiiurtiiii  <-xaminalioii :  rieeralion  of  a  lar.L'e  poriiuii  of  llu'  inlestines  and  iieifoiation  in  se\»'ral  jdaei-s:  fatty 
(Ifjreiii'ration  of  the  liidneys. — Armnrii  Sijii,ir<   Ihi^j'ilnl.  HUshiinilini,  />.  C. 

Cask  'Si'}. — I'rivale  Simon  Vm^fX.  Co.  C.  liOth  Me.,  was  admitted  .laii.  li,  l.**!;."',  and  died  on  the  Hmh.  J'lint- 
wird/H  examination :  Lnnj;s  collaiised  ami  pale;  left  adliereiil  to  ]ierioardinm,  wiuliIiI  ten  oiinei'S  and  a  half;  liroiiehi 
tilled  with  ]ius;  rjirht  sixteen  ounces,  luiddh^  lohe  intlanied  ;  heart  leu  ounces,  clot  in  rif;lil  \euiiicle.  l.iver,  nixty- 
orie  ounces,  healthy;  };aH -Id  adder  lit  led  with  Idle;  s|deeu  li\  e  ounces.  Iieall  liy.  Momaili  and  iejunum  normal;  ileum 
ulcerated,  jievforated  iu  einht  )daees,  its  walls  siirroumled  wiih  ]iiis  and  interailhereiil  ;  colon  slii^htly  iiitlanied  sit 
its  u|Piier  end;  iiu'scnterii^  ^'aiids  eularj;ed,  tilled  with  cheesy  matter.  K  idneys  four  ounces  each  ;  su]irareiial  ••aiisiiles 
mu(di  softened.— /'V/V/i.  .(dhi/  Ciirjin  I'iild  Ifoxjiital,  Aniiii  n/  I'iiIdiikic. 

(E.)  Contlitiuii  uf  I'l jiir'n  imlfliin  not  nlntnJ:   tin  inlixlintH  iniujcxldl  nr  hitUimid  hut  mil  uUinilid — II  viixin. 

Cask  2111. — Private  Daniel  MeCloud,  Co.  C,  ITtli  l'.  S.  Inf.,  was  admitted  An;;.  II,  IXlili.  with  tyjilioid  f('V«tr. 
'ldu;;ue  dry  and  cracked ;  sordes  on  teeth:  luiilleriii^j;  delirium:  |iulse  wi'akaml  frei|iienl:  exirenii'  enia<'i:ilioii.  llu 
died  ou  the  1  til h.  I'liKt-miirU'iii  examination:  Low  er  iiortiou  of  ileum  hi;;lily  coii;;ested  and  coni  r.icled,  its  nuIiiiiik'oiih 
coat  thickened  and  its  mucous  coat  softened. —  'I'hird  lliriniaii  Ihixjiihil,  AUjanilriii ,   In. 

Cask  LM7.  —  I'rivale  Mark  K.  Koliiiison,  Co.  1'.,  Killi  W.  \u.;  a;;c^  L'l  :  was  admitted  Ftdi.  ICi,  lS(ir>,  <'()iii]daiiiinj; 
of  severi^  )iaiii  in  1  he  left  side  and  in  the  hack  of  the  hi' ad.  His  skin  w  ,is  hot,  luilsi*  1 1(1,  frei|UeIil ,  small  and  com- 
Jircssilde,  face  darkly  llnshed,  toii;;iie  <lry,  red  and  cracked;  his  dejections  wire  fre(|m'nl,  c(i|iioiiM  and  liiinid,  his 
alidomi'ii  tyui]ianitie  and  tender  on  iiressure.  A  dia|iliorelie  mixliiri'  was  ordered,  with  te|iid  s]iou;;iii;;  of  tho  liody, 
cold  to  the  Iieail  and  mils  I  a  id  to  tlu'  ankles  and  iiajie  of  t  he  ni'ck.  lie  hecamo  did  ir  ions  during;  the  iii;;ht,  liis  jml.s(( 
incn'ased,  and  his  teeth,  ;;iims  and  lijis  hecame  covereil  with  sordes.  l^iiinine,  oil  of  turiii'iilino  ami  caihonate  of 
ammonia,  were  ^jivcii,  with  chlorate  (if  )iotasli  as  a  month-wash.  He  died  on  tlio  L'Oth.  /'ii.v/-/»iii7(i«  ex.amination 
I  went  y -four  hours  afier  dealli :  Hoily  slijjhtly  eniacialed.  The  vessels  of  the.  iiia  maler  were  lille(l  with  dark  Idood  ; 
I  he  eerehi mil  jiiid  eel cliel  1 11  111  Were  coll ;;es ted  jiosteriorly .  The  Inn;;s  were  con;;ested  ;  th(^  lower  1  oho  of  t  he  left  lull;; 
was  he|i:ili/ed.  I'he  sloiuach  and  intestines  were  distended  with  ;;as:  exteiisivo  patches  of  inlhimmal  ion  wcro 
I'ouiid  in  t  he  Jeiniiuni  and  ileum.     The  spliMMi  was  verv  lai';;e. — AvI.  A'o^'l  Siiri/.  »S'.  Ji.  ll'ixlj  CiiiiiIk  rlniid  Jlnxjiihd,  Mil. 

Casi',  I'IS.—rrivale  Theojihilns  (Jillesiiie,  Co.  A,  Ktlli  W.  y-.,.-.  •.\iS.r  2:i;  was  admit te(l  Keh.  !!,  1  S(i.">,  w i t h  ty])hoid 
fever.  He  was  \  eiy  feelile  and  aiilioliie,  his  toiie;ue  dry,  skin  hoi,  pulse  UK),  howels  loose  and  alidomeii  Kuolleii  and 
Jiaiiiful.  (Quinine,  oil  of  turpentine,  lead,  o|iiiim  and  whiskey  were  ;;iveii.  Vomiting;  set  in  on  tlio  Vlli  and  ho  died 
next  day.  I'lixl-morliiii  examiiial  ion  two  hours  after  death :  Sli;;hl  emaciation;  ;;oo(l  iiiiisciil.ir  <levelo]niieiit.  'I'lio 
epi;;lottis  w  as  thickened  and  ulcerated ;  the  liniii;;  miMiihraiio  of  the  larynx  and  of  the  tiaidiea  as  far  iih  the  bifiir- 
catiou  was  similarly  alfected:  the  \ocal  cords  were  alnioHt  ohlilerated.  'I'lii^  liiue:s  and  heart  weio  liealthy.  'I'ho 
s]dc('ii  was  very  laif;e,  wei;;hiiii;  iiiiieteeii  ounces;  the  liver  (•iilaij;e(l  and  coii^fesled ;  the  ;;all-ldadder  <'ii(iriii(>iiNly 
distended  w  itii  Idle.  'J'liere  was  no  intestinal  ulceration,  lint  Hcattcred  patches  of  iiillammation  wcio  foiiiid  in  (lie 
ileum.  A  lai>;e  iiiiantity  of  coa^julated  hlooil  was  extravasateil  in  tlu^  lower  ]>orliou  of  the  ahdominal  recti  mnseles 
and  ill  the  intermii.scnl.ar  septa. — Afl.  Asx't  Siirii.  Siiiiqilc  Ftiril,  ('iiiiihirliiinl  Ifii«j)iliil,  Mil. 

Cask  2J!t.— riiili])  Fisher,  recruit,  ittli  Ohio;  a^c  W;  was  aduiitled  Nov.  »l,  IStil,  with  typhoid  fever.  'I'her(< 
w  as  much  fehrile  act  ion,  dusky  counli'iiauce,  jian  lied  tongue,  cough,  diarrluea  and  ti'iidcriiess  over  t  he  alxloiiieii.  A 
grain  of  nuiniue  was  given  every  four  hours,  and  on  Dcecinlicr  5  half  an  ounce,  of  hraudy  three  times  daily  was 
oi(l(Med,  with  glycciiiio  to  inoistcu  the  tongue  and  morphine  to  allav  alidomiiial  pain,  which  had  liecoiiii)  sevcri^ 
After  a  fi^w  days  the  cough  hccaiiic  more  annoying  and  there  was  diilncss  on  jierciissioii  over  the  left  sido  of  the 
chest;  the  pulse  hccame  rajiid  and  feidihwind  th(5  diarrho'a  troublesome.  Acetati^  of  lead  with  opium  was  added  to  the 
treatment.  On  the  iL'tli  the  tongue,  lips  and  mouth  W(^re  very  dry,  tliiMoiiiitcnanee  livid,  and  liroiK  iii.d  rales  were 
heard  over  the  left  lung:  hut  on  the  11th  an  iiiiiiroveiiieiit  took  place,  the  tongue  hecoming  moist  and  the  diarrluea 
i|iiieting;  pnl.si^  ll'Oand  feehle  Next  day  he  was  a|i]iarently  much  letter  than  at  any  t  iiue  since  his  admission  ;  liiit  in 
the  afternoon  he  was  sei/ed  with  inleiise  ])aiu  in  the  hack  w  liicli  ciiiised  liiiu  to  make  loud  outcries.  Hot  cloths  were 
applied  and  nioipliine  administered.  In  an  hour  he  seemed  relie\ed,  and  remained  comfoitalde  iinlil  midnight, 
when  his  lire.ithing  liecame  Imriied.  He  died  coiu.-itose  two  hours  tlieie:ifter.  I'nul-iiiin-tiiii  examination  thirty-six 
hours  after  death  •  The  pericardium  contained  four  ounces  of  Heriini.  The  right  lung  was  healthy;  the  left  was  firmly 
adherent  to  the  costal  jdeiira  and  diajihragm;  the  hronehial  in i icons  memhrane  u  as  inllaiued  thronghont  on  the  left 
and  iu  the  larger  tubes  on  the  light.  The  under  surface,  of  the  diiiphragm,  the  abdominal  walls,  the  stomach,  intes- 
tines and  left  lobe  of  the  liver  were,  coated  with  a  thick  layer  of  straw -colored  lymph  The  spleen  was  of  normal 
Bize  hut  contained  several  cavities  filled  with  a  soft,  white,  cheesy  substance;  two  of  these  had  ruiitiiied  inio  the 
Mki>.  Hist.,  1't.  111—50 


394  rO?T-MOr;TF.M    P.F.rOKt)?    OF 

lu'iitoiieal  oavity.     Tin'  iimooiis  laciiiliraiu'  of  tlie  ilonm  was  slijilitly  iiillanu'd:  tlu'  ('(ildii  was  laijjjcly  distiMiiird  with 
gas. — .Un't  Stauj.ll.  C.  May,  lin///  jV.  Y.,  Hosjntiil  Xa.  8,  XuslinUe,  Tenn. 

Cask  2ri0. — Private  (Jeorfji'  Lubeiik,  Co.  K.  Itli  Mich.  Cav.:  ago  ;il;  ailiiiitted  Fi'b.  1,  IMti-l.  Typhoiil  fever. 
Died  17th.  Poni-moi-tnn  exaiiiiiiiiticm :  Hixly  iiuideiately  emaciated.  Lungs,  heart,  stoinacli,  liver,  spli'eii  and  large 
intestine  healthy:  the  small  intestine  and  kidneys  highly  congested. — Ilos^iilul  Xu.  1,  Xashrillc,  Tcmi. 

Case  2.")1. — Theodore  Jeter,  1th  Ind.:  age  22:  was  admitted  March  21,  1803.  lie  became  sick  .lannary  lii.  at 
Vicksburg,  Miss.,  with  typhoid  fever,  mild  in  form,  but  with  a  tendency  to  diarrhiea.  Sniipnration  occurred  in  the 
liarotid  gland,  and  lie  died  April  12.  I'oxt-iuorlnii  examination:  Pleuritic  adhesions  on  riglit  si(h';  heart  fatty,  right 
ventricle  thinned.  Ileum  congested;  colon  congested  and  softened.  Kight  parotid  gland  entirely  bioUeii  down  liy 
suppuration,  leaving  the  external  carotid  bare  but  intact. — City  HoiipU<(l,  St.  Louis,  Ma. 

Case  252. — Thomas  J.  Slaton,  private  of  an  Alabama  regiment,  admitted  Oct.  2tt,  IStU,  with  tyjihoid  fever. 
Bowels  tender  and  somewhat  loose;  tongue  narrow,  treimilous,  dry,  slightly  furred  and  rid:  jiulse  11(1,  w<'ak:  he 
was  dull  and  drowsy  and  became  gradually  weaker  until  death  took  place  December  .">.  /'"^•^»lo)•/(  »i  examination: 
Ureat  emaciation.  Abscess  in  left  lung:  atrojdiy  of  heart:  congestion  of  bowels  aiul  enlargement  of  mesenteri<'  and 
solitary  glands ;  fatty  degeneration  of  the  liver;  spleen  small. — Ad.  Ans't  Surg.  H.C.  Xt'wkirJi,Iiocl~  iKlaiid  Hospital, III, 

Case  2.')3. — Private  William  Brown,  Co.  1, 1st  Ark.;  died  March  Ifi,  18(i5.  ro.ft-morttm  examination  :  The  s])leeu 
was  much  enlarged;  the  bowels  distended  and  in  many  places  disorganized;  the  mesenteric  glands  enlarged.  An 
abscess  of  the  arm  and  shoulder  had  discharged  a  large  amount  of  pus  for  some  days  before  death:  on  in<;ision  great 
disorganization  of  the  muscles  was  revealed. — Act.  Ass't  Surg.  H.  H.  lluascll,  Ilock  Ixlaiid  Hospital,  III. 

Case  254. — Private  Milton  L.  Coon,  Co.  I,  85th  N.  Y.:  age  23;  was  admitted  Aug.  19,  1862,  with  typhoid  fever. 
Died  suddenly  November  18.  Posi-morttm  examination:  Extensive  inHammation  of  the  lower  part  of  the  ileum  and 
ca'cum,  with  pin-head  enlargement  of  the  solitary  follicles,  [Spi'cimin  153,  Med.  Sect.,  Army  Medical  Museum];  mes- 
enteric glands  enlarged;  liver  and  kidneys  fatty. — Sur;/.  A.  C.  Hournouvillc,  V.  S.  ]'.,  Ilospital  Fifth  ami  liullonwood 
xtriets,  I'liilailelpiliia,  I'u. 

Case  255. — Private  Lewell  Gates,  Co.  A,  12th  Ky.:  admitted  April  24,  1865.  Died  May  7.  The  conr.se  of  the 
disea.se  was  that  of  typhoid  fever;  shortness  of  lireatli  was  the  only  ])neuinonic  symptom  observed.  I'oxt-mortvm 
examination  thirty-six  hours  after  death:  \o  emaciation.  lioth  lungs  were  congested,  the  left  partially  he]iatized; 
the  heart  normal.  The  liver  was  enlarged,  friable  ami  resembled  that  of  yellow  fever;  the  spleen  and  kiilneys  were 
normal.  The  intestines  were,  immensely  distended  with  gas,  and  the  mucous  membrane  of  the  ileum  and  colon  was 
congested. — Aet.  Ass't  Surg.  E.  IToUlcii.  ll'ard  Hospital.  Xtirark,  X.  .J. 

Case  2.56.— Private  Patrick  Cady.  Co.  P,  35tli  111.:  admitted  .Inly  23, 18ra.  Tyjihoid  fever.  Died  Seiitember  22. 
Post-morttin  exaudnation:  Boily  much  emaciated.  'I'lie  intestinal  mucous  membrane  was  congested  and  lnllanie<l.  but 
not  ulcerated,  in  the  lower  third  of  the  ileum  and  in  the  colon.  An  abscess  holding  two  ounces  of  light-colored  pns 
was  found  in  the  right  lobe  of  the  liver.     Tln^  other  oi'gans  were  normal. — Hospital  Xo.  8,  Xashrille,  Ttiiii. 

(  F.)   Condition  of  Pcyir's  palilits  stall  il  rnriou^lii,  hul  not  uloeraltd  .and  iivncrall  ij  without  ulceration  of  tin  inlislinis — 12  ca.ics. 

(a.)   Pryir's patches  normal  or  healthy. 

Ca.se  257. — Private  Edwin  A.  Maxfield,  ('o.  (i,  7th  Me.;  age  27;  was  adnntted  Aug.  14,  1864,  with  remittent 
fever.  On  admission  the  patient  had  a  weak,  fre<nient  jiiilse,  a  dry,  coated  tongue  and  loose  pa.ssages  of  a  light  color. 
Next  day  he  had  fever  and  headache.  On  the  16th  lu^  became  didirious  and  somewhat  drowsy,  and  on  the  18th  he 
died  comatose.  IK;  was  treated  with  citrate  of  potasli  and  nitre,  cold  lotions  to  the  head,  and  afterwai<ls  with  calo- 
mel, i]iecacuanlia,  camiihor  aiul  blisters  to  the  back  of  the  neck.  I'osl-inorlem  ex:iinination  nine  hours  and  a  half 
after  death:  Body  not  much  emaciated:  rigor  nuutis  well  marked.  The  base  of  the  brain  was  covere<l  with  a  thin 
layer  of  lymph,  the  pia  mater  was  injected,  the  liipiid  in  the  ventricles  opaque.  The  trachea  contained  a  consider- 
alde  <|uantity  of  whitish  frothy  sjiuta  streaked  with  the  color  of  prune-juice;  the  right  lung  weighed  twenty-tivo 
ounces,  its  posterior  portion  nnich  congested,  its  anterior  margin  normal;  the  left  lung  weighed  twenty-three 
ounces  and  a  half,  its  posterior  and  lower  part  in  the  state  of  red  Iii-patization,  the  rest  of  the  lung  healthy.  Tho 
pericardium  contained  two  ounces  of  straw-colored  serum;  tlie  right  side  of  the  heart  a  small  fibrinous  clot.  The 
stomach,  liver  and  spleen  were  normal  in  apjiearaiu'e ;  the  last  weighed  nine  ounces  ami  a  quarter.  Tins  kidm^vs 
were  somewhat  injected.  The  nnieous  mendirane  of  nearly  the  whole  of  the  small  and  large  intestines  was  congested, 
l)ut  Peyer's  patclies  and  the  solitary  glands  were  normal. — Act.  Ass'l  Sury.  H.  M.  Dean,  Lincoln  Hospital,  If'ash'n,  D.  C. 

Case  258. — Private  .Tames  II.  Morrison,  Co.  li,  151st  Pa.;  age  2t!;  was  admitted  .Tune  17,  1863,  with  typhoid 
fever.  [He  entered  Kaloraimi  hosiiifal,  Washington,  D.  C,  Dec.  1,  1S62,  with  small-pox,  and  was  returned  to  duty 
Eel).  17,  1863;  Douglas  hos])ital,  Washington,  I).  C.,  June  14,  with  diarrluea,  and  was  transferred  to  Philadelphia 
next  day.]  He  was  much  debilitated  and  had  severe  diarrbo-a  which  continued  throughout  the  case.  On  .July 
4  there  was  swelling  of  the  right  parotid  gland  ami  on  the  6tli  constant  vomiting.  He  died  on  tho  14th.  Astrin- 
gents, <niinine  and  iron,  turpentine,  lieef-tea,  wine  aiul  milk-pun<h  were  inescribed.  Post-morleni  examination: 
Body  much  enia<'iatcd;  skin  marked  with  variolous  scars.  The  bronchial  niucons  membrane  was  inllamed;  the  left 
lung  was  covered  with  a  thin  pseudo-membrane  stained  with  blood,  the  surface  laterally,  jiosteriorly  and  at  the  base 
was  darkly  ecehymosed  and  there  was  a  large  clot  with  a  quart  of  bloody  serum  in  the  pleura,  but  no  rupture  of  tho 
lung.  There  were  four  ounces  of  liijuid  in  the  pericardium  and  white  filirinous  clots  in  the  cavities  of  the  heart. 
The  spleen  contained  three  soft  tubercular  masses  the  size  of  hickory  nuts.     The  mesenteric  glands  were  somewhat 


TITK   COXTINrF.ri   FEVER?.  395 

eiilartri'il  and  iiiniiy  of  tliem  liluclicmil.  Fdiir  intii.ssuscoptiiiii.s  wiic,  fdiiiid  in  the  ili'iiin,  tlie  inncons  incnihrano  of 
wliicli  .^lidwiil  iirc;j;nlaily  ditiiised  intliiniiiiatidn  w  itli  black  di'iiosits;  the  solitary  glanil.s  Were  soincwliat  congested; 
I'eyeiV  iiatches  weie  healthy. — Stitlirlii-  Ilnsjiildl.  Vhihithlphiii,  I'd. 

Cask  i'jit. — I'livate  (leori^e  .Stone,  Co.  K,  TSd  Ohio:  a);e  L'O:  admitted  .Inne  l.">,  lM;;i.  witli  phthisis  and  tyi>hoid 
fever.  Died  .Inly  U.'i.  rnxt-iiHiiii in  examination  eleven  lionrs  after  death:  Ennieiation.  Urain  forty-ei};ht  onnees, 
soft;  lati'ral  ventricles  filleil  with  etfnsiou.  Mnciins  inemlirane  of  trachea  easily  lorn,  slifjhily  discolored,  delicate 
l>uriileat  its  lower  portion:  tube  containing  tough,  tenacious  s]inta  :  lymidiatie  ghinils  at  I  li  I'm  eat  ion  healthy.  Mucous 
lining  of  (esophagus  pale  and  extensively  erdde(l,  especially  lielow.  K'iglit  lung  eight  dniicrs.  unifurnily  i)ale,  lower 
l(dje  slightly  injected;  left  lung  seven  ounces  and  a  lialf,  lower  ldl)e  slightly  inji-cted  and  containing  a  Cdnsdlidation 
about  the  size  of  a  horse-chestnut,  with  a  central  cavity  as  large  as  a  hazid-nut :  walls  of  cavity  well  di'tined  and 
enclosing  a  secretion  similar  to  that  found  in  the  trachea.  I'eritardium  large  and  containing  twelve  drachms  of  ivale, 
liMi]iid,  straw-colored  licinid  :  a  small  librincuis  clot  in  the  right  ventricli'.  I.iver  tirm,  of  a  dark-pnriple  C(dor  externally 
and  showing  jiortal  engorgenu'Ut  on  si'ctiou  :  sph'en  four  ounces  and  a  half,  linn  and  of  a  dark  mulberry  e(dor;  omen- 
tuni  crowded  u]i  under  lower  edge  of  liver,  well  su))|died  with  adi)iosi'  tissue.  TI|iper  i>art  u\'  the  snniU  intestine  con- 
gested, lower  portion  empty  and  much  congested  :  I'l'yer's  patches  |ierfectly  healthy:  large  intestini'  normal  and  filled 
with  healthy  fa'ces.  Kidneys  firm  and  congested  internally,  a  Idackish  blood  exuding  on  siH'ticui. — .Isn'l  Siin/.  II.  .llleii, 
TJ.  S.  A.,  Lhiiohi  Ifonpllal,  Jt'aiihinyloii,  D.  ('. 

Cask  2tW.— Private  George  M.  (Jrover,  Co.  C,  7th  Me.;  admitted  .Aug.  10,  ISt;:!:  typhoid  f,.ver.  Died  L'lst.  I'oHt- 
mortiiii  examination:  Body  much  emaciated;  ajiiparently  about  JO  years  of  age:  skin  of  trunk  niinntidy  eC(diymosed. 
The  lungs.  In-art,  stomach  and  spleen  were  healthy:  the  liver  was  bright  ccdored  and  exhibiled  disi  inctly  the  outlines 
of  its  acini.  The  mucous  membrane  of  the  lower  inirt  of  the  .jejunum  ami  of  thi'  ileum  was  inllanu'd.  the  iullannna- 
tion  being  nuist  intense^  in  the  lower  ]iart  of  the  latter;  the  solitary  and  agminated  glands  ap]ieared  healthy  and  con- 
tained no  deposit  of  black  i)iguu'nt:  tlu^  ascending  and  descending  portions  of  the  colon  were  nniderately  inllanied 
but  not  ulcerated. — .1(7.  .Isn't  Siiy;!.  ./.  I.iidi/.  Siitliylii-  Ilnsjiitiil.  I'htUiiUliihiu,  I'd. 

Cask  2fil.— I'rivale  \V.  C.  Swails,  Co.  I,  I'.lth  I'a.;  admilted  Aug.  10,  IXtlL':  typhoid  fever.  Died  Si'plember  «. 
ro«t-mi)it(  III  examinatiiui  lU'xt  day:  Age  ab<uil  10  yi'ars:  body  cxlremi'ly  emaciated;  skin  eceliymosed.  Lungs  lilleil 
with  bloody  li(|nid:  heart  pri'senting  an  opai|ne-w  bite  membranous  spot  (Ui  the  surface  of  the  right  ventricle  and 
containing  a  huge  white  clot  in  thi^  right  and  a  soft  black  clot  with  liipiid  blood  in  tlu^  left  vcntri(d<'.  Slonukch  pre- 
senting three  large  inlhuued  palidies;  its  cul-de-sac  soflened.  IJvcr  dull-brown  in  color  but  otherwise  natural; 
kidni'ys  healthy.  Ileum  inllauu'd  in  |);itehes:  its  glautis  not  diseased:  UM'senteri(^  gl;inds  opa<|Ue,  cream-colored  and 
someulial  enl.-nged:  large  intestine  dilfusely  inllamed  in  lhee(don,  jiarticularly  in  the  ca'cnm  and  Hignniiil  Hcxuro, 
anil  i-xlending  into  the  rectum  along  its  rugn'. — .1(7.  .-(.s»'/  Suri/.  .1.  I.iiili/,  Sdtlirin   IIii.ijiildl,  I'lnliiililphiii,  I'd. 

( li.  f   rfiin's  jiiili'his  nttt  iilcirdtrd. 

C.vsk  •_'(;■_'.  -I'rix  ale  IlKMuas  Ward,  Co.  D,  iL'd  \.  V.:  age  :!(l;  was  ailmilted  Se))!.  20,  IS(!2,  with  a  shell  wound  of 
the  right  cheek  .-iiid  lyplioid  fever.  lie  died  \o\ember  17.  /'osZ-mni/rw  examinatiiui  ten  hours  afti'r  death:  (ireat 
em.icialion.  l.nngs  :iiid  pleuiie  healtiiy:  |iericardium  distended  with  serum  ;  heart  paler  than  nalural.  Liver, spleen 
and  kidneys  healthy.  Mnc<ms  membrane  of  st<uiiaeh  pale,  s(dtened  and  willi  spots  of  exiravasated  blood;  i>(  ileum 
injected  liul  md  softtMied  and  I'eyer's  patidies  not  nlci'nited;  id' C(don  and  rectum  greatly  injected,  thi(d<eni'd,  but 
neither  s<dteiied  nor  ulcerated, — .I.ik'I  .'<iirg.  ('.  II.  Aii<lnis,  ]-Jf<lli  .V.   )'.,  .*>7('ic»r/'.v  Mdiixiini  Hnxjiildl,  Udlliiiini-r.  Mil. 

Cask  2(i:i.— Corii'l  Daniel  I.andis,  Co.  C,2lL'th  I'a.;  age  22:  admilted  Oct.  21,  ISIU.  Diagnosis— typhoid  fever. 
Died  Novenilx'r  2.  riinl-iiiiirlim.  examination  twenty  hours  after  ilealh:  Marked  rigor  mortis:  some  einacialion  :  Ix'd- 
Mores;  two  very  large  aliscesses  under  eaidi  ear,  Lowtu'  join'  of  right  lung  hejiatized  posteriiu  ly.  Heart,  liver,  pancreas 
and  kidneys  normal:  gall-bladder  containing  two  oun<es  of  bile;  spleen  enlarged,  blac^k,  soflened:  mucous  coat  of 
small  and  large  intestines  much  congested  but  no  thickening  or  nlci'ial  ion  iif  I'eyer's  jiatdies  or  the  solitary  folliides. 
The  repiuter,  Dr.  Thomas  l!nw  kn,  says  thai,  in  view  «{  the  diagnosis  being  typhoid  fever,  a  very  careful  examiiiati(Ui 
of  the  small  inti'stine  was  made-. — Si'coiiii  Dirinion  Uoxjiitiil,  Atvxdiiilriu,  /'<(. 

(c.)   Peyir'n jmlclies priiiiiimnt,  roiiitpiciioiin,  inldriji'il,  tliirhiniil,  ilc. 

Case  2(U, — Private  Henry  Clay,  Co,  1,  17!ttli  N,  V.,  w,is  iidmltted  May  11,  Wi't,  niuch  emaciated,  very  weak  and 
unable  to  sjieak;  his  teeth  and  gunis  covered  with  sordes;  juilse  thri'ady  and  irregular:  respiration  laboreil.  He  was 
washed  with  tepid  water  and  whiskey,  and  treated  w  itli  stimulants  and  nutritivi's,  tiirpintinc,  i|niniue  and  ojiiate 
eneiuata.  He  died  on  the  10th,  Pont-iiiortimi  examinalion:  Eina<-i,ition  extreme.  Membranes  of  brain  amemic. 
Lower  lobe  of  left  lung  congested  ;  heart  containing  a  few  snnill  coagiila;  blood  generally  diffluent.  Liver  of  normal 
size,  showing  fat-cells  under  the  microscope;  spleen  large,  s(d't.  lleniu  and  ca'cuin  much  congested  and  iutlaiued,  in 
a  few  places  ulcerated;  Peyer's  patches  (luite  prominent  by  a  .soft,  friable  deposit;  mesenteric  glands  large,  tilled 
with  similar  deposits.     Kidneys  congested, soincwliat  fatty:  urine  albuminous. — .tiiyiir  Ho-ipitiil,  .ilijriinilrid,  f'n. 

Case  2t)5.— Privatt^  William  Ploinb,  Co.  I,  Ith  N,  .J,:  admitted  Aug.  !),  1X112:  typhoid  fever.  Died  10th,  I'ost- 
mnrlrm  exaniinati<ni  next  day.  Hody  well  formed  and  robust.  The  lungs  were  healthy:  the  heart  llabby  but  idher- 
wi.se  normal.  The  liver,  stomach,  pancreas,  spleen  and  kidneys  were  healthy.  The  ili'uni  was  deeply  reddened,  and 
the  agminated  and  solitary  glands  more  than  ordinarily  conspicuous,  but  without  ajiparent  disease;  the  eoUui  was 
slate-colored,  with  ))atches  of  redness,  and  lueseuted  a  nuinber  of  scattered  ulcers  about  the  size  of  peas. — Jit.  Asis't 
Surg.  J.  Leiiiy,  SaiterUe  Uonpital,  Philndtlphia,  I'a. 

Case  260, — Private  Eugene  Mason,  Co.  (1,  l,")7tli  N,  Y,;  age  10:  admitted  Sejd,  19,  IStU ;  tyidioid  fever.  Died 
October  3.     PoHt-mortem  exaininatiou  eighteen  hours  after  death:  .Slight  rigor  mortis;  much  euiaciatiou.     Uraiu  fifty- 


396  pOfiT-MORTRM    RECORDS    OF 

Hix  ouiici's.  Right  Iniig  nine  ounces,  soniewliat  eiinipresseil  ami  niUieiinK  liiiiily  to  the  thoracic  wail:  left  linif; 
seven  oiinees;  heart  six  ounces  and  a  half,  contaiuini;'  liliriuous  clots  in  ri;;lit  and  l)laek  clots  in  left  cavities.  Liver 
forty  ounces,  nonua! :  s])leeii  three  ounces  and  a  half,  tirni.  .Small  intestine  conj;esteil,  some  of  its  solitary  follicles 
ulcerated  and  I'eyer's  patches  thi<kened;  largi^  intestine  studded  with  small  ulcers  a  quarter  of  an  inch  in  diameter. 
Kidneys  normal. — .tcl.  Ass'l  Siiiu/.  II.  M.  Dean,  Liiuuln  lliiap'ilnl,  ll'dshiinjtoii.  It.  (.'. 

Ca.se  2()7. — Serg't  K.  A.  Hiihcock,  Co.  H,  27th  Mich.,  was  admitted  Ausj;.  12,  18('):i,  having  hcen  stitfering  for  six 
weeks  from  fever  and  diarilHea.  Under  opium,  camphor,  hhu'-iiill  and  sulise<iuently  quinine,  aromatic  sulphuric  acid 
and  morphine,  he  imjiroved  until  the  2(ttli,  when  the  diarrliiea  became  profuse,  and  was  followed  liy  jirostration  and 
deliriuin  which  terminated  in  death  on  the  2r)th.  Post-mortem  examination:  Heart  tlabliy,  ])ale:  spleen  enlarged, 
.sofltuied;  nuisenteric  glands  enlarged;  elliptical  patches  near  the  ileo-Cieeal  valve  hypertrophied  Ijut  not  ulcerated. 
— Act.  Asd't  Siirgii.  C.  T.  Simp.wH  and  J.  F.  White,  tl'ent  End  Hospital,  Cincinnati,  Ohio. 

Ca.se  268. — Private  Jacob  Walder,  Co.  E,  2d  Mass.  Cav.,  was  admitted  Sept.  27,  1864,  in  a  semi-conscious  con- 
dition; pulse  90  and  feeble,  tongue  brown  and  slightly  cracked,  bowels  constipated,  right  iliac  region  tender  and 
urine  retained.  Three  pints  of  urine  were  withdrawn  by  catheter,  and  oil  of  turpentine  and  milk-punch  were  ordered. 
On  the  29th  his  urine  passed  involuntarily,  his  condition  otherwise  remaining  the  same.  On  October  5  the  tympa- 
nites had  subsided  and  the  tongue  was  cleaning.  The  turpentine  was  omitted,  and  as  the  bowels  continued  consti- 
pated an  enema  was  given.  On  the  12th  the  patient  fell  into  a  state  of  almost  complete  stupor.  As  there  was  mudi 
difliciilty  in  swallowing,  beef-essence  and  whiskey  were  administered  per  rectum.  lie  died  on  the  17th.  Poat-morteni 
examination  twelve  hours  after  death:  Body  much  enuiciated.  A  tumor  about  the  size  of  an  orange;  was  found 
between  the  posterior  portions  of  the  cerebral  hemispheres;  it  was  quite  firm  and  cut  like  soft  cartilage.  [^Specimen 
535,  Med.  Sect.,  Army  Medical  Museum.]  The  lungs  were  congested;  the  heart,  liver  and  kidneys  healthy;  the 
8])leen  and  glands  of  Peyer  enlarged. — Act.  Ass't  Surg.  W.  S.  Adams,  Hospital,  Frederick,  2Id. 

Ca.sk  2()i). — Musician  Joliii  Hummel,  Ith  N.  Y.  Cav.:  age  29;  was  admitted  .Tune  28, 1863,  having  sutfered  for  an 
unknown  time  with  typhoid  fever.  Ho  appeared  to  be  doing  well  until  .July  7.  when  he  began  to  sink,  and  died  next 
day.  I'osl-mortvm  examination  nine  hours  after  death:  Spleen  greatly  enlarged:  glands  of  Briinner,  I'cyer  and  of  the 
mesentery  enlarged;  mncous  and  muscular  coats  of  .small  intestine  ulcerated  throughout  their  whole  length. — Aot. 
Ass't  Surg.  A.  P.  Crafts,  Third  Dirision  Hospital,  Alexandria,  I'd. 

Case  270. — Private  Leonard  Snell,  Co.  C,  2d  X.  Y.  Cav.;  age  27;  was  admitted  Nov.  29, 1862,  with  enteric  fever; 
Hot  skin,  freqiu'iit  feeble  pulse,  dry  tongue,  coated  with  dark  fur,  dry  cough  and  severe  dys])n(ea,  delirium,  slight 
diarrlnea,  tympanitic  distention  of  bowels  and  dnlucss  on  percussion  over  the  lower  lobe  of  the  right  lung.  He  died 
December  1.  Post-mortem  examination;  The  lower  lobe  of  the  left  luiij;  was  hcpatized;  the  upper  portion  of  the  left 
lung  and  the  lower  lobe  of  the  right  lung  were  congested ;  the  heat  t.  liver  and  spleen  were  normal.  The  snuill  intes- 
tine w.as  injected  and  the  glands  of  Peyer  enlarged. —  Third  liirisinn  Hospital,  Ahxandria,  }'((. 

Case  271. — Private  Jefterson  Perkins,  Co.  F,  3d  Ky.  Cav.;  age  21;  was  admitted  Feb.  22,  18(;t,  with  typhoid 
fever.  His  ease  progressed  favorably  till  one  day,  after  sitting  on  the  close-stool  for  a  long  timi^,  he  grew  worse, 
failed  rapidly,  and  died  March  (i.  Post-mortem  examiiuition  twenty-three  hours  after  death:  Lungs  healthy;  right 
cavities  of  heart  containing  a  large  clot  which  extended  into  the  great  vessels;  liver  somewhat  pale  ;  Peyer's  patches 
enlarg«;d. — Hospital  Xo.  8,  Xashville,  Tenn. 

Case  272. — Private  Benjamin  Ostrander,  Co.  ll,  91st  N.  V.;  admitted  May  (i,  1865.  Diagnosis — tyjilioid  fever. 
Died  11th.  Post-mortem  examination  fourteen  hours  after  death:  Lungs  and  heart  normal;  liver  enlarged  and  .softened; 
ileum  congested  ;  Peyer's  iiatches  much  enlarged. — s'ij-//(  Armij  < 'orps  Fiiht  Hospital,  Army  of  I'otomac. 

Cask  273.— Private  .Tames  Roberts,  Co.  B,  67th  Ohio;  admitted  Oct.  27,  1x62;  typhoid  fever.  Died  .Tan.  27,  1863. 
Post-mortem  examination:  Age  about  22;  no  enuiciation;  a  puridish  color  from  gravitati<ui  of  blood  into  the  skin  of 
tli<'  occii>ut;  a  uumlier  of  reildish  spots  on  the  front  of  the  alidomen  and  chest.  Lungs  ami  heart  healthy.  Spleen 
enlarged  and  llabby;  liver  healthy.  Ileum  presenting  dilfused  redness  with  a  few  ecchvuuised  spots;  lower  agiui- 
natid  glands  nuxlerately  eiilargeil,  ujiiier  glaiuls  healthy;  lowest  solitary  glands  enlarged  and  in  a  few  instances 
slightly  ulcerated  on  the  siinmiit;  large  intestine  with  a  grayish  as])ect  of  the  mucous  membrane  accompanied  with 
a  few  inflamed  streaks.  [Sjieeimens  102-5,  Med.  Sect.,  Army  Medical  Museum,  from  this  ease,  show  various  degrees 
of  enlargement  and  ulceration  of  the  agminated  glands,  105  being  s|iecially  noteworthy  as  exhibiting  an  extensive 
sloughing  patch.] — Act.  Ass't  Surg.  ./.  Le.idij,  Satterlee  Hospital,  Philadelphi<i,  Pa. 

(d.)   Peyer's  patches  reddened,  congested  or  inflamed. 

Case  271.— Private  William  Kckard,  Co.  E,  149th  N.  Y.;  admitted  .Tan.  18,  1863;  typhoid  fever.  About  a  week 
before  his  death,  Felirnaiy  21,  pneunu)nic  symjitoms  were  ob.sci  vimI.  Post-mortem  examination:  Body  slightly 
emaciated;  ap])areiit  age  20  years.  The  brain  weighed  fifty  ounces  and  a  half:  it  was  light  colored  ami  of  normal 
consistenci'.  The  right  lung  weighed  nineteen  ounces  and  three-(|uarters,  the  left  seventeen  ounci^s  and  three-quar- 
ters; on  both  melanie  nuitter  was  c<uisi>ii'uously  arranged  in  lines  coiicspouding  to  the  course  of  the  rilis.  The  left 
lung  coutained  a,  deposit  of  tubercle  and  there  were  several  consolidated  loluiles  in  its  ujiiier  lobe;  similar  lobules 
were  ob.served  scattered  through  the  right  luug;  a  few  cretetied  tubercles  wer<>  fouuil  in  both;  the  bronchial  tuhes 
of  the  left  lung  were  intensely  congested  and  containeil  purulent  matter;  several  of  the  bronchial  glands  contained 
calcareous  deposits.  Thfie  was  a  white  librinous  clot  in  the  right  side  of  the  heart  extending  into  the  pulmonary 
artery;  in  the  left  side  a  black  (dot  from  which  a  white  fibrinous  branch  extended  into  the  aorta.  Thi;  liver  weighed 
sixty-seven  ounces;  its  acini  were  distinctly  marked;  the  gall-bladder  was  empty.     The  spleen  weighed  six  ounces 


THK    f'ONTINTKP    I-'KVKTIS.  .YJ  i 

.'Hill  11  (|u:iilcr:  it  was  of  a  lii;lit  1m  ick-icil  coldr  ami  vrrv  .soft.  'I'lic  |iaii(ri-as  ucinlicd  lliicf  ounir.s  aiul  a  (|uartcr.:  it 
was  Mini  and  (if  a  li,\'lit  ]iiiikisli  icilnr.  'll,,'  kiiliifvs  ami  Miprairnal  lapsnlrs  ucir  natural.  'I'lif  niiiriiiis  im-iiiliiaii<> 
(if  tile  stomarli  was  very  sdfl  :    lliat  nt'  llic  small   iiiu-si  im-  was  i;.-mT:ill>    scit'l.-mil.  .siMcially  in  tin- ji'Jiiiiiiiii.  when' 

it   had  a  volvcty  aii]H-ai!iiici- :   tlir  ilrinn  was  ihin.  dilalfd  in  placid  and  s uliat  cnii^ii'stcil :    I'l-yiT's  i.atidics  wi-ic 

ri'ddeiii'd;  tlio  larjic  intestine  was  slale-eid.ned  e\ie|il  in  llie  leelnin.  where  it  was  eiiiii^i-sled  ;  the  iiicseiiteije  and 
iiiesociilic  tilamls  were,  m.nnal.— ./s.v'/  Sun/.  (:,ur;ir  M.  Mvdill.  I'.  S.  A..  I.inailii  lln^^jiilul.  ir.i.v/iiN<//i/»,  It.  ('. 

Cask  27:". — l'iivat<-  (ieiiryi-  I'.  'riKinias.  Cn.  (J,  i:;d  lihio:  af;e  L'ti:  was  admitted  I'"el).  I,  IXt;."),  with  the  erupt  ion 
id'  measles  well  di'\ehi[M(l.  In  a  tew  da\s  the  eiii|p|iciii  had  aliimst  entii'idy  disafipeaii'd  :  liiit  sym|)tonis  of  ly|dioid 
fever  were  manifested,  and  lie  dic-d  on  llie  iLMh.  I'ii.^I-hkiiIi m  examination:  The  hrain  was  normal.  The  liinjis  were 
congested  ]iosterioiiy  and  jiresented  nodiilateil  intlammal  ion,  llie  siihsianee  id'  wliieh  was  heavier  than  water:  f;real 
niimhers  of  miliary  tuhercles  lllled  tin-  posterior  and  inferior  ]iorli(ms  of  the  liint;s;  the  rif;ht  Inn;;  wcijihod  thirty- 
seven  oiinees.  Clots  were  found  in  lioth  sides  of  tlii^  heart.  The  li\er  and  pan<'re:is  wi'ie  normal;  lli<'  Ni)h>en. 
six  onnei's,  contained  iniliai  \  t  nipeicles  :  t  lie  kidneys  w  ere  son  lew  hat  enlaii;ed  and  lot  m  la  ted.  ea(di  wi'if;liinj;  eif;lil 
ounces.  The  stomach  was  c-oiiliacted  and  its  nincoiis  nieniliram-  somewliat  i'oiii;i'stcd.  Ill  the  ileum  small  raisi'd 
]ioints  were  obserx  I'd.  which  were  hard  to  t  he  tee!  ,  I'eyer's  patches  were  generally  t  nmid  and  dark  :  aliont  the  middle 
of  the  ileum  its  mucous  tohls  were  deeply  coiij;esied,  and  aliove  thesis  a  loiif;  I'eyer's  patch,  <'nlaij;ed  and  rcd<li'ned, 
was  sitnated  in  the  midst  of  another  eonf;ested  re};ion;  amoiif;  the,  valviihc  coniiivenles,  siirioiinded  hy  eonjjestion, 
was  a  patcdi  a  foot  in  lciii;tli  ii-semhlinj;  a  I'eyer's  pat<  h  in  strneliiri^  ami  enl.iri;i'd,  as  wi're  sinli  )ialelies  in  the  ileum. 
Tlio  traiisverso  and  deseeiidini;  iiortioiis  (d"  tlio  colon  \ven>  reddened;  tho  rectum  congested. — .Ixh'I  Siinj.  dm.  M. 
MrCill,  C.S.  .(.,  XdlioiKil  llmintal,  Haltlmorc,  MiL 

Ca.sk  27(>. — I'rivate  I'liineas  Wooster,  Co.  E,  K^Ttli  N.  Y.;  ajjo  S.'i;  ndinitted  .Ian.  11,  IStJIi.  Diajinosis — tyjilioid 
fever.  The  clinical  history  is  iiieafire,  consistinjr  of  only  one.  entry  dated  Feliriiary  1  :  I'lilse  frcc|iienl,  easily  coni- 
pres.sed;  tonfinc  dry,  edf;es  white;  skin  dry  and  liarsli ;  iiifjht -sweats;  bow(ds  loose,  stools  thin  and  cdfeiisive.  Treati'il 
liy  wine  and  Jiorter  with  ojiiates  at  hedtime.  He  died  on  the  lllth.  I'oxl-iiiiirtnii  examination  twenty-einlit  hours 
lifter  death:  liody  iiiiich  emaciated.  Tln^  hrain  w  as  anM'inic.  The  rij;lit  hint;  wciKheil  seven tei'ii  ounces  and  a  i|uar- 
fer,  its  upper  loUe  coni;ested  poslerioi  ly  and  its  lower  henatized  ami  eontainint;  small  alpscesses  which  couununicated 
with  the  hroncliial  tubes;  the  left  liiiifi  w  cii;lied  eleven  ounces.  The  pericardium  adhered  to  the  surface  of  the  heart, 
on  which  were  dark  spots  and  exuded  lymiili;  the  heart  was  tlabliy  and  contained  tiliiimuis  clots  in  both  ventricles. 
The  liver,  forty-four  ounces  and  a  (|Uarter,  \v;is  tlabliy  and  lij;lit  ccdiircd  ;  tin'  t;all  bladder  contained  two  ounces  of 
thin  t;reeu  bile;  tln^  spleen  was  small  and  t(m}.;h.  The  duodenum  was  much  eonf;csled  in  its  u|>p(^r  ])ait,  its  serous 
coat  was  sl;ite-c(doreil:  the  Ji'jnnuiu  In  its  upper  jiart  was  slate-colored  without  and  hijj;lily  contjested  within,  iind 
lower  (low  II  the  color  of  the  serous  membrain!  was  darker;  I'eyer's  ]iatclies  wer(»  coufii'stcd,  the  valvuhe  softeni'd  and 
the  coats  of  the  ihiim  jienerally  thinned  anil  reddened;  the  aucendilig  colon  was  slate-colored.  The  left  kidney  was 
slij^hlly  coniicsted. —  l.iiii-nln  /li>sj)iliil.  WimliiiKihiH,  1>.  C. 

Cask  277.— Private  M.  W.  Ree.se,  Co.  H,  .i2d  Miss.;  rebel;  ase  28;  admitted  Auf;.  3,  IKfil!;  typhoid  f.ver.  Died 
Ulli.  J'fiKt-iiioflfm  e.xamination :  Hody  rifjid,  not,  emaciated.  liraiii  forty-seven  ounces,  healthy;  lateral  ventricles 
distended.  Trachea  pale  aliove,  inirple  and  congested  towards  the  bronchi;  (csophiigus  iiale,  with  light  purjilisli 
[latclies  in  its  np]ier  third  iuid  ochre-colored  below.  Kight  lung  eighteen  ounces,  much  congcHted,  several  <d"  the 
lobules  of  the  up]ier  lobe  KuiTounded  by  a  dark-reddish  material  resembling  clotted  blood;  left  lung  seventeen 
ounces  and  a  half,  engorged  with  semi-solidified  blood  in  the  jiostt^rior  part  of  its  lower  lobe.  Heart  nine  ounces, 
no  clot.  Liver  sixty-four  ounces,  mottled  light  and  dark  purple  externally,  slightly  Jiale  internally;  gall-bladder 
cont:iining  an  ounce  of  bile;  sjileen  fourteen  ounces,  dark  but  firm;  pancreas  four  ounces,  healthy.  Inteslines 
healthy  except  near  the  ileo-ca'cal  valve,  where  I'ejer's  jiatches  seemed  to  be  congested,  but  they  wiTe  not  swollen 
nor  ulcerated.  ]!oth  kidneys  were  anaemic,  with  the  jielves  ]iale  and  tlu!  pyramidal  bodies  of  a  dark-inirple  color. — 
Axs't  ISurg.  ITiirrhon  Allen,  U.S.  .1.,  Lincoln  llospitdl,  Ifn-ihiiii/lon,  D.C. 

Case  278. — Serg't  Alexander  Dcatty,  Co.  I,  15th  N.  .7.;  age  22;  was  admitted  .Jan.  2,  lS(;.i,  with  gangrene  of 
the  toes  following  typhoid  fever.  Tlie  gangrenous  condition  was  attributed  to  frost-bite  while  sick  in  camp.  Hoth 
feet  were  amputated  through  the  metatarso-phalangeal  articulation.  On  February  '.i,  the  day  after  the  operation, 
<lelirium  set  in  and  continued,  with  occasional  lucid  intervals,  until  death  on  the  IDth.  I'oKt-morlrm  examination  an 
hour  and  a  half  after  death:  Xo  rigor  mortis;  skin  sallow:  in  the  sole  of  the  right  foot  was  an  abscess  with  otVi'ii- 
sive  grayish  contents,  and  over  the  external  malleolus  of  tho  left  foot  was  another  which  cmnmunicated  with  tlu^ 
■wound  of  operation;  the  cartilages  exjiosed  by  the  aniiuitation  were  niuih  eroded,  and  those  of  tho  cuboid  and 
internal  cuneiform  bones  were  nearly  destroyed.  The  subarachnoid  space  and  the  ventricles  of  the  brain  contained 
an  unusual  quantity  of  scrum.  The  right  lung  weighed  eleven  ounces,  the  left  nine  and  a  nuartcr;  in  the  upper 
lobe  of  the  left  lung  were  two  small  round  masses  of  cheesy  tubercle  and  an  abscess  the,  size  of  a  chestnut,  which 
contained  offensive  ])us;  a  similar,  rather  smaller,  abscess  was  found  in  the  middle  lobe  of  the  right  lung;  the  bron- 
chial tubes  contained  a  whitish  exudation  ;  the  bronchial  glands  were  dark-colored  externally  and  contained  a  w  hite 
calcareous  deposit.  The  heart  was  tlabliy.  The  liver  was  of  firm  consistence  and  somewhat  congested;  the  spleen, 
sixteen  ounces,  was  dark-colored,  firm  and  congested;  the  pancreas  was  of  a  light-red  color  and  firm.  IJoth  kiilneys 
were  of  firm  consistence;  in  the  lower  jiart  of  the  right  kidney  w.-is  a  small  cavity  containing  whitish  cheesy  pus. 
The  stomach  was  healthy;  the  jejunum  darkly  congested;  the  lower  part  of  the  ileum  intensely  congested,  its  soli- 
tary glands  enlarged  and  inflamed  and  Peyer's  patches  congested  and  somewhat  ])rominent;  there  was  a  region  of 
congestion  in  the  ascending  colon. — J,«s'<  Surf/.  Giorf/e  M.  J/cGi//,  V,  S.  J.,  Lincoln  Iluxpital.  Wimhington,  I).  C, 


39<S  rosT-^roTr|•|•;M   i;>:('okds  ov 

Cask  279 — Oorp'l  Jdlm  Scli.'iirncr.  <'(..  11,  1  Uli  \ci.  1,'c.-,,  Cnip,-.;  udinilnd  M:ircli  '_'N.  1!«',1;  lyiiljoid  fr\(.|.  Died 
April  3.  I'lixl-iiiorti  III  I'xatiiin.itioii  cii^liii'fii  li(iiir>  .il'li-i  driu  li  :  |!i"l\  iiiiirli  ciiKn'i^itiil .  Tin'  (liiiiilniiiiii  »  .i^  coii^i'strd  : 
the,  jejuinini  .sli,t;lilly  roni,'i-slcd  in  |i;iti-lii-s :  tin-  ilciiin  unnu'i'^'fl  tlii(iin;li(iiil  :  l'i-yci'>  )mI<1ks  coiijifslfd  Imt  ikiI 
ulcerated;  there  was  oik^  eorijiesled  sjmt  in  tlie  lower  eidcm.  u  liicli  was  dtlierwisc  lira  ll  li\  .  — -.le/.  .I.s.s'/  Sinij,  ('.  '/'. 
Traiitmaii.  Ilariu-mtd  IliiKjiitid,  ll'iishiiii/luii,  1).  <'. 

Cask  '2W. — I'rivate  Conrad  II<dd.  Co.  I).  TiL'd  X.  Y..  was  admitted  Feli.  i:i,  ISri)!,  witli  lever  and  iicrsislent 
vomit  inj^.  Kpistaxi.s  occur  I'ed  on  the  ITtli.  and  w  itli  the  vimiit  iiiil  continued  to  I  he  end,  tlie  Ideedinj;'  usually  reeui- 
ring  at  ni^lit.  The  jiatienl  hecanie  slu]iid  on  tlie  L'lst .  and  tliei'e  was  some  diarrluea.  wliieh  (li<l  md  last  beyond  I  he 
2Stli.  Creasote.  aei'tate  ol'  moijiliia  and  lilisters  had  no  ell'eet  (Jii  tile  vomitini;.  Medicine  was  diseaided  towards 
the  end,  St  imulants  and  nourishment  only  lieiiiij;  used,  lie  lin,i;eied  mil  il  Maii-h  7.  I'dxl-iiinrlciii  fs;ii\\\iui\']ii<t:  'I'lie 
.Ulamls  of  I'eycr  were  coiiLTestcd  and  swollen  and  tlierc^  were  some  sij;iis  of  recent  ]peri<'arditis.  The  spleen,  liver, 
kidneys  and  luni;s  were  iiornial. — Ad.  Ax-s't  Si(r<i.Joliii  K.  Smith,  DoikjIhk  noxjiitul,  ll'iialiiiii/tiiii,  li.C. 

Cask  281.— Private  Henry  (i.  Howell,  Co.  I,  27tli  X.  J.,  was  admitted  Fell,  lo,  l><t)3,  in  a  ])idstrale  and  didirioiis 
condition,  jle  had  freiinent  lits  of  cougbinj;  and  cxjieetorated  a  viscid,  transparent,  frothy  luueus.  Diirinj;  tln' 
followint;  nijiht  his  fac^^  hecanie  purjdi.sli,  his  delirium  increased,  and  a  clammy  perspiration  liedewed  his  skin.  He 
dii-d  next  day.  roKt-iiiniiiiii  exaininatiou  four  hours  after  death:  Body  roliust ;  apparent  ajjo  2.")  years.  The  hrain 
weiiflied  fort,v-six  ounces  and  was  soft  and  conj;esteil  to  redness.  Tlu're  were  pleuriti<i  adhesions  ou  liolli  sides; 
the  rifjht  lunj;  wei^jhed  forty  ounces  and  a  half,  the  left  thirty-three  ounces;  the  lower  lobes  of  liofh  lunf;s  and 
portions  of  the  upper  lolies  were  in  a  state  of  red  hepatization,  apinoachiuj;  K'"',v;  *'"'  hrouchial  tulies  were  con- 
i;ested  and  in  some  instances  |iln.i;<,'ed  w  itii  a  librinous  deposit.  The  heart  emitained  larj;'e  iiliiinoiis  clots  on  both 
sides.  The  liver  weighed  t wcnty-ei^dit  ounces  and  a  half,  its  acini  were  ilistinct ;  th<^  s|)leeii,  four  ounces  an<l  three- 
(juarters,  was  lifjht-cidored  aiul  soft,  with  distinct  trabecuhe:  the  right  kidney  weighed  live  ouncis  and  a  half,  the 
left  five  and  a  ipiarter;  the  suprarenal  cajisiiles  were  small,  dark  and  tough.  The  stonnuh  was  laige  and  its  fundus 
congested  ;  the  glaiuls  of  the  duodenum  were  slightly  enlarged ;  the  upper  third  of  tln^  jejunnni  was  iriegul.arly  con- 
gested :  tlu'  ilcMuii  was  congested,  its  solitary  glauds  enlarged  and  red<lene<l  and  ihi'  palclns  ol'  I'eyer  iricgiilarly 
inlianied  and  thickened.  The  large  intestine  was  distended  with  gas.  the  s(dilary  glands  swollen  and  irddein'd — 
twi'lve  of  thest^  {■niarged  glands  wen^  counted  in  a  sijuare  inch  selected  at  i'a.ndom:  the  niesenlerir  gl.inds  were 
enlarged  and  inllamcd. — ./.«'/  Siirij.  diin-gc  M.  McGill,  V.  S.  .1.,  Lhicohs  Iloitpitiil,  Wusliiiiiihiii,  I).  ('. 

Cask  2)^2. — rrivatc  Henry  Cajiipbell,  Co.  H.  2tltli  Midi.,  was  admitted  .Ian.  21,  IXtV.i.  with  typhoid  l'i\er,  and 
du'il  February  2.  Pnxl-iiuiiiiin  examination  sixty-eight  hours  after  death:  Body  widl  develojied  and  fal.  The  brain. 
forty  ounces  and  a  half,  was  of  light  color  and  lirm  consistence.  The  heart  contained  clots.  The  luiii^s  were  con- 
gested hyposlatically;  the  left  lung  weighed  eighteen  ounces,  the  right  twenty-four  ounces.  The  li\iT  wciglieil 
forty-five  ounces;  the  spleen  ten  ounces;  the  kiilueys  seven  ounces  each:  the  jianereas  two  ounces  and  i  lMci'-(|uai- 
ters;  the  gall-bladder  was  empty.  The  mucous  menibrauc  of  the  stotuach  was  congested;  a  luinhricoid  worm  was 
found  in  the  jejunum,  which  was  irregularly  coiigeste<l;  its  lower  part  and  the  ujipcr  part  of  the  ileum  were  much 
thinned;  I'eyer's  patches  were  enlarged  and  iiiliamed,  especially  near  the  ileo-ca'cal  valve;  the  coats  <d'  the  largi^ 
intestine  were  very  thin  and  the  miu'ous  membrane  eoiigestiHl,  especially  in  the  upper  portion  of  the  colon. — An«'t 
Surij.  Gi'oryr  il.  MvGiU,  U.  S.  J.,  Linculn  Iluspital,  Waahinijton,  D.  C. 

Ca.sk  2S:!. — I'rivate  Martin  Dusentiery,  recruit.  !Hli  Ohio  Cav.:  agi'  20:  was  admitted  Oct.  11.  IN  Jl!.  wii  h  typhoid 
lever.  He  had  been  sick  four  or  live  days.  His  fever  was  slight,  but  there  was  some  delirium  and  cougli  wiili 
mucous  sjmta;  his  bowels  were  open,  and  there  was  slight  tenderness  in  the  eiiigastric  and  right  iliac  regions. 
\ext  day  the  delirium  had  disa])peared  and  he  was  otherwise  better.  On  the  IXth  his  tongue  was  more  coati'd, 
bowels  open,  abdomen  tender,  ccuigh  aggravated  and  resjiiration  hurried.  During  the  night  of  the  lUlli  he  was 
actively  delirious,  rei|uiring  restraint;  and  next  da.v  there  was  severe  pain  in  the  right  lung,  with  dulness  and 
ere]>itant  rales.  He  tiled  on  this  day.  I'ont-moiiiiii  examination  three  Inuirs  after  <leath  :  Left  lung  i-ongested  ;  lower 
two-thirds  of  right  lang  heiiatized.  with  pleuritic  adhesions  esiiecially  of  the  dia|iliragin.  and  twelve  ounces  of  serum 
in  the  pleural  cavity.  Intestines  congested;  I'eyer's  patches  enlarged  and  inllamed  Imt  not  ulcerated. — Dnnil.sini 
Hospital,  Ohio. 

Cask  2^. — Privatt^  (ieorge  \V.  Harvey.  Co.  H.  21th  JUiiie  :  age  :il ;  was  admitted  .Inly  21,  IMii:;.  fliis  patient 
was  a  deserter,  and  although  rational  on  admission  his  minil  was  much  exercisi'd  on  the  subject  of  his  cajiture  and 
]irobable  punishment.  This  had  an  I'vident  inlluenee  on  the  progress  of  his  disease.  Low  delirium  followed  and  con- 
tinued until  death  on  the  ;:!Oth.  I'lixt-iiiurliiii  examination:  Heart,  lungs  and  liver  liealthy;  mesenteric  glands  and 
those  of  llriinner  and  I'eyor  extensively  enlarged  and  inllamed;  mucous  coat  of  small  intestine  softened  and  ulcer- 
ated throughout  its  entire  length. — Act.  J.sn't  Siinj.  A.  I'.  CraJ'l,  Third  JUi-isioii  Jluxpital,  Alcjandrin ,  lit. 

Cask  28.">.— Corp'l  William  H.  (ilattz,  Co.  K.  1th  Del.;  age  2H:  was  admitted  .Inly  2S,  IStW,  in  an  advaiK^'d 
stage  of  typhoid  fever.  He  died  on  the  2l>th.  I'nxt-miirtim  examination  :  Lower  lobe  of  right  lung  congested  ;  I'eyer"s 
patches  inllamed  and  elevated;  mucous  follicles  of  tlu;  colon  much  t'ularged:  spleen  congested;  liver  and  kidneys 
uornial. — .l<l.  Axx't  Surg.  '/'.  Tiirntr,  Third  Lirinimt  lloxpilid,  Alijinidriii,  I'd. 

Cask  2H0. — Fi'ivate  IVter  A.  Wayman.  Co.  I>.  Hist  N.  V.:  admilleil  .May  ti.  1SI>.">.  I'iagnosi.s — lyjdioid  fcM^r. 
Died  on  the  11th.  riixl-iimrli  m  examinaticn  -ixly  lion  is  a  Iter  death:  Cpper  lobe  id'  right  lun^  In'palized  and  adin-reni  : 
left  Inn"'  and  heart  normal:  spleen  doubli-  the  usual  size;  stomach  healthy:  l'ey<'r"s  jialidies  swollen  anil  inllamed; 
colon  normal. — Sixth  Arnnj  Curpx  I'iild  Hoxpiliil,  Armij  nf  T'lilomiic. 

(e.)  ri'yer'x  jintchix  piijminlnl. 

Case  287.— I'rivate  William  fSibley,  Co.  A,  2d  JIass.  Heavy  Art.;   age  2."i;   was  admitted  Sept.  10,  18fir>_,  liaving, 


THK    CUi\rlNT-KTi    KEVREP.  -^f^^ 

from  his  dun  .statciiii'iii ,  luiii  sick  I'ur  u  Inii^  t\u\i-  witli  Irvfr  !in<l  (luinlici';i.  lie  hml  ;i  hot  sUiii.  ilryand  coaled 
tongue  anil  tcchU^  inli'iinitti'nt  jmlsu:  In-  Ihmuimo  di'lirions  diirinj;  tlic  in;;hl ,  and  died  iicxi  day.  I'<isl-miirli  m  exam- 
ination ti-n  liours  at'tt-r  <li'alli :  Xot  nmc-li  cniaidation  :  no  i  ij;oi mortis.  Tlio  suliarachnoid  spafo  contained  aliont  two 
ounces  of  senna,  and  a  small  (juantity  was  found  in  tin'  ventricles  ;  llie  jda  mater  \vas  conjjesled  ;  cecliymosed  sjiots 
were  oliserved  on  the  summit  of  the  rif,dit  cerehral  liemisplieri'  and  on  the  rij;lit  .side  of  the  lloor  of  llie  fourth  ventriide; 
the  seel  ion  <d'  the  hemis]dieri's  sIkiw  ed  numerous  |inncta  vasiiilo>a.  .\  larjie  jnution  of  the  lower  loin'  of  the  left 
liiii;^  was  in  the  first  sta.i;e  of  |ineunionia:  the  iif;ht  Iiiulc  wa>  i-ouf^ested  ]iosteiiorly  and  weifjhed  twenty-two 
ounces,  t  he  left  I  hirly-l  wo  ounces.  Tlic  licai  I  weiLjIied  t  u  el\  e  ounces  :  1  hi-  auricular  sejil  mil  u  as  perfonited  :  I  here 
was  a  mixed  ehd  in  the  riirlit  side,  a  little  lliiid  Idood  in  llu-  Icll.  file  liver  was  lirm,  dark-cololed  and  weiijhed 
fifty-ci^hl  and  a  i|iiarler  ounces;  I  he  nall-liladih-r  c(Uilaiiicd  a  small  iiiia  lit  it  y  of  lliin  lirow  n  hile;  the  s]ili'en  was  soft 
and  wcijihi'd  six  ounces,  'flic  siiuiiaeh  was  thin  .-iiid  discolored:  tlie  ileum  eon;;ested  in  rej^ions,  its  scditary  glands 
enlarged  and  l'(\vi'r's  (latehcs  iiiomiiient  and  speckled  with  lilood;  the  large  inte.stine  llaeeid  and  in  part  discolored. 
The  kidneys  were  large  and  soft .— .I.v.v'/  Sui-'j.  Cmr;/,   M.  M,i;\l].  r.  S.  A.,  IlicL'x  lliixjiilal,  Ildllimon  .    Mil. 

Cask  L'W.— I'rivate  Henry  11.  .loyce,  Co.  I'.,  Ctli  \  a.  iichel)  luf:  admitted  .\ug.  I!,  iMiii:  tyjilioiil  lever.  Died 
7tli.  /'o-sZ-wd/'/cm  examination  sixteen  luuirs  after  death  :  I'lody  not  emaciated  :  ligor  mot  t  is  slight  :  appaieiit  age  2H. 
The  brain  was  lirm  and  weighed  forty-eight  luinci-s:  the  pia  mater  was  congcsled  o\i'r  the  imsterior  piution  of 
both  liemis))hei'es.  Tlii^  niiiccMis  nu-mlirane  of  the  tiaeloa  u  as  ciuig<'sted,  tin'  congestion  extcuding  into  tlic  biiMi- 
c  Ilia  I  tubes;  the  lyiuphalic  glands  at  the  bifiiKation  of  I  lii^  liaidica  wi-H'  lirm  and  blacdi.  There  wi-re  pleiiiitie  adhe- 
sions on  both  sides;  the  right  lung  weighed  nineteen  ounces,  its  upper  hdie  sliglilly  congested  anil  ii  frothy  secre- 
tion exuding  on  ])res.sure,  its  middle  lobe  I'ongesled  hyposlalically  and  having  on  its  Mirfaee  numerous  spots  of 
transuded  blood;  the  h'ft  lung  weighed  twenty  ounces,  i(s  upjier  lolie  Jiormal,  but  tlii'  lower  ecchyinosed  and  greatly 
congested.  'I'lie  right  auricle  of  the  heart  contained  a  thin  lihrinoiis  clot  which  extended  into  I  he  \cnlricle  and 
thoiiee  into  the  |)ulnionary  arteiy  and  its  br.anehes  for  a  distance  of  111  lee  or  four  inclies;  the  endocardium  ill  the  riglit 
aiirieh)  was  purplish.  The  liver  was  some  w  liat  ciuigeslcd  and  rat  her  Ihibby;  the  gall-bladder  contained  half  adraelim 
of  thick  bile:  the  s|dcen,  nineteen  ounces,  was  lirm  and  of  a  rich  mahogany  color;  both  kidneys  were  moderately 
iirin,  the  surface  somewhat  gri'cnish,  the  cortical  substance  |iale  cxcejit  at  the  suiierior  ext  lemitii's  of  the  organs, 
where  it  was  congested,  the  iiyrainidal  bodies  purplish;  the  pancreas,  three  ounces,  was  purplish  and  of  normal 
lirmncss.  The  mucous  membrane  of  the  fundus  of  llie  stomacli  was  dark-colored,  in  the  rest  <d' the  organ  it  was  palt^ 
The  Niiiall  intestine  |i  resell  ted  nothing  remarkable  e\ee]it  a  dark- purplish  congest  ion  in  the  lower  third  of  I  he  ileum  ; 
I'eyer's  ]ialelies  weie  |>;ile  will nsjiicnous  blaidi  k])oIs  in  their  follicles,  but  nowhere  were  they  Ihickeiieil  or  ulcer- 
ated.    The  large  inlcsline  was  he:ilt  hy .  — .l.sx'/  .S»)v/.  Ilarrinoii  Alliii,  I'.S.  A.,  I.hicohi  HiixjiihiJ,  ll'iixliiiiiilnii,  II.  C. 

Cam:  L'S!I.  —  I'lisate  Jacob  lli'iison,  Co.  (i,  Kith  I'a.  Cav.:  age  IS;  w  a.s  admitled  .March  \l't,  IStil,  very  weak 
and  much  cimicialed,  w  ith  a  frei|iient  and  feeble  ))iilse  and  hurried  respiration.  lie  was  i|iiite  deaf;  he  had  a  bed- 
sure  two  inches  si|iiaii',  with  highly  inllamed  margins,  over  the  lower  part  of  lite  sacrum;  his  right  knee-joint  was 
acutely  inllanied,  i|iiile   red  over  the  internal  condyle,  very  hot  and  exi|iiisitely  painful.     Kriuii  the  testimony  of  a 

c i.iile  it   was  learned  that  the  ]iatient  had  been  alfected  with  erysijielas  and  tyjihoiil  fever,  and  that  the  intlamma- 

1  ion  of  t  he  knee-joint  occurred  a.s  a  sciiiiel  to  these  diseases.  Cold  water  was  aiiplicd  to  the  knee  and  extension  kept 
up  by  (iiiidon  lluck's  aiiparatus  with  a  thiec-pound  weight.  Opium  and  whiskey  were  administered.  Next  day 
1  he  ciuidil  ion  of  (he  knee-joint  w  as  improved ;  hut  the  |>aticiit"s  eyes  w  ere  yellow,  his  skin  imriiurie  and  dry  and  his 
face  Hushed;  he  had  jiain  in  the  left  side  with  some  dnine.ss,  bronchial  respiration  and  increased  vocal  resonance,  ii 
hacking  cough  but  no  expectoration:  he  had  also  some  diarrluea.  Dn  the  2Sth  he  had  a  severe  chill,  which  recurred 
next  day  and  was  followed  by  ]irofuse  jicrspiration.  After  this,  although  there  was  manifest  iiii]>rovement  in  the 
coiidit  ion  of  the  knee-joint  and  lung,  his  strength  failed  gradually,  and  he  died  on  A]iril  7.  I'lmt-mnrlfm  exam iiial ion 
fourteen  hours  after  death:  Hoily  iiitich  emaciated;  skin  dingy  with  many  purpuric  spots;  rigor  mortis  well  marked. 
The  brain  was  healthy.  The  right  lung  was  healthy  but  firmly  adherent  on  all  sides;  the  left  ideuial  cavity  con- 
tained two  pints  of  senuii ;  the  lower  lobe  of  the  left  lung  was  covered  with  tihrin,  at  one  point  nearly  half  an  incli 
thiidi.  and  in  its  lower  and  posterior  part  was  an  abscess  the  size  of  a  large  walnnt  surrounded  by  nincli  solidified 
tissue.  The  ])ericardium  contained  two  ounces  of  serum.  The  liver,  seventy-one  ounces,  was  firm  and  waxy  and 
had  ])ale  spots  scatteriKl  over  its  surface;  tlie  gall-bladder  was  enijity:  the  pancreas,  s|)leen  and  kidneys  were 
healthy.  The  siditary  and  agminated  glands  of  the  intestines  were  pnuiiincnt  and  dotted  with  dark  points.  'I'lie 
knee-joint  contained  two  ounces  of  pus  mixed  with  librinous  Hakes,  <uie  of  which  was  over  an  inch  and  a  half  in 
diameter;  the  cartilage  on  the  lateral  aspects  id'the  femoral  articulating  surl'ace  was  destroyed,  laying  bare  the  can- 
cellous structure  of  the  tioue;  the  synovial  membrane  was  vascular,  es]>ccially  above  the  patella,  where  also  it  was 
covered  with  shreds  of  fibrin;  the  bursa  beneath  the  exteiLSor  tendon  of  the  thigh  comiuunicated  with  the,  jidnt  by 
several  orifices  and  was  filled  with  ]iiis  and  l,vmph, — Lincoln  Jlonj>iliil.  W'lmhhKjttm,  I).  C. 

Ca.se  2fl0.— Private  Daniel  Criim,  Co.  C,  61st  N.  Y.;  admitted  .July  L'ti.  ISti'J;  typhoid  fever.  Died  August  24. 
I'nat-mitrtnti  examination  next  day:  Organs  generall.v  healthy  except  that  the  agminated  anil  solitary  glands  were 
lliiekened  and  of  a  most  remarkabh'  black  color,  resembling  the  bluish-ldack  marks  of  tafooing:  the  surrounding 
parts  of  the  mucous  membrane  were  pale  and  devoid  of  anything  like  congestion. — Act.  Aax't  Surij.  J.  l.c'uhj.  Sathrhc 
lliiKj'iliil,  J'liiliidelphid,  I'a. 

Case  291. — Private  Thomas  J.  Crumb,  Co.  D,  41th  N.  V.:  admitted  Aug.  ID.  isti2;  typhoid  fever.  The  jiatient 
had  diarrluea  on  admission,  and  during  the  last  few  days  of  life  was  delirimis.  Died  2Tth.  I'ont-morlcm  exam- 
ination next  day:  Body  much  emaciated;  age  about  25  years.  Hrain  natural  in  a|i]iearanco  except  that  the  pia 
mater  was  unusually  bloodless,  opaque  and  wrinkled.     Heart  sniall,  coutracted,  w  ithoitt  ;»  vestige  of  adipose  tissue, 


400  POST-MORTKM    RECDRDS    OK 

liquid  blood  ill  ifs  rli^lit  sidn,  the  Icfl,  (Miijity  cxcciit  ii  sniiill  (•(i:i},niliiiii  of  lllirin  iiU;ii-liod  <o  flu^  cliord:!'  fciidiiiea'.. 
Liiii.!;s  lioiiltliy.  ].ivcr  khmII,  dii>ky-]iiii|)]i'  ulmvi-  and  .sI:itc-c'oIorcd  liclnu;  splci'ii  small,  in  M'<-tiiin  iliill-lniiwii. 
.StiHiiacli  and  intcst  Inus  distended  witli  air  and  jin'sentiii.t;  no  evideiiee  of  inllaiiiiiialioii ;  aj;iiiiiiated  glands  liealtliy 
excejit  that  tliey  eontaiiu'd  a  deposit  of  black  niattei-;  nolitaiy  i.;lands  uiiiisiially  proiniiieiit  and  eontaiiiinj;  li]ael< 
matter;  iniicoii.s  iiieiiiliiane  of  tlie  e(doii  i  reain-eolored,  reiuaikalily  bloodless,  solitary  inlands  liarely  |ierce)jlilile.— 
Act.  Jus't  Snrij.  J.  JahIij,  SnUvrhc  lliinpila!,  I'}t[la(hIphUi,  I'd. 

(Jask  2'J2.— I'ri\ale  Tliomas  Rose,  Co.  A,  liHIi  I'a.;  admilled  Au,y-.  in.  istl2;  fypboid  fever.  Kied  S<-pleinbi'r 
23d.  /'o.</-Hi(»-((Hi  exaiiiinat ion  :  A,i;e,  aliont  2(1;  body  coiisideralily  eiiiaeiated  and  every  wlii'ie.  oechyniosed.  I.niii;s 
und  heart  healthy,  the  latter  oontaiiiiii^' a  white)  clot  in  the  rij;ht  ventriele  exteiidinj;  into  the  ]iiilinonary  aitiiy. 
another  in  the  lelt  auricle  and  a  third  in  the  comineneemciit  of  tli(!  aorta,  i^pleen,  liver,  kidneys,  snprari'nal  bodii-s 
and  pancreas  natural.  Mucous  iiiemlpiano  of  stoniaeh  inllamed  mole  or  less  ditlusely  and  with  occasional  small 
patcln^s  of  great(!r  intensity.  Jlenni  inllamed  in  |iatcli<'s.  iiu'ieasin^  in  intensity  towards  the  lower  end;  solitary 
glands  eiilari.jed,  inflamed  and  containing  lilack  mat  tei:  agmiiiated  glands  with  black  deiiosit  but  otla^rwise  apjia- 
rently  healthy.  Cohm  disteiidi'd  witli  air,  excejit  descending  portion,  which  v.as  narrowly  contracted  but  not 
intlained;  ca'Ctim,  ascending  and  transverse  colon  inllanied;  solitary  glands  conspicuous  ami  containing  black  pig- 
tiient. — Aci .  A-^n't  >'"*■.'/.  •/.  l-<i(l>l,  Siittcrhf  Ilo.^piUd,  I'liiIti(Mplii(i.  I'ti. 

Case  2li:j.— Private  A.  W.  I'arris,  Co.  H,  2d  Vt.;  admitted  Aug.  1(1,  lW(i2;  typhoid  fever.  Dieil  2(ith.  /Vs/- 
mi)rti:in  examination  next  day:  J'.ody  largo,  somewhat  wasted,  aged  aliont  ;i(l  years;  skin  bronzed  and  npoii  tlu^  trnnk 
somewhat  ecehyniosed.  Heart  niirnial,  containing  a  tibrinoiis  clot  and  much  liciuid  blood.  Lungs,  liver  and  spleen 
healthy.  Stomach  distended  with  air  and  liiitiid,  its  niucons  iiu^mbrani!  dusky-gray  and  with  an  inllamed  patch  near 
the  i>yloru8.  Ileitni  highly  inflamed  in  patches;  agniinated  glands,  thirty-six  in  number,  all  dotted  with  black  pig- 
ment but  otherwise  natural;  solitary  glands  inconspiciions.  Colon  contiacteil.  gray,  with  a  few  small  red  patches, 
and  with  black  pigment  in  the  solitary  glands. — Art.  J.s.1'/  Sm-ij.  ■!.  [.liilij,  Sulhrln-  Hospitnl,  I'iiUdildphui,  I'n. 

Ca.sk  2E)4.— Private  James  H.  Hendricks.  Co.  F,  tfttli  Pa.:  admitted  Aiiir-  K'-  1«H2:  tyjihoid  fever.  Died  14th. 
I'oxl-mtiricm  exaniinat  ion  :  'I'lie  organs  of  the  chest  and  abdonieu  a]ipeared  to  bi>  healthy  exce|it  thi^  ileiiin  and  colon, 
in  both  of  which  t  he  iniicoiis  iiieniluane  was  inflamed.  The  agniinated  and  solitary  glands  contained  points  of  black 
Iiignient,  but  otherwise  seemed  n.itural.  —  Act.  Av'<'t  Surg.  .1 .  LrUli/,  Siitlirlcc  Iliixpitiil .  J'hiJiidcljihid,  I'd. 

Cash  2itr,.— Private  .Toseph  Iv'obbins.  Co.  Tl,  tilth  Pa.:  admitted  Aug.  10. 1X(;2:  typhoid  fe\er.  Died  llth.  /Vi.-V- 
morliin  examination  next  day:  The  body  was  much  emaciated:  the  skin  of  the  trunk  in  some  jdaces  a|ipeared  as  if 
ecehyniosed.  The  heart,  lungs,  liver,  stomach,  spleen,  pancreas  and  kidneys  were  healthy.  The  niucons  membrane 
of  the  ileum  was  inllamed  tlirougliont,  but  near  the  lower  end,  for  about  ten  inches,  the  inflammation  was  most 
aggravated  and  had  attached  small  but  numerous  shreils  of  opanue-white  pseiidoinembianous  matter,  which  under 
the  microscope  was  found  to  consist  of  a  flbro-granular  matrix  and  granular  C(n'puscles  resembling  ordinary  pus 
corpuscles;  the  solitary  glands  were  invisible  or  absent,  excejit  a  few  scatteriHl  here  and  there  in  the  Jejunum; 
the  agniinated  glands  were  oonspicuous.  dotted  with  black  pigment,  but  not  perceptibly  diseased.  Tll(^  colon  was 
exceedingly  contracted;  within  the  cacuni  and  ascending  colon  the  mucous  membrane  was  red  and  the  solitary 
glands  large  and  coiiNpicnous  by  the  ]iresence  of  black  iiignient;  the  lower  two-thirds  of  the  colon  ineseiited  a, 
mingled  ri'd  and  slate-color,  with  many  small  ulcers  apparently  resulting  fiinu  The  destruction  of  tli<^  siditary 
glands. — All.  .inx'l  Siiyi/.  J.  Liiily,  S<iHirJvr  Iloxpitdl,  I'hihidijjiliiiij  I'a. 

Cask  29(1.— Private  Tliomas  IClder.  Co.  1).  llth  U.  S.  Inf.:  age  lH;  was  admit  ted  -Vug.  10.  lMi2.  with  typhoid  fever, 
and  died  on  the  ISth.  ruxl-iiiiiiii  in  examination  next  day:  I5ody  not  much  wasted.  Heart  and  inner  surface  of  peri- 
cardial sac  roughened  with  old  ])seiido-menibranes :  right  lung  engorged.  Liver  large;  gall-blad<ler  nearly  empty; 
mucous  membrane  <d'  stomach  inesenting  u  large  reddened  jiatcli  on  the  lower  part  of  its  cardiac  extremity;  spleen 
showing  an  inllamed  condensation  of  its  tissue  about  the  size  of  a  nutmeg  at  its  upper  end,  with  the  omentum  in 
contact  also  inllamed.  The  miicous  membrane  of  the  ileum  was  iiitlamed  in  regions,  one  of  wliiidi  was  two  feet  long 
and  stopped  about  six  inches  from  the  ileo-colic  valve.  There  were  thirty-two  agniinated  glands  ranging  from  half 
an  inch  to  three  inches  in  leiiijth;  a  large  patch  on  each  fold  of  the  ileo-colic  valve  was  dotted  with  black  jiigment, 
but  appeared  otherwise  healthy:  the  next  gland  above  also  apjieared  healthy;  the  others,  except  the  tirst  two, 
were  much  thickened,  opaque  and  white,  or  thickened  and  reddened  by  inllammation,  but  none  were  uh'erated:  tlii^ 
solitary  glamis  generally  were  invisible  in  the  jejunum  and  were  few  in  the  ileum,  but  where  obvious  in  the  latter, 
they  were  quite  ]>rominent  and  red.  The  colon  was  niucli  contracted;  its  mucinis  membrane  was  of  a  slate-color 
mingled  with  small  patches  of  inflammation,  and  the  solitary  glands  were  black.  ISjxrimciin  22S  to  2:)1,  Med.  Sect.. 
Army  Medical  Mnsenni.  are  from  this  case.] — Ad.  As«'t  Snrij.  Jumph  Li'uJij,  Siitttrhr  fFospital,  l'hilii(U'Jpk'ui ,  I'a. 

Cask  2;i7.— Private  Daniel  Katou,  Co.  H,  3d  X.  J.  Cav.:  age  20:  was  admitted  April  29,  18(1.5:  Pulse  l.">0;  tongue 
dry,  brown  and  glazed;  teeth  and  lips  covered  with  sordes;  pupils  cousider:ibly  dilated;  mouth,  nose,  cheeks  and 
hands  stained  with  blood;  re.spiration  fieiiuent  and  deglutition  difHenlt.  Ho  moaned  constantly  and  lay  in  a,  state  of 
low  muttering  delirium,  from  which  1;;^  e(,ul(l  be  partly  aroused,  but  was  tiuable  to  articulate;  there  were  fre<iuent 
slight  convulsive  iiio\emeiils  of  the  body  somewhat  like  those  iiroduccd  by  moderate  shocks  of  an  electric  battery; 
his  urine  was  jiassed  in\ uliiiitarily  and  tliere  was  a  very  otlensive  ammoniacal  odor  about  his  person.  He  died  May  1. 
['ii.it-morlim  examination  IIm^  hours  after  de.itli:  Pody  but  little  emaciated.  The  vessels  of  the.  ])ia  mater  were 
engorged.  The  ii]ijier  lobe  of  the  left  lung  was  liepatized.  and  hepatized  jiatches  werc^  found  here  and  there  through 
both  lungs;  the  rest  of  the  lung-tissue  was  congested.  The  pericardium  contained  about  an  ounce  and  a  half  of 
.serum.  The  spleen  was  enlarged.  Fever's  glands  were  milarged  but  not  nlcciated:  slate-colored  patches,  having  a 
peculiar  punctated  appearance,  were  scattered  here  and  there  in  the  lower  portion  of  the  ileum  and  in  the  colon  ill 
the  vicinity  of  the  ileo-ca^eal  valve,— .tt7.  J.tis'f.  Surg.  G,  MU-i  J'orter,  Cumhirlund,  HospUaU  Md. 


A"..  rK'^U-ke'^ff  P'l'nim;  (.%:  , 


1IKI2  /irr'i  St.,  Fhiladelphin. 


CICATRICES  OF   ULCERATED   PEYERS    PATCHES. 

No.  490.     MEDICAL  SECTION. 


THE    CONT  INT  K] '     !■  EV  V:R>.  \()l 

(/■)  Pfi/i  I'd  ]iiiti'hi  fi  iiri(lii:eil. 

C'a.sk  LW. — Kccniil  .Jdsepli  Hiirrhos,  7th  >'.  Y.  I'av.;  at;e  Hi;  was  admitted  .Ian.  31,  1865,  with  plitliisis  coiitiecu- 
tive  to  camp  IVvcr.  llr  liad  lieeii  wiik  tivc  inoiilh.-..  llr  coiiiiiiaiiifd  lit'  palpitatidii  of  tin-  heart  and  jiaiii  in  tlie  loft 
breaKt  ju.st  below  tile  nipple,  with  eoiij^li  and  slifilit  expeeloral  ion.  .Sinapi.sms  were  ap|>lied  to  the  chest  and  hiown 
mixture  jireKciilied.  with  Dover's  powder  al  ni^lit.  Stnoiil.Liils  seemed  to  ajif^ravate  the  ehe.st  symptoms.  He  died 
February  X.  I'oni-iiinili  in  examination:  The  brain  was  ipiiie  lirni.  Thi-  rijilil  Innj;  was  snuill  and  had  a  few  tubercles 
at  the  ape.x;  in  tlio  left  there  were  numerous  vomien'.  The  abdominal  cavity  contained  a  quantity  of  serum  ren- 
dered turbid  with  curdy  (lakes  of  lymph;  the  viscera  were  coali'd  with  soft  white  lymph.  The  mucous  membrane 
of  the  ileum  was  of  a  grayish-slate  <Hilor,  its  villi  were  hy |iertrophied  and  at  the  apex  i>f  ea<'h  was  a  deposit  of  black 
pigment;  Peyer's  patches,  which  had  been  ulcerated  away,  were  in  eveiy  stage  of  cicatrization,  the  ulcers  being 
smooth  and  the  gut  around  them  ]>uckered.     |  See  sjitciiiiciis  ISil-lIU,  Med.  Sect.,  Army  Medical  Mn.seum.  and  the  )date 

facing  this  jiage.]     The  colon  was  cream-colored,  its  s(ditary  fidlieles  black  and  with  minute  central  (U'pressions. 

Jet.  Ass't  .Siu-y.  (r.  V.  Miitiif,  Tliiid  Division  Hiiiijiiliil,  Aluandriii,  I'd. 

•  K'rrluolviiiL^-  I'lir  tin'  present  tlie  eiij,;lit\'-eiL:;lit,  eases  iii  which  the  jiatches  (if  Teyi.'!'  were 
Kiiid  te  have  been  uh'erated  as  imlieal iii^-  the  pivseiiee  (if  the  fy|ihoiil  puison,  and  the  t'orty- 
oiic  cases  of  uhjemtimi  (if  the  ihann  of  small  intestine  as  failing  to  exclude  the  [lossihility  of 
tvphoid  from  a  want  of  precision  in  the  language  tise(|,  attention  is  im'itcd  to  a  hi'K'l  consid- 
eration of  the  intestiiud  lesions  in  the  remaining  iili  \'-thi'ee  cases:  ]n  (.'le\'en  ol  these,  2i6— 
256,  the  condition  of  Peyer's  patches  was  not  state(l,  and  the  intestine  is  said  to  have  been 
congested  or  infiamed  Imt  not  ulcerated,  and  in  forty-two,  eases  257-298,  various  conditions 
of  tlie  patches,  not,  however,  including  ulceration,  were  r(>p(M'te(b  and  the  intestines  also  were 
found  to  ]>o  geiieraJl}'  fre(/  from  ulc(.'ration. 

Case  253,  one  of  the  eleV(Mi,  may  be  set  aside  as  im[ilying  in  the  disorganizati(Ju  ot  the 
intestine  a  }>ossibilit\'  of  typhoid  sloughing  of  the  closed  glands.  The  history  in  sin'cii  ot 
the  cases,  249-252  and  254-256,  shows  that  the  patients  lived  long  enough  i'or  notable 
changes  to  have  taken  iilace  in  the  a^minaled  "laii'ls  had  typhoid  lever  been  really  iireseiit; 
but  the  records  refer  only  to  a.  congestion  of  the  intestines;  in  2o2  the  solitary  glands  wdc 
euhirged  and  in  251  their  apices  were  ulcerated,  Imt  tla.'  agminated  glands  were  unalleeted; 
in  2  f9  tlK-^re  was  no  t\-phoid  lesidii,  but  whelher  the  changes  in  the  spleen,  which  cause(l 
the  fatal  jieritonitis,  wei'c  malarial  or  not  is  uncertain.  Jii  one  other  case,  24S,  time  was 
alTorded  iiefore  death  for  the  development  of  tyjihoi(l  ulceration  of  the  glands  had  the  typhoid 
poison  been  the  primar\'  cause  of  the  fatal  sudcness,  for  the  patient  lived  long  eiKHigh  t(j 
present  extensive  ulcerations  of  the  larynx  and  trachea.  In  two  cases  the  duration  of  the 
sickness  is  unknown;  but  in  one  of  these,  246,  tlie  condition  of  the  ileum  is  exjire.ssed  in 
language  that  admits  of  no  doubt  of  the  absence  of  tvphoid,  and  as  in  the  other  case,  247, 
tlio  pnst-inurte/n  ajipearances  indicated  typhus  or  a  malarial  fever,  the  inference  is  that  the 
disease  was  malarial. 

Of  the  iorty-two  cases  presenting  various  conditions  of  the  agminated  glands,  not,  how- 
ever, including  ulceration,  the  glands  were  normal,  heaUhij  or  nut  dtseasfd  \n  jirf  cases,  257- 
261.  In  the  first  of  these  the  patient  was  only  live  days  in  lio.^pital  when  death  occurred 
with  syniptoms  of  cerebral  implication  which,  if  not  due  to  a  malarial  cause,  was  certainly 
not  owing  to  t\'phoi(l  lever.  A  tumefaclK^ii  ot  the  glands  ot  Peyer  has,  since  the  time  ot 
LuUis,  been  in-gaixh'd  as  the  initial  and  essential  lesion  of  this  fever;  but  in  the  case  in 
question  these  glands  were  heaUhv  whihj  the  biam  preseiite'l  signs  of  inflamnialieii.  In  the 
four  other  cases  there  was  ample  time  all'onJed  befor(.'  death  for  well-developed  ulcer.it  ion  ul 
the  patches,  but  a  congestKni  of  the  lining  membrane  was  the  only  morbid  intestinal  ap[iear- 
ance.  and  m  259  this  was  maiiih'  foun(]  in  the  U[ijier  jiortion  of  the  small  intestine. 

\n  tiro  of  the  iortv-two  cases  the  patches  were  reported  as  vof  vlrerafrrl.  and  in  both 
the  patients  were  in  hospital  long  enough  to  permit  of  the  occurrence  of  well-marked  changes 
Mei>.  Hist.,  Pt.  111—51 


402  POtT-MORTEM    RECORD.-    OF 

if  tvplioiil  fever  had  been  tlie  cause  ui  their  sieknerif^.  In  one  of  ihe.'^e,  ease  263,  it  is  recorded 
that,  in  view  of  the  diagnosis,  special  attention  had  been  jniid  to  ilie  post-moj-fo/i  coiKhtion 
of  tlio  s!nall  intestine. 

In  accordance  with  patliolou'ical  doctrines  which  are  generally  acce|«ted,  the  jn-duiinent 
condition  of  the  patches  in  the  fc/t.  cases.  264-273,  must  be  regarded  as  indicating  the  jires- 
ence  of  enteric  fever  at  the  time  of  death.  But  since  the  fatal  illness  in  most  of  these  cases 
histed  loner  enough  for  sloU!j;hin>i-  of  the  patches  to  have  taken  place  liad  it  been  Ivnhoid 
fever  from  its  inception,  some  morbid  cause  must  have  been  in  npei'atioii  bei'(.)i-(^  the  influence 
of  the  typhoid  poison  was  mamfested:  and  there  is  nothing  m  thr  paKf-imirtetii  lesions  to 
c<inti'aindicate,  but  on  the  contrary  much  to  sustain  the  upinitm,  derived  fi-om  clinical  obser- 
vation in  other  and  concurrent  cases,  that  this  antecedent  disease  was  an  active  malarial 
afi'i'ctiun.  These  cases  may  therefore  be  viewed  as  truly  typho-malarial,  the  typhoid  aflec- 
tii.m  supervening  on  the  malarial  attack. 

(_)f  tlie  thirteen  cases,  274-2S(3,  in  which  the  vascular  supjily  of  tlie  [latches  had  umler- 
gone  notable  changi'S,  these  were  associated  with  tumefaction  in  seven  cases,  275,  279,  2Sl- 
284  and  286,  in  most  of  which  the  short  period  elapsing  before  the  fatal  issue  suggests  death 
from  tyjthoid  fever  in  advance  <if  the  jicriod  when  slougliiiig  usually  takes  [)lace.  It  may 
be  remarked,  however,  tliat  if  tumefaction  and  cmigestidU  of  the  }iatehes  are  eV(.'r  developed, 
ill  the  afisence  of  ente'iic  lever,  as  a  con.sequence  of  morbid  vascular  action  allei'tmg  the 
mlestmal  canal  as  a  whok'/"  the  claims  of  some  ot  tliese  cases,  to  wit:  27-.)  and  27'.*,  as 
.ilhistrative  of  this  condition  might  lie  entitled  to  consideration.  Two  of  the  thirleeii  cases, 
280  and  285,  may  be  regarded  as  truly  typho-malarial,  since  they  pi-esi'uted  the  glninls 
swollen  but  entire  at  a  period  when  in  pure  typlioid  the  eliniinjitive  process  wouM  have 
been  ill  (Operation.  In  277  there  was  no  tumefaction  ol  the  agmiiialed  glands,  ;dilpMigli  the 
])atienL  was  eight  days  in  hospital  and  sick  l(.ir  pruhably  a  longer  time.  In  271  and  27''>, 
ill  which  the  I'ever  lasted  long  enough  tor  the  establishment  of  the  ulcerati\'e  pi'oi'ess  if  a 
tvphoid  element  had  lieen  present,  the  plaijiies  were  altered  only  in  so  far  as  tliev  partici- 
])ated  in  a  general  and  long  continued  eoiigi-stiou  ot  the  intestinal  nieinlirain,'.  LasiK-,  in 
27s,  which  ended  fatally  at  a  late  j»eriod,  the  patches  were  not  ulcerated  but  onlv  congt'sted 
and  somewhat  prominent  in  an  intestine  which  was  darkly  injected  throughout. 

Ill  iii)i:hc  of  the  forty-tW(.)  cases,  287-21)8,  the  intestinal  lining  was  pigmented,  but  the 
agminated  glands  were  not  ulcei'ated.  In  the  llrst  of  these  there  was  neither  ulceration 
nor  sloughing,  although  the  patient  was  sick  for  a  long  time;  the  ileum  was  congesteil  in 
regions,  its  jiatches  prominent  and  speckled  with  blood  and  its  solitary  follicles  conspic- 
uous. In  the  eight  cases,  288-295,  the  solitary  and  agminated  glands  were  dotted  with 
black  pigment,  and  in  most  of  these  there  was  ample  time  before  death  for  ulcei'atioii  ^A 
the  patches  to  have  taken  place,  for  even  in  295,  which  had  been  only  live  days  in  hospital, 
the  patient  had  lived  long  eiiuugh  fur  the  development  of  ulceration  in  the  solitary  follicles; 
nevertheless  the  agminated  glands  were  intact  but  for  the  })igmentary  deposit.  But  in  the 
remaining  three  cases,  296-29.S.  an  enteric  element  was  su[»eradded  to  the  pigmented  con- 
diti(;n;  in  290  certain  of  IVyer's  glands  were  thickened,  opaque  and  whitt!  or  redd(;ned  hv 
couijestion ;  in  297  tliev  were  eiilaived,  and  in  298  the  ulcerated  ijlands  had  become  cicatrized. 

In  summing  up  the  analvtical  results  briefly  enumerated  in  the  above  paragraphs  it  is 
luund  that,  of  fifty-three  cases  characterized  by  so  many  of  the  so-called  typhoid  symptoms 

*  See  infrii^  liage  45G. 


THK    inNTINTKI'    FKVKliS.  403 

that  till'  artf'iiiliii'j.-  nu'ilu-al  dtH'-'-rs  tMiHit-.]  a  (lias:iii"'.-is  nf  tvpliuiil  fever,  no  less  than  thirty 
faileil  to  |ir<-.'nl  at  th^^  y<".v/-/))'//7, ;/,  examination  tli'i.-i' analr'niical  ehances  wlih-h  t'l^.m  the 
time  (i|  Lulls  ha\i'  Inmii  ^.■n.  rallv  reijanl.Ml  as  |iatlM.i:ii.imi.nir  n\'  the  iliscasc;  lail.  siiMweil, 
on  tin'  oontraiA',  a  s'l'i'S  i>\  lr>i(iii<  iii  pert.ci  haiiii"ii\'  wiili  i>ur  kiinwh'ilij:!'  ol  the  irr([uenl  Iv 
oeeuiTiiiii  liiit.  iml.  i  -.-.lit  lal  iiiridi'iii-.'  nl'  tin'  malarial  |"iis(i]\  di  the  inti'stmal  eaiial.  It  i> 
suhirnttiMl  that  these  cases  t'lilK'  sustain  tln'  statiMiicnt  that  aiuniitj;  th<isi>  ri']M)rtril  as  tvplaiiil 
t'<'\'i'r  w.a-e  niaiiN'  whii-li  WiVf  |iui-«'l\'  ainl  ~im|il\'  malarial  Irvrrs;  ami  simc  similar  ca^'s 
ha\c  ho'ii  iiri'sriiti'il  iViHii  th''  t\'|ihi>-malanal  rrci.nls,  ainl  iscn  I'l'nm  tlmsi'  ni  th''  parowsmal 
f('\ers,  till'  i-om-hi.-i.iii  that  t\(ili(iiii  s\i'i[itMiiis  were  i)nt  neccssanh' assoeiateil  with  a  sjK.'eilic; 
oritenc  |ii>is(iii  must  ln'  ailmittr.l. 

Till'  nnsl  iii'irfriit  riM-niiU  ciiiilaiii  al>ii  a  .-'-rns  ul  srxcntv-nine  rases  variousK-  repcirtrd 
at  fir>t,  liiit  from  thrir  laltT  s\-m['tnms  nr  iiriTii,^eii|iic  apjiraranei'S  attiTwards  rr^anloil  as 
t\'|ihc>iil  t'i_'\'fr.  'Hii'M'  arc  ol  mtirc-l  as  shuwiii'j;  the  I'datKiiis  ul  l\|ili<iul  to  \arinus  niher 
(liseasrs  Thivi'  cases,  ;'i(l| ,  ;'>  17  ami  :>•)<>.  ailmil  tcilliv  t  he  at  I  end  in  i!'  medical  oiHcers  as  mala- 
rial  levers,  sheiild  lia\'(^  been  [iresented  m  a  |ire\i"iis  pail  of  tins  s^ectiiui ;  Imt  tlaar  ahsence 
from  the  series  dl'  cases  re|i(irleil  as  t\'|ihii-malarial  dues  nut,  alter  the  cniichisKiiis  that  lia\'e 
been  diaived  frnin  an  iinestii^'atinn  nf  that  series,  while  m  their  present  cnnnectKni  they 
serve  a>!  dclenaies  iVnm  the  t vphd-malarial  cases,  each  ilhisti'ative  <>r  tvpical  u\  its  kind; 
301  a.s  iiistamaiej;  true  t\'plii>  malarial  l'e\  ,']•  - -t  vphoid  niodiiicd  li\-  malarial  cuinpiicat  hMi- ; 
347  as  represent  iiiLi;  malarial  le\"er  with  t  xplmi.!  sx'inptems,  the  recunl  cf  which  fails  \<>  Aw^w 
wlielher  the  intestinal  ulceration  was  due  to  the  malarial  or  tlu'  t\phnid  element, — .-iich  ca.-cs 
have  in  tlii.^  I'eport  heen  sc-t.  aside  as  prohahK'  Ix'phoid;  and  'M\^\  as  illuslrat  iii'j;  paro.wsmal 
fe\cr  wiih  tsplii'id  s\-in]itiims,  hut  with  no  /I'lst^ninrliin  lesion  lo  indicate  the  presence  ol'  a 

Speialic   ellleriC    poison, 

d'liese  se\-eiit \-- nine  cases  have  lieeii  arraii^i'd  in  acccirdance  with  the  aiiatoimcal  chaiiL;cs 
111  1  he  iiiiestinal  canal, 

(.\.)    l'KYKl:'S    l',\lClli;S    fI.CKH.\TKIi — !'_'  C,-\SKS, 
(  IC  )      All   (/iiK/Hl/MS. 

Cam-:  J'.III,— I'l  i\  ale  (ifurf;e  II.  IJiiiuT,  Co,  I.  LMlli  N.  Y.  Cav.;  :v^n  Ui,  «a«  uclHlittml  .Iiiik^  "JI,  1S(H.  wuli  a  >ini\- 
sliol  lli->h  uiiiiiiil  III'  llii'  U'ft  If^.  (In  Jiil.v  1  si,i;ii.s  (it  iaiii;!rslioii  nt  the  luaiii  iiiado  tlii'ir  a|ip«'ar'ari<c:  Ilii-  ]iii|}il.s 
will-  laii;ily  (lil.iii'il,  tlu!  ligiit  bfiiij;  larger  than  tlm  left;  tlie  Iji  ail  u.is  liot  and  «itli  tlio  cIk'si.  h.cm  cmeri'il 
Willi  a  eoiiious  iiersi>ii'ati<)n ;  the  fa'ce.s  anil  mine  were  pas-seil  iuvolimtarily;  aitieiilatinn  wa.s  iniliHtiuel.  He  ilieil 
on  the  oil.  J'usl-iniii-hiii  exaniinatiiin  twelve  hours  al'ter  deatli:  'i'ho  hiuly  was  siiinewliat  einaeiateil.  The  I. lain 
weiglieil  sixty  ounces;  its  hliioilvessels  weie  ninih  injected,  and  tlie  lii|iiid  in  the  veiiliieles  and  siiliaraelinnid  spaces 
was  ineieased  in  <iuaiitity.  The  Inngs  were  sli,ghtl.v  adherent  at  their  apices  liy  recent  lyiiipli;  tlie  riglit  weii^hed 
eleven  oinnes  and  a  half,  the  left  thirteen  ounces;  the  lobes  of  the  left,  lung  were  inteniilheient  and  the  jiusi.  rim 
part  of  the  lower  lobe  was  hepatized.  The  heart  weighed  seven  ininees  and  a  half,  the  liver  fifty-nine  ounies,  and 
the  sjileeii  nine  ounces  and  a  half.  The  stomach  was  normal.  Many  of  Peyer's  patches  were  extensively  ulcerated, 
the  others  thickened:  the  solitary  glands  were  mudi  enlarged  :  the  large  intestine  was  congested  and  in  its  lower 
portion  ulcerated, — Act.  Asu't  Sun/.  II.  M.  I><<in,  Lincoln  Ihixpitid,  Wa-fliiiintim,  I).  C 

C.\SK  300.— Private  John  Rice,  Co.  F,  10th  Vt.;  age  23;  \v,is  admitted  from  lield  hosjiital  at  .Sandy  Hook.  ,\ug, 
27,  1861,  in  11  low'eondition,  lying  dull  and  inattentive,  complaining  of  eM|iiisile  |iain  in  the  abdomen  and  having 
frequent  mucous  discharges  from  the  bowels.  Ilotfnianii's  anodyne  m  as  prescribed  and  a  large  ]ioultiee  ajiplied  ii\  er 
the  abdomen.  On  tlieSOtli  there  was  much  headache,  wliiili  ennliiiued  on  the  31st  ;  on  tliis  day  the  disehaiges  were 
controlled  by  cneniutii  containing  lead  andopiiini.  Seiil  ember  I  I  lie  sym  plums  were  more  fa  vol  able,  lln-.sUin  |,.>.s  harsh 
and  sonietimes  pcis])iriii.g,  the  pulse  less  rapid  anil  not  so  weak,  I  nit  there  were  occasional  recurrences  of  febrile  action, 
I!eef-tea.  wine  and  citrate  ot  iron  and  iiuinine  were  given,  with  opiate  enema t a  and  woolen  packing  to  the  abdonieu 
instead  of  the  iiuultice;  turpentine  was  also  adminisiered.  The  iiatieiu's  apjielite  was  good,  but  he  remained  \er,v 
weak  and  his  tongue  continued  red  and  dry.  Towards  the  end  of  .September  the  telii  ilo  syniptonis  returtied,  assum 
inn-  the  tertian  ty]ic.  and  the  iliarrlnea  continued.  I  In  i  Iclnber  3  the  jiatient  beeaiiie  dull  and  was  amused  with  diffi- 
culty; the  dejections  were  jiassed  involuntarily  and  w  ere  mixed  with  blood  and  pus;  bed-sores  appeared  on  the  lii))s. 
Wine  and  stimulants  were  freely  given,  but  the  ]ialieia  grew  worse  lapidly .  and  died  on  tin-  1  llli,  /'"</  iimr/rm  inves- 
tio-ation  showed  the  coats  of  the  large  intestine  extensively  thickened,  its  calibre  diniinished  and  its  miicoiis  tissue 


404  POST-MORTEM    RECORDS    OF 

(lestroyeil  in  patches  by  ulooratioii ;  these  ])atches  were  nicist  minierfius  in  the  sigmoid  flexure,  where  perforation  had 
taken  plae<!,  the  oritioe  being  two-thirds  of  an  inch  in  diameter.  T!ie  nmcous  coat  of  the  ileum  was  eroded  and  the 
agniinated  and  solitary  glands  ulcerated;  the  Jejunum  was  inflamed  in  patches.  [See  nijicimciis  459  and  460,  Med. 
Sect.,  Army  Medical  Museum,  and  plate  facing  this  page. J — Jsn't  Siir/i.  C.  Bacon,  jr..  U.  S.  A.,  AunapoHn  Uospilal,  Md. 

(b.)   Diagnosis:  Remiltent  fcrer. 

Case  301.— Private  Jesse  Steiner,  Co.  D,  167th  Pa.;  age  30;  was  admitted  July  12, 1863,  with  debility  and  remit- 
tent fever,  and  died  on  the  2l8t.  Post-mortem  examination  twelve  hours  after  death:  Body  well  developed;  rigor 
mortis  well  marked.  The  brain-substance  was  firm  and  slightly  congested ;  half  a  drachm  of  l)lood}-  fluid  was  found 
in  the  lateral  ventricles.  The  trachea  was  discolored  and  filled  with  viscid,  dark-brown  sputa;  its  mucous  mem- 
brane was  rather  soft  and  the  lymphatic  glands  at  its  bifurcation  were  enlarged,  hlackeiied  and  softened,  except  in 
the  centre,  where  there  was  a  calcareous  degeneration.  The  oesophagus  was  pale  and  rather  contracted;  numerous 
dark-colored  spots  were  found  at  the  lower  portion,  one  of  which  was  the  seat  of  superficial  ulceration.  The  right 
lung  weighed  twenty  ounces;  its  upper  lobe  was  covered  with  fibrinous  adhesions;  this  lobe  and  the  lower  lobe  were 
slightly  congested,  but  the  middle  lobe  was  healthy;  the  bronchial  tubes  were  filled  with  a  secretion  similar  to  that 
found  in  the  trachea.  The  left  lung  weighed  twenty-three  ounces  and  was  somewhat  congested  at  its  apex  and  of  a 
dark-purple  color  from  venous  engorgement  in  its  lower  lobe.  The  heart  contained  a  very  small  clot  in  the  right 
ventricle.  The  liver  was  of  a  delicate  purplish  hue  externally,  its  acini  pale,  capsule  readily  torn  and  parenchj'nia 
firm;  the  spleen  was  mulberry -purple  and  moderately  firm.  T'he  snuill  intestine  was  perfectly  healthy  to  within  a 
few  inches  of  the  ileo-ca'cal  valve,  where  several  Peyer's  patches  were  ulcerated.  Numerous  ecchymosed  spots  were 
found  in  the  upper  portion  of  the  large  intestine;  the  lower  third  contained  an  inuucnse  quantity  of  unripe  black- 
berry seeds,  and  its  mucous  membrane,  jiurple  in  color  and  rather  firm,  was  lined  with  an  extensive  black  clot. — Jsa't 
Sitrij.  JI.  Allen,  U.  S.  A.,  Lincoln  Hospital,  Washington,  D.  C. 

(c.)  Diagnosis:   Gastritis. 

Cask  302. — Private  Lorenzo  Weakley,  Co.  C,  7th  Va.;  age  19;  was  admitted  Aug.  21,  1864,  his  previous  history 
being  unknown.  lie  was  emaciated  and  exhausted  from  epigastric  pain  and  incessant  vomiting,  his  food  and  drink 
being  almost  instantly  rejected;  he  had  a  slight  diarrhoea;  his  pulse  was  feeble  and  his  tongue  covered  with  a  gray 
moist  coating.  The  vomiting  and  diarrlnea  continued  until  the  23d,  when  there  was  some  abatement;  but  the  sur- 
face of  the  lK)dy  became  cold  and  clammy,  and  he  died  on  the  25111.  He  was  treated  with  1)randy,  morphine,  mild 
astringents  and  sinapisms.  Poal-mitrUm  examination  six  hours  after  death:  Abdomen  tympanitic.  The  lungs  were 
empliysenuitous  and  in  their  posterior  parts  congested;  the  right  side  of  the  heart  contained  a  large  fibrinous  clot, 
the  left  was  empty;  the  ])cricardiuni  contained  about  six  ounces  of  licjuid.  The  liver  was  slightly  enlarj^cd  and  pale; 
the  gall-bladder  nearly  filled  with  dark  viscid  bile;  the  spleen  normal  in  size  but  dark-colored.  T'he  pericardium 
and  omentum  were  congeste<l;  the  mesenteric  glands  enlarged.  T'he  mucous  membrane  of  the  stomach  was  thick- 
ened and  of  a  deep  red  color  at  its  cardiac  end.  The  snuill  intestine  was  healt  liy  to  the  middle  of  the  ileum,  below 
which  i)oiiit  it  was  congested  and  ulcerated,  the  ulcers  being  larger  and  more  numerous  at  the  lower  end;  the  aiier- 
tures  of  the  solitary  follicles  and  lubuli  were  colored  with  black  pigment,  giving  the  mucous  membrane  the  appear- 
ance of  being  covered  with  small  blacdc  spots;  the  lower  portion  of  the  descending  colon  was  consideriildy  tbickened 
and  softened.  The  kidneys  had  a  largir  de])osit  of  fat  about  the  pelves  and  their  medullary  substance  was  ahnor- 
nuiUy  jiale.  [Speciiiuns  107  :ind  lOS,  Med.  Sect.,  Army  Medical  Museum,  are  from  this  case.] — Act.  Ass't  S'ury.  ().  I'. 
Sweet,  Carver  Hospital,  IVasliitKjton,  1).  C. 

(d.)  Diagnosis:  Cerebrospinal  meningitis. 

(Ja.se  303.  ■ — Privale  Davis  N.  Hosmer,  Co.  F,  45th  Mass.;  age  IS;  was  admitted  .Ian.  30,  1863.  Two  days  before 
admission  he  had  a  slight  chill,  which  was  succeeded  hy  violent  headachi-,  slight  epistaxi.s  and  Jiain  in  the  back  and 
limbs.  On  admission  he  had  severe  occipital  headache,  lever  and  delirium;  his  head  was  thown  back.  Diarrho'a  set 
in,  but  was  controlled  by  acetate  of  lead  and  opium;  cough  also  was  tiduldesome,  and  sibilant  raleti  were  heanl  over 
both  sides  of  the  chest.  On  February  4  the  pulse  declined  to  100,  the  skin  hi-came  cool  and  moist  and  the  ability  to 
answer  ijuestions  retnrned.  Next  day  there  was  gurgling  in  the  right  iliac  region,  (^n  the  titli  the  i)atient  became 
rather  stupid  and  affected  with  low  delirium,  but  there  was  no  diarrlnea.  Several  spots  api)eared  on  the  abdomen  on 
the  7th.  lie  became  conuitose  on  thi^  8th  and  died  on  the  lOtli.  Post-mortem  examination  fourteen  hours  after  death; 
The  cerebral  membranes  wi^re  slightly  injected;  the  lateral  ventricles  were  distended  with  turhid  serum;  a  firm 
dejiosit  of  lymph  from  a  (|uartcr  to  three-eighths  of  an  inch  in  thickness  covered  the  inferior  asjiect  of  the  ecrcliel- 
lum  and  medulla  oblongata.  The  lungs  were  congested  jiosteriorly.  The  heart,  liver,  stomach,  spleen,  ]>iui(-reas, 
ki<lneys  and  bladder  were  normal.  The  Solitary  glands  of  the  intestines  were  enlarged  and  Peyer's  jiatehcs  thickeued 
and  in  one  or  two  places  ulcerated. — Ass't  Surg.  J.  Ji.  Treadwell,  i5th  Mass.,  Stanleg  Hospital,  New  Berne,  N.  C. 

(e.)  Diagnosis :  I>iarrhtca.\ 

Cask  .301. — Private  Milo  liolmes,  Co.  (J,  37th  Mass.;  age  38;  was  admitteil  .luly  28,  1863,  having  been  sutVering 
more  or  less  from  diarrlxea  for  the  previous  twelve  mouths.     He  was  much  emaciated   hut  was  able   to  sit    up  and 


*  Tliis  ra^c  w;is  (iiiMi^linl  liy  .1.  Ft.  I'l'MAM,  Bo.^nn  MM.  aiiTi  Siirff.  Jnurn'it,  Vol,  LXVin,  18fi:l,  p.  lot,  as  uiic  uf  t;crebru-8iiin.'i]  inoiiiri'iitiH. 

|<'m  AiM.KS  [I.  ]:  wvviiNj  Surf.',  .'jlll  Iowa  Vols.,  .inn:ri'''m  MMii-al  Tinthx,  Vol.  IV,  ISG'2.  p.  129,  ln-iffly  Plluiin^rates  the  eylnptuiiis  of  two  fatal  ca-soa  of 
nanip  typliMitl  i'f\ir.  Tlirs.'  were  at  first  rcf^afded  ji.s  diarrhiji'as  and  tn^atcd  as  sucli  in  cpiurti-rri  without  any  l)Oiieficial  rewnlt.  At  the  cud  of  fivn  days 
they  wre  taken  to  hospital,  w  here  soon  after  fever  of  a  remittent  type  was  developed,  jtresenting  in  its  eourse  a  dry,  red  tongne  ;  siilisultus  ;  delirium 
forty -eifiht  hours  hefore  death  ;  a  pulse  ran^inj^  from  120  to  IGO  and  feehle,  iniiH'reeptihle  at  the  wrist  for  two  days  i)reecdiiig  tlio  fatal  terniination.  The 
ahdeinen  was  tender  in  the  first  ease  hut  not  in  the  other.  Both  jwtienta  sueeunitied  ten  days  after  the  attaek.  The  treatment  eonsisted  of  the  admin- 
istration of  stinuilants  and  niairishnient.     The  mucous  membrane  of  the  alimentary  traet  from  the  cardiae'  extremity  of  the  stomaeh  to  the  anus  was 


lUliptyPe. 


A'.   '^T^('.v/t-^   f  ,)  .   /iostoti. 


CICATRICKS  OF  ULCERATKD   I'EYER'S   PATCHES. 
No.  459.     MF.DICAl.  .SECTION. 


THK    CONTINUKP    KFVF.RS.  405 

^alk  ardiiiicl  n  littli'.  He  lnul  im  ;i]i|M'titi' ;  had  several  tliiii  .stouls  daily;  liis  pulse  was  i|iiiik  ami  weak.  ti>ii>;ne 
furred,  liMii|M-ratiiie  (d'  1iimI\  Ihu  .iiid  Iprealliiii-;  sldw  and  lalmred.  Tin  re  was  no  marked  chaiifie  in  these  svmiiti)nis 
until  An;.;nst  (i,  whi-u  I  he  sIihiIs  iM'eaine  iii\  olinitavy  and  he  a|i|ieared  Id  lie  Hinkin-;.  Coma  siiperveMed  on  I  he  M  h, 
and  he  died  next  day.  I'tisl-iinirl(  in  exainiiial  ion  I  went  \  lidurs  alter  death:  The  hddy  was  very  mneli  emaeiated 
'J'he  lirain  weij^lied  Idrty  (iniiees  and  .1  ipiarler;  I  lie  |iiis|ei  inr  pari  iif  I  he  eerehniiii  was  liy  pdsl:ilieally  ciinjiested  : 
one  drachm  and  a  hall'  id'  (dear  seiinii  was  edntained  in  the  lateral  vent  lie  les:  t  lie  Inaiii-snlislaiiee  was  rather  linn. 
The  traeliea  was  jiale  and  sninewhal  purplish  lietweeu  the  riiin's;  the  lyni]iliati<'  f;lamls  at  ils  hiriirealldn  were  «mall 
and  md  sdt'tened,  lint  of  a  nidderately  Idaekish  eiddr;  the  iesii]diaiieal  liuiiiK  w.is  linn  and  of  a  yellow  ish-nchre  eidor. 
The  iijiper  hdie  (d'  the  rifiht  liiiif;  was  hyiioslatieally  eiiniiested  |iosteri(irly,  hut  ils  anterior  port  ion  was  lieallliy;  the 
middle  lohe  was  of  a  dark-jiurple  eolor  ami  its  eeiitral  )ioitiou  was  s))leniru'd  posteriorly;  the  wei:;hl  of  this  liiiifj  was 
thirleeii  onnees  and  a  hall'.  The  1<  It  lunji  w<dsiln'd  fourleen  ounces  and  a  half;  it  was  of  a  dark-imriile  hue  poste- 
riorly and  its  lower  hdie  was  lonsideraldy  enudrixed  with  \eniius  Idood.  The  heart  was  normal;  its  ea\ilies  coi-- 
taiued  a  soft  jelly-like  (dul  :  a  l.iiLle  lilninoiis  clot  was  lound  in  the  pnlmouaiy  arlerv.  exieiiilin;;  a  loni;  distance 
beyond  its  lii furcation,  and  ly  ini;  on  t  he  ]ioslerior  surface  of  the  vessel  surrounded  hy  a  thin  venous  lliiid.  The  liver 
was  sonu^wh.'it  conu'esled  ;  (ilisson's  capsule  was  readily  torn;  the  ^all-hladder  iMiiitained  six  draidiiiis  of  Idle;  the 
s)deen  was  firm  and  of  a  mulherry  eolor.  The  small  iiitcstini'  presented  nothing  remarkalde  exee|it  in  the  ncif;lilior- 
hood  of  the  ileo-ca>e.al  valve,  where  were  si'veral  ulcers  of  I'eyer's  ])atclics,  evidently  of  Ion;.;  slandiufj;,  circular  in 
form  and  penetratiii};  to  the  lransvers(^  museular  lihres.  'J'he  kidneys  were  soft  and  amemic  hut  somewhat  injected 
on  their  external  surface. — .tss'l  Siiri/.  II.  Allin,  ('.  S.  A.,  Lincoln  Hnxjiiliil,  Wanhinijiioi,  I).  ('. 

Ca.se  ;iOr). — Private  Charles  .lillson,  Co.  (i,  IKith  Ind.,  was  admitted  Aiijj;-  2,  18(1"),  with  chronic  diarrlnea.  lie 
Lad  pain  In  the  hypogastric  re};ion  and  very  fieiiucnt'ntools.  He  died  on  the  (!tli.  I'lml-mmtim  exanunation:  lirain 
iionaal.  Liiiiij^s  (I'dennitous  posteriorly,  wcijjht  of  each  twenty-six  ounces;  heart  normal,  a  Mack  clol  in  the  left  ven- 
tricle, a  mixed  one  in  the  rij;lit.  Liver  somewhat  dark-colored  and  i|uitc  full  of  hlood;  spleen  dark -colored,  \veijj;ht 
six  ouiKu^s;  pancreas  ami  kidneys  normal.  The  fumlns  of  the  stomach  was  cou}j;esled,  anil  there  were  loufijitudinal 
streak.s  of  coni;estion  in  the  (esophagus,  i'lie  ileum  was  congested  and  I'eyer's  pat(  lies  thickened  and  ulcciated. 
especially  near  the  ileo-ca'cal  valve.  The  contents  of  the  large  intestine  \vcr(^  seiui-lluid  and  of  a  dark-green  eoloi 
mixed  with  a.  yellowish  granular  matter. — Axu'l  Siiri/.  GiDnji  M.  Mcdill,  I'.  S.  A.,  ///(7,.s  lli»i])ili(l,  lintlimon-,  Mil. 

Case  liOti. — I'rivate  Kichard  I'arker,  Co.  K,  133d  I'a.,  was  admitted  Dec.  iid,  ISIi'i,  having  heen  sick  three  weeks. 
When  the  fust  notes  were  taken,  .Ian.  1,  18(>3,  tlit^  diagnosis  recoi'dcd  was  typhoid  l'e\er,  hut  this  was  afterwards 
changed  to  chronic  diarrho'a.  The  patient  was  sleepless,  his  mouth  dry  and  his  tongue  smooth,  glazed  and  red;  his 
emaciation  was  progrcssixe  and  ultimately  liecame  extreme.  A  loose  cough  set  in  on  the  llith,  and  a  few  days  later 
he  liecame  jaundiced.  He  died  on  the  17th,  having  vomited  a  good  deal  of  y(dlow  mattei  the  day  lv(d'ol'e  his  death. 
I'nal-iiiiirlvm  examination  twenty-three  hours  after  death:  There  were  strong  pleuritic  adhesions  on  tlu^  anterioi-  snr- 
iace  of  the  upjier  lolie  of  the  right  lung;  the  parenchynni  of  the  lung  was  congested  and  ;i  purulent  secridion  i.ssned 
from  its  bronchi  ujion  pressure.  The  left  Inng  was  less  congested,  but  the  ]miiileut  discharge  from  the  smaller  rami- 
fications of  it.s  tubes  was  of  a  thicker  consistence  than  that  found  on  the  other  side;  cheesy  tubercles  were  thickly 
scattered  throughout  the  parenchyma  of  this  lung  except  in  its  upper  portion.  The  right  cavities  of  the  heart  con- 
tained filirinous  clots.  The  liver  had  a  nutmeg  appearance  and  weighed  forty  ounces ;  the  spleen  was  of  a  dark  color 
and  weighed  three  ounces  and  a  half.  The  mucous  membrane  of  the  lesser  curvature  of  tlie  stomach  was  injected 
in  points;  the  jejunum  exhibited  irregular  jiatclies  of  congestion  in  its  lower  part;  Peyer's  patches  were  almost 
destroyed.     The  kidneys  weighed  live  ounces  and  a  half  each. —  Lincoln  Ifospitiil,  ll'dxhinffton,  I).  C. 

Case  307. — Private  Matthias  Koou,  Co.  E,  8th  N.  V.;  age  50;  was  admitted  Dec.  1,  1804,  in  a  partially  comatose 
condition.  Diagnosis — diarrluea  and  anasarca.  He  died  on  the  ir)th.  Post  mortem  examination  :  Kigor  mortis  maaked  ;'' 
siidamiua  on  left  breast.  Trachea  congested;  bronchi  tilled  with  bloody  Huid;  bings  congested;  the  middle  and 
lower  lobes  of  the  right  lung  sank  in  water;  the  right  lung  and  upper  lobe  of  the  lung  were  adherent  to  the  parietal 
pleura.  Pericardium  thickened  and  containing  six  ounces  of  straw-colored  .serum.  Peritoneum  thickened  and  con- 
taining sixteen  ounces  of  straw-colored  serum.  Liver  mottled  light  brown,  fatty;  two  ounces  and  a  half  inspissated 
bile  in  gall-bladder.  Kriinuer's  glands  ;ind  I'eyer's  patches  ulcerated;  ileum  inllamcd;  mesenteric  glands  tilled  with 
chalky  concretions.     Kidneys  large  and  fatty. — Third  Itirixion  Hospital,  Alcxanitriii,  Tfl. 

Ca.se  308. — Corp'l  Jo.seph  Cole,  Co.  }i,  2d  N.  Y.  Mounted  KiHes,  was  admitted  ,Iuly  24,  1801,  much  emaciated 
from  chronic  diarrluea.  Under  treatment  by  wine,  opium,  catechu  and  milk  diet  he  improved,  and  his  stools  were 
natural,  August  7-9,  but  on  the  lOtli  hi»  throat  became  swollen  and  covered  with  false  membrane.  He  died  on  the 
12th.  Post-mortem  examination  eleven  hours  after  death:  Larynx  thickly  covered  with  false  membrane;  glottis 
cedemat(ra8.  Lungs,  heart,  liver,  spleen  and  kidneys  normal ;  Peyer's  patches  ulcerated,  e8p(;cially  near  the  ileo-ciecal 
valve;  large  intestine  healthy. — Fairfax  Seminary  Hospital,  I'a. 


red  fiiiil  tliirkfiioil ;  Pcyrr'n  glaiiils  wt-rt' tlik'lit'iuMl  l.ut  nut  ulfcniti-tl.  In  u  tliinl  casi-  the  patclii's  wi'i-i>  fxlfiisivcly  nlciTiitctl.  The  nature  ami  cxifiit 
(if  the  inti'stinal  affi'ctitin  ri'Vralrd  l.y  pi>.^t-i,h>rfnit  cxaniiiiatioii  Icii  tc  the  aliaiiiiiniini'iit  nt  the  stimulant  nimk'  uf  trfatincnt  in  tlif  ttiirty  ca-scs  wliicli 
^lt('(•(liiy  I'lillowi'il.  (.'upK  anil  lili.sti're(  to  tliu  alKiunicii,  witli  turjiciitinc  I'liiulsiun  cnntainin^'  uiiiimi,  ami,  in  tin'  prewnct*  nf  diarrlnca,  castur  nil,  were 
wucccssfiilly  i-nipluycil.  But  t'ln-  fatal  case  occurred  afti-r  this,  ami  in  it  tin-  inti'stinal  miicons  mcinlininf  was  nil  as  in  tlic  previous  casi-s.  *'  Kvery  (ine  (if 
Peyer's  patrlies  was  nlcenited  tii  its  I'lillest  size,  eiiiprniuusly  raised  and  spread  nut  lilie  a  liill-ldnw  11  ruse,  if  i  may  use  tlie  e.xpressiuu.  They  wuuld  raliKe 
fruiu  a  five-cent  jiieee  to  the  si/e  uf  a  dullar.  Every  inucuus  fulliide  anil  duct  was  thickened,  raised  and  ulcerated  fnuii  the  si/e  of  a  pin's  head  to  a  jica, 
(In  passin;;  tlirougli  into  the  ca-cum,  at  the  juiictiun  of  the  ileum,  was  an  nicer  as  larj^e  as  a  teacup.  The  whole  nineuns  meiuhrane  to  the  rectiuu  was  in 
a  frijrhtfnl  state  of  disorganization."  [The  three  cases  liriefly  sketched  hy  Pr.  U.\wsus  ap|»'ar  on  his  >lunttily  Report  of  Sick  and  Wounded  for  Decem- 
ber, 1801,  as  cases  of  ga.stro-eiiteritis.  The  thirty  ciuses  said  to  have  terminated  favorahly  cannot  he  iileiititied  on  the  official  reports  unless  they  aro 
included  auiung  neveiiteeii  ca-ses  of  typhoid  fever,  three  of  wliicli  were  fatal,  and  forty-three  casis  of  remittent  fever,  none  of  which  were  fatal,  specilied 
on  his  monthly  reports  for  December,  ISO],  and  January,  ISO'2.] 


40(i  POST- MO  I  ir  KM    RECOKns    OF 

Cask  lioil, — Private  Siiiitli  Uyeily,  Co.  C,  r>7tli  I'a.;  agis  '_"i;  was  ailmitltHl  Fi-1).  4,  1805,  witli  oliroiiio  diarrhcpa, 
anil  ilii-il  "11  Ilie2><tli.  /'().s/-m»)/(  hi  i-.\aiiiiiiat  ion  :  Hijilit  Iniiij;  aillu-iriit  I'oi' tlio  iijiiii'V  t  wo-tliiiil.s  of  its  extent ;  eifflit 
onnris  of  a  Kfi'o-imrnlent  Hi|iilil  in  tin-  |iliiiral  sai-:  |ifricanliiini  inltanii'd  anil  it.s  i:a\  ity  literally  tilled  with  pus. 
Liver,  spleen  and  kidneys  very  iinnli  softi  iied.  Ileiini  jieifo  rated  at  its  jn  tie  t  ion  witli  tlie  lolon,  tlie  aiiertnro  being 
alioiit  tlie  size  of  a  Spanish  half-dollar;  hhkiII  iiiteslino  iiineh  inllaiueil,  with  some  dej;iee  of  iileeration  scattered 
throiifjhoiit  and  well-marked  nleeration  of  the  f;hiiids  of  I'eyer. — Ad.  Asx't  Snrij.  li.  li.  Milts,  .larvin  Ilospilal,  Haiti- 
miiyr,  Mtl. 

Cask  :ilO. — I'rivate  Charles  II.  Dehino,  Co.  I,  7th  Me.,  was  admitted  Auf;.  10,  IXty,  with  dial  iliiea,  and  died 
on  the  liOtli.  Post-nwrtrm  examination  next  day:  Body  exceedingly  emaciated;  apparently  ahoiit  lliiity-tive  years  of 
age.  Lungs  healthy  although  adherent  to  the  costal  pleura  throughout :  heart,  liver  and  sjileen  iionnal.  The  mucous 
niemhrane  of  the  stomach  presented  numerous  injected  points  aliont  the  size  of  mustard-seed,  and  the  rngie  along 
the  great  curvature  near  the  ]>ylorus  were  intlamed.  The  ileum  was  inflamed  in  patches,  some  of  them  intensely; 
the  h(wer  tifteeii  agmiiiated  glands  were  ulcerated,  some  C(un)detcly,  others  with  from  one  to  three  small  ulcers; 
the  upper  glands  were  intlanied  hut  not  ulcerated.  The  colon  was  inflamed,  especially  in  its  descending  |iortion, 
which  presented  many  small  hiack  stellate  ulcers  in  ])ositions  formerly  occupied  hy  solitary  glands;  a  patch  of 
intense  intlammation,  extending  from  the  sigmoid  Hexiiie  into  ilie  rectum,  wa.s  covered  with  an  o])ai|ue-wliite  mem- 
liranous  matter  which  the  micioscope  exliiliilcd  as  a  tiliro-graiiular  snl'stauce  mingled  with  desi|uanialed  eiiitlieliuni. 
— Act.  Axs'l  ■'<iir<i.  ./ii.scpA  Ltidii,  Sttltn-Jtr  Ho.ipili(l,  I'liiliiililphia,  I'd. 

Cask  Sll. — I'rivate  J.  K.  Kveits,  Co.  (i,  2d  E.  Tenn.;  age  '22;  was  admitted  from  Kichmond,  Va.  (a  jiaroled 
])risoner),  April  18,  IStU,  with  diarrhiea.  lie  died  May  ;>il.  I'dnt-mortem  examination  twenty-four  hours  after  death: 
Large  vomii'a  in  left  lung  with  two  quarts  of  etfusion  in  pleural  cavity,  pushing  the  heart  to  the  right  side;  vomica 
in  middle  lohe  of  right  lung  and  tnhercular  dejiosit  in  upper  lobe  with  adhesion  of  ]>leiiral  surfaces.  Ite.irt  Hahliy 
and  i>.-ile;  aortic  valves  thickened.  .Sjileen  soft  and  frialile;  gall-hladder  empty.  Peritoneum  iiillanied;  omenliim, 
lower  ]>arl  of  ileum  and  whole  of  rectum  gangrenous. — [.S'yipciwoi.v  :f()7  and  .'tdS,  Med.  Sect.,  Army  Medical  Mu.seuni, 
showing  ulceration  of  the  solitary  follicles  and  I'eyei's  patches,  with  exuded  lyni|ih  on  the  jieritoiieal  suiface.  are 
from  this  case.] — Act.  Atis't  Siii-i/.  fi.  H.  .l/i/c.v,  .liirri^  lliiKpilid.  Hnlliiiiiirr,  Mil. 

(UsK  :!1L'. — Private  (Jilliert  F.  Sherwood,  Co.  K.  Itttli  N.  V.,  was  admitted  .Inly  I'd,  IStiii,  with  chronic  di;ir- 
rliiea.  Tyidioid  symptoms  set  in  ahoul  .August  1.  The  low  delirium  was  conceived  to  have  lieeii  favorahly  inlluenced 
hy  a  large  Mister  over  the  epigastrium,  lie  died  mi  the  L'lst.  I'lisl-ninrtini  examination  Isvelve  hours  after  death: 
The  w  hole  of  the  intestines  were  indanied,  especially  the  caput  coli  and  twenty  inches  of  the  ileiiiii,  the  mucous 
meiiilirane  presenting  a  deep-red,  velvety  appearance  with  many  ulcerated  patches,  [^f^itiiimiu  7t!,  Med.  .Sect.,  Army 
Medical  Aluseum,  shows  the  ulcerated  patches  of  the  ileum  and  the  follicular  ulcers  of  the  ca'cum  in  this  case.  | — Act. 
Jxn't  Siii-f/.  F.  HiiilAc,  ./ori'i's  Uoxpitiil,  Baltiinon ,  Mil. 

Case  313.— Private  John  Weiant,  Co.  E,  118th  Pa.:  age  23;  was  admitted  Aug.  30,  18tU,  with  diarrhtv.i.  (In 
Sejiteniher  13  he  liecame  much  prostrated  hy  cou,stant  vomiting  and  diarrhcca.  He  died  on  the  2t)th.  I'ost-moitrm 
examination  eighteen  hours  after  death:  Some  emaciation.  Tlie  hrain  was  normal.  The  larynx  and  trachea  con- 
tained a  large  iiuaiitity  of  frothy  rose-colored  sputa.  The  right  lung  weighed  thirty-one  ounces  and  a  half  and 
was  mucli  congested  and  hepatized  posteriorly,  exuding  on  section  much  frothy,  rust-colored  s]>nta:  the  left  lung 
weighed  fourteen  ounces  and  contained  a  similar  frothy,  reddish  tinid.  The  heart  iiiclo.sed  a  medium-sized  tilirinous 
clot  in  its  right  side  and  a  small  one  in  the  left.  The  liver  weighed  eighty-one  ounces;  the  spleen  sixteen  ounces 
The  stomach  was  normal:  the  solitary  follicles  of  the  lower  ileum  were  enlarged  and  Peyer's  patches  ulcerated, 
there  were  a  few  small  ulcers  in  the  ciecuni,  hut  the  large  intestine  was  otherwi.se  normal:  the  left  kidney  was 
much  congested. — Act.  Asx't  Sury.  H.  M.  Demi,  Lincoln  Idixjiitiil,  iVuKhiiuitou,  1).  C. 

Case  314. — Corp'l  Andrew  Richardson,  Co.  K,  18itth  N.  Y.,  was  admitted  .Jan.  17,  18tj5,  with  chronic  diarrhiea, 
and  died  on  the  2t'th.  /^OkZ-wio/^m  exaniinatiou :  The  right  lung  weighed  forty  ounces  and  the  left  twenty  ounces ; 
the  right  pleural  sac  contained  juis,  and  the  Inng  was  adherent  and  hepatized;  the  heart  weighed  eight  ounces,  the 
liver  seventy-four  ounces  and  the  spleen  eight  ounces  and  a  half.  -The  stomach  was  injected  at  its  cardiac  end;  the 
jejunum  much  intlamed  ;  the  ileum  injected  and  Peyer's  jiatches  thickened  and  ulcerated  ;  there  were  some  small  ulcers 
in  the  upper  part  of  the  colon. — Fifth  Armi/  Corps  FiehJ  Ho«pital. 

Case  315. — Private  Orlow  Lawrence,  Co.  F,  llOtli  N.  Y.,  was  admitted  .Jan.  17,  18t)5,  with  chronic  diarrhoea, 
having  previously  sutiered  from  what  was  supposed  to  he  remittent  fever.  Me  died  on  the  26th.  I'lmt-mortem  exam- 
ination: The  right  lung  weighed  eighteen  ounces,  the  left  thirteen  ounces  and  a  half;  there  was  an  ahscess  in  the 
lower  loheofthe  left  lung,  and  the  left  i>liiiia  contained  twenty-four  ounces  of  serum  with  much  plastic  lymjih.  The 
liver  weighed  seventy-two  ounces  and  presented  the  nutmeg  ap|)earance;  the  spleen  weighed  six  ounces.  The  ileum 
was  injected  throughout  ;  Peyer's  jiatches  were  thickened  and  ulcerated  as  was  also  the  colon:  the  mesenteric  glands 
were  much  enlarged. — Fifth  Armij  Corpn  Field  Ho-ipital. 

Case  316. — Private  John  H.  Henjamin,  Co.  II,  127tli  N.  Y.,  was  admitted  July  2!(,  1863,  with  chronic  diarrhcca  of 
three  months' standing.  A  few  days  after  admission  it  was  discovered  that  he  was  also  lahoring  under  a  tertian 
ague;  this  was  controlled  hy  i|uinine.  but  the  diarrhiea  ciintinued.  He  liad  a  scorbutic  appear.ince  ;  his  gums  were 
spongy  and  he  was  feeble  and  emaciated.  He  gradually  sank,  and  died  comatose  .\iigust  27.  Fn-itiiiortnii  examination  : 
Peyer's  patches  were  extensively  ulcerated  and  the  solitary  follicles  enlargetl.  Theniucous  membiane  of  the  rectum 
was  converted  into  a  jmlpy  mass. — Jet.  Ain't  Sury.  IV.  H.  Lelterman,  Duiiylax  Hospital,  IVuthingtun  1>.  C. 


THE    OONTINUP'.D    FK.VRRS.  407 

Cask  S17.— Private  ,T.  W.  Foieman.  Co.  M,  5tli  V.  S.  Art.;  ailinitted  Oct.  10,  1803;  cliroiiic  dianlKua.  Died 
ITtli.  /'osNi/Kud/H  fxaiiiination  :  lioilv  somewhat  emaciated.  Luiirn  normal ;  lieait  atrophied.  Liver  .sliiilii  ly  hyjier- 
trophied;  gall-ldaihler  distended:  fipleen  enhirj;ed.  Stoniaeli  conf^ested:  dinxhMiuni  coni;c,slrd  and  thickened:  Jejn- 
iium  normal;  Pever's  patches  enlarged.  con»;ested  and  in  some  instances  nlccrat<'d  ;  cidon  ci)ni;ested,  thickened  and 
ulcerated  in  jiatclics:  rcctnm  lliickcniMl,     Kifj;ht  kidney  normal,  lel'l  lutly. —  Unit  wtuiil  ll,isj,il,il,  Wnshitiiilnti,  l>,  ('. 

Cask  :ilS.—('orp'l  Charles  M.  Mosher.Co.  A,  IL'-JdN.  V.;  admitted  Aiirir.'l,  ISC:!.  Chronic  diarrlnca.  Uied  Ma\  7 
J'lisl-iiiiiiltiii  examination:  Hody  much  emaciated.  The  right  hing,  lie:iit  and  pcricar<liiim  weri'  li<:ilth\;  the  hiwir 
hdieoC  the  left  liing  was  liejiali/ed  and  a  portion  of  its  )>lenra  thickened.  The  liver  was  mot t lid  and  tatty;  the  s]decn 
mottled  and  donlde  the  nsn:il  si/e.  The  stiima<  h  was  healthy;  thednodennm  injeeled  in  |i;itches;  the  jejannni  slighly 
injected  iind  iiresenting  small  nlceis:  theinncims  mendirane  of  the  ih-nm  \v;is  congested  in  patches,  thinned  :inil  sofl- 
ened.  and  I'eyer's  glands  were  reddened  and  nicerated.  The  ascending  ami  descending  ]>ortions  of  thecidon  present i>(l 
small  pnrjde  spots  with,  in  the  I'ormer.  several  small  distinct  nh'crs.  some  ol'which  were  hc;ili'd;  there  w;is  one  large 
intlamed  piitch  in  the  tr:insverse  colon  ami  a  )inrple  spot  1hr<'e  inches  long  in  the  rectnm.  Somi'i'ysts  were  oliserved 
in  the  kiilneys. — .1(7.  .Isn't  .S'hiv;.  //.  Ilirshfuhl,  Ilnri  irtmil  lloxjiiliil,  }ViiKhiii(it<iii,  /'.  ('. 

(Ia.sk  lillt. — I'rivati'  William  (Jreen,  Co.  H,  llth  Mich.  Cav.,  was  admitted  .Inhy  lill,  ISliS,  with  chronic  di:irrho'a. 
Under  treatment  he  seemed  to  improve  nntil  .\ngnst  10,  when  snddiii  indstral  ion  lann-  oti.  Next  day  he  I'elt  hi'ller, 
l)nt  in  theevening  the  prostration  recurred  with  slight  delirinin,  lasting  nntil  dc^ath,oii  the  IL'th.  I'nul-miirtim  exam- 
ination eighteen  hours  a  Iter  ileath  :  Lungs  son\<^what  congested.  Solitary  rollicles  of  inlcsiincs  nli'cialed;  I'eyer's 
glands  enl.irged,  intlamed  ami  nicerated. — Tliiid  Dirinimi  //n.'./iidi/,  .Ihriiiidiin,  I'li. 

(Ja.se  320. — Private  David  Knmhaley,  Co.  A,  ;!L'd  Mass.;  age  L'O  ;  was  admitted  August  30,  ISdl.  ha\  ing  heen  sick 
for  two  weeks  at  City  Point,  Va.,  with  diarrhtea  ami  oec:isional  rigors.  He  was  enuKuated,  had  anorexia,  pain  in  liolli 
byi»ndn)iidriac  regions  and  si^veio  diarrlnea  with  invidnntary  stools;  his  tongni!  was  coated  in  the  ciMitre  with  adark 
fur.  On  Septemher  4  there  was  intense  ]i;iin  in  the  right  side  i<(  the  chest,  with  slight  cough,  aeceh'ral«'d  pulse  and 
breathing  and  continuance  of  the  .morexi:!,  diarrlnea  and  ]irogressive  ileliilily.  Ucliiium,  with  great  |iiostrat  ion, 
set  in  in^xt  day,  ami  he  died  on  the  (ith.  I'lml  iiiorltiii  6xamiualion:  The.  larynx  ami  trachi'a  were  healthy;  Hie 
lungs  were  congested,  the  left  maikcdiy  so,  and  whili'  lioth  were  in  i);irt  closely  and  firmly  adiierc'iit  to  the  parietes 
the  right  had  a  coating  of  recent  lymiili  on  its  pleura.  The  pericardiiim  was  firmly  adherent  to  the  costal  cartilages 
and  steiiinm;  the  right  side  of  the  heart  cmitained  a  large  lihrimms  clot,  hut  the  left  was  nearly  em)>ty.  The  Mmt 
was  enlarged  and  soft  and  I'oniiected  liy  recent  lymph  to  the  alidoiniiial  wall  and  tin'  iliaphragiii :  the  spli'cn  was 
enlarged,  soft,  of  a  dark-browu  color,  coated  with  rccreiit  lyiii|di  and  adherent  lo  the  alxloniinal  wall.  The  stomach 
was  red  and  congested  towards  the  c;irdia,  thickened  and  softened  at  the  pylorus.  I'lie  small  intestine,  distended 
with  Ihilus,  was  healthy  in  its  iiiiper  part,  lint  toward  the  ileum  the  agmimiled  glands  and  the  miicons  iiiemlirano 
around  them  were  congested;  lower  down  these  glanils  and  the  solitary  follicles  were  enlarged  and  iirominent,  occa- 
sionally presenting  di'cp  ulcers  with  red  areohe,  which  liecanie  more  nmnerous  and  stained  with  yi-llow  pigincnl  near 
the  ih'o-Ciecal  valve.  [SjiiiiDiiiin  \'2\  :iud  1L'.">.  Med.  .Sect.,  Army  Medi<'al  Museum.]  I'he  large  inti'sline  was  disli'iided 
w  ith  air:  tlii^  .ascending  colon  eongi'sted  ,ind  presenting  a  few  small  ulcers;  the  transverse  and  descending  |iortioiis 
slightly  congested  and  the  oriliees  of  their  solitary  follicles  covered  villi  lilack  jiignient:  the  meseiiterie  glandH 
enlarged.     The  kidneys  were  normal. —  let.  .Isn't  Snr;!.  (I.  I'.  Sinil,  dirrtr  Ihisjiitnl,  ll'iisliiiii/ttin,  l>.  ('. 

(f.)    IHiiijnims:    Djisi'iitirii. 

Case  321. — Private  Thomas  .lones,  Co.  A,  1st  P.  S.  Art.,  was  admitted  M:ii(li  li;.  IS(i.">,  with  dysenlcry,  and  died 
on  the  23d.  /'ii.v/-»ii))7(i»  examination  :  Wigoi  mortis  well  marked.  Kiglit  lung  complitely  hepati/ed;  left  lung,  heart 
ami  ]icrii'ardiiini  norinal.  Stomacdi  intlamed  along  its  lower  horiler  and  pyloric!  oriliee;  lower  jiart  of  ileum  slightly 
lutlamed  and  Peyer's  glands  ulcerated,  the  ulcers  surrounded  hy  a  red  areola. — I'mt  Sliomi,  In. 

Case  322.— Private  William  H.  Morse,  Co.  H,  147th  N.  Y.;  age  33;  w.as  admittiMl  Aug.  20,  IXlil,  w  illi  dysentery 
of  four  weeks' standing.  He  had  about  twelve  passages  daily,  with  tormina  and  tenesmus.  The  disease  did  not  yield 
to  treatment.  He  died  on  the  30th.  Post-mnrti'in  examination:  Peyer's  jiatdies  were  much  ulcer.ilcd.  some  to  the 
muscular  coat  and  one  perfor.ating  the  intestine,  [Spirimt  iis  374  and  37."),  Med.  Sect.,  Army  Medii'al  .Miiscnin,|  hut 
there  w-as  no  liquid  in  the  ahdominal  cavity;  a  small  ciil-de-sac  existed  in  the  ileum. — Act.  .Us't  Smij.  D.  L.  Iliii<ilil, 
Douglas  HoKpital,  H'oshiiiytmi,  I).  C 

Case  .323.— Private  Addison  Uritliu,  Co.  (i,  141th  N.  Y.,  was  admitted  .Inly  211,  18t>3,  with  tyidioiil  dysentery. 
He  was  much  |irostrated  for  two  hours  after  his  entry,  but  b«  rallied  and  seemed  in  fair  condition;  pulse  88  hut 
feeble;  much  tormina  and  tenesmus;  ahdomen  tender  upon  jiressure,  es]iecially  over  the  ilco-ca'cal  valve:  tongue 
smooth,  glossy  and  red  in  front  and  coated  white  with  a  greenish-yellow  tinge  hehind.  On  the  <lay  of  adnii.ssion  the 
discharges  consisted  of  glairy  mucus  sjiccked  in  a  few  |ilaccs  with  hlood.  Tills  of  had  ai'ctate,  opium  and  blue 
mass,  w  ith  an  opiate  enema,  gave  him  a  rather  i[iiiet  night,  w  ith  only  four  jiassages,  so  that  next  morning  his  con- 
.dition  was  encouraging;  hut  at  4  v.  M.  he  passi'd  a  large  i|iiantity  of  Mood  from  his  bowels  and  died  within  an  hour. 
I'ost-murli III  examination  tifteen  hours  after  death:  The  inucons  coat  of  the  small  intestine  was  softened  in  its  whole 
course  and  in  many  places  not  able  to  bear  its  own  weight ;  the  glands  of  Peyer  were  softened  and  nicerated,  some 
completely  disorganized:  the  mesenteric  glands  were  enlarged  to  the  size  of  a  jiigeon's  egg.  The  large  intestine  in 
its  whole  length  was  softciu'd  and  disorganized. — .Id.  .tss't  Siiri/.  If.  //.  I.ittirmnii.  Iiniiiilns  llo$i>itiil,  ll'iisliiiiiitnii.  It.  ('. 

Case  324. — Private  (Justaviis  Frank.  Co.  P.,  20th  \.  Y.,  was  admitted  .July  2t!,  18ti2,  w  ith  chronic  dysentery,  and 
died  August  9.     I'ost-inuriem  examination  the  same  day:  The  body  was  much  emaciated.     The  heart  was  pale  and 


408  POST-MOKTF.M    KKCOIIPS    OK 

Haliby.  with  opaqiio,  white  patches  on  the  right  ventricle  iilioiit  tlie  size  ut  ,i  <linie  unci  simihir  hnt  qnitc  small  patches 
on  both  auricles,  togetlier  with  some  roughness  ot  the  coriesponcliiiir  portions  of  the  ]>i'ricariliuni.  I'lu'  lungs,  liv^r, 
stoniaeli,  pancreas  and  8pU>en  were  healthy.  I'he  nineous  nieiulnaue  of  the  ileum  was  inllaiued  and  the  aguiinaled 
glands,  with  the  exception  of  the  upper  ones,  were  thickened  and  intlanied  and  in  several  instances  juvsented  small 
ulcerations,  ISptcimrns  242  and  243,  Med.  Sect.,  Army  Medical  Museum:]  tin-  nu'senteric  glands  were  linuelliil.  I'hc 
mucous  membrane  of  the  colon  was  inflamed,  especially  towards  its  extremities. — Ail.  .tn«'t  Snrii.  .lofiiili  l,iid>i,  Snt- 
terlec  Hijspitdl,  Pliili((hljiliiii,  I'd. 

(fj.)   Diui/iiiiKix:   Tjijihuid  itrhilitj/. 

C.vsK  32."i.— Private  Howard  Kice,  Co.  H,  20Gth  Pa.:  age  27;  wa.'*  admitted  Oct.  14,  18l)l,  with  debility,  and 
died  on  the  HOth  from  gastric  and  intestinal  hemorrhage.  I'o-'it-morlim  examination  forty-two  hours  alti'r  death: 
Muscles  wt'll  developed.  The  spleen  was  dark-colored,  enlarged  and  softened.  Peyer's  patches  in  the  lower  part  of 
the  ileum  and  a  few  solitary  follicles  in  the  ca'cum  and  in  the  first  six  inches  of  the  colon  were  thickened  and  ulcer- 
ated, but  beyond  this  the  large  intestine  was  normal.  The  lungs,  heart,  liver  and  kidneys  wire  normal:  the 
stomach  was  healthy  Imt  contained  four  ounces  of  grnmous  liquid. — .4ct.  .tun't  Siirtj.  Thomiin  Hiiin  ii.  Sunnil  Dirixion 
Sospilul,  Alexatuhiii,  Va. 

(.'.\SK  32ti. — Private  Jeremiah  Klair.  Co.  C,  202d  Pa.:  age  38:  was  admitted  Nov.  4,  IStil,  with  di'ldlily,  and 
died  on  the  (ith.  I'ost-morliiii  examination:  Peyer's  patches  near  the  ileo-ca'cal  valve  were  thickened  and  ulcerated 
in  two  or  three  places;  the  mesenteric  glands  were  enlarged:  the  liver  dark-colored;  the  sph'cn  enlarged:  the.  other 
organs  healthy. — Stcoiid  Dhiaion  Honpital.  .UexmuJria.  Va. 

Cask  327. — Private  Isaac  H.  Cole,  Co.  M,  6th  Pa.  Art.:  age  40:  admitted  Oct.  17,  1864;  died  November  7. 
I'unt-mortem  examination  twenty-six  hours  after  death:  Marked  rigor  mortis:  no  emaciation  :  extensive  suggillatiou 
posteriorly.  The  left  lung  was  congested  posteriorly  and  a  small  portion  of  its  upper  lobe  was  hepatized:  there 
was  an  ounce  of  serum  in  the  right  i)leUTal  cavity  and  two  ounces  in  the  left.  The  pericardium,  which  w  as  slightly 
reddened,  contained  four  ounces  of  serum.  The  great  onu^ntum  was  inflamed  and  adherent  to  the  small  intestine, 
the  coils  of  which  were  interadherent ;  there  were  extensive  deposits  of  lymph  on  the  peritoneum,  and  the  cavity 
contained  two  i)ints  of  a  thick  straw-colored  liquid  having  a  fipcal  odor  and  some  floating  shreds  and  small  masses, 
.ipiiareutly  fiecal.  about  the  size  of  barley-grains.  The  liver  was  enlarged:  the  coats  of  the  gall-bladder  were  disor- 
ganized from  extension  of  the  peritonitis:  the  pancreas  normal:  the  spleen  enlargeil  and  softened.  Several  of 
Peyer's  ])atclies  in  the  lower  ileum  were  thickened  and  ulcerated,  one  ulcer  about  two  feet  fiom  the  ileo-ca^cal  valve 
having  perforated:  the  mucous  coat  of  the  cacum  and  of  the  first  few  inches  of  the  C(don  was  inflamed  and  thick- 
ened; the  mesenteric  glamls  were  much  enlarged  and  quite  dark. — Sveond  Dirision  Hospital,  AlexaHdria,  la. 

Case  328.— Private  William  DePraley,  Co.  I,  118th  Pa.:  adtnitted  Oct,  10, 1863.  Debility.  Symptoms  of  peri- 
tonitis were  observed  on  the  evening  of  the  28tli.  Died  29th.  Post-mortem  examination  :  Body  much  emaciated. 
The  lungs  and  heart  were  normal:  the  pericardium  contained  four  ounces  of  liijuid.  The  abdominal  cavity  con- 
tained a  large  iiuantity  of  serum:  the  liver  was  adherent  to  the  adjoining  visiera:  the  gall-bladder,  spleen,  stomach, 
duodenum,  .jejunum  and  kidneys  were  normal.  The  ileum  was  inflamed  and  Peyer's  glands  ulcerated:  one  of  the 
ulcers  just  above  the  ileo-ca>cal  valve  had  perforated  the  peritoneum:  the  colon  ami  rectum  were  much  inflamed. 
—  Hunwood  Hospital,  Washington,  D.  C. 

(b.)   lliatjnosis:  Bronchitis. 

Cask  329.— Private  John  Connor,  Co,  P>,  28th  Ma.ss.:  age  22:  was  admitted  Oct.  18,  1863,  with  acute  bronchitis, 
and  died  November  8.  J'ost-mortim  exatnitiation  twenty-two  hours  after  death:  The  brain  was  natural.  The  larynx 
and  trachea  were  inflamed;  the  mucous  membrane  above  the  chordie  vocales  was  greenish-brown  in  cidor  and  much 
puffed  out  and  thickened,  ))articularly  on  the  right  side;  a  slight  exudation  was  observed  on  the  cords  and  under 
surface  of  the  I'piglottis;  the  sub-e])iglottideaii  follicles  were  enlarged,  softened  and  blackened;  the  mucous  mem- 
brane below  was  of  a  ](aler  color  but  still  greenish,  becoming  grayish  in  the  bronchi.  The  (eso]>hagns  was  iutlamed, 
its  lower  part  dark  juirplish-red  ami  presenting  numerous  ])ur]>ura-like  spots  which  invaded  the  sub-nnicous  tissue, 
its  upper  i)art  greenish-brown  and  very  much  softened  and  thickened.  The  right  lung  \veighe<1  fifteen  ounces, 
contained  much  pigmentary  matter,  was  well  tilled  with  air  and  on  sectiofi  exuded  little  or  no  lironchial  secretion; 
the  left  lung  weighed  twelve  ounces  and  was  healthy,  excepting  the  slate-color  of  the  bronchial  membrane;  the 
pleural  cavities  contained  three  pints  of  serum.  The  heart  was  firm  and  almost  free  from  dots:  three  ounces  of  fluid 
were  found  in  the  pericardium.  The  liver  was  jxrfectly  healthy:  the  spleen  was  firm  ami  weighed  three  ounces 
and  three-ciuarters;  the  pancreas  four  ounces.  The  small  intestine  was  thin  and  the  valvuhe  conniventes  almost 
obliterated;  the  solitary  follicles  were  not  enlarged;  Peyer's  i>atches  were  of  a  deep-brown  color  and  but  little  ele- 
vated— such  as  were  ulcerated  were  surroun<led  by  .a  light-red  areola,  but  the  ulcerations  wi'ie  in  no  ]dace  deep 
and  had  everywhere  the  ajipearance  of  undergoing  the  healing  process.  The  large  intestine  was  of  a  darkish  gray 
color,  its  solitary  glands  normal,  Hoth  kidneys  were  somewhat  congested. — .lus'l  Surij.  Horrixoii  .tUen,  U.S.  .(.,  Liii- 
eoln  Hospital.  Washington,  It.  C. 

Ca.sk  330. — Private  E,  K.  Dolph,  Co.  H,  27tb  Conn.,  was  admitted  March  9,  1863,  having  be<-n  suffering  for  six 
weeks  from  a  rather  severe  attack  of  bronchitis,  for  which  he  had  been  treated  in  ([uarteis.  On  admission  his  jiulse 
was  108,  tongue  clean  and  moist;  he  had  considi-rable  lough  w  ith  white  frothy  sputa  and  some  substernal  soreness; 
his  stools  were  rather  infrequent  (not  daily)  but  loose  and  watery.  Next  day  he  seemed  better:  juilse  84.  On  the 
nth  his  pulse  was  108,  respiration  20,  tongue  furred  and  a  little  tinged  with  brown,  and  he  had  one  watery  passage 
in  the  preceding  twenty-four  hours.     He  continued  in  this  condition  until  the  1  Ith,  when  he  had  three  loose  jiassages 


THK    CONTINUED    F?n'ERS. 


409 


and  comi)lained  of  some  tenderness  over  the  whole  eoiiv.se  of  tlie  eolon.  Next  day  the  pulse  and  ivsi)iration  became 
slightly  accelerated  an<l  the  touj;iie  dry;  he  had  two  loose  passa^i's.  On  the  Itith  the  pulse  was  IL'O,  the  respiration 
'JX,  the  lips  dark  in  patches,  the  tonjjne  dry  and  dark;  he  did  not  answer  <inest ions  sensibly;  thealxloinen  was  tendiT 
all  over;  his  congh  was  loud,  dry  and  very  annoying;  the  respiratory  murmur  was  absent  and  there  w;is  dulness  on 
pi  rciission  from  the  lower  extremity  of  the  scapula  downwards  on  the  right  side,  but  elsewhere  the  murmur  was  loud 
and  dry.  'I'nbular  breathing  was  heard  on  the  17th  below  the  fifth  rib  on  the  right  side  anteriorly  and  laterally.  He 
died  on  the  L'Otli.  The  cough  ceased  during  the  last  three  days  of  life.  The  abdomen  was  at  no  time  tympanitic  nor 
were  any  rose-ci  doled  s])ots  observed.  I'oxl-mDiIrm  examination  :  [The  condition  of  the  thoracic  viscera  is  not  recorded.  | 
There  were  about  twenty  five  indurated  Peyer's  patches  in  the  ileum,  six  of  which  were  uUeiated;  the  ilco-c:eial 
valve  was  thickened  and  presented  an  indurated,  sliglitly  ulcerated  patch  on  its  cacal  surface;  the  neighburiug  parts 
of  the  ileum  and  colon  were  much  congested;  the  luesenterie  glands  were  enlarged.  [Siii<'iiii('ii  l"i(i,  Med.  Sect.,  Army 
Medical  Museum,  is  from  this  case.] — Sui-ij.  IV.  0.  McDonaUl,  Hoxpilol,  21th  Conn.  Vols. 

(i.)  DiagnoHiii:  PniumonUi  or  ti/jihoiil  pneumonia. 

Case  331.— Private  Orlando  Stevens,  Co.  A,  otli  Vt.,  was  admitted  Jan.  2,  1863,  with  pneumonia.  As  marked 
typhoid  symptoms  were  present  a  supporting  treatment  was  adopted.  He  improved  to  within  a  day  or  two  before 
his  death,  when  prostration  set  in.  He  complained  at  one  time  of  a  dull  pain  in  the  left  breast  and  of  some  dilheulty 
in  breathing;  he  had  also  a  slight  diarrluea.  He  died  on  the  16th.  Pont-mortcni  examination  six  hours  after  death: 
liody  much  emaciate<l ;  skin  sallow  and  tightly  stretched.  The  lower  part  of  the  upper  lobe  of  the  left  lung  I'ontained 
a  few  small  masses  of  hepatized  tissue;  tlie  lower  lobe  was  liepatizeil,  its  small  bronchi  tilled  with  false  mem- 
brane and  its  whole  surface  covered  with  a  thin  layer  of  exuded  lymph.  The  spleen  was  small  but  of  normal 
consistence  and  color;  the  kidneys  and  liver  were  natural.  The  stomach  was  contracted,  its  greater  curvature  having 
strongly  marked  ruga'  in  front  and  towards  the  pyloric  orifice;  the  fundus  was  injected,  i)articularly  at  the  lowest 
point  and  near  the  cardiac  orifice;  the  mucous  membrane  to  the  right  of  the  cardiac  and  towards  the  pyloric  orifice 
was  mammillated.  The  small  intestine  was  healthy  to  the  upper  end  of  the  ileum  ;  below  tliat  jioint  it  was  coiigt>Nted 
in  patches  which  occupied  about  half  the  surface  for  two  feet  and  a  half  in  length,  thence  it  was  uniformly  congested 
to  the  ileo-ca'cal  valve.  Peyer's  patches  were  punctated — some  were  reddish;  they  were  sliglitly  swollen  and  much 
softened;  within  a  foot  of  the  ileo-ca'cal  valve  were  eight  or  ten  over  which  the  mucous  membrane  was  eroded,  w  hile 
the  muscular  tissue  beneath  was  much  congested ;  the  ulcers  as  a  rule  diil  not  occupy  the  w  hole  of  these  patches,  but 
in  the  middle  third  of  the  ileum  there  were  several  in  which  this  was  the  case;  the  mesenteric  glands  were  normal. 
The  peritoneal  surface  of  the  ca'cuni  was  congested  ;  the  mucous  membrane  of  the  descending  colon  w  as  slightly  con- 
gested near  its  commencement,  then  slaty  in  color  to  the  sigiiioiil  flexure;  in  the  lower  two-thirds  of  the  gut  the 
solitary  glands  were  distinctly  marked  and  filled  with  a  dark-blue  deposit;  in  the  sigmoid  fiexure  were  several 
small  ulcerations  not  exceeding  a  line  in  diameter,  but  the  mucous  membrane  was  of  normal  consistence. — Afl.  Ass't 
Siir(j.  T.  n.  DunylhoH,  Lincoln  Honjiilal,  Waxhiniilon,  I).  ('. 

(ASF.  332. — Private  M.  \V.  Knowles,  Co.  D,  tiitli  I'a.,  was  admitted  Feb.  .'i,  1864,  with  pneumonia,  and  died  on 
the  Xth.  I'i>s1-miirtim  examination  :  The  right  lung,  exceiitinga  pait  of  its  anterior  margin,  w.is  heiiatized  ;  the  left 
was  ciuigested.  The  liver  was  slightly  granular  and  fatty;  the  spleen  large,  soft  and  of  a  dull  purjile  color  infer- 
nally; the  kidneys  congested.  Peyer's  patches  in  the  lower  part  of  the  ileum  were  ulcerated  but  the  surrounding 
villi  were  not  affected.  [^Spidmin  201,  Med.  Sect.,  Army  Medical  Museum.]  The  large  intestine  presented  isolated 
ulcers  mostly  confined  to  the  ca'cum ;  the  mucous  membrane  was  of  a  dull  whitish-bine  color. — A««'l  Sunj.  Harrison 
Allen,  U.  S.  A.,  Lincoln  Hospital,  Wushinyion,  I).  C. 

Case  333 —Private  I-.  M.  Cole,  Co.  K..  16tli  Me.;  age 20;  was  admitted  March  26,  1864,  with  imeumonia,  and  died 
on  the  28th.  7'().>i/-»i()/7(wiexauiiuatiou  twenty -three  hours  after  death  :  Hody  much  emaciated.  Brain  healthy.  Trachea 
inucli  congested;  right  lung  twenty-six  ounces,  left  twenty  ounces — both  congested;  bronchi  filled  with  bloody 
mucus  and  each  pleural  sac  containing  a  small  (|Uaiitity  of  blooily  serum.  Heart  pale.  Uver  ameiuic,  weighing 
fifty  ounces;  spleen  healthy,  nine  ounces.  (Ksophagus  and  stomach  normal;  small  intestine  much  congested, 
especially  towards  the  ileo-ca'cal  valve,  where  the  mucous  inembrane  was  of  a  bluish-slate  color;  I'eyer's  )iatche8 
and  the  solitary  follicles  prominent,  several  showing  points  of  ulceration;  large  intestine  congested  near  the  caput 
coli.  Mucous  inembrane  of  bladder  around  orifices  of  nreters  dark-bluish  colored  in  spots,  varying  in  size  from  a  jiea 
to  a  large  cent. — Act.  Ass't  Surg.  II.  M.  Dean,  Lincoln  Hospital,  Washington,  1).  C. 

Cask  331. — Private  Henry  Shrum,  Co.  F,  2d  Md.;  age  .">.");  was  admitted  Sept.  6,  186.">,  with  pneumonia.  Two 
weeks  before  his  entry  he  had  a  chill  lasting  for  half  an  hour,  followed  by  oppression  in  the  chest,  with  ccuujdete 
anorexia  for  five  days.  On  admission  he  had  diarrluea,  a  suffocative  feeling  on  taking  a  deep  breath,  a  ])urple  pus- 
tular eruption  on  his  hody  and  coldness  of  the  hands  and  feet.  He  died  on  the  8th.  rost-nwrtcm  examination  ;  Left 
lung  adherent  and  collapsed  posteriorly;  right  lung  congested  generally  and  solidified  posteriorly.  Spleen  enlarged 
and  softened.  Peyer's  patches  of  ileum  elevated, enlarged  and  in  some  instances  ulcerated;  solitary  glands  of  cidon 
anil  rectum  enlarged  and  presenting  the  shaven-l)eard  appearance.  Kidneys  with  many  superficial  cysts  containing 
a  transparent  light-brow  n  fluid. — .lc(.  AssU  Surg.  Carlos  Carrallo,  Douglas  Hospital,  Washington,  D.  C. 

Case  335. — Private  John  Strickland,  Co.  E,  103d  III.;  age  31  ;  was  admitted  June  21,  1X63,  with  typhoid  pneu- 
monia. He  was  delirious  on  admission,  but  it  was  learned  that  he  had  been  seriously  ill  for  two  or  three  weeks.  His 
pulse  was  small,  tongue  dry,  thirst  excessive  ;  he  had  not  much  diarrho'a,  but  expectorated  large  quantities  of  purulent 
matter.  His  condition  remained  unchanged  until  the  morning  of  the  23d,  when  a  large  |)0(d  of  bright-red  blood, 
which  had  flowed  from  his  bowels,  was  discovered  under  the  bed.  Ten  drops  of  solution  of  percLloride  of  iron  were 
Med.  Hist.,  Pt.  111—52 


410  POST-MOHTKM    IvKCOims    oF 

onlert'd  fi>  li«  taken  cvrrv  tliirty  iiiinntes,  and  the  jiaticnt  was  pla I  on  anotlicr  l>eil;   lint  lie  oontinncd  to  lileod  so 

freely  that  tliis  also  l)e<tann>  speedily  soaked.  Jiy  the  time  the  third  dose  of  the  iron  was  ijiven  the  hleedinj;  had 
eeasi'd,  Iml  the,  ]ialieMt  was  extremely  exhausted  and  almost  pulseless.  He  rallied,  however,  and  seeuu^d  to  lie  doinj; 
Well  untti  the  evening;  of  the  L'tith,  when  he  suddenly  lieeanui  restless  and  his  pulse  aeeelera  ted.  lie  died  next  uiornini;. 
I'i)nt-mi>rlciii  examiuati<iu  ten  hours  jifter  ileath :  The  nu^senterie  glands  were  en  la  ri>;e<l,  softened  and  in  some  eases 
nearly  hroken  down.  Only  two  uleerati'd  I'eyer's  ji.atehes  were  found:  these  were  huge  anil  layyed.  sitnate<l  a  ihort 
distance  from  the  ileo-e:eral  valve:   there  was  no  lilooil  in  the  intestines.  —  f.airxini  llaipitdl .  St.  /.iiiii«,  Mo. 

Cask  ;>;i(j. — Private  Morris  Hyatt,  Co.  A,  1  Ilid  ( )hio  National  (iuard;  a>;e21;  was  admitted  July  2!-!.  ISlU,  with 
typhoid  imeuiuonia.  He  was  dtdiriou.s  ami  had  a  sliffht  eouj^li,  without  expi^ctoration,  and  an  iufrei|Uenl  (liairh(e<i. 
1m  the  pro};r<'ss  of  the  ease  thl^  jiulse  beciinie  ra])itl  and  weak,  the  lireat  hini;  hurried  and  the  eonnlenaiiee  ilnsky.  lie 
died  Aunust  1.  Pmt-mnrtnii  examination  fix  hours  after  death:  l!ifj;or  mortis  marke<l.  The  Inuj^s  were  eufiorjii-d  p<is 
teriorly  and  sonuiof  11m>  1oIiu1(^.s  liejiatized.  The  liver  was  enf^orfjed,  enlarged  and  softened;  the  spleen  sofleiied. 
The  niueons  nuMtilirane  of  the  Ktom;ieh  in  the  region  of  the  greater  eurvatuie  was  uiueli  softened  ,'ind  easily  torn. 
I'eyer's  jiatehes  and  the  solitary  ghindsof  the  small  intestine  wereextensively  diseased,  this  eondition  lieeoniing  mure 
nnirked  toward  th<^  lower  end  of  thi^  ileum  ;  for  three  or  four  feet  above  the  ileo-ea'eal  valve  the  niorliid  palehes  were 
einuihir,  from  the  si/.e  of  a  pinhead  to  that  of  a  two-cent  pieee,  or  oval,  some  of  the  latter  having  the  gii>ater  axis 
ox  er  t  wo  inches  long  with  a  thiekness  in  some  cases  of  three-.sixte,enths  of  an  inch  :  t  hey  were  linn,  the  edges  smooth 
and  legular,  I  he  surfaces  in  those  most  advanced  slightly  excavated  and  in  all  iu<ir<^  or  less  covered  with  a  yellowish- 
green,  easily  deta<died  coating  or  deposit.  [See  specimens  376-3S0,  Ated.  Sect.,  Army  Jtedieal  Museuni,  and  plates 
facing  pages  410,  412  ami  430,  )«/ra.]  The  mesentery  was  greatly  thickened  and  the  glands  enlargeil,  some  to  Iho 
si/e  of  a  largi^  peach-stone,  Iftjiiciiiicn  3K1,  Anny  Medical  Museum.]  The  large  intestine  was  generally  healthy. 
The  kidneys   were  normal. — lldiujhix  Ilminlal,  Wdsliinyton,  I).  C. 

C.vsK  337. — I'riviite  Krederick  Hrand,  Co.  E,  lltli  Pa.;  admitted  .J.m.  7,  1S('>.">;  tyjihoid  pneumonia.  Died  Keli- 
ruary  1.  I'osl-iiiorltiii  exaniinalion  ten  hours  after  ileath:  Itoth  lungs  were  he|iatized  (gray)  and  closely  adhi-rcnt  to 
the  costal  phuira.  >Sliglit  adhesicms  existed  lietween  the  liver,  diaphragm,  ascending  colon  :iml  small  inteslini':  llii' 
intestines  were  coveri'd  with  plastics  lymph;  the  ahdondual  cavity  contained  twelve  ounces  of  a  colorless  liipiid; 
the  mesentery  was  thickened  an<l  congested  throughout  and  contained  large,  soft,  white  deposits  wliieli  resciiililed 
tubercle.  The  diuidenuui  was  healthy:  the  n)i]ier  part  of  the  jejunum  was  slightly  congested  in  s)iols  and  its  lowei- 
|>arl  presented  a  large  uli-er:  the  ileum  was  congi'sled  Ihronghout  aiid  Peyer's  patches  ulcerated.  The  asceiidiiig 
colon  was  hi'althy:  the  rest  of  the  colon  au<l  the  rectum  nmch  congested  but  not  uleer;iled.  The  other  viscera  were 
normal. — .ict.  .Ihh'I  Siirij.  ('.  T.  'rraiilmmi,  fliirewoiid  Iliisjiital,  WanhiiKjioii,  I>.  ('. 

C.\SK  33IS. — Serg't  Alexaiub-i-  M.  Klgiu,  Co.  P.,  13itth  Pa.:  a<lmittcd  April  21,  1S(')3:  tyiiboid  imeumonia.  Died 
May  21.  l'oKl-mi>rlim  examination:  The  left  ))arotid  glanil  and  surrounding  cidlular  tissm^  foruii'd  the  site  of  an 
aliscess  which  pem^trated  to  the  o'sophagus.  The  lungs  and  heart  were  iioriual.  TIk-  duodenum  and  .jejunum  were 
dark-lead  colored  and  contained  fresh  bih^;  \\u;  ileum  was  thin  and  daik  colored,  its  mnc'ous  inembr:iue  much 
iiije<'.|ed:  I'eyer's  ]iatches  and  (Certain  of  the  solitary  glands  were  deeply  colored,  softcni'd  and  in  soml^  instances 
ulcerated.  'I'he  large  intestine  exhibited  large  black  spot.s  scattered  over  its  surface.  The  liver  was  black  on  its 
uinliu'  surface,  its  parenchynni  fatty;  the  gall-bladder  distended  with  bile:  the  sjileen  and  kidneys  noiiu.-il. — -.lit.  .\s>.'t 
Siiry.  Tliiix.  II.  /''Iliiill.  Hdiewoiid  Jlospilid,  Wuxhinijlun,  I).  ('. 

C.vsK  33!l. — Private  H.  V.  Wardwall,  Co.  1),  33d  Mass.,  was  admitted  Fi'b.  !•,  18(53,  with  great  dyspntea  and  com- 
plete aphoni.i.  Heath  occurred  from  sulfoeation  on  the  lotli.  Then^  was  no  indication  during  life  of  any  intestinal 
lesion,  nor  was  the  jiatient  emaciated  as  he  w  iiubl  |>roiiably  have  been  if  just  recovering  from  tyjihoid  fever  or  chronic 
diarrlnea.  I'iist-inorldii  examination:  The  lungs  were  tuucIi  congested,  but  there  seeuu'd  to  be  enough  of  comliara- 
tively  healthy  tissue  to  have  enabled  respiration  to  go  on.  The  trachea  was  highly  inllamed,the  larynx  ulcerated  and  . 
the  glottis  oi'clmled  by  (edema.  The  mucous  membrane  of  the  small  iutestin(\  and  es])ecially  of  the  ileum,  ]iresente<l 
the  softeni'd  and  tunu-lied  as|iect  usually  found  in  cases  of  chronic  diairlnea,  and  there  were  numerous  ulcers,  one 
near  the  ca-cum  being  two  inches  In  diameter.  [Sjuriiiiiii  207.  .Med.  Sect.,  Army  Medical  Museum,  showing  ulceration 
of  I'eyer's  glan<ls.  is  derived  fidm  this  case.  ] — MvtI.  Cadet  K.  Ctnies,  ('.  ,'?.  J.,  Mitiiiit  I'ledSiuil  IJiispitiil,  Wiishiniiton,  1).  C. 

(k.)    DidiiixixiK:   I'liiirixi/. 

C.\sk3I(1. — Private  lleury  Mead.  Co.  D,  lOtli  X.  V.  Cav.:  agelil:  was  admitted  April  7,  IXtjo,  with  idenrisy.  |  He 
•  entered  the  <avalry  coriis  lios])ital.  City  Point,  \'a.,  March  27,  diagmisis  chronic  diarrlnea,  and  was  transferred  to 
hincolu  hospital,  Washington,  I).  ('.,  Ajiril  1,  wliere  his  case  was  registered  bronchitis.]  He  was  jiale  and  much 
debilitated;  tongue  white;  bowels  loose:  ajipetite  poor;  ]iulse  full,  weak,  not  freiiuent,  intermittent  and  sometimi's 
resembling  Ihewliir-r-i  of  an  aneurism;  breathing  harried  and  dilticult:  he  was  unable  to  lie  on  his  right  side. 
Physical  examination  iliscovered  dulne.ss  over  the  left  lung  and  interiorly  over  the  right  Inng,  crepitation  over  the 
right  Inng  ]iosterior  ly,  with  ;i  large  moist  rale  over  its  middle  lobe  and  a  sibilant  rale  over  its  lower  lobe  and  <lis- 
]ilacement  of  the  hc'art  four  inches  low  anls  t  he  liglit,  its  ,ipe\  seeming  to  be  under  t  he  right  nipple.  He  died  on  tlu' 
I2th.  I'lisl-iiKirlrm  examination:  Thcic  were  two  gallons  of  liloody  li<|niil  in  the  left  thoracic^  cavity:  the  lelt  lung 
w:is  compi-es.sed  against  the  spinal  lulnmn  and  so  dense  as  to  sink  in  wati'r;  the  right  was  passively  congi'sted, 
espi'cially  in  its  low  <'r  lobe.  The  heart  was  dis|ilaeed  to  the  right  and  contained  a  soft  coagulum  in  its  lelt  ca\ities. 
a  libiinoiis  one  in  the  right:  thei<^  was  slight  etVusion  into  the  peiieardium.  I'he  liver  was  soTuewhat  congesteil. 
Tlu' small  inlesline  Wiis  congested  and  some  of  Peyer's  ]iatclies  were  ulcerated. — SkIIii-Iic  Ilosjtitnl.  riiihfdcJiiliin.  J'a. 


Am.  Photo-RelUf  Printina  Co., 


10U2  Arch  St.,  FhitadelfAia. 


SLIGHTLY  THICKENED   PEYER'S  PATCHES. 

No.  377.     MEDICAL  SECTION. 


THE    CONTIXrKD    FEVERS.  411 

(B.)  Condition  of  Peyf.r's  patches  not  .statek;   the   ii.etm  ok  the   small  intestine  said  to  have  keen 

XTAEKATED — 21  CASES. 

(((.)   Il'iiKiDiin'iH :  hill  fiiiitli  lit  finr. 

Case  'M\. — Private  Jacdl)  Slioiildcrs,  Co.  1!.  iritli  \:i.:  a^jc  2i;:  was  ailmitti-d  Any;.  :>1,  IXiM.  witli  iiitiTiiiittfiit 
fever,  and  died  Si-yitemlier  13  with  tyjdioid  synqitoiiis.  I'lixl-miiiiiiii  exaiiiination:  Hyi)()statl(^  ciiiii;i'sti()ii  of  lioth 
lunjis.  Liver  larij;e,  weijiliiiii.;  five  poniids;  s|ileen  very  lar^e,  twenty-tiiix  ounces:  left  kidney  small,  tliiee  oiinees; 
ileum  for  three  feet  ahove  the  ileo-cieeal  vahe  intensely  inthnned  and  eontainiuj;  thirty  ulcers,  some  of  the  size  of  a 
silver  dollar. — Act.  Auk'I  Siii-i/.  /?.  /}.  Mih'x,  ,/iirvix  HoHjiitnl,  Biillimorv,  Md. 

(h.)   iyuui»iii>is:   Crrihral  iTiKiasi-. 

Case  .S42. — Private  Zeliulon  V.  Whittaker.  Co.  K,  lOth  Me.,  was  admitted  Felj.  1,  1865,  as  a  eonvaleseent  from 
tyjihoirt  fever.  He  was  hypochondriacal  and  nostalgic,  coniidainiu};  ot  severe  headache,  intense  lumliar  )iain  and 
constipation.  Hlisters  were  apjilied  liehlnd  the  ears  and  <lry  and  wet  cnps  to  the  liai'k  with  hut  tcm|>orary  rclii'f 
lie  vomited  larj;e  (jnantities  of  a  };reciiisli  watery  li(iuid,  and  later  had  involuntary  stools  and  i>ara  lysis  ol  the  Madder 
iiecessitatiiifj  eatheterism.  He  lieeaine  very  restless  and  noisy,  and  on  the  2<)tli  had  to  he  laslcncd  lo  his  Led  to 
]ircvcnt  his  leaving  it.  He  died  on  the  24th.  Piixt-iiinrtnii  examination  :  lirain  normal.  I.uu^s  (dni;ested,  softened 
and  friahle.  Stomach  sliowiui;'  numerous  iM'chynuises;  ileum  and  ileo-ca-cal  valve  presenting  a  few  isolati'd  ulcers, 
liladder  thick,  sm.'ill,  ecchymosed. — Ait.  .Ink'/  Siirij.  Ciirhis  Curralhi,  lliiiiiihix  l/iixjiitnl,  11  nxliiiiiitiiii.  I).  ('. 

(c.)    DUigtiiixiK:   Diiin-Iuni. 

Case  343.— Private  P.  M.  Hapnnin,  Co.  F,  l.")()th  N.  Y.;  age  41;  *as  admitted  July  (I.  lX('.:i,  with  chronic  diar- 
rliiea  and  Keueral  dehility.  He  was  doing  well  up  to  August  22,  when  lueningitis  supervened,  .ind  he  died  on  the 
2."illi.  /'«v7-Hi()c((«i  examination :  (!lose  adhesion  lietween  tlie  ]iia  mater  and  the  hemisphcies  of  the  eerelirnin,  with 
an  unusual  i|nantity  of  serum  in  tlui  suliarachnoid  spaces;  ossitieation  of  a  racchionlaii  graioilalion,  {Spiiiiinii  41, 
Med.  Sect.,  Ai-my  Medical  Museum.]  Lungs  and  heart  healthy;  liver  and  spleen  soflciu'd  anil  c<iugesled;  ileiuu 
inlhimed  and  ulcerated  in  |ialches. — Art.  .tux'l  Siinj.  I',.  I!.  Milix.  ./iin-iit  lluxiiilnl,  lUiltiiiimi ,  Mil. 

f'ASE  .•il4.— Private  Fianklin  Sollans,  Co.  E,  122d  Ohio;  age  22;  was  admitted  Aug.  12.  ISCI,  with  diarrh<i-a, 
and  died  on  the  liHIi.  rust-innrli  iii  cxamiual  ion :  flu^  \fs.sels  of  Ihc^  |ila  nuifer  weri^  ana'iuic  and  seemed  to  contain 
gloliules  of  ail  ;  there  were  two  ounces  of  .serous  effusion  at  the  liase  of  lli<!  lirain;  the  third  ventricle  contained 
oui'  ouuci^  of  lii|uid  ;  the  lirain-suhstance  was  luitinal.  Tliere  w.as  extensive  int(M  lohnlar  <'nipliysema  of  holh  lungs, 
wliicdi  were  congested  jiosteriorly;  the  areolar  tissue  of  the  anterior  luediastlnuni  was  inlillratcd  wilh  air.  The 
lieait  and  kidneys  were  initnral;  the  liver  large;  tlie  spleen  congested.  There  were  three  ulcers  in  I  lu^  IIcmiu;  two 
of  whii'h  were  oue  inch  ami  the  other  eight  inches  aliove  the  ileo-ca'cal  valve;  the  mucous  meniloaue  to  llie  e\lent 
of  a  fixit  IV(Mn  the  valve  was  very  lunch  congested. — .Ut.  A.-<s't  Siirti.  H.  li.  Afilix,  Jiirri.t  lln.tjiitiil.  lUiltiiiinvi,  Mil. 

Case  lUf),— Private  Charles  A.  Taylor,  Co.  A,  ilth  Mieh.  Cav.;  age  IK;  iidmitted  dea<l,  .March  I.  lsi;i,  having 
cHed  iu  Hu',  amhnlauee  on  the  way  to  hospital.  I'lixl-morli m  examiiuition  fonrti^en  hours  after  dcalli:  Hoily  greatly 
em.iciated.    The  lungs  were  healthy;  the  heart  snuill  and  llahliy.    The  liver  was  large  hut  of  normal  coiisislenci';   the 

left  kidney  engorged  with  hlood,  the  right  small  and  apparently  fatty.     The  omentnni  had  lost  its  fat;    the  sen 

teric  glands  were  enlargeil  and  there  were  imlications  of  fornn-r  peritonitis.  The  stoniaidi  was  healthy;  thc^  umkcmis 
nu-mlirane  of  the  Ileum  was  destroyed  hy  ulcerati(Ui  in  many  jilaci's  and  thickened  in  others. — Suni.  \Vm.  <'.  Ullir- 
8011,  U.  S.  {'.,  HiLipHiil  .\ii.  8,  XnnhriUe,  Titni. 

Case  346.— Private  Martin  O'Niil,  Co.  E,  lltli  X.  .1.;  age  4(»;  was  admitted  Nov.  5,  1M64.  He  had  heen  sick 
for  two  weeks  with  diarilicea  complicated  with  kidney  disease  and  a-dema  of  the  hands  and  feet.  He  died  .Jan.  30, 
lS(ir>.  J'oxt-muiiiiii  examination  nineteen  hours  after  death:  Mucous  luemhrane  of  ileum  and  ca'iiim  ulcerated  in 
a  dozen  patches,  two  of  which  |ierforated  the  gut  about  two  feet  ahove  the  ileo-(;ecal  v.ilve;  alidoniinal  cavity  <on- 
taiiied  about  six  oniu'cs  of  jius.  I^eft  kidney  Honiewhat  enlarged,  |iale  and  mottled;  right  noruuil  In  size  but  ciiu- 
geMei\.—Jct.  J»sV  Siiri/.  S.  I'.  U'liiti,  ll'urd  llitxpitul,  Xnrurk,  X.  .1 . 

Case  347. — Private  Rudolph  Norman,  Co.  (i,  2Sth  Mass.:  age  28  (a  paroled  iirisoner);  was  admlttid  from 
Eichmoud,  Va.,  April  18,  1864,  with  chronic  diarrlnea.  He  died  .luue  4.  I'oxt-tiiin-tnii  examiuation  twenty-four 
hours  after  death:  laings  healthy;  heart  flabby  and  au:emi<',  tilled  with  white  clots;  liver  .idhering  bv  its  entire 
npi)er  surface  to  diaphragm;  spleen  large;  miu'ons  <'oat  cd'  Intestines  much  congested  and  thickened;  ileum  perfo- 
rated in  ten  or  twelve  jdaces  by  ulcers;  peritoneum  congested  and  adherent  in  many  jdaces. — Act.  Axx't  H>ir<i.  B.  B. 
Mills,  Jiirrm  Hoxpitii},  Bnltimorr,  Md. 

Case  348. — Private  Alfred  A.  King,  Co.  F,  2d  Pa.  Cav.;  age  16;  admitted  Aug.  9,  1864,  from  Army  of  Potomac; 
chronic  dianh(ea.  Died  next  day.  I'ost-miirtt-m  examination:  Much  emaciation;  enlargement  and  suppnratiim  of 
parotid  glands.  Ulceration  of  ileum,  ciecniu  and  i)art  of  colon;  a  half-pint  of  lumbricoid  worms  scattered  through 
the  intestinal  canal  and  ([uite  a  lot  of  them  iu  the  c^ecum. — Third  Dirixiuii  Hospital,  Alf.iiiiiilrin,  In. 

(d. )   Diai/iiusis :   IhhiUty. 

Case  34!t.— Private  Henry  C.  Davis,  Co.  C,9th  N.  Y.  Cav.;  age  32 ;  was  admitted  .Inly  23,  1863.  with  debility. 
He  was  aiipointed  an  assistant  nurse,  but  .symptoms  of  meningitis  canu^  on,  tor  which  cups,  blisters  and  eiiemata 
were  emidoyed.  He  died  August  3.  I'o«l-iiioi-tiin  examination  fourteen  hours  after  death;  '■On  removing  the  cere- 
brum slight  adhesion  was  found  on  the  left  side  with  some  eti'uslon,  the  meninges  of  the  brain  being  softer  than 
usual.     The  liver  was  congested  and  weighed  four  pounds  and  six  ounces,  and  an  ulcer  was  found  iu  it  near  the  gall- 


412  [POSTMORTEM    KECOKPS    OF 

1iI.-mI(1it:  tlio  Nj)l('<^ii  weiKli"'!  tno  piMiiiils  mihI  t'lmr  (jiiucck.  'I'lieie  was  nlci'ial  ioTi  iiloiii^  t!io  ilt-iiiH." — Act.  .Isn't  Siirii. 
I:    /;.  Mills,  .liirris  1 1  IIS  jilt  III,  liiiltiiiiiiri .  Mil. 

Casio  X<i\. — I'livatc  I.yiMaii  Avciy,  Co.  1,  iHli  N.  Y.  Car.;  fige  L'li;  wa.s  adiiiittt'il  July  I'll,  l.sii:!.  willi  dchilily,  and 
dii-d  Aiii;ii.st.  II.  I'ltsl-iiioflim  exaiiiiiiatii.il  lui'iity  liimis  after  dcatli:  Hiaiu.  liiiiss,  heart  and  li\i-i  lieallli\:  ileum 
NJMiwiM;;  eieat  rices  iif  old  iileer.s  in  tlieir  diU'eiciit  stage.s. — Act.  Ass'l  Siirij.  />'.  />'.  Miles,  .lurris  lltisjiilul,  lUiUiiiiun  .  .Mil. 

Cask  3."iI. — Private  Ifeiiiy  Lott,  Co.  D,  173d  N.  V.;  age  2'2;  was  admitted  Oct.  2!l,  ]8(!;!,  siitleriii';  tVoiii  eoii^l <l 

tyidioid  deliility.  Next  day  it  was  noted  that  liis  abdomen  was  covered  with  luiriile  spots,  ami  on  Novemlx  r  2  that 
lie  had  dysentiiy  luit  «  itli  little  tenesmus.  He  was  treated  with  carhonate  of  ammonia,  whiskey,  noiirisliuieut  and 
hot  apiilications  to  his  extremities.  He  died  on  tlie  3d.  r<).tt-mortcm  exaininatiou  twenty-six  lionis  atter  ilialli: 
Iiitlainiuation  aii<l  iileeraticm  of  the  intestines. — .let.  Asn't  Surg.  W.  W.  Uuijitl,  llitsinlnl,  Aiiiiiijiiilis,  Mil. 

(e.)   Didfjnosis:  Uhiiimulism. 

Case  3r)2. — Private  Daniel  Eei)|>lo};el,  Co.  A,  61.st  Pa.;  age  2S ;  was  adiiiittiMl  Aug.  21!,  IStU.  with  rheiiiiiatism, 
and  died  Septemlier  22.  Pont-miirtvm  examination  twenty-four  hours  after  death  :  The  miildle  lohe  of  the  right  luug 
was  Iiepati/ed  and  iiitiltrated  with  jins.  The  ilenm  was  intensely  congested  in  spots  and  presented  four  large  ulcers 
at  a  little  distance  from  the  ileo-ca'cal  valve.  The  bladder  was  very  much  thickened  and  contracted. —  let.  Axs't  l^iirg. 
/.'.  /.'.  .1/i7r,v,  Jiirris  llDspitiil,  IkiUimori ,  Md. 

(f.)   DiiiiiiKisis :  Piirniiiniiiii  or  tijjihoUl  piirumonia. 

(!ask,  li-'i:!. — Private  Richard  Vaughn,  Co.  F,  llGth  lud.;  age  26;  was  admitted  .luno  S,  IXdo,  having  been  sick 
for  ten  ilays  with  jineuiiionia.  On  admission  his  bowels  were  rather  loose  and  he  had  some  cough  with  free  e\pecto- 
ration.  He  improved  steadily  until  the  13th,  when  permission  was  given  him  to  go  to  t'limbeiland  to  be  mustered 
out;  but  he  became  much  exhausted  by  the  way,  was  abandoned  liy  his  friends,  and  returned  to  tin!  hospital  on  the 
lltli  ill  a  i>rosti'ate  condition.  He  died  on  the  17th.  Post -mm- Inn  examination  eight  hours  after  death:  There  were 
plciiritii!  adhesions  on  both  sides.  The  abdominal  cavity  contained  a  (juaiitity  of  Kciiim  and  the  intestines  were  coated 
with  coagulable  lyiiijih.  The  liver  was  large,  intensely  congested  and  softened;  the  sideen  l.irge,  congesfi'd,  soft- 
ened and  of  a  black  color.  The  mucous  membrane  of  the  jejunum,  ileum  and  ciecum  was  intlamed,  softened  and 
ulcerated, — Art.  Js.i't  Surg.  S.  B.  West,  Cumberland  Himpiinl,  Md. 

Cask  3r>4.— Private  Philip  Dick,  Co.  A,  187th  N.  Y.;  ago  28;  was  admitted  Feb.  20,  18fi.">,  with  ])iienmonia.  He 
died  March  4.  Post-mnrtiiu  examination  eight  hours  after  death:  Purpuric  sjiots,  the  largest  one-fourth  id'  :in  inch 
in  diameter,  were  scattered  on  the  lower  extremities.  The  lower  lolie  of  each  lung  was  deeply  congested  and  on  the 
outside  of  the  left  was  a  sunken  star-shaped  cicatrix,  with  beneath  it  a  collection  of  tubercular  matter  about,  as  large 
as  a  butternut,  connected  at  its  inner  side  with  one  of  the  bronchial  tubes:  The  iieart  was  healthy  and  contained  a 
large  white  clot  in  the  right  ventricle  and  a  smaller  one  in  the  left.  The  liver  and  kidneys  were  healthy.  The  8]deeii 
weighed  twelve  ounces  and  adhered  strongly  to  the  diaphragm;  in  its  substance  beneath  the  adhesion  was  a  cavity, 
jiartly  divided  by  a  ]iartition  extending  to  its  bottom  and  containing  about  an  ounce  of  viscid  greenish  tliiid,  [Sjier- 
iiurn  ri2:>,  Med.  Sect,,  Army  Medical  Museum,]  The  stomach  was  iutlamcd  and  exhibited  one  ulcer  about  the  middle 
of  its  greater  curvature;  the  diiodenum  was  congested;  the  jejunum  injected  in  ]iat('lies,  its  lowerthree  feet  heallh.v, 
as  was  the  first  foot  of  the  ileum:  the  rest  of  the  ileum  ulcerated;  the  mesenteric  glands  inflamed;  the  large  intes- 
tine healthy, — Sunj.  IV.  A.  Fn.rou,  'r>2d  .Muss.,  Dipiil  Uospitiil,  Piftli  .Irniji  Citrps,  Cittj  Point,  I'd. 

Case  li;"!. — Private  Charles  Hackett,  Co.  1),  12!ltli  lud.:  age  2(i;  was  admitted  May  26,  1804,  with  pneumonia. 
When  lirst  si^eii  by  the  reporter  .lime  5,  the  ]iatient  was  feelde,  delirious  and  had  diarrluea  w  itli  involuntary  stools. 
He  died  .lune  10.  Pnst-miirlrm  examination  :  There  were  recent  adhesions  and  a  large  serous  ett'iision  in  the  left  pleural 
cavity;  the  ui)|ier  lobe  of  the  left  lung  was  congested,  the  lower  partially  I'onsolidiited  ami  coated  with  iisiMido-iiiem- 
lirane;  the  right  lung  was  coiii|iaratively  healthy.  The  heart  was  tlabby  and  soft.  The  spli'en  was  enlarged,  con- 
gested and  easily  torn.  The  ileum  was  much  intlamed  and  ulcerated  in  a  number  of  places.  The  left  kidney  was 
slightly  indaiiied. — Act.  Ass'l  Surg.  L.  ./.  Il'ultoii,  Ila.'ipitdl  Xu.  8,  Nashville,  Tenn. 

Case  3r)(i. — Private  Kdwiu  Preston,  Co.  D,  oth  N.  Y.  Cav.;  age  20;  was  admitted  Oct.  1.'!,  18lil,  w  ith  tv]ihoid 
pneumonia,  and  «lied  on  thi^  2ltli.  Piist-inorteiu  examination  twenty-four  hours  after  death:  Adhesion  and  almost 
complete  consolidation  of  both  lungs,  which  did  not,  however,  sink  in  water;  a  band  of  lymiih  conne<'tiiig  the  two 
surfaces  of  the  pericardium;  twelve  ulcers  in  the  ileum  penetrating  to  the  serous  coat.  (Jtlier  organs  normal. — Aet. 
Ans't  Surg.  ]i.  li.  Miles,  Jurris  Hospital,  Pallimore,  Md. 

Ca.se  3;">7. — Private  Meredith  1*.  Osboni,  Co.  I,  9tli  Tenn.  Cav.,  was  ailmittt^d  with  tyjihoid  pneumonia,  and  died 
Oct.  27.  18()1.  Post-mortem  examination  ;  The  right  lung  was  healthy;  tlii'  left  was  in  a  state  of  gray  hel>atization  with 
etliision  of  about  one  pint  of  serum  in  the  pleural  cavity.  There  was  a  large  white  clot  in  the  right  side  of  the  heart. 
Tilt!  liver  was  much  congested;  the  ileum  ulcerated;  the  mesenteric  glands  enlarged. — Act.  Aks'I  Surg.  J.  K.  Brooke, 
Jtoek  Island  Jlospiial,  III. 

Case  358. — Private  \Villiam  Walters,  Co.  I,  17th  Ohio;  age  34;  was  admitted  Aug.  27, 18(54,  with  typhoid  pneu- 
monia. He  died  Si'ptember  1.  Post-mortem  examination  on  the  day  of  death:  The  lower  lobe  of  the  left  lung  was  in 
the  state  of  red  lu'patizatiou.  The  heart,  liver  and  kidneys  were  iioriual.  The  spleen  was  softened  and  enlarged; 
the  lower  portion  id'  the  ileum  ulcerated  in  patches. — Field  Hospital,  Chattanooga,  lenu. 

Cask  S.V.t. — Private  An.sel  Fraley,Co.  F,  33d  Ohio;  age  16;  was  admitted  Aug.  21, 1864,  with  typhoid  pneumonia, 
and  died  (September  8.  Post-mortem  examination  next  day:  Both  lungs  weri^  congested  and  several  lobules  of  the 
lower  hdie  of  the  right  lung  were  hepatized.     The  mitral  valve  was  thickened.     The  liver  was  somewhat  softened; 


Helioiype. 


James  R,  Os^cod  tSr*  Co..,  Boston. 


THICKENED     FEVER'S     PATCHES. 
No.  3S0.    MEDICAL   SIXTION. 


THE   CONTINUED    FF.VKRS. 

the  8])leen  and  kidneys  normal.     Tlio  nincous  nienilnano  of  the  h)wer  portion  of  the  ilenin  was  di'ej)ly  congested, 
softened  and  presented  a  nunilier  of  iilceis. — Fiild  Uosj>itiil,  C'hattunoinjK,  Tiiiii. 

Case  360. — Private  Kley  Hall,  Co.  D,  3d  Va.  Cav.;  age  17;  was  admitted  Dec.  27,  INil,  with  pneumonia  of  the 
left  lung,  and  died  .Jan.  (i,  186.^.  ront-morttm  examination  twenty-four  hours  after  death :  About  three  ounces  of  liquid 
and  .some  recent  adhesions  in  each  pleural  cavity;  lower  lolie  of  I'acli  lung  deeply  congested  and  slightly  hepati/ed. 
Heart  and  liver  normal;  s]deen  large  aiul  soft  :  kidneys  congested.  I'ei  itoneal  cavity  containing  a  liout  two  pints  of  a 
turbid  liiiuid;  ileum  above  the  ileo-ca'cal  valve  presenting  numy  deep  and  large  ulcers,  oin^  of  which  had  perforated 
the  gut;  colon  slightly  ulcerated. — .let.  Jss'l  Suiij.  li.  IS.  MHi'n,  ■liirvix  Ilanpittd,  Baltiinuri',  .)/</. 

(i/.)    Dirijitioxin:   I'l  rildiiitix. 

C.vsE  301. — Private  William  Riley,  alias  Cohen,  Co.  C,  11th  Conn.,  was  ailmitted  Feb.  13,  ISti."),  with  peritonitis. 
Large  doses  of  anodynes  weie  given  per  rectum,  the  stomach  being  too  irritable  to  retain  anything.  He  died 
on  the  17th.  I'ost-miirUm  examination  live  hours  after  death:  Peritoneum  thickened  and  iuliamed.  containing  twelve 
ounces  of  pale  serum;  small  intestine  adherent  liy  bands  tif  lymph:  lower  ileum  show  lug  many  large,  deep,  iriegular 
ulcers  and  containing  three  living  lumbrlcoid  worms:  large  intestine  iiillamed  and  In  the  ri'ctum  presi-nting  ulcerated 
hemorrhoidal  tumors;   liver  normal:  spleen  enlarged:  kidneys  small. —  Third  Diiiaioii  IloxpHtil,  .llciiiiulriii,  I'li. 

(C.)    CoMJITION  OK    PkYEK'.S    I'ATCIIES  NOT   .STATEl^;    THE    INTESTl.N.VI.   MICOIS    ME.MliUANE  NOT  ll.CEliATEU 1  CASES. 

(<i.)   Diai/Honis:  I'lieumonia. 

Ca.se  362. — Private  (iarrison  North,  Co.  K,  oth  Mich,  ('av.;  admitted  March  2.">,  18t)3.  I>iagiu)sis — |)iuum<uiia. 
Died  April  9  of  typhoid  fever.  i'()«<-mtir(cwi  examination  two  hours  after  death:  Hrain  forty-seven  ounces.  Kiglit  lung 
eighteen  ounces, some  pleuritic  adhesions  of  ujiper  lobe;  left  lung  twenty-ounces,  lower  lobe  much  cong<^sted  :  bionclii 
of  both  lungs,  especially  of  upper  hdjes,  thickeiu'd  and  imlurated,  feeling  on  section  like  nodules.  Heart  thirteen 
ounces  and  a  half.  Liver  eighty  ouiu;es,  daik-pur|ile,  a<lherent  to  diaphragm,  acini  not  well  marked,  cajisule  easily 
tiuii;  two  drachms  and  a  half  of  ]>ale  bile,  w  Ith  while  llakes,  in  gall-bladder;  s]ileen  fourteen  ounces  and  a  half, 
slate-colored  externally,  mulberry  colored  Intel ually,  sid'teiu'il.  Stomach  of  a  d<dlcate  pink  color;  duodenum  anil 
jejunum  yellowish,  mucous  membraiu'  tough  ;  aleum  pink,  miu-li  congested,  ami  solitary  glands  enlarged,  especially  in 
the  lower  part.  Large  intestiiu'  greenish  at  the  ca'cum  and  rather  jiale  in  other  parts,  with  hy]iei;emic  spots  irregu- 
larly distributed  over  the  stirface;  solitary  glands  dotted  with  black  pigment. — Ass't  Siinj.  Uiirrinon  Allen,  U.  S.  A., 
Lincoln  Ilospital,  Washington,  D.  C. 

Case  363. — Klim  Bess,  Mo.,  guerilla;  age  30:  was  admitted  Nov.  2,  1S64,  with  typhoid  pneumonia:  Tongue  dry, 
slightly  furred  and  red,  bowels  regular,  pulse  100;  he  had  no  cough  or  expectoration,  nor  did  he  complain  of  i)ain 
or  <liscoiufort,  but  was  so  drowsy  he  could  not  be  aroused  to  give  his  history;  the  lower  lobe  of  his  right  lung  was 
considered  to  be  hepatized.  During  the  last  two  or  three  days  of  life  the  bowels  were  tympanitic  and  tender.  He 
died  December  2.  J'osl-niorttm  examination  two  hours  after  death:  Lower  lobe  of  light  lung  hepatized;  spleen 
enlarged  and  softened ;  mesentery  intlamed  and  glands  much  enlarged:  solitary  glands  disorganized:  Imwels  e(ui- 
gested. — .1(7.  .hs't  tiurij.  H.  ('.  Niwkirk,  Hock  Island  Ilospital,  III. 

(h.)   Diaynosis:  Ilheunialisni. 

Case  361. — Private  Salem  lirocket,  1st  Kans.  Kat'y;  age  16;  admitted  June  9,  l^fil.  A  liniment  of  lluid  extract 
of  acoirite,  ehloiolbrm  and  tincture  of  camphor  gave  relief:  but  typhoitl  symiitoms  supervened,  with  cough,  pain  in 
the  right  side  ami  expectoial  Ion  of  leiuicious  mucus;  the  stools  were  passed  involuntarily.  Pills  of  acetate  of  lead 
and  opium  were  given  with  carbonate  of  ammonia  and  brandy.  He  failed  gradually,  became  deliiious  and  dieil  on 
the  20th.  I'osl-morliiii  examination:  Jjungs  much  congested,  right  iiartially  adherent ;  pericardium  containing  two 
ounces  of  serum;  liver  and  spleen  enlarged,^  lower  ileum  intlamed;  kidneys  nearly  double  thenormal  size. — Hospital 
No.  X,  Nashville,  Tenn. 

Case  36,"). — Private  Aaron  Dudley,  Co.  E,  3l8t  Me.;  age  31;  was  admitted  June  6,  1861,  with  rheumatism,  and 
died  of  tyidioid  fever  Aiignsl  S.  I'osl-niortim  examination  twenty-four  hours  after  death:  Lungs  coiigcstnl  poste- 
riorly; liver  iKirmal :  gall  bladder  distended;  kidneys  much  congested:  spleen  large  and  rather  soft;  intestines  con- 
gested in  spots;  ileum  near  the  ileo-ca'cal  valve  much  congested  and  presenting  many  ecchymoses;  mesenteric  glands 
very  iiiiich  enlarged. — Act.  Ass't  .S/ov/.  />'.  B.  Milts,  Jiirvis  Hospital,  Baltimore,  Md. 

(D.)    I'EYEli'S    PATCHES    VAKIOUSLV    STATED,  HUT   NOT    ll.CEUATEU — 12   CASES. 

(a.)  I'eijer'x  patches  healthy. 
iJiaynosis :  luterniittenl. 

Case  366. — Private  Francis  F>leakley,  Co.  E,  6th  Pa.  Heavy  Art.;  age  21 ;  was  admitted  Oct.  10, 1861.  with  liiter- 
nutteul  level.  He  died  November  11  of  typhoid  fever.  I'ost-Mortem  examination  thirty  hours  after  death:  I'.mac  la- 
tlou;  bedsores  and  sugglllatlon  posteriorly.  Kiglit  lung  uormal  anteriorly,  congested  and  indurated  postci  ii.ily, 
spleiiilied  in  a.  small  portion  id'  the  lower  lobe;  left  lung  normal  In  Its  up|iei  but  congested  in  its  lower  lobe.  Lowci 
ili'iiiM  iiiugested  in  )>atche8,  but  Peyer's  ])atclies  were  healthy.  Kidneys  slightly  congested ;  pancreas,  liver  ami 
spli'cii  normal. — .ict.  Ass't  Snr(j.  Thomas  Boaeu,  fiecond  Dirision  Hospital,  Alexandria,  Va. 

lliaiiiiiisix :    I'l  rihtnitis. 

Cask  367. — Private  James  Wynii,  (  o.  D.  17r>tli  Pa.:  ailmitted  .liily  (i,  1X63,  with  fever  and  l>eritoiiitis.  I)ied 
7th.  I'ost-mortem  examination:  15ody  not  much  emaciated.  Lungs  and  heart  healthy.  Liver  large  and  mottled, 
adherent  to  the  diaphragm  and  intestines.     The  cavity  of  the  alidomen  contained  much  yellowish  serum  In  which 


414  POST-MOKTEM    RECORPS   OF 

flaken  (if  yi'llowisli  lyiiipli  tliiiiit!<l.  Tlie  iiitf.stiins  w.ri'  iii.jectt-il  and  iuteiadbeieut  liy  leceiit  Ijiiiph;  the  mesenteric 
glaiiils  iiiMcli  <Milarf;>'<l  and  tin'  nifscnteiy  tliickcncd;  the  ileum  \vii«  uliglitly  injected  iind  jiiesentcd  in  its  lower 
portion  two  pei  loiatinj;  nlc'cis,  one  as  Iarj;e  as  a  ])ea,  tlie  other  the  size  of  a  ten-eent  piece;  IVyer's  ^hiuds  were 
free  from  (lis<Mse. — Jvl.  ./.sv/  Sin-;/.  I.lot/d  Diirxn/,  Han  irnnd  ffonpittil,  U'lixhiiigloii,  l>.  C. 

(  h.)  I'liii !■'■■<  iiatdtia  ihirkinid  mid  jirDiiiiiitnl. 
I)iiii/nn!.i/i :    I't  riidrilili:*. 

Cask  :1(>S. — Hiram  Hailey,  coU)red:  age  >\ ;  was  admitteil  <in  the  eveninj;  of  Pec.  22,  ISii."),  comphiiniiig  of  pain 
in  the  stoniach  and  howels.  He  came  to  liospital  on  fool  williont  apparent  diHi<  iilty.  A  dose  id" opium,  w  itii  ginyer 
ami  capsicum,  was  a<l ministered  and  lie  rested  well  dnrini;'  the  niglit.  Next  day  cat  hai  tic  pills  were  j;i\t'iL.  witli  castor 
oil  in  the  evening.  On  the  2 It h  the  patient  hail  a.  copious  stool,  hut  in  t  he  nu'antiiue  lie  had  fallen  into  a  lethargic  con- 
dition; eyes  open  and  staring;  pulse  W,  weal<;  skin  natural;  head  cool :  mucous  rales  heard  oM'r  the  huge  lirouchi ; 
chest  resonani;  no  swelling  or  tenderness  of  the  alxlomen.  t^uinine  was  given  freely  anil  at  short  intervals,  with 
ninstard  to  the  spine,  feet  and  chest,  hut  death  took  place  on  the  morning  of  the  2."i|li.  I'o>^l-iiiiiiii m  e.xaiiiination 
six  hours  after  ileath:  The  hrain  was  noriiial.  The  right  plenral  sac  contained  ten  oiiiiccs  of  serum;  the  lungs  were 
normal  hnt  for  Hie  presence  of  a  few  scattered  tiiliendes.  The  pericardinni  and  heart  were  Hriiily  adherent  except 
at  a  small  space  where  was  an  ounce  of  seiiini:  the  heart  substance  wa.s  normal.  The  liver  and  spleen  were  somewhat 
enlarged.  In  the  ileum  several  of  I'eycr"s  patches  were  slightly  elevated  and  (|nite  dark,  nearly  lilack  in  color.  The 
other  abdominal  viscera  were  normal. — /.'Oiirerliirf  i/wsjiito/,  Aluiiiidrid.  Vn. 

DiKgnonix :  PUiirisi/. 

Cask  'M'.K — Private  Charles  A.  Hoadley,  Co.  I,  ;id  Vt.,  was  admitted  .Ian.  2,  iHii'A,  with  pleurisy,  and  died  on  the 
8tli.  riixl-miirliiii  examination  thirty -si.v  hours  after  death:  The  brain  weighed  forty-seven  ounces.  The  right  lung 
weighed  lifty  ounces ;  between  its  lolies  was  a  deposit  of  yellowish  semi-organized  fibrinous  lymph ;  jiosteriorly  it  was 
consolidated  and  in  jiart  hepatized,  the  consolidated  jiortioiis  being  readily  reduced  to  a  pulp  and  exuding  a  reddish- 
gray  iiiiiiiloid  nialtci.  The  left  lung  weiglicd  tifty-two  ounces;  its  lower  lobe  and  the  lower  and  posterior  portions 
of  its  upper  lobe  were  inliltrated  with  iiuruloid  matter.  The  right  auricle  of  the  heart  contained  a  lilirinoiis  clot 
which  extended  thnuigh  the  ventricle  into  the  pulmonary  artery:  tlffe  left  cavities  contained  a  black  clot;  abmit 
the  middle  of  the  thoracic  aorta  were  some  transverse  yellow  bands  which  were  supposi'd  to  be  atheromatous.  The 
liver,  sixty-nine  ounces,  was  tinely  mottled  and  of  a  light  reddish-brown  color;  the  splei'U,  nine  ounces,  was  light- 
colored,  hardened  in  small  portions  and  .softened  near  the  hiliis,  whence  a  thick  reddish  piiiuloid  matter  was  readily 
pressed;  the  right  kidney  weighed  seven  ounces,  tin:  left  six  ounces  and  a  half.  The  stomach  was  softened  and  con- 
gested; the  , jejunum  was  irregularly  congested  towards  its  termiiiiitioii ;  the  ileum  was  very  thin  and  there  were 
spots  of  intense  congestion  in  its  middle  third;  Peyer's  jiatehes  were  enormously  thickened,  especially  towards  the 
cieeuni. — Ans't  »S'/o;/.  Cvonji'  M.  McdiU,  U.  S.  A.,  lAiiiolii  Ilosjiital,  If'iinhiinjtuii,  1>.  V. 

DiidiHtixi" :   Pnniinoiiia. 

Cask  37(1. — Private  ,Iolin  Mosiier,  Co.  B,  119th  N.  Y.,  was  admitted  .Jan.  18,  1<S()3,  with  typhoid  |iiieiinionia.  The 
patient  was  very  deaf  and  almost  unconscious;  his  skin  was  hot  and  -.iry,  respiration  hurried,  tongue  dry  and  ]iulse 
95;  there  was  dulness  on  percussion  and  line  crepitation  on  the  right  side  of  the  chest,  lie  was  ordeicd  blue  ]iill, 
ipecacnanliaand  tartar  emetic  in  small  doses  with  dry  cups  to  the  chest.  On  the22d  the  tongue  becamediyer.  the  piil.-,e 
more  rapid  and  the  expectoration  bloody  and  of  a  dark  color.  Stimulants  and  beef-csstmce  were  employed,  with  a 
blister  to  the  right  side,  but  they  were  unavailing:  death  took  place  on  the  2Ttli.  Ptnil-mnili  m  cxamiual  ion  four  hoiiis 
after  death:  ISody  tiiiely  develo|ied.  The  brain  weighed  forty-nine  ounces  and  a  half.  The  right  Inngweighed  thirty 
two  ounces  and  a  quarter,  the  left  twenty-eight  and  a  half;  the  right  lung  was  much  congested,  the  lower  iiait  of 
its  upper  lobe  in  the  static  of  gray  hepatization  and  parts  of  its  lower  lobe  in  the  state  of  red  hepatization; 
the  lobes  of  the  left  lung  were  iuteradhereut,  the  lower  congested  and  partly  soliditied;  the  bronchial  glands  were 
large, soft  and  blade.  The  heart  weighcduine  ounces;  there  was  much  adipose  tissue  about  the  auriculo-veiitrieiilar 
rings;  the  cavities  on  both  sides  contained  small  clots.  The  liver  weighed  eighty  ounces,  its  acini  were  distinct; 
the  spleen  weighed  nijie  ounces  and  a  half;  the  right  kidney  eight  ounces,  the  left  seven  and  three-iinarters.  The 
fundus  of  the  stomach  was  extremely  congested,  as  was  the  mucous  membrane  of  the  whole  intestinal  tract;  in 
the  lower  part  of  the  large  intestine  the  congestion  was  so  inten.se  as  to  resemble  ecchymosis;  the  glands  of  Peyer 
were  large. — .i«*'/  SHrg.  Geortje  M.  McGill,  U.  S.  A.,  Linmln  Hospilut,  IViifhingtoii,  D.  C. 

Cask  371. — Private  .Tolin  Beaton,  Co.  D,  1st  Vt.  Cav.;  admitted  Nov.  2,  18G2,  with  typhoid  iineiimonia:  Hot  dry 
skin,  pulse  H't,  coiiipressible,  tongue  coated  with  brown  fur,  nioilerate  diarrhtea,  sndamina  profusely  distributed  about 
the  neck  and  thorax,  gurgling  and  some  tenderness  in  the  right  iliac  region,  dry  cough,  severe  dyspinea  and  almost 
complete  aphonia;  dulness  on  |iercu.ssion  and  bronchial  respiration  over  the  lower  portion  of  both  lung.s;  no  rose- 
colored  s)iots.  Treatment:  .Small  doses  of  calomel,  ipecacuanha  and  opium;  dry  cups  and  turpentine  stupes  to  the 
chest;  a  mustard  cala]ilasm  to  the  abdomen.  l>icil  5th.  I'osl-inorlcm  examination  eigliteen  hours  aCler  death:  The 
lower  portion  of  both  lungs  was  hejiatized.  The  heart,  stonia(!h,  s)ileen,  liver,  kidneys  and  large  intestine  were  nor- 
mal.    The  glands  of  Peyer  were  enlarged  and  intlanicd. — Tliiril  Dirisioii  Ilonpiial,  Ab  riindr'M,  la. 

Cask  ;j72.— Private  Charles  Whitten,  Co.  K,  2(ltli  Me.;  age  Hi;  was  admitted  Nov.  IH,  1S62,  with  typhoid  pueu- 
iniuiia.  He  complained  of  a  dull  ]iain  below  the  right  nipple ;  his  pul.se  was  fiei|Ueiit  and  feeble  ;  his  tongue  covet ed 
with  a  white  fur:  skin  hot  and  dry;  bowels  coiistijiated.  There  was  dulness  on  [icrciission  over  the  right  side,  and 
crepitus  was  distinctly  heard  both  anteriorly  and  [losteriorly.  .Small  doses  of  calomel,  opium  and  i]iecacuanha  were 
given,  with  dry  cnjis  to  the  right  side  of  the  chest.     In  the  progress  of  the  case  the  cough  became  more  troublesome 


THE    rONTTNrKD    FEVERS.  415 

and  tlip  icspiiation  liuniod:  diarihua  siiiperveiied.  aO((iiii|iaiiir(l  liy  Kitat  tyiiiiiaiiitis  of  the  alidmiifii ;  tlif  toiijjue 
Ipecaiiif  dry  and  tissuicd  and  tin-  \i\<s  an(\  trt-rli  cdveii-d  with  kukIis.  Stininlants  wen-  fifcly  adiriiiiistoicd.  lint  he 
dii'<l  on  the  2lith.  Posl-mnrti m  cxaiMination  :  'I'lic  siiiface  of  tlii'  l>iidy  was  liluish  fidm  i'a|iillary  I'lpn^csticni  :  the 
ahdonirn  tnniid.  The  Mppor  h  plies  of  lp<pth  Inn.^s  were  eiin;;esteil  ami  the  hiwcr  Jul  pes,  with  the  niichlle  hilie  (in  the  ri^ht 
side,  ht'iiatized.  The  stuniaeh  and  eiihin  were  immensely  disleniled  with  i;as;  the  miK'iiiis  memlnaiie  nf  I  lie  small 
intestine  was  hij;hly  injeeted;  the  ;;lands  iif  I'eyer  enlar.i;ed.  The  liver,  spleen  and  kidneys  appealed  to  he  normal. 
— Third  l>irini(in  Hix^jiihil,  Alixaitdrin,  In. 

(c.)    rtfiir's  jiiilchiK  vDiiijefitfil  or  iiillidiud. 
Ditignoais :   nhiitmathm . 

C'.\SE  3T;>.— Private  James  MaUin.  Cip.  1!.  iL'lth  fa.:  ajle  alpioil  L'.'i:  admitted  Dee.  2(!.  IKtW.  Hn-d  Keli.  17.  ISliH. 
Vost-niiirttm  eNamination  torty-eiijihl  minntes  after  death:  Uiuor  mentis  marked;  hypostasis  jjeni'ial.  Mr:iin  foity- 
fonr  onnees.  lii;ht-e(phired.  moderately  tirm.  Pharynx  |pnrple.  eoiijii'sti'd;  tipnsils  yellow,  eiilariji'd  to  thi'  size  of  an 
alnupiid.  Ki>;lit  liin;;  twenty  onnees,  left  seventeen  and  a  half,  c'on^ested :  lironehial  };lands  lilark.  Ile;irt  eleven 
ounces  and  tliree-(|uaiters;  lilprinoiis  clots  in  lp(pth  sides  exti'iidiiif;  into  vessels.  Liver  sixly-i'iy;ht  ounces,  liKht-eol- 
ored,  firm;  <;all-liladder  lif;ht-c<plored,  coiilainiu^  seveiiieeii  diaclinis  of  watery  liile:  spleen  seventeen  oiineen  and  a 
qnarter,  soft,  of  a  dark-purple  eoloi',  intensely  c<ini;i's|cd  ;  pancreas  lliiee  ounces  and  a  half,  dai  k-cohired,  sliijlitly 
coni;i'sted.  Diiodeiinm  slifjlitly  eon;;ested,  stained  with  Idle,  valvula'  thinned:  jejuniini  li<;ht  lirow  iiisli-yellovv, 
thinned  in  lower  two-thirds,  solitary  inlands  slij^htly  eiilart;ed  in  upper  third:  ileum  thinned,  solitary  glands  sipnie- 
wlial  enlarj;ed  and  I'eyer's  patches  in  u]ip(^r  third  slii;li|ly  conf;ested:  hirfje  inti'stine  j;euerally  e(pni;ested.  Supra- 
renal capsules  lij;lit-eohpred,  soft,  decidedly  fatly:  rifjlit  kidney  six  ounces  ami  a  ipiarter,  left  six  and  lhrei'-((uarter8, 
somewhat  coufjesti'd. — ./««'/  Surij.  (jiunjr  M.  Mi:(lill,  I'.  S.  A.,  Liniolii  Ho!<pil<il,  Wiinliiuijlon,  It.  C. 

DitifinosiH  :   Dhirrhiru. 

Cask  371.— Private  Cyrus  (i.  ChattiMton,  Co.  C,2Uh  N.  Y.  Cav.,  was  admitted  .Inly  21,  18t>l.  He  was  tjreatly 
emaciated,  having  snlVcred  from  diarrliiea  for  some  time.  The  stools  wi'ie  l'ri'(|iwiil,  i|uite  watery.  I'lay-colored  and 
aecomiianied  with  ;;riliinK  pains  in  the  alidonuii:  he  liail  no  .'ippctite;  his  tonf;ii<>  was  red  and  lia<l  marked  eleva- 
tions of  tlii^  pajiilhe:  pulse  100  iind  very  we;ik.  In  a  few  days  the  passaijes  liecame  less  fre(|uenl  and  of  a  dark-jjreeii 
color.  Iiiil  all  lioniih  I  liiis  iniprovin;^  he  coiil  iiiiicil  depressed  in  mind.  <  In  .\ii,i;iisl  :>  I  he  iif;lil  side  of  I  he  face  ln'eaine 
nil  I  ell  swollen  and  I  lie  villus  swollen  and  red  liul  mil  Ipl.'cdin};.  I  he  •;cneial  a|ipeai:nic  e  of  I  hi'  pa  lien  I  lifiiii;  scoilmtic. 
Chloiale  (pf  polasli  was  niven  internally  ami  as  a  wash.  Next  day  he  had  miicli  dillicully  in  opcniii;;  his  month, 
and  <'omplained  of  sore  lliroal  :  the  fances  lieciiiiie  much  inllaincd,  the  Imisils  covered  with  pseiido-memlprane,  por- 
tions of  which  wi'rc  expecloiated,  and  ninciiiis  lah's  wric  dr\clnpid  in  I  hr  chcsl.  Ili^  die<l  on  the  lith.  /'ii.s7- 
iiinrhiii  examili.'ll  ion  :  liody  \'ery  mucli  em.icialed.  The  larynx  .and  faiicis  were  eiivried  with  palchesof  false  meni- 
Ipranc.  The  ri>;ht  liiiit;  was  slightly  adhcicnl  ;  the  left  Inn^  and  hear!  normal.  The  liver  was  normal;  the  spleen 
measured  live  imdies  and  a  Inilf  liy  four  inches:  the  rij;lil  kidney  was  seven  inches  and  a  half  Ion;;,  ils  siilpstanee  firm 
and  healthy:  lln'  left  kidney  ami  suprarenal  capsule  \ver<!  alisent,  their  place  Ipcin;;  ipciaipied  liy  a  closed  I'vst,  one 
inch  and  a  half  loiii;,  in  which  no  kidney  slrMcliuc  could  be  detei;ted.  I'eyer's  ]palehes  were  much  inllamed;  the 
mesciilfnc  ;;lands  hcallhy. — .Id.  .hs'l  >'i()v/.  /■,'.  Diirid,  luiirfitx  iSeminiirii  lloxpihil.  I'n. 

Cask  ;{7ri. — Private  ]'",lias  Zimmerman.  Co.  D,  IStli  Pa.;  a;;e  IS;  adniillid  .Inly  21,  ISlil.  from  Cil>  Point  hos- 
IPital,  Va.  Died  Aiinnst  "i.  I'lisl-niiirlnii  cxaminal  iipu  :  iSody  much  einacialed.  I'eyer's  palchrs  inllanied;  solitary 
follioles  exlt^isively  ulcerated.      Other  organs  normal. — .til.  .Inu'l  Siiri/.  <l.  11'.  i'lrr.  Fiiirfiij-  Si miiKirii  llnnpilitl,  \'a. 

Cash  :!7li. — Private  Franklin  D(>n;;herty.  ('o.  D,  KlOth  Pa.:  a^e  \X:  admiltcd  .Inly  Tp,  1,S(;1.  with  chionic  rhen- 
matisni  and  diarrhoa.  lli^  was  (^(Uisideralply  cniaci:ited,  ha<l  anorexia  and  sevens  diarrluea,  with  pul.se  weak  and 
frei|iient  and  ton^ne  coated  in  the  centre  with  a  thick  f^ray  fnr;  the  left  parotid  was  p.iinfiil  and  mmh  swolli'U. 
The  ]panptid  abscess  was  cppemd  on  the  l.-pth  anil  a  small  i|uantity  of  dark  fetid  pus  was  obl.iined;  meanwhile  the 
diarrluea  persisted  and  the  patient  seemed  to  be  sinkin,^  ijradnally;  he  had  a  slight  remission  of  fi'ver  in  the  fore- 
lupon  of  evi'iy  day.  In  the  progress  of  the  case  the  inte;i;iiinents  eovi^rini;-  the  parol  id  shiiii;liid.  ilc'iirinm  set  in.  at 
first  chielly  at  nijchl,his  face  became  more  lluslied  and  the  daily  remissions  less  marki'd.  Il<!  died  un  llir  22d.  I'-i.sl- 
mnrlim  cx.nnination  si.x  hours  after  death:  JSody  greatly  emaciated,  rigor  mortis  well  marked.  ].niigs  much  con- 
gested, heart  pale  and  Habby.  Liver  slightly  congested;  gall-bladder  distended  with  bile:  s]pleen  enlarged  and  pale; 
kidneys  healthy.  Stomach  reddened  in  patches,  whieli  were  more  numerous  ne;ir  the  pylorus;  duodenum  :ind  .jeju- 
num healthy;  Peyer's  glands  congested  slightly  in  the  upper  portion  of  the  ileum  and  the  solitary  follicles  in  the 
]ower  porticpu  considerably  enlarged,  many  luiving  incipient  ulcers  on  their  sumniils.  Miieons  meinbrane  of  the 
large  intestine  puckered,  softeneil  and  presenting  several  small  ulcers  In  the  ca'ciun  and  in  llie  lower  portion  of  the 
descending  colipii.  Fpper  jpipition  of  left  pariptid  gland  exjioscd  by  sloughing  of  integument  and  snperlicial  fascia; 
dark  fetid  jpiis  had  biirrowi'd  :i  short  distance  dipwn  the  side  cpf  the  neck.  \SiiiTimiiix  lis.")  lo  :J;)ii,  .Mid.  Sect..  .\iin\ 
Medical  .Mnsenm,  are  from  this  case.] — .ivt.  A.tn't  tiitrij.  I),  /'.  liieicl,  Cdrrcr  JJmiiihd,  Wanhimjlun,  I).  C. 

\n  didipinsix  :    Dralli  frniii  Imirl-t'liit. 

Case  .■!77. — Private  Nicholas  Sassaman,  Co.  E,  ."pOtli  Pa.,  was  admitted  (l<.t.  11.  l.'«:i;i,  al  noon.  His  ]inlse  was 
weak  and  intermittent,  breathing  hurried,  diliiciilt  and  mainly  alidoininal:  his  extiemities  were  cold  and  he  co'  i- 
plained  of  se\  ere  pain  o\er  the  pracordia  and  rpig.isi  i  jnm.  In  I  lie  e\  cuing  i  wo  wel  enps  were  apjilied  o\  ii  i  :r|i 
hing,  after  uhiili  In-  arose  from  lied  and  walked  to  tlu'  chair  to  stool:  he  expiriMl  as  he  sat  down.  I'lixl-iiinrlnit 
examinatiipu  ten  Ikpuis  after  death  :  I'.ody  well  developed  and  not  emaciated;  rigoi'  mortis  strongly  marked.  There 
were   (pld   jpleuritic   adhesions  on  the   right   side;  the  lower  lobe  of  the  lung  was  congested,  the   upper  contp.inetl 


416  POST-MO RTl•;^t   rkcokps  of 

tnlierclen;  the  li'fl  Iiinj;  was  bcaltliv.  Tlit!  lit'art  \vci};lir<i  (wohc  (miihi's  anil  a  half;  tihriiiDus  clots  were  found  in 
the  right  ventricle,  the  walls  of  which  were  hypertroi>hie(l;  the  mitral  valve  was  thickened  and  its  light  segment 
stndded  on  the  margin  with  ronndish  tihrLiious  bodies,  some  aliont  the  Ki/e  of  a  jiin-head,  others  as  large  as  a  pea. 
The  liver  was  enlarged  and  fatty;  the  spleen  was  triple  its  normal  size  and  mottled  with  sjiots  surrounded  by  red 
dish  areola',  exuding  on  section  a  sero-puruli!nt  liquid;  the  kidneys  were  enlargol  and  fatty.  I'eyei's  patches  weie 
indanied  and  the  meseuteric  glands  enlarged. — Armory  Square  Ut»i])il(tl,  H'dxhiiirjtoii,  I).  C. 

Of  the  above  seventy-nine  cases,  /'or/y-Zwo  in  wliicli  Peyer's  patches  were  ulcerated, 
and  tiventy-one  in  whicli  the  ileum  was  idcerated,  may  bo  set  aside  as  being  tlistinctly  or 
probably  cases  of  tyi)hoid  lever.  In  four,  3G2-3G5,  of  the  remaining  nixleoi  tlie  intes- 
tinal lining  was  congested  or  iiiHamed.  It  is  not  stated  that  tin'  nicndjrane  was  not  ulcer- 
ated or  that  Peyer's  patches  were  7iot  afiected;  for  ilieae  posl-))wHem  records  seldom  embody 
negative  evidence  in  terms  so  positive.  It  must  be  inferred  that  if  the  membrane  had  been 
ulcerated  the  imjuirer  who  noted  its  ecchymosed  condition  would  have  observed  its  ulcer- 
ation, and  that  had  the  agmiiiated  glands  been  implicated  the  anatomist  who  took  note  ol 
the  enlarged,  pigmented  and  disorganized  condition  of  the  solitaiy  foUirlos  would  not  have 
overlooked  the  condition  of  the  others,  particularly  in  cases  in  whii.'h  typhoid  fever  was  in 
questicjn.  Now,  as  there  was  no  posf-morfcin  evidence  of  typlujid  fever  in  these  cases,  the 
change  in  the  diagnosis  must  have  been  occasioned  by  the  occurrcMice  of  typhoid  symj)- 
toins,  /.  e.,  in  tliesc  cases  typhoid  symptoms  were  pn'escnt  although  typhoid  fever  was  not. 
Of  the  remaining  twelve  cases  five,  3(58—372,  presented  ap[ioarances  of  tlu^  patclies  consistent 
with  the  theory  of  tleath  at  an  early  period  of  the  progress  of  typhoid  fever;  but  in  the 
others  the  presence  of  that  fever  cannot  be  considi'red  established:  In  ^>66  and  3G7  Peyer  s 
glands  were  healthy.  In  373-377  they  are  said  to  have  been  congested  or  inflamed,  but 
this  condition  alone  may  imt  !»>  acce|>ted  as  pathognomonic  of  typhoid,  since  in  376  the 
ulceration  of  the  solitarv  follicles,  with  whicli  it  was  associated,  wliile  giving  assurance  that 
had  the  patches  been  ulcerated  their  condition  would  have  been  stated,  indicates  that  the 
patient  had  lived  long  enough  for  this  change  to  have  taken  place;  indeed  the  prolonged 
duration  of  the  fatal  illness  is  sutHciently  attested  by  tlie  ilisorganization  of  the  parotid 
glands.  But  foi' the  congestion  of  the  agminated  glands  the  case  of  death  from  heart-clot, 
377,  would  have  found  place  in  the  malarial  series  in  c(jmpany  with  its  cases  95  and  96. 

In  the  absence  of  clinical  histories  it  is  impossible  in  many  cases  of  the  above  series 
to  sav  whether  the  change  in  the  diagnosis  was  based  on  clinical  or  j)ost-iiiortem  consid- 
ei'ations.  It  is  certain,  however,  that  in  sixty-eight  of  the  seventy-nine  cases  the  pod- 
morteiib  lesions  authorized  the  change,  while  in  eleven  their  testimony  was  less  positive. 
In  some  of  the  latter  clinical  observation  must  have  suggested  the  presence  of  typhoid 
fever,  as  the  intestinal  appearances  were  inadequate  to  sustain  the  diagnosis,  but  in  others 
the  presence  of  typhoid  seems  to  have  been  based  on  a  mistaken  view  of  the  impoi-t  ol 
these  appearances. 

A  few  cases  illustrative  of  accidents  in  tlu'  course  of  ty[)hoid  fever  or  morbid  condi- 
tions lollowing  it  complete  the  pod-niortem,  records  of  cases  reported  under  this  liradmg; 
but  from  the  condition  of  tin;  intestines  in  some  of  these  cases  it  is  doubtful  if  tvplioul 
was  the  antecedent  fever. 

Case  378. — Limibricoid  udrm  in  larynx. — Private  .Jose]di  .Shnman.  Co.  M,  1st  N.  J.  Cav.;  age  17;  was  admitted 
Jan.  Ill,  18t)4.  with  typhoid  fever.  The  patient  was  doing  very  well  under  tonics  and  stimulants  when,  on  the  18th. 
he  suddenly  died  as|diyNiated.  At  tlie  autopsy  a  Inmbricoid  worm  nine  inches  long  was  found  extending  from  the 
trachea  into  the  right  liroiic'lnis. — (See  upecimKii  290,  Med.  Sect..  Ainiy  Medical  Mmscmiii. ]—.(<•/.  A^s't  Siiri/.  S.  I!.  Wiird, 
Third  Dirisioii  Hoipihil,  Alijumhia.  Id. 

Cask  379. — Smldcii  diiilh  diiriiuj  coiinile-icnirt  :  hiort-rlol :  rerehriil  loin/i'^linn. — l'ri\ale  .lames  F.  Wilson,  Co.  C. 
16th  Me.;    age  21;   was  admitted  Feb.  H,  1865,  convalescing  from  typhoid  fever.     He  had  a  slight  cough,  liut  was 


THK    COKTINfKD    KKVKRS.  "  417 

otiienvisc  well  and  coiitiiiiR-d  to  tjaiii  htroujitli  until  tlic  21tl].  At  3  A.  M.  on  this  day  the  nurse,  in  ))a.ssin{;  tliiough 
th<^  \vaid,lo"nd  liini  awake,  put  tlie  blankets  over  him  and  gave  hini  siinie  water  to  drink.  He  was  then  well.  Tliree 
Iiours  later  he  was  toiinil  dead,  having  ai>]>ai'cntly  died  without  a  struggle.  I'dnl-morlim  exaniiiiatiou :  No  llvidlty 
about  till-  fai-e;  ]iiii>ils  dilated;  rigor  mortis  well  m.nkiil  on  the  right  side,  slight  on  the  left.  A  eoiisideralde  quan- 
tity of  venous  blood  eseaped  on  ojn-ning  the  eraniuui :  some  I'xudatiou  was  found  on  the  araeliuoid;  the  sub.stanco 
of  tho  cerebrum  and  eerebellnm  w  as  highly  engorged,  and  liriglit  blood  willed  iij)  in  unusual  (juautities  when  sec- 
tions were  made;  the  lateral  ventricles  were  distended  with  a  sero-sanguiin(Uis  li(juid.  The  lower  lobe  of  the  riglit 
lung  was  engorged.  The  right  ventricle  contained  a  large  tibriuous  clot.  Jhcre  were?  no  other  unusual  appear- 
aiiees. — Acl.  Ans't  Siirij.  11'.  Koiqiati r,  I'aitcrt^oii  I'liik  Jluspita},  ISaltUnuir,  Md. 

Case  380. — Dixtriiclirc  injlaiiuiialiini  of  liiii<j.i. — Private  Kichard  11.  Nelson,  Co.  A,  Hth  Mieh.,  was  admitted  Dec. 
30,  18(52,  with  typhoid  fever.  On  Jan.  24,  IHG'.i,  heajipeared  to  be  convaleseeut  and  was  walking  about  the  ward,  eoni- 
plaining  occasionally,  however,  of  pain  in  the  riglit  side  of  the  chest.  On  February  18  he  had  heaihiehe,  slight  irrita- 
tion of  the  fauces,  constipation,  difficulty  of  micturition  and  severe  pain  in  t  he  riglit  side  of  the  chest.  He  was  ordered 
to  bed,  a  laxative  administered  and  warm  fomentations  a)iplied  to  the  chest.  Next  day,  feeding  better,  he  got  nj)  and 
went  out  of  doors,  after  which  the  pain  in  the  side  returned  and  he  began  to  cough  and  expectorate  a  miico-puruleiit 
matter.  His  cheeks  were  llnshed,  jmlse  120,  respiration  22;  a  friction  sound  with  siliilaut  rales  was  heaid  over  the 
latei'al  portion  of  the  right  lung;  the  resjiiratory  murmur  was  absent  in  front.  On  tlie22d  he  seemed  nincli  im])roved; 
the  pain  was  not  so  si'vere;  his  appetite  wasgoodaud  bowtds  regular,  but  tli<^  exiiectoration  remained  copious.  Two 
day.s  later  lie  had  chills  followed  by  fever  and  increasing  pioslralion.  He  died  Jlarcli  8.  /'()x/-Hiti/7i;/i  examination 
twenty-eight  hours  after  death:  liody  slightly  rigid,  not  emaciated;  apparent  age  21  years.  Tlit^  brain  was  healthy. 
There  was  a  white  tibrinous  clot  in  the  right  side  of  1  he  heart  extending  iiit,)  the  pulmonary  artery,  and  a  small  w  hito 
clot  with  some  dark  blood  in  the  left  side.  The  riglit  lung  weighed  thirty-four  ounces  and  a  half;  it  was  congested 
generally  and  consolidated  on  the  posterior  and  inner  part  of  itir  lower  lobe;  its  bronchial  tubes,  esjieeially  those 
proceeding  from  the  cons(didated  portions,  were  somewhat  congested  and  I'ontained  a  puruloid  matter;  its  anterior 
surface  was  coated  w  itli  a  thick  layer  of  tibrinous  lym]di  and  the  pleural  sac  eoiitaiued  sixteen  ounces  of  pus.  The 
left  lung  weighed  twenty-seven  ounces ;  iiorlioiis  of  it  w ere  cainilied;  its  broiuhial  tubes  wcri' congested  and  con- 
tained a  purulent  matter;  the  pleural  cavity  was  sacculate<l  and  contained  twenty -two  ounces  of  straw-colored  serum. 
The  liver  was  firm,  coarstdy  mottled,  of  a  light  reddish-brown  externally  anil  covered  w  itli  niinuMous  blood-spots; 
on  section  it  was  slate-colored;  the  gall-bladder  was  em)ity.  The  sjilcen,  twenty  ounces  and  three-ijuarters,  was  of 
tirin  consistence,  dark-]uir|di>  in  color  and  with  prominent  trabecuhe;  in  its  inferior  border  was  a  hard  nodule  about 
the  si/.e  of  a  ha/el-nut.  'I'lie  pancreas  was  firm  and  of  a  light-straw  color.  The  kidneys  were  of  a  puridish-slatu 
color;  tlie  sn])rareual  capsules  lirm,  large  and  of  a  reddish-ash  c(dor.  The  mesenteric  glands  were  nuudi  enlarged. 
The  stoiiiaeli  was  softeiuMl  and  congested  along  the  longitudinal  folds  and  in  the  lesser  curvature;  the  duodeiinm 
and  jejuniim  were  irregularly  congested;  the  ileum  (leci<lcdly  congested  ;  I'cyer's  palidies  aiijiareutly  healthy;  the 
S(ditary  glands  slightly  enlarged  and  congested.  'l"he  aseending  colon  and  ca'cnm  were  dilati'd.  their  mucous  mem- 
brane thill  and  soft;  the  transverse  colon  was  somewhat  contracted  and  covered  with  black  sjiecks;  tin'  sigmoid 
liexure  congested ;   the  rectum  normal. — ./««'/  Siiry.  (livri/f  M.  McCiU,  V.  <S'.  .1.,  IJticnlii  Hoxpilul,  ll'iishiiii/tuti,  J).  C. 

Cask  381. — Iiijlamiiuttinii  of  the  parotid;  jxinili/sis  and  hi/jiirantlt(«i(i  of  the  limits. — Private  .John  Parker,  Co.  li,  3d 
Ohio  Cav.,  was  admitted  JIandi  4,  18t>l,  as  a  convalescent  from  ty[ilioid  fever.  His  tongue  was  very  iniich  coated 
and  the  jiarotid  gland  was  slightly  swollen.  In  a  few  days  the  swelling  had  almost  disappeared  but  he  continued 
feelile,  lost  the  use  of  his  arms  and  legs  and  complained  when  they  were  touched;  this  sensitiveness  was  especially 
marked  in  the  right  arm  and  left  leg.  Diarrhua  set  in  on  the  11th,  w  hen  his  tongue  became  dry  and  pulse  small; 
death  took  jilace  on  the  13th.  Post-mortem  examination  eighteen  liours  after  death:  Uody  not  much  emaciated.  The 
lungs,  heart,  stomach  and  intestines  ajipeared  to  be  healthy.  The  liver  was  pale,  much  enlarged,  and  showed  evi. 
deuce  of  a  local  jieritonitis;  its  right  lobe  was  congested;  the  gall-bladder  was  empty.  Both  kidneys  were  much 
congested. — .ic(.  Asa't  Surg.  L.  A.  Walton,  SoKpital  A'o.  8,  -V((«/in7/c,  Tciin. 

Cask  382. — Psoas  abscess. — Private  S.  E.  Kobinson,  Co.  A,  3d  Md.;  age  21);  was  admitted  from  Patters<ui  Park 
hospital  .Si'pt.  21,  18til,  as  a  convalescent  from  typhoid  fever.  (Jn  the  28tli  he  had  a  chill  and  two  days  later  there 
was  pain  in  the  ujiper  part  of  the  right  thigh,  where  redness,  swelling  and  lluctuation  were  observed.  On  October  1 
llatiis  and  fa'cal  matter  were  brought  away  by  an  exploring  needle,  and  the  case  was  regarded  as  one  of  tyjdilitis 
with  perforation  and  adhesion  of  the  bowel  to  the  abdominal  walls.  A  free  incision  was  made  and  a  considerable 
(luantity  of  pus  escaped  mixed  with  fa-cal  matter.  The  xiatieut  became  delirious  on  the  4th  and  had  obstinate  hic- 
cough. He  died  on  the  (ith,  after  having  been  unconscious  for  thirty-six  hours,  rost-morteni  examination:  A  largo 
l)Soas  abscess  had  dissected  the  muscles  of  tln^  thigh  as  far  as  the  uiiddh^  third.  "No  perforation  of  the  bowel  was 
discovered,  so  that  what  was  sujiposed  to  have  been  fa'cal  niatti^'  must  have  be<'n  altered  pus.  It  is  but  right,  how- 
ever, to  state  that  several  medical  men  present  at  the  time  concurred  in  the  opinion  then  torme<l."  [The  condition  of 
the  mucous  membrane  of  the  intestine  was  not  recorded.] — Mower  Ilospilal,  ritiladrlpliiu,  I'a. 

Case  383. — I'untleiit  collcelioiis. — Private  J.  W.  Cunningham,  Co.  I,  ITOth  Ohio;  age  2ti:  was  admitted  from  hos- 
pital, Frederick,  Md.,  Aug.  7,  18ti4;  diarrhcra  following  typhoid  fever.  He  died  September  8.  I'ost-mortem  examina- 
tion twenty-four  hours  after  death:  Abscesses  were  found  under  the  right  arm,  on  the  anterior  aspect  of  the  right 
forearm  and  on  the  dorsum  of  the  left  foot.  JSotli  lungs  contained  abscesses;  the  lower  lobe  of  the  left  lung  w  as  one 
immense  cavity  which  had  opened  into  the-ldeural  sac,  tilling  its  low<'r  half  with  pus,  but  adhesions  of  tin'  parietal 
and  pulmonary  jileuras  around  the  upper  part  of  the  lobe  separated  this  purulent  collection  from  the  upper  half 
of  the  pleura;    on  the  right  side  the  abscess  under  the  arm  communicated  fieelv  with  the  pleural  cavity,  which 

Med.  His.,  Pt.  111—53 


418  POST-MORTKM     i:i:rOIU>S    OF' 

was  filled  witli  piis.     Tlio  peiic.'iidiiUM  -nns  (li.sti'ndiMl  witli  sciinii.     'riic  liver  Wiis  iioiiiiul:  the  f;;ill-Ma<ler  disteiKlcd. 
— Jrl.  .iuf'l  Surif.  B.  li.  Mihx,  Jayrh  /fnipildl,  lUillimnre.  Mil. 

Cask  ;{K1. — IHjthtliiria  iiiiil  iiiJUiiiiiiiiilinii  nf  tin'  xDhiinuiUiirii  iifoml. — I'lixalo  (JliiuUjs  WilliiuiiK,  ('o.  V,  ri2(l  I'a.; 
age  21;  was  adiiiittcil  Si'|)t.  22,  IXdl,  with  typlioid  |>iiiMuiioiiia.  He  was  lei'oveiiii)^  I'rom  an  attnek  ol'  typhoid  fever 
and  was  thin  and  liiokeii  down  ;  liis  skin  ]ins(nt(d  a  iMculiai-  liion/.ed  ai>peaiaiue  in  spots,  fioni  wlii(di  tlie  epider- 
mis was  easily  peeled  oH',  leavin<r  an  almoiinally  wliiti'  sMrta<'e  lieneatli;  lie  siillered  eonsideralily  from  diarrlnea. 
There  was  diilness  on  jierenssion  and  an  alisence  of  tlie  respiratoiy  inMinuir  oviT  the  base  of  the  rij;ht  luui;;,  with 
slight  iiueturnal  eoMnli.  His  eondition  did  not  ehanj^e  niiieli  nnt  il  t  lie  middle  of  Novenilier,  when  he  had  an  ilttaek 
of  diphtheria,  fidhiwed,  after  a  few  ilays.  by  iiiMammation  id'  the  left  siibiiiaxillary  i;laiid,  wliieh  suppurated  and  was 
opened  about,  Ueeember  1.  On  the  (ith  he  eomiilained  of  eoiigli,  diltieult  exiieetoratiou  and  eonslaiiti  pain  thidugli 
the  lower  part  of  Ixdli  lungs,  with  oecasional  paroxysms  of  |iain  of  a  more  laiieiiiatiiig  idiaraeter.  There  was  dulness 
on  percussion  anil  brunch  i  I  ie  rales  at  the  base  of  both  hings  with  friction  son  nils  sniieradded  ;  tliesir  signs  afterwards 
gave  |)lace  to  blowing  ies]Mi'ation  with  entire  aWseiiee  of  the  vesicniar  mnrniur,  and  linally  to  loose  niiiC(Mis  and  sub- 
mncoiis  rfiles.  lie  died  December  24.  I'oxt-miirUm  examination:  l5oth  lungs  were  boiiinl  to  the  thoracic  jiarietes  by 
extensive  and  tiriii  adhesions  ;  the  lower  portion  (d'each  lung  was  in  a  state  id' gray  heiiatization.  [There  is  no  record 
of  the  condition  of  the  intestinal  mucous  membrane.] — (.'iijih'i-  lloxpilid,  I'liihirhlphia,  I'a. 

Of  tlie  fevers  rejiurted  as  typlius  the  feeiirils  furnisli  Imt  five  cases  in  wliii'li  the  poHt- 
mor^ew- appearances  are  descrilied.  Jii  one  ot  these,  oSo.  (.'xlmsive  disease  <>(  tlie  agiiiin- 
ated  olaiids  sufficiently  indicates  its  tyjilioid  character.  Case  386  appears  to  have  been  an 
example  of  pernicious  malarial  fever,  for  although  the  disease  had  lasted  some  time,  most  of 
the  patches  were  healthy,  a  few  only  being  infltuned  and  somewhat  thickened  and  none 
ulcerated,  while  the  large  intestine  was  ecchyniosed  and  ulcerated.  Case  387,  with  its  prom- 
inent ami  pigmented  solitary  glands,  was  ap[)arently  of  a  similar  nature.  Mtiiiy  cases  pre- 
senting intestinal  lesions  of  this  character  have  already  been  noted  as  referable  to  the 
malarial  rather  than  to  the  typhoid  influence.  From  the  necroscopic  appearances  388  seems 
related  to  the  suddenly  fatal  cases  which  were  reported  as  cerebro-spinal  meningitis.*  Case 
389  is  tlie  only  instance  in  which  the  pod-mortem  lesions,  so  far  as  determined,  were  con- 
sistent with  till-  diagnosis,  and  as  the  case  occuri'i'd  in  the  city  of  Philadelphia,  it  is  pi-oba- 
ble  that  it  is  the  representative  of  that  verittililr  tvphus  wliicli  occurred  among  soldiers 
exposed  to  circuinscrilu'd  foci  of  infection  during  a  temporary  residence  in  the  large  cities. 

Cask  .385. — Private  Burton  White,  Co.  K,  147tli  N.  Y.,  was  admitted  April  22,  1863,  with  an  incised  wound  of 
the  right  leg.  He  died  May  2f>,  of  pneumonia  sii|)erveuiug  on  an  obscure  disease  resembling  typhus.  J'oKt-miirtciii 
examination:  Body  plump  and  full:  depending  parts  ilark-(>olored.  The  adjoining  halves  of  the  lower  and  middle 
lobes  of  the  right  lung  were  intiltrated  with  ])us.  The  lower  ])art  of  the  ileum  was  extensively  ulcerated  in  patches, 
in  (Mie  of  whiih  was  a  small  jierforation  closed  by  adhesion  to  the  peritoneum  covering  the  bladder;  there  had 
been  no  escape  of  intj'stinal  contents  and  there  was  no  indication  <d'  peritonitis.  The  spleen  and  the  niesenterio 
glands  were  enlarged  and  softened.  {^Spi'chiiciis  180  to  183,  Med.  Sect.,  Army  Medical-Musenm,  aro  from  this  ease: 
see  also  plate  facing  this  Jiago.] — Surg.  Thomas  R.  Crusby,  U.  S.  V.,  Columbian  Hospital,  Washington,  D.  C. 

Case  380.— Private  Charles  B.  Dorr,  Co.  B,  17th  U.  S.  Inf.;  adndtted  Aug.  10, 1862,  from  the  Army  of  the  Potomac. 
Ty])hus  fever.  Died  22d.  I'oxt-morlcm  examination:  Age  about  22  years;  body  moderately  emaciated  and  w  ith  dif- 
fused ecchymoses  on  the  skin  of  the  trunk;  the  muscles  were  of  their  ordinary  character,  but  the  viscera  of  the 
chest  and  abdomen  were  generally  softer  than  usual.  The  lungs  and  heart  were  normal  except  that  there  were  two 
ecchyniosed  spots  about  a  ([uarter  of  an  inch  in  diameter  near  the  base  of  the  latter.  The  blood  presented  nothing 
unusual.  The  liver  and  spleen  were  natural.  The  mucous  membrane  of  the  stomach  was  inflamed  near  the  pylorus 
and  presented  a  nuHiber  of  small  ulcers,  about  a  line  in  diameter,  along  the  lesser  curvature.  [Specimen  272,  Med.  Sect., 
Army  Meilical  Museuni.]  The  ileum  was  inflamed  in  patches,  some  of  which  were  intensely  atfected  ;  the  solitary 
glands  were  enlarged  and  inflamed;  most  of  the  agminated  glands  were  healthy,  some  were  inllamed  and  slightly 
thickened,  but  none  were  ulcerated.  ISpecimcnx  273-276.]  The  niucons  membrane  of  the  colon  was  more  or  less  slate- 
colored,  with  patches  of  inflammation,  a  number  of  ecchymoses  about  half  an  inch  in  diameter,  and  in  the  descending 
portion  a  number  of  stellate,  blackened  ulcers. — .let.  .Is^'t  Surg.  J.  Leidji,  Sutterlce  IJoxpital,  rUiUulelphio,  Pa. 

Case  387. — Private  .lohn  Mills,  Co.  C,  43(1  N.  Y.;  vigorous  looking,  b)it  somewhat  emaciated;  admitted  Aug. 
10,  1862.  Died  14th.  [Case  supposed  by  Dr.  Ati.EK,  the  attending  physician,  to  be  typhus.]  I'ost-niorlem  examina- 
tion next  day:  The  skin  of  the  front  and  sides  of  the  chest  and  abdomen  was  slightly  eechymo.sed.  The  lower  lobe 
of  the  left  lung  was  afl'eeted  with  recent  pleuro-jineiunonia;  the  upper  hdie  was  inflamed;  the  right  lung  was  some- 
what congested.  The  heart,  stomach  and  spleen  were  natural,  and  the  liver  exhibited  a  healthy  color  and  texture, 
but  presented  an  iinnsually  lobular  appearance  (as  in  the  rat).     The  mucous  membraue  of  the  small  intestine  was  of 

Pee  infra,  yi.  .^)52  ft  setj. 


^711.  Phtito-Rehef  Frmtinri  Co., 


1I1U2  Arch  at.,  fhiladelt'hM. 


SLOUGHING   PEYERS  PATCH. 


No,  i8j.     medical  section. 


TIIK    CON'TIM.'KI)    KKVKKS. 

a  ]iiiiki.sli-orciim  color  jiml  iiiijii'il  willi  hilc;  tin-  Kolitiiry  j,'laiHl.s  uf  tin-  jcjiiiiiun  wfvi-  c>|^:l(|llc■-\vlli|(^  iiiid  lliosi-  of  the 
ildiiiii  iimiKiiiilly  iniiiiiinciit  and  (liiltc<l  with  black  pi};irifiif  :  tlic  a,:;Miiiiati-il  ^laiiils  were  Hlif^lilly  thicker  than  usual 
l)iit  (lid  not  apl'car  ]iositively  diseased.  'J'lie  colon  was  much  i()ntraete<l  and  its  nincons  nienilnaiie  sli>;htly  inllanied  ; 
the  solitary  glands  were  largo  and  prominent,  esjiecially  in  thi'  ciecMni.  and  were  marked  liy  a  dejiosit  of  black  ])ig- 
meiit. — Act.  Axx't  Surg.  J.  Lddi/,  Sditci-lcc  IlosjnlnJ,  J'liil(((lrlphiii.  I\i. 

Case  38H. — Jeremiah  Sanlslmrj;,  a  colored  .soUlicr,  died  (d'  typhus  Jan.  L'l,  ixiil.  I'nsl-mnrtim  examination 
eight  hours  alter  death:  liody  stout  and  well  developed.  There  were  well-marked  dejiosits  of  viscid  pus  between 
the  I'onvolutions  of  tlus  frontal  lobes  iind  of  the  parietal  lobes  near  the  longitudinal  lissure,  as  also  over  the  luins 
medulla  and  crura  ;  a  mass  of  pus  overlaid  tlu^  anterior  coipora  (juadrigeudna,  ami  the  menil>rane  covering  them  was 
finely  injected;  the  substanco  of  the  brain  was  gorgeil  with  blood,  but  thechoroid  plexus  was  ]iale  and  tlie  ventricles 
not  enlarged  although  containing  soiue  effusion.  The  pericardium  was  liill  of  seium  and  the  right  cavities  of  the 
heart  containc^d  fibrinous  clots.  The  lower  lobe  of  the  left  lung  was  cougestc^d  liy  hypostasis,  but  there  were  also 
some  sjiots  of  iirojicr  hejiatization.  The  liver  was  darker  than  usual  and  full  (d' blood.  The  colon  and  ileum  were 
inflated.  (There  had  been  strabismus  during  the  last  three  or  four  days  of  this  patient's  life.) — Art.  A.-i«U  Snnj.  W.  C. 
Minor,  h'liiyhl  Gctiirul  lliiipitid. 

C.vsi.;  3Xfl. — Private  William  W.  Fenno,  Co.  K,  115th  I'a.;  age  lil:  was  admitted  Dec.  K!.  W6'>,  with  chronic  rheu- 
matism and  debility,  and  so  far  recovered  as  to  be  able  for  guard  duty;  but  on  Feb.  17,  ISliM,  hi^  was  taken  with  diar- 
rlnea  and  iie.xt  day  he  had  a  high  fever,  ([uick  breathing,  tremulous  voice  and  a  dark  fuiied  lougui'.  lilth:  Diag- 
noses— tyi>hus  fever:  dysimiea  greatly  increased;  diarrhiea  almost  ci'ased  :  sluiiid,  but  could  hf  aroused  l)y  a  loud 
voice;  abdomen  tym]panitic;  capillary  circulation  feeble:  no  eruption.  2(lth:  Su]ipression  of  urine.  1.30  ]•.  M., 
voiTuted  a  large  lumbricoid  worm  and  other  matters;  restless  (hdirinm  alternating  with  comatose  i|uiet.  Died  at 
4  ]'.  M.  I'iiKt-niortnii  exannnation  :  Suggillatiou  distinct ;  no  vibices;  peteidiia'  over  epigastrium,  stated  by  the  nurse 
to  have  existed  during  life,  lirain  md.  examined.  Lungs  congested  ])ost<!riorly.  Left  ventricle  of  heart  tilled  with 
bla<k  llui<l  blood;  right  containing  two  librinous  clots.  Liver  large  but  healthy;  spleen  much  enlarged  and  lohii- 
lated;  kidneys  and  intestines  healthy. — Ciiyler  Hospital,  Philadclphiu,  I'd. 


v.— ON  THE  PATHOLOGICAL  ANATOMY  AND  I'ATHOLIXJY  OF  THE 

CONTINUED  FEVERS. 

I.— THE  CASES  AND  THEIR  ANALYSIS. 

Three  liundred  and  eiglity-iiine  cases  I'ndii  the  po-sl-jiior/cni  reeords  liave  been  aub- 
mitted.  These  were  regarded  by  the  iiiechral  ofHeers  in  attendance  as  fatal  instances  of 
continued  fever.     Tliey  have  been  presented  as — 

1st.  Fifty  cases,  l-."iO,  presumed  from  tlu'ir  sym]doms  to  liav(^  been  uiimodilie<l  typhoid: 

2d.  Sixtji-six  cases,  51-1I(),  of  an  adynamic  continued  fever,  wliicdi  might  from  the  symptoms  or  diagnosis  have 
been  individually  either  cases  of  modified  typhoid  or  of  adymimic  nuilarial  fever; 

3d.  I'ico  liiiiuirid  ami  xixtji-tiiihi  cases,  U7-3KI,  of  fever  which,  although  report eil  as  typhoid,  might  individually 
have  been  typhoid,  tyjiho-malarial  or  adyiiairiic  malarial,  iu  view  of  the  uncertainty  attaching  to  the  diagnosis; 

4th.  Fire  eases,  38.T-3W),  reported  as  typhus,  but  which,  in  like  manner,  might  have  been  due  to  other  perni- 
cious causes  than  the  typhus  or  the  typhoid  poison. 

The  study  of  tlie  intestinal  lesions,  as  conducted  in  the  last  section,  has  nioditied  ante- 
iiiorteni  views  as  to  the  relationship  of  these  cases  one  to  the  otiiei-,  and  rendered  a  rear- 
rangement advisable  to  facilitate  further  investigation  intn  their  pathological  anatomy. 
The  diagnosis  of  the  fifty  cases  presumed  to  be  uninodilleil  typhoid  was  confirmed  by  the 
evidence  ot  the  iiirminated  dands  or  liv  such  conditions  of  the  ileum  as  were  suftrestive  of 
a  glandular  involvement.  Tlie  sixty-six  contimi('"d  febrile  cases  of  an  advnamic  or  tvphoid 
type  consisted  oi  forty-Hix  in  which  tlie  lesions  of  typhoid  were  associated  with  malarial 
synijitoms  and  of  itvoify  in  wliich  the  alisetice  of  these  lesions  indicated  the  malarial  iiiHu- 
enco  as  tlie  sole  cause  of  tlie  morbid  plieiiomena.  Tlie  two  hundred  and  sixtv-iight  cases 
oi  n^ported  typhoid  enmprised  //VVrcv!  cases  in  which  \\\o  post-wortnn  appearances  testified 
tliat  some  tebrile  cause,  which  from  its  symptouis  was  of  a  malarial  nature,  had  preceded 
the  onset  of  a  ty|>hoid  attack,  forfi/-one.  in  which  typlioid  lesions  were  not  discovered, 


PATHOLOGIOAI.    AKATOMV    AM>    I'ATHOLUiiY 

and  two  hundred  and.  twelve,  in  wliich  these  lesions  were  present  ur  sueli  ulceration  of  tlie 
small  intestine  as  might  he  attrihuted  to  either  ty})hoid  fever  alone  or  to  typhoid  as  modi- 
fied by  the  concurrence  of  malarial  fever,  tlius  constituting  a  mixed  series  of  typlioid  and 
typho-malarial  cases.  The  five  cases  reported  as  typhus  were  similarly  found  to  consist  of 
one  tv]_)hoid  case,  two  malarial  cases,  one  case  related  to  cerehro-spinal  fever  a,nd  one  of 
probably  true  typhus. 

Aggregating  these  in  accordance  with  clinical  history,  diagnosis  and  intestinal  lesions, 
there  appear — 

Fiftij  CiLsi's  of  iinmoililicd  tyjilioid,  cases  l-.")!); 

iSisty-thnr  cases  of  malarial  fever  with  typlioid  or  ad.viianiic  syiiipfoiiis  Imt  wilhiiiit  t,v])lioi<l  lesions,  cases 
70-73,  76,  78-81,  W,  87-91,  104,  10.->,  108,  113,  115,  21(^l'.-,2,  L>r>4-'_'t)3,  271,  I.'7t>-1'78,  L'87-'_';tr.,  3t;2-3t;7,  37.S-377,  3Sti  and  387;* 

Sixty-one  cases  of  true  typlio-nialurial  fever,  ca.ses  51-69,  71,  75,  77,  82,  83,  85,  86,  92-1(13,  1(16,  107,  109-112,  114, 
116,  264-273,  280,  285  and  296-298 ;t 

Two  hundred  (did  fhirtit')!  cases  of  a  mixed  class, consistingcliielly  of  typho-malarial  fever,  but  jirobably  containing 
some  instances  of  typhoid  alone  and  of  nuilarlal  fever  alone,  cases  117-245,  253,  275,  279,  281-284,  286,  299-361,  368- 
372,  378-384  and  385; 

One  case  of  cerebro-spinal  fever,  (?)  case 388; 

One  case  of  typhus,  (?)  case  389. 

The  results  of  an  analysis  of  tlie  pod-mortcrn  appearances  in  these  cases  is  Jierewith 
submitted;  and,  to  admit  of  a  comparison  between  the  anatomical  details  of  the  typhoid  cases 
of  the  war  and  those  of  civil  life,  a  summary  of  the  lesions  in  the  cases  so  carefully  observed 
by 


Louis  is  given  below. J 


Analysis  oi'  tiik  Post-mortem  Appk.vr.ixces. 

The  Salivary  Glands. — In  but  one  of  the  continued  febrile  cases  was  mention  made  of  an  inflamed  condition 
of  the  submaxillary  or  sublingual  glands,  but  a  destructive  inflammation  occurred  with  some  frequency  in  the  parotid 
region.  It  was  present  in  sixteen  of  the  recorded  cases:  in  six  the  glands  were  swollen  and  indurated  and  in  ten 
destroyed  by  suppuration.  In  three  cases  tlie  morbid  action  affected  both  sides,  while  in  thirteen  it  was  confined  to 
one  side:  the  riglit  gland  was  involved  in  five  cases,  the  left  in  three;  in  five  the  record  does  not  specify  the  side. 

Parotid  abscess  occurred  in  but  one  case,  31,  of  the  fifty  typhoid  cases :  one  side  only  was  affected.  In  258  of  tlie 
malarinl  series  the  right  parotid  was  swollen,  and  in  three  cases  abscess  was  formed, — on  the  right  side  in  251,  on  the 
left  in  376  and  on  both  sides  in  263.  Parotitis  occurred  in  four  of  thy  ti/pho-maluriiil  series :  In  53  on  one  side  and  in  65 
and  97  on  the  right  side;  suppuration  was  present  on  one  side,  in  103.  In  the  mmrf  series  of  cases  swelling  existed  in 
two  ca.ses  and  snpiiuratiou  in  five:  The  swelling  in  118  and  381  does  not  appear  to  liave  culminated  in  abscess; 
the  right  gland  suppurated  in  125;  the  left  in  193  and  338,  and  both  glands  in  222  and  348.  Suppuration  occurred  in 
the  submaxillary  glands  in  case  384  of  this  series. 

The  condition  of  the  pharynx  and  (KSOI'IL\gus  appears  to  have  been  seldom  observed  by  our  medical  officers. 
The  nuicoiis  nienibrancwas  reported  pale  in  case  23  of  the  typhoid  series.  It  presented  morbid  appearances  in  six 
of  the  malarial  cases, — purplish  coloration  in  90  and  277,  deep  congestion  in  373,  erosion  without  accompanying  con- 


*  T<.  tlicsc  niiglit  with  propriety  bo  added  certjiin  cases  reported  as  typlio-mal,irial  fever  by  the  attending  officers,  but  submitted  in  the  second 
part  of  this  worli  as  ciws  of  diarrlicca  and  dysentery.  Thus,  in  case  :il3,  entered  as  typlio-malarial  fever,  the  small  intestine  was  found  healthy;  in  303, 
reported  as  typhoid-remittent  fever,  the  dnmlenum  was  of  a  dark-purple  color,  but  the  remainder  of  the  small  intestine  was  healthy  e.\cept  near  tho 
valve,  where  were  many  small  circular  snpc-rficial  ulcers,  the  solitary  «lands  being  ]proriiincnt  and  the  patches  of  I'eyer  pale  but  neither  ulcerated  nor 
elevated ;  in  .lis,  n'pirted  typho-nialarial,  the  mucous  nic-ml>ian"  of  the  ileum  was  somewhat  inflamed  ;  in  R32,  at  first  regarded  as  remittent  fever  and 
afterwai-ds  as  typhoid  dysentery,  the  ileum  wils  congesti'd  and  studded  with  small  ulcerations,  while  the  large  intestine  was  more  extensively  nli'erated 
and  almost  gangreucnis.  I>erliai«  also  case  783  should  bi-  added  to  these,  as  the  patient  had  an  adynamic  fever  from  the  tim"  he  entered  the  hosidtal, 
yet  po,«(-?nnrreni  investigation  showed  tlie  small  intestine  to  be  in  a  healthy  condition.  In  fact  many  cases  of  tln^  diarrhcjcal  series,  in  which  the  typhoid 
lesion  was  not  found  after  death,  presented  more  or  less  of  a  clinic-al  resemblance  to  tyjihoid  fever. 

tTn  these  might  be  added  the  case  submitteil  in  the  second  part  of  this  work  as  f<23  of  the  diarrbmil  series ;  tho  diagnosis  was  typho-malarial 
fever,  and  p..»(-»inrtem  examination  revealed  the  ileum  and  colon  stmlded  with  ulceration.  Perhaps  43(;,  presenting  fever  of  an  adynamic  tyi>e,  with 
hemorrhage  from  the  bowels,  and  showing  at  the  autopsy  the  small  intestine  ulcerated  in  iiatches  and  the  large  intestine  perforat<-d,  may  also  have  been 
a  trno  typho-malarial  case.     For  a  discussion  of  the  connection  between  the  diarrhieal  ca.ses  and  the  continueil  fevers,  boo  infra,  p.  C15v(  sei/. 

J  The  fcdiowing  abstract  of  the  jM«(-mo,(««  appearances  found  by  Loris  in  his  forty-six  cases  maybe  of  interest  in  connection  with  tho  lesions 
observed  in  the  fifty  tyidioid  cases  of  the  text ; 

The  SALIVARY  nr.ANOs.— The  submaxillary  and  sublingual  glands  were  not  altered  in  any  of  the  cases  ;  but  in  two  there  was  suppuration  in  the 
parotirt  regi(m,  due  in  one  instance  to  inflammatum  of  the  snrrouniling  eelhilar  tissue  and  in  the  other  to  inllanunation  of  the  glandular  structure. 

The  PHARYNX  was  afTectiil  in  eight  cases;  nherated  in  six  and  eovere<l  with  false  membranes  associated  with  purulent  infiltration  of  tho  sub- 
nincouB  cellular  tissue-  in  two.  The  ulcerations  were  few,  thee  t.i  i-ight  line.i  in  their  gri'atest,  tlie  vertical,  diameter  and  situated  on  the  lower  and 
lateral  aspects  of  the  s:o'.  As  no  such  ulcer.iti..n  was  found  in  seventy  ca.scs  of  other  acute  diseases,  Lorns  considered  it  an  importiint  lesion  and  one  of 
the  Recrtndary  anatomical  characteristics  of  the  tyjdioid  affection. 

The  o^s.iPHAors  was  ulcerated  in  seven  rases,  only  two  of  which  were  includeil  among  those  having  tlie  iiharynx  affected.  The  lllcei-s,  when  few, 
M-fre  sitnatiHl  near  the  cardia,  when  numerous  they  extendeii  throughout  the  whole  of  the  tube,  but  were  more  freiiu.'Ut  and  larger  towards  the  lower  end. 
Loots  associated  these  ulcers  with  those  of  the  pharynx  as  peculiar  to  typhoid  fever. 


OF  THE  CONTINUED  FEVERS.  421 

gestion  in  259,  softenini;  and  denudation  in  71.  and  dijilitlieritic  exudation  in  371.  In  tlie  lii]ihii-iiiiil<iri(il  serieH  a 
morliid  condition  i.s  mentioned  in  Imt  tliiee  in.stances:  In  tir>  the  inne(nis  nieinbiane  was  intianied;  in  "il  inllanied  and 
nlceiated;  in  (i7  abscesses  weie  found  on  tlie  left  side  in  front  of  tlie  liyoiil  l)one.  In  tlie  inixid  series  morbid  apjiear- 
auces  were  noted  in  twelve  instances:  Tlie  a'soplia^eal  liniiii;  was  of  a  ]iale  color  anil  Mlieralcd  in  its  lower  part  in 
1H7  and  1X7,  while  in  the  same  region  in  301  it  i)resente<l  daik-colored  spots,  one  ni'  uhieli  was  eroded;  it  was  con- 
gested in  longitudinal  streaks  in  3()."i:  indamed,  purplish,  and  iu  its  lower  part  eidiyniosed  in  32!':  in  l.")()  the  a'so- 
jdiagus  was  of  a  purple  or  brown  color  and  its  walls  contained  an  abscess  as  large  as  a  chestnut,  and  m  1R">  there  was 
an  ulceration  on  its  posterior  wall  on  a  level  with  the  larynx,  while  the  tube  below  was  tilled  with  a  whitish  exuda- 
tion; in  l.">5,  199  and  304  the  mucous  membrane  was  yellowish  and  in  ls:>  pur]de;  In  338  the  pharyngeal  coats  were 
perforated  by  matter  frcun  tlie  parotid  region. 

The  STOMACH  was  normal  in  four  of  the  fjiphoid  cases,  11,  27.  35  and  3(i,  and  in  one,  Ki,  it  was  not  examined. 
Of  twelve  eases  in  which  a  morbid  change  was  n'ported  its  mucous  meiiibvaiie  in  21.  21!,  29,  11  ami  17  was  reddened 
from  congestion;  in  9  the  congestion  was  in  circumscrilied  jiatches;  iu  s  the  rmidus.  which  was  of  a  dull-red  color, 
contained  live  lumbricoid  worms;  in  21  the  mucous  membrane  was  pah>  and  ihickeued;  in  22  slaty  and  mottled;  in 
23  mottled,  congested  and  blackened  from  pigmentary  deposits  near  the  pylorus;  in  IN  thickened  and  softened,  and 
in  31  thickened  and  congested,  the  viscns  containing  about  a  pint  of  an  otlensive  yellow  liiiuid.  Of  the  sixty-three 
mtilariid  cases  the  cinidition  of  the  stomach  was  not  stated  in  thirty-fmir,  and  in  the  remaining  twenty-nine  it  wau 
normal  in  IVuirteen,  congested  in  six.  thickened  and  softeiu'd  in  three,  inllanied  on  its  peritoneal  surface  in  219  and 
along  the  great  I'urvature  in  91 ;  ulcerated  along  the  small  curvature  in  3H();  tlai'cid,  thin  and  greatly  discidored  in 
287;  ecchymosed  but  nucongested  in  2(12.  and  in  71  the  organ  contained  a  |)iiit  of  dark-cohued  lii|iiid  in  which  tloated 
shreds  of  its  disintegrated  mucous  meinbrane  <*f  the  (//^)/ii)-«i(i/(ii-i«/ series  the  conditi(Ui  of  the  stomach  was  mentioned 
in  sixteen  cases:  It  was  normal  in  six,  congested  in  two,  103  and  296;  softened  in  two,  98  and  112,  in  the  former  of 
which  the  lining  membrane  was  almost  disintegrated;  in  93  it  was  unusually  corrugated;  in  1)5  and  llti  inilamed;  in 
9t)  it  presented  black  patches  and  was  ulcerated  near  tlie  pylorus ;  in  (>2  it  was  tilled  witli  dark  grnnions  blood,  and  in 
106,  in  which  death  resulted  from  iieriionitis,  it  contained  fa'cal  matter.  In  the  mixed  scries  of  cases  the  statu  of  the 
stomach  was  mentioned  seventy-four  tinu's:  In  thirty-tliree  it  was  normal,  but  iu  one  of  these,  325,  it  contained  a 
grumons  lii|uid:  in  four  it  was  merely  distcniled.  Of  the  remaining  thirty-seven  cases  its  mucous  membrane  was 
congested  and  more  or  less  softened  in  sixteen;  softened  in  tour,  to  pultaei'onsness  iu  213:  injected  in  live;  iiitlamed 
in  six,  in  one  of  which,  35 1.  there  was  ulceration,  and  in  another,  239,  thi'  visi-us  coutaini'il  mailer  like  colfee-gronnds; 
grayish,  slate-colored  or  marbled  in  three;  ecchymosed  in  one,  312;  in  191  the  stomach  was  filled  willi  bih^  anil  in  1.56 
with  a  lii|iiid  of  a  greenish  color  and  liecal-likc  odor. 

The  DUODENUM  was  distended  in  ease  5  of  the  ti/plioid  series,  normal  in  2(;,  lillcd  with  thick  tenacious  inneus 
in  23  and  undergoing  putrefactive  changes  in  22;  its  mucous  membrane  was  congested  or  inllanied  in  17,  18,  29  and 
50,  softened  and  thickened  in  -18;  in  11  its  glands  were  enlarged  and  iu  9  congested  Morbid  changes  were  defined 
iu  lour  of  the  iiuilaridl  series:  In  87  the  glands  of  Hriinner  were  enlarged;  in  271!  and  373  the  lining  membrane  was 
congested  and  in  71  disintegrated;  but  in  other  instances,  as  81, 113  and  2.59,  a  congested  or  inllanied  condition  of  the 
dnodeniim  may  be  inferred.  Ten  observations  were  recorded  in  jirecise  terms  or  by  iuferenec  in  the  tjipho-iiidhtrial 
series:  In  four  a  normal  condition  was  indicated;  in  2()9  the  glands  were  enlarged;  in  53  tliere  was  follicular  iiillam- 
niation  with  softening;  in  86  the  lining  membrane  was  dark-colored  and  congested;  in  1)5  and  lit!  iullamed  and  in  96 
ulcerated.  Twenty-six  observ;itions  were  noted  in  the  mixid  series  of  cases:  In  ten  a  healthy  condition  was  stated; 
in  four  the  glands  alone  were  mentioned,  enlarged  in  122  and  281,  inllanied  in  281  and  ulcerated  iu  307:  in  nine,  181, 
182,  190,  279,  317,  318,  'XA,  370  and  380  the  mucous  membrane  was  congested;  in  oni^,  243.  imltaceous;  and  in  two,  156 
and  338,  dark-colored. 

The  ,iK.rrNtTM  was  ilistended  in  case  5  of  the  tiiphmd  series;  normal  in  10  and  2ti  and  probably  also  in  23. 
In  17,  18,  29,  47  and  50  it  was  more  or  less  congested;  its  inncous  membr.ine  was  softened  in  8  and  48  and  white, 
inelastic  and  easily  torn  in  22.  Its  condition  was  altered  in  seven  of  the  iiinUiiidl  cases:  In  90  its  calibr^'  was  con- 
tracted and  its  mucous  membrane  jiale;  in  247,  259,  2t!0,  27ti  and  278  there  Wiis  more  or  less  of  congestion  or  iiiHam- 
niation,  in  some  general,  in  others  alfecting  the  lower  portion  only;  in  274  the  mucous  membrane  was  softened  and 
velvety.  It  was  mentioned  as  normal  in  six  cases.  Eleven  oliservations  were  made  iu  the  tjijiho-mnUirinl  cases:  Iu 
live  the  jejunum  was  normal;  it  was  congested  in  81!  and  95;  softened  in  :53;  iullamed  in  (>5;  ulcerated  in  2()9  and 
slate-colored  in  112.  In  many  of  the  mixed  series  a  healthy  condition  of  the  Jejunum  may  be  inferred;  in  others,  as 
171,  174,  180,  195,  196,  210,  etc.,  the  inllammation  which  att'ected  the  ileum  appears  to  have  extended  upward.  But  in 
forty-two  instances  its  condition  is  s])ecilied  in  ])recise  terms;  In  seventeen  of  these  it  was  normal;  in  fourteen,  141, 
187,  189,279,281,282,300,306,314,  321,  354,  369,  370  and  380,  congested ;  in  three,  191,323  and  339,  softened;  in  seven, 
I6r>,  239,  284,  309,  318,  337  and  353,  ulcerated,  and  in  one,  338,  le;id-ii)Iored.  It  was  normal  in  181,  although  the  duo- 
denum and  ileum  were  im])licated,  and  in  241,  notwithstanding  the  existence  of  an  iutussnsce])tion ;  in  354  its  lower 
part  only  was  congested;  in  239  and  282,  res))ectively  ulcerated  and  congested,  there  were  lumbricoid  worms. 

iNTii.ssusCKPTiON  OK  THE  .SMAi.i.  IXTKSTINK  Was  Hot  recorded  as  having  been  observed  in  any  of  the  typhoid  or 

Tlif  STiiMAi-H  Wiif*  lit^iilOiy  ill  tliirti'fii  r:is.s  jui.l  in  tin-  utlu-rs  ninri-  or  lt's.s  !ilti-ii-,l  hy  liy|MTii'iiiii'  roiitlitiulis ;  in  fimr  thiTi-  weiv  siuiill  iilrfratiniirf 
.11-  iTusiun-,;  liiit  Hilnilar  i-haugrs,  jiini  in  in-arly  tin'  >ann-  iirnp'Ttiiili.  wcri-  fininil  in  .;cvrnt.v-t\vo  palifiits  win.  i  licit  of  utlnT  ilisi-a.-^i-K. 

'tin'  iirnliESl^M. — Tin-  noti-.s  (in  tliL-  ci.nililiiin  i,f  ttiis  iinrtitni  of  ttic  atinn-ntary  ninal  an*  ri'>trirt('il  tn  t\v,'nty-t\vi»  t-tuies,  in  eight  of  wliirti  it  was 
tii'altliy.  Of  ttni  rfinainiiifr  fnnrti-iMi  ttif  tniii'nn^  tnrnitintni'  was  ri-il  in  fimr.  tin-  ri-itni'HH  In'injr  ilitfiisnl  mi-  rirrninsiTitifil ;  gniyiwli  in  two ;  suft  in  tlirt't*, 
in  wliirli  it  was  als.i  ii-it ;  Itriinnrr'K  jrlamls  wi-ii-  niix-li  i-nlargiit  ni-iii-  tin-  iiylorif  i-n.t  in  tlin-i',  tw.»  uf  wliit-li  liaii  tin-  mui-ims  niemtimne  sufteneJ  and 
in  two  tliero  was  sliglit  ulceration  ni'ar  tin-  vatvf.  \Vitli  Ito-  i-xri'iition  of  tin-  nlrcnition  similar  i-onilitious  worn  fmuitl  in  tliirty-six  caso«  of  doath  froui 
aoute  (liswisos  otlier  than  typhoid. 

iNTUsairacEPTloN  of  the  muall  intestin.-  was  found  in  tliri*t'  i-a^t-s. 


422 


PATIIOLOiJicAL    ANATO^[Y    AM'    PATITOT.OGY 


typho-malarial  cases;  but  it  wits  noted  in  NX  and  LTiS  of  the  imdufhiJ  scries,  -muX  in  tivt-  cases,  lL'7,  130,  21i2,  234  and 
241,  of  the  mixed  series  ot  felirile  cases. 

LrMiiKicoil)  WOUMS  were  noted  in  cases  (!  and  8  of  the  tj/phoid,  in  2;ii>,  2X2,  34>*,  3(>1  and  37X  of  the  muid  series, 
and  in  tlie  ^//j^/ihs  case  389.     Their  pre.sence  was  not  observed  or  reeoriU-d  in  any  ot  the  iniilarial  or  typho-maJnridl  cases. 

The  PATCHES  Of  I'KYKl!  Were  ulcerated  in  tliirty-tlivee  of  tlic  lifty  ti/iihoiil  cases,  wliile  in  seventeen  their  con- 
dition was  not  stated;  but,  as  will  lie  seen  m  referrini;  to  the  occurrence  ot  perforation,  the  ulceration  of  the  intes- 
tine in  the  latter  cases  was  of  the  same  circumscribed  and  ])enetratinii  character  as  that  definitely  stated  in  tlie 
former  as  having  its  site  in  the  patcluss.  Since  all  febrile  cases  iirescntinj;  adynamic  symptoms  have  been  in  tliis 
volume  classifled  as  tyi)hoid  v,\mn  jmst-iniiiiem  examination  revealed  In  I  hem  a  tumefied  or  uh'cratcil  ccjuditiou  of  the 
patclies,  it  necessarily  follows  that  in  the  sixty-three  eases  submitted  as  examples  of  malarial  fever  the  af,nuinated 
glands  were  not  found  to  be  thus  attected.  Their  condition  was  not  stated  in  twenty-six  cases;  they  were  healthy 
in  seven  cases, 257-2t;i,  SOU  and  3li7,  and  reported  not  ulcerated  in  21)2  and  2(>3:  in  the  r(uuainln<;  twenty-eight  eases 
they  were  ])ale,  white,  reddened,  congested  or  i)igniented.  Their  condition  was  not  stated  in  ten  of  the  sixty-one 
tiiphn-maUirial  cases;  they  were  enlarged,  congested,  inliamed  or  ]ilginente<l  in  twenty-oue  cases  and  ulcerated  in 
thirty.  Of  the  two  hundred  and  thirteen  wi-ici/ lases  their  conditiou  was  not  reported  in  sixty-eight.  They  were 
ulcerated  in  one  hundred  and  thirty-one  and  tumid  and  iuHained  in  twelve:  they  were  healthy  in  one,  380,  and  indi- 
rectly stated  to  have  been  so  in  one,  37St, — in  the  foriuei  death  occurred  from  pneumonia  six  weeks  after  the  patient 
had  so  far  convalesced  from  his  typhoid  attack  as  to  be  able  to  walk  aliout  the  ward;  in  the  latter,  as  the  object  of 
the  i>03t-mortem  examination  seems  to  luive  l)ccn  an  explanation  of  sudden  and  unexpected  death  during  conva- 
lescence, the  appearances  presented  by  the  agminated  glands  were  not  referred  to  except  in  so  far  as  they  may  lie 
included  in  the  general  statement  that  there  were  lu)  other  unusual  appearances  than  those  recorded  as  having  been 
observed  in  the  brain,  heart  and  lungs. 

The  condition  of  the  Mucou.s  .memhuaxk  of  the  ileu.m,  in  the  intervals  between  the  ulcerated  patches,  was 
not  stated  in  twenty-two  of  the  tifty  tiiplwid  cases.  What  may  have  been  its  condition  in  these  instances  is  uncer- 
tain. If  credit  be  given  to  the  records  as  well  for  what  is  not  said  as  for  what  is  stated,  the  mucous  membrane  pre- 
sented no  morbid  appearance  of  note  beyond  its  destruction  over  the  site  of  the  affected  glands.  Hut  such  negative 
evidence  is  of  doubtful  value,  ami  has  iu>t  heretofore  been  admitted  in  these  aiuilytical  observations.  Nevertheless, 
it  seems  probable  that  iu  at  least  some  of  these  cases  there  was  no  general  congestion  of  the  meniljrane,  for,  as  will 
be  .seen  immediately,  congestion  when  present  in  other  cases  was  confined  to  thi^  vicinity  of  the  ati'ected  patches,  and 
in  cases  23  and  48  the  bases  of  the  ulcers  are  said  to  have  been  of  a  reddish  color,  which  distinction  could  not  well 
have  been  made  had  the  general  lining  of  the  intestine,  iucluding  the  part  surrounding  the  ulcers,  been  in  a  highly 
injected  condition.  In  twenty-five  cases  the  ileum  was  reported  congi'sted,  but  iu  nine  of  these,  8,  9,  16,  26,  30,  34, 
39,  40  and  4(>,  the  congestion  was  confined  to  the  lower  part  of  the  intestine  or  to  that  part  in  which  the  destruction 
of  the  i)atches  was  greatest,  and  iii  many  of  those  in  which  a  general  congestion  is  intimated  it  w  as  more  intense  at 
this  part  than  higher  up,  where  the  disease  of  the  patches  was  less  advanced.  The  mucous  membrane  was  softened 
iu  two  cases,  15  and  29,  and  of  a  dull  whitish  color  in  one  case,  22.  In  5  the  ileum  was  contracted  and  in  27  it  con- 
tained a  frothy  semi-liquid  saugniuolent  matter. 


LcMintwon)  wohms  wrri'  noted  in  two  cases;  but  tliis  dues  not  express  the  freqiieiuy  uf  tlieir  jiresence,  fur  Muuie  instauees  t>f  their  imssiif^e  from 
the  body  during  life  and  others  of  tlieir  detection  after  deatli  were  not  recunled. 

Tlie  i'ATciiES  or  Peyku  were  altered  in  structure  in  tin;  lower  2-S  feet  of  the  small  intestine  iu  all  the  <-ases;  in  the  whole  lenj^th  of  the  canal 
in  one  case  only.     Those  nearest  the  ("ecnin  were  nn)st  altered,  those  farthest  from  it  least  altered;  whence  it  is  infei-riMl  that  the  uiorhid  proc(;ss  did  not 

i-omnience  siniultal usly  in  all  the  jiutches,  hut  was  pro;:ressive  in  an  upward  direction,  and  that  the  changes  to  whicdi  an  individual  plaijue  is  suhject 

may  heal>I)reeiate(l  I.y  a  study  of  the  various  patches  from  ahove  downwards.  They  wei-e  at  first  sliy:htly  elevated  ami  r)f  a  pale-rose  col(»r,  the  elevation 
heingdne  to  a  hyperplasia  of  the  iwrts  or  an  e.\au;;er{ition  of  the  normal  structure.  Afterwards  tlii-y  Ijecanie  retlder,  thicker,  Iar;;er,  softer  and  adherent 
to  the  suhniiu'cais  tisisue,  which  was  reddened  and  tliicken<-d  heneatli  them.  Then  ulceration  took  place,  or  a  process  of  ahsorptioii  without  nlceratiiui. 
The  destruction  of  the  nnu-ous  nu-ndtnine  coverin;;  a  patch  was  due  to  the  union  of  many  ulcerative  points  or  to  the  ext<Misioii  of  one;  luuice  the  ulcer- 
ations diJTered  from  each  other  consideraldy  iu  apiM.'arani.'e.  Their  outliiu'  was  generally  regular,  oval  or  rounded,  but  sometimes  angular;  in  Sfiiiie  the 
edges  were  iier|H'ndicular,  in  othel-s  they  sloped  gradually  into  the  central  and  deeper  jtjirts  of  the  ulcer;  the  muscular  coat  was  exjiosed  in  some, 
and  in  a  eei-tain  numher  the  serous  coat  was  jterffU-ated.  On  the  estahlishment  of  recniierativo  acti<»n  the  red  color  became  tin.ged  with  gray  or  bine, 
and  a  thin  cicatricial  pellicle  was  devido|M'd  from  the  surrounding  mucous  sui-face.  In  tlnise  that  had  not  undergone  ulceratiou  a  similar  i-hange  in  color 
was  aectimjiauied  liy  a  diminution  of  the  tumefaction  and  softness.  Lorrs  gave  the  nanii!  of  soft  patidies  ipliKjuei^  moll^")  to  the  agminatetl  glands  when 
aflected  as  lias  bi'eii  described,  a[>plyiiig  the  term  hard  patches  {plu'juft  'liirct^)  to  them  when,  superadded  to  the  cuuditious  present  in  the  soft  pa,tclies, 
there  was  a  tninsfonnation  of  the  snbmucosa  by  an  interstitial  exudation  of  a  homogeneous,  unorganized  and  more  or  less  friable  snbslaiici'  of  a  faint 

rose  or  yellowish  color  ubich  attained  a  thickness  of  two  or  tlire('  lines.    When  the  mucous  meiiibn over  tlese  plates  was  unbroken  they  bad  a  smooth 

uniform  appearance;  but  when  ulcerateil  their  ajipea ranee  was  uneven,  furrowed  and  stained  w  itli  bile.  This  substance  was  also  tVirmed  beneath  some  of 
the  irregular  pateln's  intervening  between  the  pjitches  of  Peyer,  ami  in  some  cases  it  appeareil  in  the  form  of  proniineiices  two  or  three  lines  in  diam- 
eter and  of  equal  height.  These  harri  patebi's  were  found  in  thirteen  of  the  forty-six  ca.ses,  in  ten  of  which  the.y  alone  constituted  the  local  lesion, 
while  iu  three  they  were  asswiated  with  the  plaipies  luolles.  The  solitakv  r.LANUS  of  the  small  intestine  were  affected  in  twelve  cji-ses,  but  generally  only 
within  a  few  feet  of  the  ca'cum.  They  were  flattened  and  white  or  rounded  and  of  a  grayish  eohu-.  In  one  instance  they  had  a  grayish  point  in  their 
centres;  in  three  others  they  were  nlci'iat-'d.     Loris  cimsidered  it  doubtful  if  all  the  small  white  elevations  present  iu  .some  of  the  casi-s  were  really 

enlarged  cryjits.     S<dtiug  aside  the  < lilion  of  the  patches  of  Peyer,  thesit  changes  iu  the  small   intestine,  the  result  of  congestive  or  intlanimatory 

jirocesses  in  its  mni-ous  meiiibniue,  were  found  in  other  acute  diseases  and  in  nearly  the  siinie  ]ii-oportioii  as  in  t.vphoid  fever.  Even  the  changes  iu  llu; 
solitary  glands  may  not  he  excepted,  as  iu  five  cases,  three  of  which  were  eases  of  scarlet  fever,  those  near  the  ca'cnni  wi-ri'  enlarged  and  reddem-d. 
Hence  these  morbid  changes,  like  tlmsi-  atlecting  the  stomiich,  were  considered  b,v  Loris  as  the  result  of  a  eootiiiuaiiee  of  febrile  action  on  thi-  system. 

But  as  the  alleetioli  of  the  a:_'ininati'il  glands  was  nut  t'oiiml  in  any  other  disea,s,'  it  wa.-  coi iveil  to  l.i-  lie-   iiiiniary  and  pathogiioinoliic  lesion   of 

typhoid  fever. 

In  seventeen  cases  the  mucous  membrane  of  the  .ie.icnum  and  ilecm  preserved  its  natural  color,  white  or  yellow  from  a  tinge  of  bile,  throughout 
nearly  their  whole  length ;  in  sixteen  it  was  red,  and  while  in  six  of  these  the  redue.ss  extendi-d  throughout  the  length  of  the  tulie,  in  ten  it  was  con- 
fined to  the  lower  half  or  thinl ;  in  thirteen  iwtieuts  in  whom  death  took  place  late  in  the  attack  tl lembniin-  w.is  of  a  grayish  eidor.     (if  fcaty-two 

ca^'tj  the  mucous  lining  was  of  normal  eonsisteiK-e  in  nine,  softened  throughout  in  thirteen  ami  in  its  lower  uortion  only  iu  tweuty. 


OK    TIIK    CONTIXrKl)    FKVF.RS.  423 

Of  the  sixty-tlirec  maJnriiil  cases  the  coiiililioii  nf  f  lie  miicinis  iiieiEiliiiiiie  of  the  ileum  was  not  stated  in  eifjht ; 
cougesti'd  in  jiatches  in  thiiteeii;  geueially  injeeti'd  or  intianud  in  llnitv  two,  and  variously  Htated  in  ten.  (If  the 
thirteen  in  wliicli  the  injection  was  eiieninserilied  in  jiatehes  the  lo\v<-r  (lait  of  the  ihiini  was  chietly  alfeeti'd  in  three, 
11"),  21*2  and  86«!,  the.  npjier  part  in  one.  •_'.■>!•.  while  in  nim-  a  treniial  distrilmtion  of  the  patches  lhron;;hont  tlie  ilemn 
is  indicated:  In  247  these  localized  eon i;est ions  were  extensive:  in  2 IS  seatti'red  :  in  2X~.  2!i:iaiiil  HSli  intensely  atfected, 
and  in  HI  and  'M>'>  ecehymosed:  in  84  and  2l)l  the  aj;ininated  jrlands  weic  not  diseased  not withslaiiilin;;  the  i-xistenco 
of  these  intlanied  jiatches.  Of  the  thirty-two  cases  in  which  the  e()n;;estion  of  t lie  nieniWrane  was  t;eiieial  throuKhont 
till-  ileiiiii  it  is  ex]iressly  stated  in  some,  as  in  105,  2.")i;and  2(i:i,  that  no  nleeration  was  ))reseiit :  in  litlT  thi'  intestini'  was 
Iierforated  by  nlci'iation.  lint  theiiatches  ofl'eyer  weri-  not  invcdved.  Of  the  ten  c:ises  in  wliieli  the  condition  ofthe 
ineiiihrane  was  varionsly  reported  it  was  thinned  in  STS:  thinned  aiul  reddened  in  274  anil  27t):  of  a  pinkish-cream 
color  in  IW7:  softened  in  78:  thickcni'd  and  softened  in  87:  {;anj;renons  in  80;  and  free  from  eoni;;estion  orother  lesion 
than  jiijiineiitary  deposits  in  the  closed  glands  in  00,  200  and  201.  In  the  eijjht  cases.  70.  108,277,  28!»,  374-;i77,  in 
which  the  condition  of  the  inncons  nieiiiliraiie  was  not  stated,  it  is  prohable  that  tliere  was  no  marked  confjestion,  for 
in  several,  as  in  the  pya-niic  case,  280,  the  attention  of  the  ojieratoi'  was  certainly  direcled  to  this  part  of  the  intes- 
tinal canal,  since  the  condition  of  its  closed  {rlands  w  as  ohsei  vid  and  ncorded.  MoieoviM,  as  has  been  already  shown, 
the  pont-mortei)i  appearances  in  the  paroxysmal  fevers  do  not  neci'ssarily  inclnde  coiif^i'stion  or  iiillammatioii  of  the 
lining  membrane  ofthe  small  intestine. 

Of  the  sixty-one  ii/plio-maldihil  cases  the  condition  of  the  ilenm.  exclusive  of  its  fjlands,  was  not  stati'd  in 
thirty-three.  It  was  nuire  or  less  coiifjested  or  inflamed  in  twenty-four;  but  in  threi^  of  these,  ().i,  1)8  and  Oti,  the 
morbid  condition  was  conflned  to  the  neifjhborhood  of  the  ileo-ea'cal  valve;  in  oiu'.  102.  it  constituted  only  n  border 
to  the  inllamed  or  nlcerated  patches  of  I'eyer:  in  two.  IKi  and  296,  it  was  arranj;ed  in  cireninscrihed  iiatches.  and 
in  one,  273,  darkened  by  sjiots  of  eccliymosis.  In  one,  fiH,  of  the  remaining  four  eases  the  mucous  membrane  ofthe 
ilenm  was  softened,  in  a  second,  67,  thiinmd,  in  a  third.  207,  i)if;niented  in  punctated  slate-cidored  patches,  and  in 
the  last,  208,  of  a  grayish-slate  color  from  dejiosits  in  the  villi. 

The  condition  of  the  mucous  membrane  of  the  ileum  was  not  stated  in  one  huiidreil  and  seven  of  the  two 
hundred  and  thirteen  mixid  febrile  cases;  it  was  more  or  less  re<ldened,  coii;;ested  or  inllamed  in  eighty-two  ami 
varionsly  aU'ecti'd  by  inllammatory  action  in  twenty-fonr.  In  some  the  injecticui  was  slight;  thus  in  204  it  gave 
only  a  faintly  Jiink  tinge  to  the  inembrane.  In  the  seven  cases,  1S7,  172,  108,  200,  ;i20.  :!21  and  320.  the  ciingestion 
was  coufiiH'd  to  the  vicinity  of  the  inlhiimd  aiul  ulcerali'd  patches  of  I'eyer,  around  each  of  which  it  formed  an 
areola;  in  the  last-nu'iitioned  case  the  mucous  membrane  of  tin?  upper  jiart  was  thinned  anil  its  valvuhe  almost 
obliterated.  In  the  nine  cases,  140,  208,  217.  221,  302.  341,  344,  3.50  and  238,  the  congested  or  inllamed  condition  was 
fouiirt  only  in  the  lower  part  of  flic  ileum;  in  the  last-mentioned  case  the  membraMe  was  tliinneil  and  softened  in 
the  uiijier  i>art  of  its  track.  In  the  live  cases,  100.  200,  312,  331  and  333,  the  congestion,  although  all'ecting  also  the 
ujiper  jiart,  was  noted  as  esiiecially  intense  towards  the  ilco-ca'cal  junction.  It  was  disiiosed  in  scattered  )iatches 
or  streaks  in  the  twelve  cases.  1 18.  180.  lilO,  201,  203,  275,  310,  31X,  343,  :i.52  and  3(i|l,  in  one  of  which,  203.  an  ecehy- 
mosed patch  was  ob.served,  while  the  congested  spots  in  300  were  thinncil  and  in  318  thinned  and  softened.  'I'hick- 
eniiig  was  usually  associated  with  the  congestion,  but  in  the  four  cases  already  mentioned  and  in  338  the  membrane 
was  thinned.     In  the  remaining  forty-seven  ofthe  eighty  two  cases  the  congestion  was  general  lliioiighout  the 

ilenm.     Of  the  twenty  four  cases  in  which  various  conditions  of  the  mucous  nuiinbrane  were  ri iled  it  was  said 

to  have  been  .softened  in  101.  212,  213,  2lt>.  230,  284,  323  and  330;  thickened  in  233  and  315;  thinned  in  282:  thin,  jiale 
and  easily  torn  in  the  lower  ]iart  in  181,  niiil  of  a  dark-grayish  color  in  103.  It  w.is  said  to  have  been  ulcerated, 
a)iait  from  the  ulcerations  of  the  agniinated  glands,  in  1(15,  and  the  erosions  in  300  ajipcar  also  to  have  been  in  addi- 
tion to  the  destruction  of  the  membrane  at  the  site  of  the  iileeniled  glands.  The  ileum  is  said  to  have  been  deiinded 
in  its  lower  part  in  210  and  220  and  gangrenous  in  311.  In  live  cases,  130,  Ull,  301,  301  and  354,  it  was  healthy  in 
its  uiiiier  part,  while  in  its  lower  pint  the  comlitiiMi  of  the  glands  only  is  stated;  but  in  case  332  it  is  said  that  the 
snrroumling  villi  were  not  atVectcd.  From  these  last  observations  it  seems  probable  that  in  nniiiy  of  the  large  num- 
ber of  eases  in  which  the  condition  of  the  nincons  nicinbninc  was  not  recorded  the  failure  to  report  its  appearance 
arose  from  the  fact  that  it  iire.sented  nothing  of  iniiiortance  apart  from  the  condition  of  the  glands. 

The  I, AitiiK  Ini  KSTlNE.--()f  the  tifty  typhoid  cases  the  intiammatory  processes  atfected  both  the  large  and  small 
intestine  in  seventeen,  and  the  small  intestine  alone,  so  far  as  can  be  learned  from  the  records,  in  thirty-three, 
but  in  two  of  these,  18  and  11,  it  is  stated  that  the  large  intestine  was  not  exaiuiiied.  The  large  intestine  was  there- 
fore congested,  inllamed  or  ulcerated  in  .seventeen  of  forty -eight  cases,  oi  in  35.4  per  cent.  In  one  of  these  cases,  27, 
ulceration  of  the  solitary  gl.iuds  was  the  only  abnormity  mentioned:  but  in  six  other  ca.ses  the  general  apiieaiance 
of  the  mucous  membiaiie  was  recorded  in  addition  to  llie  eondllioii  of  the  crypts,  which  will  be  eonsidered  here- 
in till'  l.ARiiK  iNTESTi.vK  ili.«ti>nli..ii  was  ,.lis,Tv„i  «illi  iiiiK'l <■  IV.'.iu'h.y  thiin  hi  On-  siiiiill  iiil.-^iin,..     n  «;,,  |,i-,Mnl  in  t«.rit.v-twii  of  tliirty- 

niiK'  casi's,  aiMJ  ill  sixti-.'ii  "f  tin-  tivnitv-tw..  it  wa.-^  roiisi.l.ralili'.     N..l»  itlislaiulini;  a  Kiial  ■listciiliiHi  ..r  il,,-  j;ni  il,  ,-..ats  w.-n-  net  tliinucil,  l.ut  on  tlie 

< Iriiry  nitlier  tliicki-innl,  a  iT.snlt  .-.■iisi.liTiil  due  to  tin'  r.a.  lion  of  llu-  nii'liilM-aii.'.i  on  ilo-  .li-lrnilini;  i.m...s.     U-  nin.oiis  nii'inliraiii'  was  wliitf  in  tliir- 

ti'fii  orf.rrty-tlirc'o  i-as.-.s  ami  .voMow-tiiicc'.l  I'roin  fa'iL.s  in  Uvo;  ils  color  «  a»  niiifoniil.v  r..l  iji  lill.  ,11  ias.>,  in  llir.-o  oC  wlii.h  tin'  nilniw  was  ci'iiiTiil  anil 
in  twflvi-  lo.alizril ;  in  four  .iisi-s  tli.Tr  wi-n-  linnnisiiil.,.,!  ,„\  |«,tiliis;  tlo'  lin-nil.rani-  «a.<  niimisli  in  .  .,loi-  in  niii.-  .as.-s,  all  of  wliiili  wcit  fatal  at  a 

lair  dali'.     Tic.' .mis  linint;  wa.s  of  noiiiiaU-onsist.n,,.  i,,  thirti-on  of  tin- foit.v-tlin-o  iusc-»;  siifti'ni-il  lliroiii;|ioiil  its  «li,.|..  .xt.iit  in  sixn-cn  ;  tliroUKli.oit 

its  tirst  oi-  siTonil  half  in  i-inlil ;  in  tin' i-a'inin  ami  riitiini  in  on.';  in  tin- .asiiiii  only  in  two,  ami  at  difl'.nnt  points  in  tin' c^xti'iit  of  tlw  intcsliin-  in  tliivc 

rasi's,     Kiilari-oniont  of  lli.'  soi.it.irt  oi.avds.  usually  not  niinnrons  ami  with  no  inanifo.st  rliaiis-"-  in  Ho-  niii.oiis  iiimil.ra 'f  tlio  loiality  ocrupiiil  by 

tlii-ni.  was  fonml  in  .•ii;lil  .aos;  in  a  nintli  .as.'  III.'  ,iilaii;r.l  s_'lalols  w.  r.-  1 ii-rons,  <,aH.-n.|  over  tin-  whole  .■xl.nt  of  tlioranal.  ill.  .Talcl  at  tli.irsnni- 

niits  aii.l  with  til.'  snliiiim..ns  ami  iniisinlar  ...ats  n.'ar  lln-m  , si.l.-ral.ly  tlii.ki'ii.-i|.     F.mr  olln-r  la.s.s  )iri..s,.nt...l  liiir.l  |«t.ln's  liki-  those  oi-nirring  in  the 

Bniall  int.'stini-.  hut  ..iily  from  tlirii-  to  four  liii.'s  in  ,iia fr,  aii.l  iil.-.Tiit..l  ..lily  in  on.'  instaiii-f.     ri..Tatioiis  wit.-  tonml  in  f..iiiti-.'ii  lasi-s,  hut  tlu-y 

wereranly  nnun-rous~tli.-y  vaiif.1  from  four  to  thirty  lin.-s  in  l.-ni.'tli  an.l  all.,  l.-.l  On- .ii-.  11111  aloin-,  or,  in  .■.injnn.iion  with  othi-r  |«iitsof  the  intestiue, 


424  PAT1I0L0GICA7-    ANATOMY    A XI)    PATITOT.OGY 

after:  Thus  in  22  it  was  soft  and  of  a  frrayisli-slate  color,  in  24  mottled  rod  and  slate-polorcd,  in  20  greenisli,  in  31 
dark-colored,  in  48  greatly  congested  and  in  50  inflanied.  In  two  cases,  25  and  28,  the  ca'cnni  was  congested ;  in  one, 
47,  dark  slate-colored,  and  in  four,  30,  32,  33  and  49,  ulcerated;  in  the  first  mentioned  of  these  four  there  was  also  an 
intiamed  condition  of  the  rectum,  in  the  second  of  the  colon,  while  in  the  third  the  cu'cuni  had  heconie  perforated. 
Ulceration  was  also  found  in  23,  in  the  lower  part  of  the  intestine,  where  it  was  unconnected  with  the  state  of  th<^ 
solitary  glands.  The  mucous  membrane  of  the  colon  was  intiamed  and  thickened  in  29.  Lastly,  in  21,  the  colon  is 
said  to  have  contained  a  considerable  (juantity  of  blood. 

Of  the  sixty-three  malarial  cases  the  large  and  small  intestines  were  affected  iu  thirty-eight,  the  large  alone  in 
two,  and  the  small  alone,  so  far  as  is  shown  by  the  records,  in  nineteen.  The  intestines  in  the  four  cases  not  accounted 
for  in  the  preceding  statement  presented  no  lesion  other  than  pigmentary  dejiosits  confined,  in  case  291,  to  the  agminated 
and  solitary  glands  of  the  small  intestine,  but  involving  also  the  walls  of  the  largt.^  intestine  iu  cases  90,289  and  290. 
The  large  intestine  was  thus  implicated  in  forty-three  of  sixty-three  cases,  or  in  08  per  cent.  In  thirteen  of  these 
cases,  71,  73,  78,  81,  88,  252,  257, 261,  263,  362,  363,  365  and  373,  the  mucous  membrane  of  the  large  intestine  was  generally 
congested  or  inflamed;  in  87  softened;  in  90  bluish;  in  287  discolored,  and  in  80  diseased,  while  iu  289  and  290  pig- 
mentation of  the  solitary  glands  was  the  only  abnormal  appearance  recorded.  The  mucous  membrane  of  the  colon 
was  congested  or  inflamed  in  ten  cases,  91,  251,  254-256,  260,  278,  292.  294  and  387,  in  the  first  of  which  the  inflamed 
membrane  was  also  eccliymosed;  it  was  thickened  and  softened  in  108,  slate-colored  in  276,  and  gray  with  a  few  red 
patches  in  293.  The  rectum  was  affected  in  four  cases:  In  72  its  lining  was  softened;  in  70  inflamed  and  softened; 
in  262  injected  and  thickened,  the  colon  being  similarly  att'ected;  and  in  274  congested,  the  large  intestine  generally 
being  slate-colored.  Ulceration  was  mentioned  in  seven  of  the  cases:  In  386  the  lining  meml)rane  of  the  intestine 
was  slate-colorsd,  with  patches  of  congestion,  ecchymosis  and  ulceration  ;  it  was  inflamed  and  ulcerated  throughout, 
but  particularly  in  the  rectum,  iii  115;  the  lower  part  of  the  bowel  was  ulcerated  in  84,  ulcerated  and  gangrenous  in 
76;  the  colon  was  ulcerated  in  89,  slato-colored,  injected  and  ulcerated  in  295,  and  thickened,  softened  and  ulcerated 
at  its  commencement  and  termination  in  376. 

Of  the  sixty-one  tijpho-mulariul  cases  the  large  intestine  was  att'ected  in  twenty-nine,  the  small  intestine  alone 
iu  thirty-one,  but  in  three  of  these,  52,  64  and  83,  the  large  intestine  was  not  examined.  In  one  case,  69,  nothing  is 
said  concerning  an  intestinal  lesion.  The  large  intestine  was  thus  involved  in  twenty-nine  of  fifty-seven  cases,  or  in 
51  per  cent.  In  three  of  these  cases  the  glands  onlj-  were  mentioned:  In  285  as  enlarged,  in  298  as  i)igmeuted  and  in 
85  as  ulcerated.  The  membranous  lining  of  the  intestine  generally  was  congested  or  inflamed  in  the  five  cases,  66, 
86,  92,  112  and  273;  in  296  it  was  slate-colored  and  injected  in  patches;  in  297  the  daik  coloration  was  confined  to  the 
ciECnm  and  iu  67  and  68  to  the  colon.  The  colon  was  congested  or  inflamed  in  100,  102,  106  and  116,  and  striotured 
in  77.  Ulceration  was  present  in  twelve  cases;  generally  throughout  the  intestine  iu  74, 103  and  266;  in  the  colon  in 
65,  99,  101,  109,  110,  264  and  265;  in  the  colon  and  rectum  in  75,  and  in  the  rectum  alone  in  98. 

Of  the  two  hundred  and  thirteen  mijri-d  cases  the  large  intestine  was  more  or  less  att'ected  in  one  hundred  and 
six,  the  small  alone,  so  far  as  can  be  learned  from  the  records,  in  one  hundred  and  one.  In  six  cases,  378,  379,  .381-384, 
the  record  is  silent  concerning  the  condition  of  the  intestinal  tract.  The  large  intestine  was  thus  implicated  in  one 
hundred  and  six  of  two  hundred  and  seven  cases,  or  in  51.2  per  cent,  of  the  cases.  Iu  fourteen  of  these  cases,  163, 
164,  168,  169,  188,  192,  193,  197,  199,  281,  319,  329,  334  and  338,  the  recorded  statements  as  to  the  condition  of  the  large 
intestine  refer  only  to  enlargement  or  ulceration  of  its  glands  or  pigmentation  of  its  walls.  The  intestine  was  more 
or  less  congested  or  inflamed  in  twenty-one  cases,  in  one  of  which,  173,  the  congestion  was  disposed  iu  patches;  iu 
another,  282,  it  was  particularly  intense  in  the  cajcum,  while  in  a  third,  370,  in  the  lower  part  of  the  bowel  it  resembled 
ecchymosis.  In  addition  to  these  twenty-one  instances  of  congestion  the  lining  membrane  of  the  large  intestine  as  a 
whole  was  recorded  as  greenish  in  181;  thickened  and  softened  in  239;  thinned,  softened,  pigmented  and  slightly  con- 
gested in  380;  soft  and  disorganized  in  323;  eccliymosed  in  301;  while  in  187  its  rugie  were  elevated  and  its  calibre 
contracted.  The  colon  was  constricted  in  two  cases,  160  and  243  ;  in  176  it  contained  coagulated  blood ;  iu  227  and 
302  its  mucous  membrane  was  thickened  and  softened;  in  162  dotted  with  minute  oval  pur])uric  spots;  iu  twenty- 
two  cases  it  was  congested  or  inflamed:  In  ten  of  these  this  condition  ai)])ears  to  have  been  general,  while  in  seven, 
170,  184,  245,  312,  327,  330  and  333,  it  was  more  particularly  observed  at  the  commencement;  in  three,  279,  310  and 
337,  towards  the  lower  end  of  the  bowel,  and  in  two,  203  and  324,  at  both  of  the  extremities.  Ulceration  was  present 
in  thirty-seven  of  the  cases.  It  affected  the  iutestine  generally  in  the  thirteen  cases,  167,  171,  178,  185,  229,  2.32,  234, 
236,  238,  242,  244,  300  and  351,  but  in  300  the  action  was  especially  manifested  iu  the  sigmoid  flexure,  where  per- 
foration had  taken  place;  it  affected  the  caicum  in  the  eleven  cases,  161,  165,  172,  177,  237,  313,  314,  325,  332,  348  and 
353;  the  colon  iu  ten  cases,  166,  233,  235,  240,  241,  315,  317,  318,  320  and  360,  in  one  of  which,  318,  there  were  pui'iiuric 
spots;  the  rectum  in  one  case,  299,  but  iu  addition  to  this  the  lower  end  of  the  bowel  was  gangrenous  in  one  case, 
311,  and  disorganized  in  another,  316. 

The  condition  of  the  soi.itauy  glands  was  observed  and  stated  iu  thirteen  of  the  fifty  typhoid  cases.  They 
were  inflamed  iu  one;   ulcerated  in  six;   sloughing  in  two;   in  most  of  the  cases  they  were  unusually  prominenf, 


in  ten  cases.  The  ulcers  were  in  some  cases  evidently  an  affection  of  the  solitary  glands,  but  in  others  their  site  was  tlio  mucous  membrane  in  the  inter- 
vals between  these  crypts.  In  one  of  tlie  cases  an  ulcer  near  the  anus  couiuiunicated  with  a  small  submucous  ab.scesH.  Excepting?  tiie  imrd  phuiucs  the 
nutrbid  changes  in  the  large  intestine  were  the  Siime  iu  those  who  died  of  typhoid  as  in  those  wlio  died  of  other  acute  affections,  and  the  differeiue  of 
[)rtipi>rtion  was  considerable  ouly  in  the  instances  of  meteorism  and  ulceration  of  the  mucous  membrane.  Thus,  in  forty-five  cases  of  typlioid  fever  the 
membrane  was  genemliy  red  in  three,  iiartially  red  in  ten,  grayish  in  nine,  generally  softened  in  sixteen  and  partially  softened  in  fourteen,  while  in 
sixty-nine  cases  of  other  acute  maladies  there  was  general  redness  in  tliree,  partial  redness  in  twelve,  a  gray  color  in  seven,  general  softening  in  twenty- 
two  and  partial  softening  in  twenty -five  cjises.  Meteurism  was  observed  only  in  three  cases  and  in  none  of  them  to  the  extent  found  in  typhoid  fever; 
wliile  exclu<!ing  one  case  <>f  dysentery,  in  wliich  the  colon  presented  many  ulcers,  erosion  of  the  meinlrt-aue  was  discovereii  in  three  cases  only,  all  of  them 
instances  of  lung  inflammation. 


OF   THE    COXTIXl'FP    FKVKRS.  425 

anil  ill  four  this  eiilaigi^inout  was  tlie  only  al)iioniial  comlitidii  iviicntcd.  In  Home  instances  it  is  nncertain  from  the 
teiins  of  the  record  whether  tlif  L;ian<ls  of  the  lar^e  intestine  were  insiilved  in  theniorhitl  processes:  Tlnis,  in  4,  <5,  7, 
I'.i,  11  and  17,  the  chanjies  in  the  solitary  glands  were  mentioned  in  eonneetion  with  those  of  the  patches  of  I'l'ver, 
while  nothing  was  specified  with  regard  to  thi'  glanils  of  the  ca'cuni  or  e<don;  and  in  L'S  and  31  the  solitary  glands  of 
the  ileum  were  particularized,  while  those  of  the  large  intestine  and  even  the  intestine  itself  were  not  mentioned. 
On  the  other  hand,  in  the  three  cases,  23,  21  and  21.  the  glands  of  the  large  intestine  were  atVeeted  as  well  as  those  of 
tli(^  ileum,  although  in  one  of  these,  2S,  the  a|ipearances  were  not  similar,  the  glands  of  the  latter  being  prominent 
only,  while  those  of  the  former  were  blackened  by  pigmentary  deposits.  Again,  in  the  two  cases,  '2ii  and  IM,  the 
glanils  affected  were  confined  to  fhi^  large  intestine.  Hence,  so  far  as  the  indefinite  terms  of  ihc  jin/il-iiiorliin  recorils 
permit  of  a  knowledge  of  the  locality  of  the  altered  glands,  those  of  the  ileum  were  atiected  in  eleven  cases  ami  those 
of  the  large  intestine  in  five. 

The  condition  of  the  glands  was  observed  in  a  larger  proportion  of  the  mahiridl  than  of  the  ty|>hoid  eases. 
Twenty-nine  observations  were  made,  in  four  of  which,  2.")7,  260,  2()1  and  2t!3,  the  glands  of  both  the  large  and  small 
intestines  were  normal.  Of  the  renniining  twenty-live  the  glands  were  re|iort;'d  congested  in  oiu',  258;  inlhimed  in 
two,  278  and  38(1:  ulcerated  in  five,  84,  8!),  2115,  375  and  37(1:  disorganized  in  three,  70,  73  and  303,  and  pigmented  in 
nine.  In  nu)St  of  these  there  was  coexisting  enlargement,  but  in  five  cases,  87,  252,  251,  287  and  373.  ]ironiinence  of 
tlu^  glands  was  the  only  abnormal  condition  stated.  In  some  instances  the  siimc  ditlicnlty  is  found  in  determining 
the  site  of  the  affected  glands  that  was  experienced  in  certain  of  the  tyidioid  cases.  They  were  mentioneil  in  general 
terms,  but  in  connection  with  the  patches  of  I'eyer  in  two  eases;  those  of  the  ileum  were  reiiorted  altered  in  seven 
cases,  in  which  more  or  less  tmcertainty  attaches  to  the  condition  of  the  large  intestine;  those  of  both  intestines 
were  affected  in  thirteen,  while  in  three  the  glands  of  the  large  intestine  alono  are  mentioned.  Hence,  so  far 
as  the  terms  of  the  record  permit  of  a  knowledge  of  the  locality  of  the  ghmds  atiected,  those  of  the  ileum  were  impli- 
cated in  twenty-two  cases  and  those  of  the  large  intestine  in  sixteen.  In  2!I0  ami  2!tl,  of  the  nine  in  which  the  change 
consisted  in  the  deposit  of  pigmentary  matter  in  the  glands,  w  ith  or  witbouf  enlargement,  congestion  or  ulceration, 
the  altered  glands  were  those  of  the  ileum:  in  ill,  28il,  2!I2,  2!M  and  387  all  tln^  solitary  glands  w<'re  thus  aifected  ;  in 
one,  362,  those  of  the  large  intestine  were  pignu'iited,  while  those  above  th(^  ileo-ca'cal  valve  were  simply  lUilarged. 
and  in  2!)3  the  black  deposit  was  reported  jirescnt  in  the  large  inti'stim*  only.  Usually  the  glands  in  the  large  and 
the  small  intestine  were  similarly  atiected,  3ti2,  already  instanced,  being  exceptional  in  this  regard,  and  also  84,  in 
which  the  glaiuls  of  the  large  intestine  were  prominent  while  those  of  the  small  intestine  were  ulcerated. 

Seventeen  observations  were  recorded  in  th<<  si.xty-one  iypho-malarial  ca.ses.  Of  these  there  was  no  unhealthy 
condition  in  two,  ,54  and  102;  simple  enlargement  in  three,  inllamnnition  or  ulceration  in  eight  and  pigmentation  in 
four.  Tlie  glands  of  both  the  large  and  siiuill  intestines  w(iri'  affected  in  three  ea.ses:  of  thejarge  intestiiu'  alone  in 
three  cases;  and  of  the  ileum  in  nine  cases,  in  w  liich  more  or  less  uncertainty  exists  as  to  the  conditiiui  of  the  large 
intestine.  Hence,  the  cryi)ts  of  the  ileum  were  altered  in  twelve  cases;  of  flu^  large  intestine  in  six  cases.  In  but 
one  instance,  llCi,  were  the  glands  of  the  ileum  said  to  have  l)('en  iiigmentcd,  although  in  2il7  the  mucous  membrane 
was  slate-colored  and  in  2!t8  deposits  In  the  villi  darkened  its  c(dor.  The  siditary  glands  of  the  colon  were  ])igmented 
in  five  cases, — in  llti  and  2118,  just  mentioiuMl,  in  ti7,  in  which  the  cry|)ts  of  the  ileum  were  not  lucntloned,  and  in  t!8 
and  2iH>,  in  which  they  were  inflamed  or  ulcerated. 

The  condition  of  the  solitary  glands  was  observed  and  noted  in  fifty-one  of  the  two  hundred  and  thirteen 
mixid  febrile  ca.ses,  and  in  one  of  these,  32i),  the  crypts  were  normal  throughout  the  vvliole  of  the  intestinal  canal.  The 
glands  were  enlarged  in  eighteen  cases,  ulcerated  in  twenty-three  and  ]>igmentcd  in  nine  cases,  in  some  of  which 
enlargement  ami  nlci-ration  were  also  jircsent.  The  site  of  the  affected  glands  is  nncertain  in  some  instancies  antl  in 
others  definitely  stated:  In  twelve  ea.ses  the  glands  were  mentioned  in  connection  with  the  patches  of  I'eyer,  whence 
it  may  be  inferred  that  those  of  the  small  intestine  were  certainly  afiecteil;  the  ileum  appears  indicated  as  the  site 
in  eighteen  ca.ses,  in  the  nuijority  of  which  the  condition  of  the  glands  of  the  large!  intestine  is  more  or  less  uncer- 
tain, as  in  only  one,  203,  are  they  stated  to  have  been  normal;  both  the  ileum  and  large  intestine  were  involved  in 
nine  easies,  while  the  large  intestine  alone  was  mentioned  in  eleven.  Hence  it  may  be  said  w  ith  certainty  that  the 
solitary  glands  of  the  ileum  were  imi)licated  in  at  least  thirty-nine  cases  and  those  of  the  large  intestine  in  at  least 
twenty  cases.  Pigmentation  was  found  in  the  glands  of  the  ileum  in  141  and  302,  in  which  no  reference  was  made  to 
those  of  the  large  intestine,  and  in  200  and  201,  in  which  the  glands  of  the  large  intestine  also  contained  the  deposit ; 
in  203,  320  and  380,  in  which  the  crypts  of  the  ileum  were  enlarged  or  congested,  those  of  the  large  intestine  were 
pigmented;  the  latter  glands  were  ])ignUT.ted  also  in  331  and  334,  in  which  tlio.se  of  the  ileum  were  not  mentioned. 

I'Kia'OliATiox  OK  TllK  INTKSTIXK  ,^Ni)  I'ElilTONlTls. —  In  twelve  of  tile  fifty  tjiiiliiild  cases,  or  in  21  Jier  cent.,  the 
intestine  was  perforated  by  the  ulcerative  processes,  the  situation  of  tlie  jii'rforation  being  in  i'eyer's  jiafches  in  the 
six  cases,  l()-20  and  32;  in  the  ileum  and  ]>robably  in  the  patches  in  the  five  cases,  43-40  and  50,  and  in  the  ca'Cuni 
in  case  33.  Peritoneal  inllammation  generally  followed  this  accident,  but  in  32  it  is  said  that  then!  was  no  evidence 
of  infiamniatory  action.  In  10  and  23  fa'ces  had  escape<l  into  the  peritoneal  cavity.  Peritonitis  occurred  in  the 
ab.sence  of  perforation  in  cases  31  and  40,  apjiarently  without  any  other  immediate  or  determining  cause  than  the 
morbid  condition  of  the  glands  of  the  mucous  membrane  and  mesi-ntery.  In  striking  contrast  with  this  record,  there 
was  but  one  ca,se  of  perforated  intestine  among  the  sixty-three  mulaiial  cases.  In  this  instance,  367,  the  ileum  had 
given  way,  while  Peyer's  patches  were  reported  fr.e  from  disease.  Peritmiitis  was  present  in  80,  in  w  liich  the  intes- 
tines were  in  a  gangrenous  condition,  and  in  210,  in  which  it  was  aiipaiiMitly  due  to  a  rupture  of  s])lcnic  cysts.  Per- 
foration occurred  in  six  of  the  sixty-one  li/pho-iiKilitriul  cases,  or  in  9.8  per  cent.:  In  107  the  small  intestine  was 
recordeil  as  the  site,  in  82,  83  and  100  the  ileum,  and  in  04  and  103  the  ulcerated  aggregated  glands,  Perilcmitis 
occurred  without  )ierforation  in  the  live  easels,  03,  03,  Ull,  2!1()  and  208;  in  03  it  may  have  lieen  connected  with  the 
Mku,  Hist.,  Pt.  m— .54 


42fi  PATHO].()(iT('AL    AXATO^rY    AX]i    PATHOLOCY 

depfeneratcd  coiiditidii  of  flic  lerfi  mnsclcs,  and  in  2!i6  with  iiioiliid  rhaiijifs  in  tlic  spli-tMi.  PcrforatiDn  «rth(^  intes- 
tine was  ()l).servi'il  in  twonty-four  of  tlii^  two  luindrcd  and  tliiilccn  iiihcil  casos.  The  aocident  is  stated  as  having 
taken  plat^e  in  tlie  intestines  in  case  lill;  in  the  hufje  intestine  in  SOO:  in  tlie  small  intestine  in  22ti;  in  the  ileum 
in  nine  cases,  221^-225,  245,  809,  340,  847,  3()0  and  3«5,  and  in  the  patelies  of  Peyer  in  twelve  cases,  152-159,  204,  322, 
327  and  328.  Case  3»5  is  exceptional  as  showing  a  possiliility  of  recovery  even  after  perforation;  in  it  there  was 
neither  escape  of  the  intestinal  contents  nor  peritonitis,  on  aceonnt  of  the  occlusion  of  the  aperture  bj-  adhesion  to 
the  serous  coverinj;  of  the  bladder.  Peritonitis  was  reported  as  liavinj;  occurred  in  seven  cases  in  which  no  mention 
was  made  of  perforation;  in  203  and  337  it  was  probably  tubercular;  in  151  connected  with  the  condition  of  the 
abdonunal  recti  muscles;  luid  in  the  others,  150,  311,  353  and  361,  with  the  state  of  the  interior  tunics  of  the  intes- 
tinal canal. 

Pkj.mkntaky  dkposits  in  the  intestine  are  mentioned  in  only  two  of  the  fifty  tjiplund  cases;  in  23  near  tlie 
pylorus  and  in  the  solitary  fjlands  of  the  large  intestine,  and  in  2ti  in  which  the  ulcerated  glands  near  the  ileo-ca-cal 
valve  were  of  a  dark-blue  color.  The  colon,  however,  was  slate-colored,  greenish  or  dark-colored  in  cases  22,  24,  26, 
31  and  47.  Pigmentation  was  found  in  twenty  of  the  sixty-three  malarial  cases,  or  in  31.7  per  cent,  of  the  cases: 
The  patches  of  Peyer  were  dotted  with  dark-colored  spots  presenting  what  has  been  called  tlie  shaven-beard  appear- 
ance in  the  six  cases,  87-90,  115  and  288,  as  also  in  the  eight  cases,  91  and  289-295,  in  which  the  solitary  glands  are 
mentioned  as  involved  in  the  pigmentation;  the  ileum  and  mesenteric  glands  were  blackened  in  258,  although  the 
patches  of  Peyer  were  healthy;  in  287  the  patches  were  prominent  and  speckled  with  blood  and  the  mucous  mem- 
brane of  the  colon  discolored;  tlie  interior  of  the  colon  was  slate-colored  iu  274  and  386,  and  its  solitary  crypts 
blackened  in  362  and  387.  The  intestines  were  blackened  by  deposited  pigment  in  ten  of  the  sixty-one  li/]>Jio-inulariaI 
cases,  or  in  16.4  per  cent.:  Peyer's  patches  were  att'ected  in  54,  86  and  96,  and  the  solitary  glands  also  iu  116  and  296; 
the  ileum  and  colon  in  297  and  298;  the  colon  alone  in  265,  and  its  solitary  glands  in  67  and  68.  Peyer's  patches  pre- 
sented dark-colored  ulcerations  or  deposits  iu  the  four  cases  148,  149,  181  and  368  of  the  mixed  series.  The  colon  or 
its  glands  are  alone  mentioned  as  pigmented  in  the  twelve  cases,  168,  169, 174, 198,  202,  203,  302,  310,  320,  329,  334  and 
380,  while  Peyer's  patches  were  also  afltected  according  to  the  records  of  200,  201,  331  and  338,  and  the  ileum  accord- 
ing to  that  of  199.  The  solitary  glands  of  the  small  intestine  were  pigmented  iu  141  and  165,  and  the  ileum  was  of 
a  blue-slate  color  in  333,  which  also  ])resented  dark-blue  sjiots  iu  the  bladder  near  the  orifices  of  the  ureters.  The 
intestines  were  of  a  dark-gray  color  iu  193.  These  tweiity-tive  instances  of  dejiosited  pigment  form  11  per  cent,  of 
the  total  of  two  huudred  and  thirteen  mixed  febrile  cases.  But  there  should  be  mentioned  in  this  connection  the 
ecchymoses  or  purpuric  spots  iu  the  large  intestine  in  cases  162,  183,  189,  301,  318  and  370. 

The  condition  of  the  mesenteric  (iLAXUs  is  mentioned  in  but  fourteen  cases  of  the  typhoid  series,  in  all  of 
which  there  was  notable  enlargeineut.  In  the  malarial  series  the  glands  are  mentioned  fourteen  times;  iu  twelve 
cases  they  were  enlarged  and  more  or  less  altered  in  color,  while  in  the  two  others,  274  and  374,  they  are  said  to  have 
been  healthy  although  Peyer's  patches  were  much  att'ected:  in  70  the  enlargement  was  so  great  and  general  that  the 
mesentery  had  the  appearance  of  being  one  continuous  gland.  In  the  ttjiihu-malarial  series  their  condition  is  recorded 
seventeen  times;  enlarged  and  more  or  less  deeiily  colored  or  affected  with  yellow  softening  iu  sixteen  eases, and  ulcer- 
ated in  one  case,  93.  In  the  mixed  series  they  were  infiamed,  enlarged  and  softened  iu  all  of  forty-five  cases  except 
two,  307,  which  contained  chalky  concretions,  and  331,  uornial  notwitlistanding  the  affection  of  the  agminated  glands. 

The  appearance  of  the  splkex  is  stated  in  thirty  of  the  tifty  typhoid  cases,  iu  only  two  of  which  was  it  nor- 
mal. The  alteration  consisted  of  eulargement  and  softeuing,  sometimes  to  pulpiness,  frequently  associated  with 
a  darkened  color.  In  case  37  the  spleen  was  three  times  its  usual  size:  in  9  it  weighed  forty-one  ounces;  in  one  case 
only,  42,  one  of  seiiuent  consumption,  was  it  small  and  hard.  Its  condition  was  rejiorted  iu  lifty-two  of  the  malarial 
leases.  It  was  normal  in  eighteen  and  small  iu  six  cases,  90,  91,  2.52,  259,  276  and  291;  it  weighed  only  three  ounces 
and  a  ([narter  iu  one  of  these,  and  was  tough  and  of  a  dark  color  iu  most  of  them.  In  the  other  instances  it  was 
enlarged,  congested,  soft,  flabby  or  frialile;  iu  70  it  was  three  times  its  usual  size;  iu  87  it  was  similarly  enlarged  and 


Tiu'  LYMPHATIC  (ii.,\Nl)S. — All  iif  tin-  tweHhTif  i^X-AmU  r()rn*s]niinliiif;  ti»  altered  j)lji([iic.-*  Knffcrcti  a  lin"litii*atii)t»  of  size,  rclor  or  consistence.  Tliey 
were  enlargeil  anil  rose-colored,  snliseiiuently  beeiunin;;  sot'ti-ned,  of  a  darker  red  and  develujiinK  yellowish  points  or  iinrnlunt  foci  in  their  tissues; 
and  even  tin-  giiinds  corresponding  to  a]>i>arentl>' heultliy  patches  in  ten  of  the  forty-six  ciises  were  found  t<»  be  enlarfjed  and  redilened.  The  m(;Av.co/ic 
Klands  were  niarketl  by  intlannnatory  chanjies  in  fourteen  of  iiiin-teen  cases  in  which  they  were  i;xainin<>d,  and  althou}j:li  these  (dianges  were  assiH^ated 
with  redin-ss,  softening  or  nlei-rution  of  the  nieinhrane  in  most  cases,  in  otliers  the  inemhrani^  was  healthy;  nevertheless,  these  glands  iu  no  case 
contained  purulent  liejiosits.  Knlargenient  and  redtlening  of  the  glands  of  the  tttownrlt  corresponded  in  three  cas<'S  witii  iuflaiuniatiiry  conditions  of 
the  inu<'ous  lining  of  that  viscus,  hut  in  a  fourth  case,  iu  which  the  glands  witc  afTeeted,  the  liniLig  was  iiealthy,  and  iu  a  fifth  casti  tliis  w.-int  of  eorres- 
pondeuie  was  reverseil.  Lulls  considered  that  this  hitter  condition  was  of  frequent  oeciirrenee,  althougli  not  reetu'ded  hy  him.  Jle  argui-d  that  while 
the  stomach  was  very  freijiiently  altered,  he  eonld  searcely  iu  hi^ipi'^'htwninH  work  have  failed  to  notict,'  eorresi)onding enlargement  of  the  glands  had  such 
a  change  heeii  present.  The  liiiiibiir  ghiuds  wrrr  large  and  firm  iu  two  cases,  iu  cue  of  whieli  the  patient  sueennihed  to  a  seipielit  erysipelas  of  the  lower 
extremities.  In  a  similar  case  the  ini/iiiual  glands  were  large,  red  and  contained  white  pus ;  iu  three  others,  iu  wdiioli  tlie  legs  had  been  blisti-red,  these 
glands  were  iufiaiued  hut  had  not  suppurated.  The  tvn-ioil  glands  were  enlarged  and  reildi-ued  in  nine  of  twidve  ca.ses  in  wliieii  they  were  examiin-d.  Six 
of  the  nine  had  eoneurrent  ulceration  of  the  pharynx,  but  in  the  three  others  there  was  no  marked  lesion  of  the  organ  corresimnding  to  the  ghiuds.  In 
patients  who  died  of  otlier  acute  maladies  tin-  mesenteric  glands  were  large  and  red  in  six  cases  of  suiall-pox,  .scarlet  fever,  pneumonia  and  erysipelas, 
and  somewhat  softened  iu  one  cas*'  of  suiall-pox,  but  in  inuie  of  tiiese  was  the  eluiuge  comparable  with  that  snlTered  by  the  glands  of  the  lower  jiarl  of 
the  mesentery  in  tyjihoid  fever.  The  cervical  glands  were  affected  iu  four  cases,  three  of  which  wen-  eruptive  fevers,  and  iu  only  two  of  these  was  there 
,a  manifest  alteration  of  the  air-pas.sages.  It  is  inferred  from  tln'se  facts  that  wbih-  the  condition  of  the  glanils  doi-s  not  iu  all  instances  depend  on  that 
of  the  organs  w  ith  wliieh  they  are  connected,  the  typhoid  alTeetion  establishes  a  marked  preilispositiini  to  inHaiinuatory  changes  in  the  mesenteric  and 
cervical  glands. 

The  sri.KFN  was  unaltered  in  four  only  of  the  forty-six  rases,  ft  was  more  tliaii  three  times  its  usual  size  iu  seveuteen  cases;  more  tlian 
double  its  usual  size  in  nineteen,  but  slightly  enlarged  iu  nine  and  apjiareiitly  small  in  one  ease.  It  was  softened  in  thirty-four,  and  in  seven  of 
these,  in  which  the  softening  was  extreme,  the  organ  was  largely  iucmisifl  iu  volume ;  but  iu  no  instance  was  pus  found  iu  its  ti.ssues.  It  was  observi  d 
that  the  tuinefaetion  and  softening  specially  ebaracterized  those  ca8e,s  that  were  speedily  fatal,  while  the  organ  was  more  freipiently  normal  or  but 


OF    THE    CONTINUED    FEVERS.  427 

contaiiitd  alitsoesscs ;  in  ST"  its  snifaco  was  iiiottliil  with  spots  smiouiKlcd  liy  rcddisli  areola'  and  its  section  exuded 
a  sei()-]iuinleul  liiiui<l:  in  25S  ii  ((intainiMl  l  iilicrinlai  masses  and  in  2I!I  cysts,  the  clieesy  edntents  ot'  which  hail  in 
])art  psca))ed  into  tlic  peiitnncal  cavity.  Its  conditiim  was  not  stated  or  not  oliseivi'd  in  nineteen,  normal  in  eif;hl 
and  altered  in  tliirty-t'oiir  of  the  sixty-one  liijiliii-iinilnriiil  cases.  In  case  L'dli  it  weii;hed  three  onnces  and  a  lialf  and 
was  iirni:  in  (J"  it  was  snnill  Imt  extremely  sot't.  Witli  these  exceptions  it  was  enlaiiicd.  iMinfrcstcd.  sol'iened  and 
often  darkened  in  color.  In  case  ilil  it  is  said  to  have  Ixmii  rotten:  in  •J!H;  it  had  an  inllamcd  condensation  of  its  tissne 
ahont  the,  size  of  a  nntmcj;  at  its  np]ier  eml  and  the  conti;;uons  omentum  was  also  inllami'd.  In  the  iiiixid  series  the 
Kpleen  was  normal  in  thirty-six  and  variously  cliani;ed  in  one  hnndred  and  seven  cases.  It  was  small  in  seven  of 
these.  201,213,  228,  2><1,  HOti,  32!t  and  SSI,  varying;  in  wei^'Iit  from  ono  oniic  and  a  lialf  in  21:!  lo  four  ounces  and  thrce- 
iiuarters  in  281.  It  was  discolored  Imt  in>t  enlarjicd  in  a  few  inslani-es.  (ienerally  the  orfjan  was  lari;e,  conscsled, 
dark-colored  and  more  or  less  softened:  in  i:i2  it  wei^lied  forty-one  onnces.  in  Slit  thirty-six  onnees  and  in  12it  thirty- 
four  onnces:  in  1H7  and  221  the  alteration  of  the  tissne  apiiroaclied  decomiiosition,  and  in  IS"  it  was  pnltai-i'ous;  in 
S()9  it  was  light-colored  and  hardeiu'd  in  portions  of  its  snbstance,  lint  softi-ned  and  snppnratinj;  near  the  liilns:  in 
354,  underlyinj;  a  diajdiraiiniatic  adhesion,  was  a  cavity  containing  an  onnci>  of  viscid  jrro'ii  lii|nid:  MS  ami  211  also 
contained  cysts;   in  2(11  the  supeilicial  layer  of  the  s]deni(^  parenchyma  was  colored  slat e-1  due  l>y  nndecnlar  deposits. 

The  appearanc<'  of  the  l.tVKi;  was  recorded  in  twcnty-nini'  of  the  lifty  liijihnid  ca.ses:  It  was  norimil  in  elevi'n, 
leaviiifi;  only  eighteen  in  which  the  attention  was  called  to  diseased  conditions.  The  liver  was  large  in  four  of  thi'.se, 
soft  in  one,  large  and  Halihy  in  one,  large  atid  pale  in  two,  huge,  pale  and  soft  in  two,  large  and  fatty  in  one,  pale 
and  fatty  in  one,  large  and  congested  in  one.  congc'sfcd  in  four  and  mottled  in  one.  In  the  sixty-three  mnUiriid  eases 
the  condition  of  the  liver  was  recorded  tifty-thice.  times;  in  tweiily-oiie  it  was  normal  and  in  thirty-two  altered. 
Enlargement  is  indicated  in  most  of  tln^  cases;  Imt  there  was  generally  more  than  this,  for  enlargement  alone  in  men- 
tioned in  Init  one  of  them,  Th(\  organ  was  soft,  llahhy  or  friable  in  five  ca.se8;  pale  in  four,  in  one  only  of  whicli 
it  was  firm;  fatty  in  four;  waxy  in  one;  congested  in  live;  dark-colored  or  liron/ed  in  sevi-n;  in  21!t  it  was  covered 
with  exuded  Iyin]ih ;  in  W)  it  adln'rcd  to  the  <liaphragm  and  in  3(17  to  the  intestines  also;  in  S7  it  contained  minute 
abscesses  and  in  2.")()  a  single  absci'ss  of  large  size.  In  the  sixty -ono  liiiiha-mdhiriol  eases  tlie  liver  was  re])orte<l  normal 
in  nineteen  an<l  variously  changeil  in  a|)pe.irancc  in  Iwenty-six  casi's;  in  sixteen  its  condition  was  not  examini'd  or 
not  stated.  Enlargement  was  gcni'rally  observed,  and  in  four  cases  this  was  the  only  change  mentioned.  The  organ 
was  pale  in  four  cases:  soft  in  four,  in  which  this  coiulit  ioii  is  stated  alone  or  with  eiilargi'ineut ;  fatty  in  four  and  of 
the  nutmeg  aiipearance  in  one;  dark  or  bronzed  in  three;  congested  in  ti\e  and  emphy.semal<Mis  in  one.  In  the  Hiixc(/ 
series  of  febrile  cases  the  condition  of  the  liver  was  not  stated  in  seventy-one,  nonnal  in  lifty-tivc  atid  alti'ri'd  in 
eiglity-Hevcn.  Enlargement  alone  iH  mentioned  in  eighteen  and  in  con.jnuction  with  vaiioiis  changes  in  many  of  the 
olheis.  The  oigan  was  pale  in  twelve,  in  two  of  which  it  was  reported  llabby  anil  in  one  lirm.  It  was  anaiiiic  in 
one  case.  333:  granular  in  111;  fatt.v  in  nine;  of  the  nutmeg  aiijiearance  in  two,  S(t(i  ;inil  315;  soft,  tlabby  or  friable 
in  eleven,  in  one  of  which,  IIMI,  its  substance  was  emphysematous,  of  ( he  color  of  saiiions  ])iis  and  possessed  of  a  dis- 
agreeable oilor,  while  in  another.  KIT.  in  which  the  ))areiichyma  was  of  a  greenish  color,  a  chicki'n-coo]i  odor  was 
iiislaiiced.  It  was  soft  also  in  live  of  liftecu  ca.ses  which  were  rciioiti'd  (•ongcsted,  and  in  two.  125  and  32(1.  in  which 
tlieie  were  ailhcsions:  in  three  others,  328,  3ii7  and  317,  the  serous  coat  adhered  to  cimtiguous  organs.  It  was  brown 
or  dark-colored  in  eight,  mottled  in  181  and  2(18,  of  a  blue-slate  <'olor  in  151,  ecchymosed  on  its  surface  and  slate-col- 
ored on  section  in  38(1,  and  small,  weighing  only  twenty-eight  ounces  and  a  half,  in  281. 

The  i;ai.i.-hi..M)1ii;u  iiu  ii.s  co.NrKNts  were  observed  in  seven  of  the  li/jihoiil  cases:  The  visciis  was  small 
in  2!l  and  hirge  in  31, — in  the  former  it  was  half  tilled  with  bile;  11  was  comi>letely  tilled  with  viscid  bile  in  48; 
it  contained  live  drachms  of  yellow  bile  in  24:  eleven  drachms  of  dark-green  bile  in  47;  twenty-six  drachms  in  23 
and  ten  ounces  of  brown  bile  in  2(i.  Observations  were  nnidi^  in  sixteen  of  the  iimhiriiil  cases:  The  viscus  was  dis- 
tended with  daik-green  oi  yellow-colored  bile  in  the  six  <>ases,  7(1,  80,  KM,  218,  3(!5  and  37(i;  one  ounce  was  said 
to  luive  been  ])rcsent  in  ilO  and  277.  and  aliout  two  ounces  in  2(13,  27(1  and  37S,  the  bile  in  the  lasl-meutioncd  case 
having  been  watery;  the  gall-bladder  in  271  and  28!)  was  empty,  •■mil  in  287,  288  and  .1(12  the  i|nanlity  of  its  thick  or 
tlaky  I'onlents  was  small.  Among  the  liipliD-iiKihiiiiil  cases  fourteen  observations  weri'  made:  'The  gall-bladder  was 
normal  in  103,  small  in  112,  em|)ty  or  nearly  so  in  (11  and  2!t6;  it  contained  six  dnii'hms  of  bile  in  (12,  three  ounces  in 
1(1(1.  and  w;is  distended  in  the  seven  cases,  (17.  (lit.  75,  8G,  !t2,  04  and  0(1:  generally  the  bile  was  of  a  d;irk  or  black 
color  and  of  some  viscidity,  but  in  the  last-mentioned  I'ase  it  was  described  as  water.v.     In  05  the  walls  of  the  gall- 

fli,L'lill>  incn;iMil  in  \c.lmi ■  .liniiiii>li.-il  in  c-.iiisi>tcTii  i-  in  tin™-  llial  ili.-.l  :il  :,n  ii.lviOniit  piTioii  ;  wlii'ii.  .•  il  wu-  i  .Mnlinl.-.l  tliat  Hum'  iii..rlii.l  .li;iri;;cs 

w.ic-  i-iirl.v  iH/(  till  anil  liMnlnl  ti.  sulisiiln  ;!.■(  On'  ilnrntii.n  nl'  tin-  iiltaik  \v;i»i  li'iiutlu-hi'il.     Tin'  i-lpinili  wiis  iliilkiT  tiniii  usual  in  uni-lnill'iir  Ilii'  ia.-i-«  ami 

li;:liti-l-  tliiin  nsiiiil  in  niiu'  rasrs:  but  no  rnnstant  i-clatiuli  exifiti'il  l.i'twi'cn  itH  ruli.r  atnt  its  vnluTn •  i sisti-lnr.      \,.r  uaw  ariv  ri'latinlisliiinii-li-rliit 

lii'twiTU  it.s  rnuilitiiin  anil  that  i)f  tin'  linirnU!*  uiftnlnaln-  nf  tin'  stiiiiiarli  ur  inti-stini-.  In  ilisi-isi-s  utiii-r  than  t.\  |ihiiiil  lliis  nrjran  was  i-nlar^iii  in  .Ii-m'ii 
anil  siifli'm-il  in  twi'Ul.v-tivi- i.l' riKht.v-thrpi'  ra.-i-s;  hut  tlii>  sufli'llint;  was  ninn-  fimini-ntl.v  inninili-il  with  a  iliniinishiil  than  an  iurnaMil  vnlunn-.  Kn.ni 
th.M'  fai  1-  it  "as  infVm-il  that  i'nlart;i'"n'nt  ami  sul'ti'Tiinu  ul'thi'  sphi-n  an-  |iiruliai  l.i  ami  rhaiarlni-li,'  nllh,'  ly|.lii,i,|  alln  li.m. 

'I'll''  I  n  r.l;  was  si-Mi.ni  nlti-nil  in  si/.i' :  it  was  larfi'T  than  usual  in  livi-  las.s  arnl  ^niallrr  iu  tun  •  a~'>.  It  was  Ui.t  lirnnT  than  thi-  linrnml  in  a 
siiiL^'li-  i-a-i-.  hut  it  was  siilliniil  iu  Iwiiit\ -rw  m,  in  fi.ui'  nf  w  Iiii  h  I  In-  tin^irs  pinitrariil  its  siih-Iau.  i-  w  illi.iul  r-.-isia  urc,  ami  this  snflurss  was  .iri-ni'ntlly 
a>-..iiati-.l  Willi  a  ].al.'  r..l..i  rallnr  llian  with  a  ••ini:i,l..l  slali'.  'tin-  IImi-  was  ,,1'  il-  M:iluia]  r.iji.r  in  Iwi  Im-  ,.l  11,,-  (urtv-six  rasis  :  it  was  |i;ih'  iu 
Iwnlv-.'ti.-  I  a -IS.  in  tnnit'-iii  I'f  wlii.h  tliri'i-  was  a  lui'xistinjr  siiftufss  ;  in  i'i{;ht  il  was  nilil-r  lliau  u-ual  :  in  urn-  it  was  Vflluw  jsh  w  itii  purtilish  slar- 
sha|i.ii  hli.l.  Ins  an  im  ti  in  iliaini  li  r  1  in  ..u.'  tin'  muaii  runtaiuiii  suppuratiuji  tuuuil>.  ami  iu  Ihn.-  il^  Mi.uiImssiI-  win-  piiunali-.I  li>  a  uii  at.  !■  t>f  li-ss 
.ji lilv  111  ail.  liul  iu  as.'  was  Ihi  n-  an.\   iUi|ili.Vsilua  "f  its  snlistan.  i-. 

Ihi-  i,\l.l.-i:l.AT.ni;n  wa-  iiiil'  nll.v  iullannii  in  Ihnr  la^i  s  in  whii  h  its  i-.iuliiils  win-  |.uinliUI  an. I  its  liniiin  nn  nihram-  nsld.m-.l  ;  in  a  fuurlli  i\ist< 
Ihi-  nii-inhi-ani-  was  uta  faint  i-i'si-n.l.ir  iniM-it  with  ^rtay  ami  tin- muti-nls  a  Inri.iil  )nu\  i-li  Iii|uiil.  'i'lu-  nil.-  was  r.il.tish-_v,ll,.w.  si.uutinu-s  with  u  ^n-i-liiish 
tili^f,  ami  viTV  liiniiii  in  twi-ut.v-livi-  lasi-s  ami  lunli'  rin-iiuis  than  usual  in  tin  i.f  lln-  lwiril\ -livi- :   in  miIui-s  il  was  thii  k,  vi.-riii  iiinl  hlaikish  :  iu  two, 

ill  whii-h  tlu-ri-  was  n.iul'ri-s:-iiin  of  tin-  i  ystii-  iliirl.  tin-  hih-  was  ri-plaii-it  hv  a  traus|.ariul  :ii|i s  li,[iiii|  ..f  tin-  rnhu-  ,,f  uriin-.      Ihit  similar  •  uuditiooa 

of  thi-  liviT,  (,'all-blailileruiiil  hil>'  wi-rn  fuuuJ  ill  othiT  ilisi-usi-s,  iilthoii^'h  Imt  pi-ihaps  with  as  liiinh  t'rt-i|iiiui  j  as  in  tytihuid. 


42A  PATHOI.OfiTrAI.    ANATOMY    AXP    PATITOLOGY 

bladder  wert^  diMoi<;iiiiiz('il  mid  iicitoratcd,  the  hilc  in  tliis  iiistMiici'  lia\  iiiy-  liccii  (if  a  li<;ht-{j;rei'ii  colcir.  'I'liirty 
obsei'vatioiia  \\v\c  iiiadi'  in  tlic  mixt'd  sciics:  The  bladder  was  lu'altliy  in  (uir  case,  82M,  large  in  one,  225,  BUiall  and 
collapsed  in  one,  201,  and  empty  or  nearly  so  in  101.  2H2.  Hll,  3X0  and  :iSl.  Jt  eontaiued  one  Hiiid  ounce  or  less  of  bile 
in  the  four  cases,  lliT,  b"i4,  1X2  and  30 1,  dark-brown  in  the  second  instance,  and  ganibojrc-colored  in  the  third.  In  loS 
it  contained  twelve  drucliins  of  dark  bile,  and  in  185,  139,  187  and  Hiti,  resjiectively,  two  and  a  half,  thri'e,  three  and 
tliree-iinarters  and  live  ounces  of  liquid.  It  was  distended  also  in  the  twelve  cases,  125,  132,  151,  171,  189,  192,  198, 
245,  302,  317,  338  and  383.  In  327  the  walls  of  the  gall-bladder  were  disorganized  by  their  participation  in  a  general 
peritonitis. 

Only  two  observations  on  the  paxcrk.vs  were  recorded  in  the  typliohl  series:  In  case  29  the  gland  was  said  to 
have  been  enlarged  and  sonnnvhat  hard;  in  21  it  was  normal.  Of  thirteen  observations  in  the  malarial  cases  the  pan- 
creas was  normal  in  eight,  81,  115,  2G3,  277,  289,  292,  295  and  36(5 ;  it  was  soft  in  one  case,  t)7,  in  which  it  was  of  a  red- 
dish color,  and  firm  in  three,  90,  274  and  278,  in  the  first  of  winch  its  color  was  white  and  in  the  other.s  somewhat 
reddened;  in  288  it  was  of  a  purplc-Hesh  color,  and  in  373  dark-colored  and  slightly  congested;  its  weight  varied 
from  two  and  a  half  to  four  and  a  ijuarter  ounces.  Nine  observations  were  recorded  in  the  li/pho-uialarUtl  cases: 
In  t)2,  68,  93,  110  and  205  it  was  normal:  in  111  large;  in  112  of  a  grayish  color;  in  67  soft  and  of  a  dull-red  color,  and 
in  86  reddened  and  increased  in  weight  to  seven  ounces.  Of  seventeen  oliservations  in  the  mixed  series  the  organ 
was  normal,  so  far  as  can  be  learned  from  the  records,  in  thirteen  cases,  its  weight  ranging  from  two  and  a  half  to 
four  ounces;  it  was  recorded  as  white  in  color  in  154,  155, 181  and  380,  not  very  firm  in  the  tirst-nientioned  case,  hard 
or  firm  iii  the  three  others. 

The  KiDNf;Y8  in  thirteen  of  twenty-seven  cases  of  iijphdUl  were  normal.  In  five  of  the  remaining  fourteen 
they  were  congested,  with  concondtant  enlargement  in  two  instances;  in  three  others  they  were  enlarged  and  in 
one  of  these  granular;  in  five  they  were  pale  or  fatty,  and  in  one.  26,  the  right  kidney  was  pigmented  on  its  surface 
and  contained  an  abscess  with  ecchymosed  walls,  while  the  left  was  merely  congested.  In  sixteen  of  thirty-seven 
malarial  cases  the  kidneys  were  normal;  in  thirteen  they  were  congested,  with  softening  superadded  in  one  instance; 
enlargement  was  noted  in  three,  in  one  of  which  the  organs  were  soft  and  in  another  fatty;  they  were  pale  in  one, 
flabby  in  one,  fatty  in  one;  in  278  the  right  kidney  contained  a  small  abscess,  and  in  374  the  left  was  rejiresented 
by  a  closed  cyst  in  which  no  glandular  tissue  could  be  detected.  Of  twenty-eight  typho-malarial  cases  they  were 
normal  in  eighteen;  congested  in  four,  in  one  of  which  they  were  said  to  have  been  fatty;  large  in  two;  small  in 
one;  small  and  pale  in  one;  in  one  case,  110,  the  right  kidney  was  small  and  transformed  into  a  thin-walled  cyst, 
while  the  left  contained  large  abscesses,  and  in  93  both  were  inflamed  to  suppuration.  In  sixty-two  of  one  hun- 
dred and  eight  cases  of  the  inijcd  series  in  which  the  kidneys  were  examined  they  were  pronounced  normal.  Of  the 
remaining  forty-six  eases  they  were  congested  in  twenty-two.  in  one  of  which,  187,  there  were  ecchymosed  s])ots; 
large  in  four,  227,  275,  369  and  370;  pale  in  two,  217  and  302;  fatty  in  five,  178,244,  307,317  and  345;  soft  or  flabliy  in 
six,  199,  181,  148,  182,  304  and  309,  and  in  the  first-mentioned  of  these  they  were  tunud  and  emphysematous,  like  the 
liver  in  the  same  case,  while  in  the  second  the  left  kidney  was  ecchymosed :  in  243  traces  of  inflammation  were  said 
to  have  been  present  in  the  right  kidney,  and  in  219  and  220  sujipuration  had  taken  place;  in  228,  222,  318  and  334 
there  were  cysts  which,  in  the  first-mentioned  ease,  contained  purulent  matter. 

The  siTPHAUEXAL  CAi'SUl.KS  Were  mottled  in  case  23  of  the  typluiid  series.  They  were  reported  healthy  in 
three  iiiitlurial  cases,  115,  274  and  292;  soft  and  fatty  in  373.  Their  condition  was  reported  in  five  cases  of  the  mixed 
series:  Yellow  in  183,  soft  in  245,  small,  dark  and  tough  in  2x1,  firm,  large  and  of  a  reddish-ash  color  in  380,  and 
showing  traces  of  inflammation  in  243. 

ITkinaky  iti.ADDEH. — The  only  observations  of  interest  respecting  the  condition  of  this  viscus  occur  in  the 
■mixed  cases:  Its  mucous  membrane  presented  bluish  spots  in  case  333  and  was  eechyniosed  in  342;  the  prostate 
in  239  was  enlarged  and  contained  pns. 

The  I'EHICAKDIUM  was  seldom  altered.  It  contained  an  unusual  ((uantity  of  eftused  liquid  in  case  36  of 
the  typhoid  series,  a  small  quantity  of  bloody  liiiuid  in  26,  and  in  42  the  sac  was  tuberculous.  A  manifest  excess  of 
licjuid  was  found  in  three  of  the  malarial  cases,  coinciding  with  ett'usioii  into  the  pleura  in  2.58,  with  bron<diial 
iutlaimuation  on  the  left  side  in  249  an<l  with  a  healthy  condition  of  the  lungs  and  pleura-  in  262.  No  indication  of 
inflammatory  action  was  recorded  in  these  cases  of  efi'usion ;  but  in  90,  in  which  only  six  drachms  had  exuded, 
the  contained  floccnli  and  the  fibrinous  coating  over  the  serous  surfaces  testified  to  an  intercurrent  pericarditis; 
in  276  there  were  adhesions  and  the  surface  of  the  heart  was  covered  with  dark  spots  and  exuded  lymph.  In  the 
typho-malariul  series  three  eases,  52,  61  and  75,  presented  an  excess  of  scrum,  with  some  injection  of  the  sac  in  the 
first-mentioned  instance;  in  280  there  were  signs  of  recent  pericarditis,  and  in  296  the  serous  surface  was  rough- 
ened by  exudation  unconnected  with  the  fatal  illness.  In  the  mixed  series  five  cases  presented  evidence  of  a  jieri- 
carditis  which  antedated  the  typhoid  attack:  In  324  the  opposing  pericardial  surfaces  showed soiuo  small  roughened 
patches;  in  356  they  were  united  by  a  fibrinous  band;  in  368  the  adhesion  was  more  intimate,  h-aving  only  a  small 
sac  at  the  ape.x  in  wliicli  was  an  ounce  of  serum,  while  in  137  and  139  the  sac  was  wholly  obliterated.  Moreovc^r, 
in  320  the  pericardium  was  firmly  uniti'd  to  the  costal  cartilages  and  sternum.  On  the  other  hand,  iu  182  and  183  the 
eftused  liquid,  although  not  large  iu  (juantity,  was  of  a  red  color,  and  in  309  t lie  sac  is  said  to  have  been  filled  with 


Thi-  KiDNKVs  w.Tr  i^tlili.iii  ;iii.[  slijilitl.v  iift'i'ctfil.  Tliry  wcTL-  stiiiicwJiut  eiiliir^*'<l  ill  tlii-fc  cjis'S  iiiiil  of  diniiiiisln'il  cuTisintf'iico  iu  wix  of  tiiirty-hi.'C 
fjiS4[^.  Thi-ir  lului'  \v:is  iljiiUi  r  lliaii  usiiitl  in  .^cvi'iiti-i'ii  i>f  furty-twu  cases,  and  this  citli'i-jitinii  uiis  nmrit  fn-iiiu-nt  in  tltnsi,  wlm  liii-ti  curly.  Tin;  niiirtuiH 
nn-iiilinui,'  i>f  tli>-  [i"l\r>  \\a-  tliirkfUril  uiul  injcctfd  ill  iiiw  caw,  unit  in  a  jjt'couil,  prcscuting  siinitur  injt,-ctiuu,  it  wiuj  Imtlicd  in  iins. 

The  lining  <if  tin-  iti.Ai'iiKU  was  injected  in  six  ca.ses,  .soun-wliat  sdfteneU  in  two,  and  in  one  slightly  ulcerated  near  tin.*  urethral  entrance. 

The  PKRicARnuM  wiis  seldom  altered  ;  in  seven  cases  it  contuirnil  a  little  siTons  liquid,  which,  in  one  instance,  was  s;itiguiiiolent.  None  of  the 
cases  presented  the  slightest  trace  of  recent  intlaniniation,  in  this  ditlcring  from  cases  of  othci-  acute  maladies  au'l  especially  from  casi'S  of  pneumonia. 


OK    THK    COMINUKl)    FKVF.RS.  429 

liiinilciit  iiiattci'.  Excess  of  lii|ui(l.  from  (iiri-o  to  six  or  fight  oiiiicfs,  \vas  foiiiul  in  ten  casi's,  13(>.  170,  173,  206,  302, 
307,  327,  328,  329  anil  3S3,  in  two  of  wliicli.  206  and  307,  the  jicricardiuni  is  said  to  liavo  lieen  thickened,  and  in  two 
others,  173  and  327,  somewhat  inJcctiMl :  I  lie  lnnf;s  were  more  or  less  enjjorged  in  fonr  of  these  eases:  in  three  the 
pleural  cavities  contained  effusion,  while  I'n  tline.  ITii.  206  and  32S,  there  was  no  roncnrrent  intlanunation  of  the 
lungs  or  pleura'. 

The  condition  of  the  iiKAliC  is  .recorded  in  seventeen  of  the  fil'ly  liipliaUl  eases,  in  Ihirteen  of  wliieh  it  was 
normal;  in  one,  \X.  pale:  in  one,  11,  soft  :inil  llalihy:  in  one,  42,  lulieri  iilons  on  its  surface,  and  in  one,  !.">,  having  its 
right  cavities  dilated.  In  addition  t<i  thi'se  olisi'rvations  the  contents  of  the  heart  were  noted  in  five  instances  in 
which  no  intimation  is  given  of  any  almormity  of  texture.  In  the  ma  hi  rial  scries  the  heart  was  nu;ntiiuied  as  normal 
in  twenty-six  eases,  and  in  ten  others  in  which  reference  w:is  made  to  its  covi'ring  or  contents  no  alteration  of  tex- 
ture was  indicated.  In  twelve  cases  there  were  niorhid  changes:  In  2.">2  and  2ill  the  lieart  was  small;  in  78  and  377 
it  presented  thickened  valves  and  hypertro)>liied  walls,  ami  in  2til  an  ojiaiiue-white  membranous  spot  on  the  sur- 
face of  the  right  ventricle;  it  was  pale  in  262;  tlahliy  in  27x;  jiale  and  llahliy  in  376:  fatty  in  251;  slightly  softened 
and  ecchymosed  in  386,  and  in  90  and  276  there  were  evidiiices  of  iiericardial  inllannnation.  In  the  typhn-mtiUirial 
series  it  was  recorded  as  normal  in  twenty  cases,  and  in  eleven  others  in  w  liich  its  covering  or  contents  were  men- 
tioned its  condition  does  not  seem  to  have  called  for  ri'mark.  Its  texture  or  appearance  was  altered  in  nine  cases: 
It  was  large  and  hy])ertrophied  in  TtA  and  96:  jiale  in  112:  soft  in  l>7:  tlabhy  in  .">7,  .')9  and  2l)."i:  pale  and  llahliy  in  21)7, 
and  flaccid  in  7,5.     The  heart  is  said  to  have  been  normal  in  siventy-onc  of  the  mi.nd  cases,  and  in  thirty-three, 

in  which  its  coverings  or  contents  were  mentioned,  the  c litiou  of  its  tissne  d<ies   not   ap])ear  to   have   hecn 

materially  altered.  Morbid  changes  were  noted  in  thirty-one  instances:  In  317  the  heart  was  reported  atro]>liied ; 
in  340  displaced;  in  206  enlarged;  its  ventricles  dilated  in  169,  186  and  l!tO.  and  its  mitral  valve  thickened  in  3.")9:  iu 
the  remaining  twenty-four  cases  the  organ  had  lost  its  normal  C(dor  and  tonicity:  Iu  193  it  was  softened;  in  242  and 
243  thinned  and  softened,  the  right  ventricle  in  the  latter  case  being  said  to  liavo  been  as  thin  as  glove-leather; 
in  133,  219  and  333  pale;  in  litl  jiale  and  soft,  this  case  ])resenting  a  small  purulent  deposit  near  the  apex;  and  flal>by 
in  seventeen,  in  ten  of  which,  137,  148,  154,  176,  182,  181,  203,  212,  214  and  231),  no  other  (lualilicaf  ion  was  stated; 
but  in  four,  150,  227,  311  and  324,  the  organ  was  also  said  to  have  been  jiale:  iu  one,  345,  snuill;  in  one,  347,  auaMiiic, 
and  in  one,  355,  soft.  In  addition  to  these,  antccedc'nt  inflammation  is  indicated  by  the  ajipearance  of  the  pericar- 
dial lining  and  contents  in  certain  of  the  cases  mentioned  iu  the  last  ])aragraph. 

The  CONTENT.S  OF  TilK  liK.MiT  Were  stated  iu  only  seven  of  the  iyphoiil  cases,  an<l  in  one  of  these,  48,  there 
was  no  clot.  Both  sides  of  the  heart  in  five  cases  contained  clots,  which  were  fibrinous  in  8  and  23,  black  in 
24,  mixed  in  32,  fibrinous  in  the  right  and  mixed  iu  the  left  cavities  in  26.  In  case  45  there  were  fibrinous  clots  in 
the  right  side,  but  the  contents  of  the  left  cavities  were  not  recorded.  Of  the  sixty-three  malarial  cases  the  cariliac 
contents  were  specified  in  eighteen :  In  one  of  these,  277,  there  were  no  clots.  Fibrijious  deposits  were  observed  in  thir- 
teen, in  two  of  which,  71  and  293,  the  side  of  the  heart  was  not  iiartii'ulari/cd  ;  in  four,  258,276,  292  and  373,  they  were 
present  in  both  sides;  in  seven,  115,  2.57.  2.59,  261,  274,  288  and  377,  in  the  right  slile  only,  one  of  these,  274,  contain- 
ing a  mixed  clot  in  the  left  side,  and  another,  261,  a  venous  or  black  clot.  In  287  there  were  mixed  clots  in  the 
right  and  lliiid  blood  in  the  left  cavities;  in  84  and  90  the  right  side  contained  black  clots,  the  left  in  the  former  jire- 
senting  a  narrow  clot  of  unstated  color  and  in  the  latter  a  mixcMl  coagiiliim  ;  in  291  the  right  ventricle  contained  lluid 
blood,  the  left  Ijciug  empty  but  for  a  small  fibrinous  clot  attached  to  the  chordie  tendinea'.  The  contents  of  the 
chambers  of  the  heart  were  recorded  in  sixteen  of  the  typho-maJaria}  ca.ses:  Fibrinous  coagulawcre  reported  in  ten — 
in  the  right  side  only  in  six,  in  one  of  which,  266,  there  were  venous  clots  in  the  left  side;  in  the  four  others  the 
fibrin  was  deposited  in  both  sides.  Clots  of  unspecified  color  were  noted  as  present  in  the  heart  in  69,  86  and  264, 
— small  and  imperfectly  formed,  in  a  black  and  diffluent  blood,  iu  the  two  ea.se8  last  nuMitioned.  Clots  were  also 
found  in  the  right  side  in  106  and  in  both  sides  in  62,  but  in  neither  is  the  character  of  the  coagnliiui  stated;  iu96tlie 
right  chambers  contained  fluid  blood  while  the  left  were  empty.  The  cardiac  contents  are  staled  in  lifty-thrco  of 
the  mixed  series,  iu  four  of  which,  1.37,  lti5,  194  and  329,  there  were  no  clots.  In  three  cases  clots  of  an  nnspecilied 
character,  in  one  mixed  clots,  in  one  Idack  clots  and  in  one  uucoagulated  blood  were  reported  as  having  bc'cn  oli.servod 
in  the  heart,  but  the  containing  cavity  is  not  stated;  in  three  lases  unspecified  clots  were  fouml  in  the  right  side 
and  iu  three  iu  both  sides;  iu  one  instance  mixed  clots  were  found  in  both  sides.  Fibrinous  coagula  were  noted  in 
the  right  side  in  twenty-seven  instances,  in  twelve  of  which  the  contents  of  the  left  side  were  not  recorded,  but  in 
nine  cases  sindlar  coagula  were  found  in  this  side — in  one  an  nnspecilied  and  in  one  a  mixed  coaguluni,  in  two  ven- 
ous clots  and  in  two  no  coagulum  of  any  kind.  The  right  chambers  contained  tlni<l  blood  in  190  and  a  mixed  clot  iu 
221  and  305,  the  left  chambers  of  the  latter  instance  being  filled  with  dark  clots.  The  right  cavities  containi'd  venous 
coagula  iu  four  ca.ses,  1.59,  169,  139  and  201,  associated  with  similar  clots  in  the  opiiosite  side  of  the  heart  in  the  second 
case  mentioned,  with  a  fibrinous  deposit  in  the  thiril,  while  iu  the  first  and  last  the  contents  of  the  left  side  were 
not  recorded.     In  172  and  203  the  heart  presented  a  fibrinous  clot  in  the  left  ventricle  only. 

Larynx  and  tk.vciika. — These  parts  appear  to  have  met  with  as  little  atti'utiou  at  the  hands  of  our  medical 
officers  as  the  contiguous  section  of  the  digestive  system.     Morbid  aiipeaiances  were  noted  in  only  six  of  the  typhoid 

Tiio  Hy.ART  was  normal  in  fiizc,  ronsiptonre  and  <-ittor  in  twi-nty-tbroo  nf  tlio  forty-six  i-a.sfS.  It'i  tissue  was  softt-r  ttiaii  natunil  in  scvi-nttTii  rases, 
in  Bonio  to  e(»  niarlicil  a  drj^rct'  that  tlic  orpan  was  flanid  and  easily  turn,  l.nss  of  color  anil  tliinnin;;  of  the  walls  won-  jienerully  as-iociatcd  witli  the 
softenilip.  Tliese  elianires  were  nsnally  more  distinct  on  the  left  than  on  the  rifrht  side ;  and,  like  the  alterations  in  the  liver  ami  spleen,  were  more 
Iiriuniiient  in  jiatieuts  \vli(»  ilied  at  an  early  i>eriod  of  the  attack.  Similar  changes  were  found,  hut  w  ith  less  frequency,  in  cases  of  other  acute  diseases. 
In  tlie  tvplioid  afTc'-tion  when  the  heart  was  hut  little  snftened  its  cavities,  esiiecially  those  of  the  ripht  side,  4-outained  fihrinous  (dots;  whereas  when 
the  softening  was  greater  thi'  inclosed  clots  were  hlack,  and  when  the  highest  d<'pree  of  tlaccidity  was  jircsent  the  cavities  contained  only  a  few  droi>B  of 
blood  mixed  with  air-huhldes.  While  these  facts  seem  to  indii-ate  a  connection  between  tin-  state  of  tin-  hloml  and  that  of  the  hwirt  it  iloes  not  apiM-ar  to 
be  a  necessary  one,  as  in  certain  cases  of  pneumonia,  in  which  the  heart  was  very  evidently  softenod,  it  contained  fibrinous  clots  in  its  right  cavities. 


430  TATlIiil.ddHAl,    ANATOMY     A.N]i    IWTirolXX'iY 

c'ascs:  III  12  (lie.  ciii^rlotf  is  Wii.s  .swiillcii :  in  .'111  iilccrali-<l  ami  (idiiiialiiii.s.  llir  vocal  i/liiinls  liriiij;  hiiniliuly  a  It'cilril ;  in 
1  tho  liiiiiiij  (if  tlio  lai-ynx  was  I  liickoiicd  liy  an  exudatiun  in  tlie  sulniiiK'oiin  cellular  tissue;  in  ■-,  2;!  and  ;>2  thr 
iiiiicouN  muinbraiie  (it'tlic  traclica  was  congested.  In  tlie  i-.ialnriul  series  the  niucims  liiiinj;  iiCtlie  liaeliea  was  pale  in 
84;  iiiflumcd,  coiijjested  or  inirplisli  in  90.  115,  259,  277  ami  2.S'^:  the  larynx  was  fciveied  with  false  incinlir.-ine  in  :I71; 
the  epiglottis  uleerat(!d,  tlu^  lining  inenibraiie  of  the  larynx  and  trachea  thickened  and  the  voea!  clioiils  iieaily 
destroyed  in  2IS.  In  tlie  li/plio-miiliiiinl  series  only  four  oli.servations  were  recorded:  In  08  ecchynmseil  s]iiits  weie 
found  on  the  jiosterior  surface  of  the  trachea,  and  in  101  its  mucous  niemlirane  was  inflamed  and  ulcerated:  in  -"'I 
the  laryngeal  OKiiiiliraiie  was  congi^sted  and  ulcerated  and  a  small  abscess  was  obs('rved  between  the  cricoid  carti- 
lage ;iiid  tli(!  jiliarynx.  and  in  (i7  the  epiglottis  and  chords  were  (cdematons  anil  an  abscess  was  connected  with  the 
right  arytenoid  cartilage.  Seventeen  observations  were  made  in  the  mind  series:  The  trachea  was  congested  in 
1X1,  210.  :i07  and  .3:C  and  in  182  the  larynx  also  was  involved.  The  lining  membrane  of  the  trachea  was  soft  and 
dark-colored  in  '.M)l :  of  a  piiride  color  in  155,  183,  187,  199  and  301,  and  to  this,  in  150,  some  spots  of  whitish  exudation 
were  added.  In  329  the  mneoiis  membrane,  which  was  thick,  soft  and  discolored,  jiresentcd  a  slight  exudation  on 
tlie  vocal  cliords  and  tlie  laryngeal  surface  of  the  epiglottis;  while  in  122  and  308  the  larynx  was  lined  with  false 
membrane.  In  185  there  was  an  ulceration  liclow  tho  vocal  chords  on  one  side  and  another  in  the  thyroidean  angle. 
Lastly,  in  339  the  trachea  was  inllamed,  the  larynx  ulcerated  and  the  glottis  occluded  by  icdema. 

The  TirYKOll)  liODY  was  mentioned  in  hut  two  of  the  cases,  both  belonging  to  the  mh'cd  series:  In  201  il  was 
enlarged  on  one  side,  and  in  193  tho  left  lobe  contained  a  calcareous  mass  as  large  as  a  walnut  and  a  small  cyst  filled 
with  dark-brown  liquid. 

The  condition  of  the  nitoNTillAl.  TfiiK.s  was  seldom  reported.  They  were  inllamed  in  a  few  ca.ses.  a.s  29,  32,  38 
and  47  of  the  t(/phi)iil  stories;  115,  249,  258,  274,  283  and  3(i2  of  the  maliiriiil ;  55,  02  and  102  of  th<^  ti/pho-iiiahd-ial,  and 
121,  118,  109,  185,  191,  193,  239,  245  and  380  of  the  mixed  series.  In  281  and  331  the  Nuialler  tubes  were  plugged  with 
tihriiious  exudation,  and  in  302  they  were  so  thickened  and  indurated  as  to  appear  on  section  like  small  promineucos. 

The  i.CNii.s  were  jironounced  normal  in  only  live  of  thirty-four  typhoid  caaea  inw  liicli  their  condition  was  stated. 
They  were  engorged  or  congested  in  fourteen  cases ;  (edematous  in  one,  3 :  more  or  less  hepatized  or  solidified  in  twelve, 
5,  6,  7,  9,  23,  24,  29,  32,  .38,  41,  43  and  45 :  splenified  in  one,  8,  and  in  one,  42,  tubercular.  Generally  the  engorgement 
and  licpatization  were  in  the  lower  and  posterior  parts,  but  sometimes  the  whole  of  a  lung  is  said,  as  in  38,  to  have 
been  affected.  Generally,  also,  both  lungs  ])articipated  in  the  piieumonitic  jiroces.ses,  but  in  s(mie,  as  in  0,  one  lung 
only  was  involved.  The  third  stagi^  of  inllaniniation  was  reached  in  case  5.  In  29  and  32,  hepatization  was  localized 
in  nodular  masses  from  the  size  of  a  chestnut  to  that  of  a  hen's  egg:  splenization  in  8  was  also  lobular.  It  is  probable 
that  th(^  term  engorgement,  congestion  or  hepatization  was  ujied  in  some  instances  to  indicate  that  condition  of  the 
lung-tissue  recognized  by  Ldt'is  as  s|ilenization,  for  in  cast!  25  the  solidification  is  evidently  distinguished  from  that 
caused  by  intianimatory  processes.  The  lungs  were  altered  in  thirty-two  of  fifty-eight  observations  in  the  maUo-iul 
series,  normal  in  twenty-three,  and  unrecorded  in  three  iu  which  phjuritic  adhesions  are  mentioned.  They  were 
(sngorged,  splenified  or  hepatized  in  thirty  cases,  two  of  which.  258  and  288,  were  marked  by  subpleural  ecchymoses, 
three,  2.52,  270  and  289,  contained  abscesses,  and  four,  105,  274,  278  and  377,  tubercle;  in  113  the  lungs  were  emphy- 
sematous, and  in  87  the  left  lung  was  coni])ressed  by  a  jmrulent  collection  in  the  pleural  sac.  In  the  typho-maJarial 
series  the  lungs  in  nineteen  of  fifty-one  cases  were  normal  and  in  thirty-two  altered.  Of  the  latter  they  were  tuber- 
cular in  one,  em)ihy.seiiiatous  in  a  second,  (edematous  in  a  third  and  congested,  s]ilenilied  or  hep.atized  in  Twenty-nine, 
in  one  of  which,  05,  there  was  a  large  abscess  in  tlie  middle  lobe  of  the  right  lung.  They  were  normal  in  forty-seven  of 
one  hundred  and  sixty-three  cases  of  the  mixvd  series;  congested,  splenified,  hepatized  or  infiltrated  in  one  hundred 
and  four,  in  three  of  which  purulent  colhH'tions  had  formed,  multijile  and  small  in  138,  single  in  315  and  383  and  of 
large  size  in  the  last-mentioned  case;  emphysematous  in  four,  tubercular  in  seven  and  in  one,  340,  compressed  by 
a  large  (luantity  of  bloody  liijuid  iu  the  left  ]ileural  sac. 

The  pi.Kfii.i:. — Adhesions  iu  tliree  of  the  typhoid  scries,  9,  37  and  45,  probably  anted.itcd  the  typhoid  attack; 
but  in  5  and  32  they  were  ci^rtainly  associated  with  the  fatal  sickness.  The  iilenral  cavity  in  12,  23,  32,  30  and  42 
contained  serous  effusion  w  hicli  was  connected  in  all  excejit,  perhaps,  23,  with  other  and  distinctly  marked  signs  of 


Tlifi  EPlflLOTTls  was  rovcroil  witll  false  nicniln-anc  hi  two  i-asi-s  in  wliicli  tlic  pliaryiix  «as  Kiliiilali.v  at1i-itc«l  ;  in  <iiii'  thcri'  \\a..^  a  r<il  sput  mi  its 
iufcriitr  aspiTt  iiial  in  sovcn  it  was  mure  or  K-ss  iiIrcratM],  tlu*  pliarynx  jiartiriiiatiiit;  iu  tin'  nlriTatinii  iit  tlircc  nf  tlio  fas(.s.  Knmi  tin-  rarity  uf  nli'i-ra- 
tien  of  tin;  cpij^Inttis  in  utbcT  acute  iliseasfs  Louis  rcfianleil  this  lesion  like  the  .similar  affectiiui  uf  tin;  jiliaryux  and  a-sophaguH  as  of  a  diaracter  |it.'culiar 
to  tyjiliinil  fever. 

The  uuiTTis  wivs  oslematous  in  two  eases,  tint  Iliis  eondition  was  rotiiiil  to  lie  e.|ually  eoiunion  in  luieumoiiia. 

The  Mcrot*8  MF.MBRANK  or  THK  I,AliVNX  was  l.laekish  ale]  sottelleii  iu  one  easi',  eovereil  w  itll  false  uieuihiiiue  iu  tliree  and  slijititly  ulcerated  iu  one. 

The  M.vi.vij  OF  THE  TRACllK.v  was  .sclilcuii  altered  iu  color  and  iu  no  case  iileerated. 

The  BRONCHIAL  MT'cors  MEMMKANF,  was  often  of  a  rerl  Color:  luit  it  was  thickened  ill  only  one  case.  (Jcnerally  the  tubes  contained  a  thin  briiiht- 
red  inueiis  ;  iu  thrco  cases  they  were  eularj;(Hl. 

The  M".\i;s  in  fifteen  cases  were  healthy  or  only  a  little  darker  in  color  iiostcriorly,  with  or  without  some  rjmnded  spots  a  few  lines  iu  diameter  and 
ileptli.  In  two  cases  they  were  somewhat  enipliyseiuatous.  There  was  splenization  in  uiiieteeii  cases,  Keni!rall.v  in  one  or  hoth  of  tlie  lower  lobes,  the 
splenified  part  bein;;  heavier  tliau  water,  firm,  of  a  dark  bluish-red  color,  frivinji:  issue  ,ui  section  to  a  thick  rlark-red  liquid  and  destitute  of  the  Jj^ranular 
iisp(.«.t  of  heiiatized  hinjr.  ('on>;estion  or  hepatization  was  present  in  seventeen  ca.ses.  some  of  which  had  the  lower  IoIk'S  splenified;  the  concestiou 
wjvs  sometimes  lobular,  more  freipieutly  so  than  the  hepatization,  but  paienilly  both  were  con  tin  nous,  althonjih  not  occupying  iu  any  case  a  larpe  portion- 
of  the  oi'Kan.  Abscesses  were  found  in  <»iie  of  tlii'  heiL-itized  lungs.  In  one  case  the  lung  contained  a  lilanientoiis  tuuu»r  one  inch  in  diameter;  iu  four 
(jases  some  semitransparent  granulations,  and  in  one  eas  •  cnide  tubercle. 

The  I'LKCU.-K. — .'VltlKuigh  adhesions  were  jiresent  iu  uinetceu  of  the  forty-six  eases,  there  were  signs  of  recent  inflammatiiui  in  two  only,  iu  one  a 
soft  false  membrane  and  in  the  other  a  flocculent  effusion;  the  pleural  sacs,  however,  in  nineteen  cases  i-ontjiined  a  reddish  serosity  varying  in  (lualitity 
iu  individual  ca-ses  from  three  to  thirty  otinces.  But  similar  conditions  of  the  tironchial  tubes,  pulmonary  ti.ssue  and  pleural  membranes  were  observed 
ia  thirty-five  cases  of  other  acute  maladies  exclusive  of  pneuraouia  and  pleurisy. 


OK    THE    CONTIKUKD    FKVKRS.  431 

iiilliuninatiou  of  tlio  nicmliraiic,  and  in  42  witli  tiilici'i'iiliii-  disfasc  of  tlic  liiiij;s;  bl 1  was  effused  into  tlio  iilcuial 

cavity  in  31.  In  tlio  viahtritil  series  adliesions  weic  found  in  tlie  live  eases,  "Jol,  'Si'<2,  'M<\,  'Mi  and  HT",  Imt  their 
recent  cliaraeter  is  not  indicated;  on  tlie  otlier  liand,  in  71,  73,  S7,  21!',  25S,  2XX,  L'xil  and  3X7  tliere  is  evi<lenee  of 
pleuritic  complication.  The  adhesions  in  57,  ">9,  6(>  an<l  L't!(i  (d'  the  tinilin-iiiKhirltil  series  are  also  of  (dd  or  uncertain 
date;  hut  in  H'>  the  clinical  history  shows  their  recent  format i<in.  and  in  tl'J  tlii'  lymph  on  the  base  of  the  lun<;  connects 
the  small  quantity  of  idoody  liquid  in  the  pie  ma  with  inllanimalcoy  act  ion.  alllioM;;h  it  is  not  certain  that  the  larj;er 
quantity  of  serum  in  69  was  the  result  of  other  than  jiassivc  processi's;  in  ().">  the  rijfht  jileura  was  inllanu'd,  and  in  1(K) 
the  right  sac  contained  four  ounces  of  san};ninolent  serum .  I'leiiritic  adhesimis,  without  other  indications  of  jileural 
inflammation,  arc  mentioned  in  twenty-three  of  the  mij-iil  series;  in  alioul  half  of  this  numlier  they  eerlainlv  ante- 
dated the  fatal  attack  and  jindialdy  also  in  others.  In  four  cases,  V2H,  23S,  32!l  and  '.MX,  etl'used  lii|uid  was  found  in 
the  jdeural  cavities,  but  whether  as  the  result  of  active  or  jia.ssive  iin>ccsses  is  uncertain.  In  three  cases,  lis,  '_M9 
and  283,  which  ]ircsented'botli  adhesion  and  effusion,  the  date  of  lu'ither  is  detined.  Thirteen  eases  showed  decidi'd 
indications  of  recent  inllammation  of  the  sckhis  membrane — 173,  185,  IIG,  3()!1,  311,  315,  318,  331,  3.Vi,  3.">7,  3(i()  and 
380.  In  addition  to  these  Hi8  and  333  had  in  each  jileural  .sac  a  small  quantity  of  dark  sanfjuirn'ous  serum,  a]ipa- 
rently  connected  with  puliuonaiy  engorgement  and  hepatizatiiui,  wliih'  31(1  ])rcsenl<d  on  one  side  a  large  elVusion 
of  a  similar  character,  which  compressed  and  consolidated  the  correspomling.lung.  I'leuritie  adhesions  in  203  and 
effusion  in  311  were  of  tu))ercular  origin.  The  presence  of  purulent  matter  in  the  pleural  sacs  of  383  was  due  to  the 
rupture  of  pulmonary  and  iutermuscular  abscesses  into  them. 

The  I5UAIN  AND  IT.S  MK.MHUASE8  Were  normal  in  five  of  tdi^vcn  tiijilioid  c;ises  in  which  their  condition  was 
stated:  The  meiubranes  were  congested  in  two  cases,  8  and  2();  in  the  former  the  cerebral  substance  was  soft  and 
there  was  a  small  <iuantity  of  li(inid  in  the  ventricles;  in  the  latter  the  brain  was  apparently  normal.  In  iit'ither 
of  these  is  mention  made  of  eft'usion  in  connection  with  the  meningeal  congesticni;  hut  in  three  others  there  was  a 
quantity  of  serum  in  the  subarachnoidal  8j)aces,  especially  at  the  vertex,  and  this  was  associated  in  45  with  a  normal 
brain-substance,  in  42  with  softening  of  the  brain  and  serum  in  its  cavities,  and  in  it  with  congestion  of  the  cortical 
substance,  marked  vascular  ])uncta  in  the  medullary  tissu(^  and  otl'iised  li(|uid  in  the  ventricles;  in  47  there  was 
much  serum  in  the  ventricles.  The  condition  of  the  brain  or  its  membranes  was  mentioned  in  seventeen  of  the 
■mahiriiil  cases,  and  in  six  of  these  both  were  noiinal.  Of  thc^  eleven  in  which  attenticui  was  directed  to  abnormal 
aj)pearances  the  brain  alone  was  mentioned  in  three — in  27t!  as  ana-mic,  in  84  as  softened,  and  in  25!)  as  soltened 
and  with  the  ventricles  distended  with  ell'used  .serum;  in  two  others  tln^  membranes  alone  were  nuMitioued,  the 
meningeal  vessels  being  injected  in  104  and  the  pia  mater  ana'inic,  (q)ai|Ue  and  wrinkled  in  201;  in  one  case,  288, 
the  pia  mater  was  congested  in  its  posterior  part  while  the  brain  was  firm.  Of  the  five  cascw  remaining  the  sub- 
arachnoid spaces  and  ventricles  contaiiuid  effused  li(|uid  in  278;  the  pia  mater  and  posterior  i)art  of  the  brain  were 
congested  in  247;  the  nmnibrancs  congested,  the  subarachnoid  spaces  distended  with  liquid  and  the  surface  of  the 
cerebrum  and  the  lloorof  the  fourth  ventricle  eechymosed  in  287;  while  two  cases  only,  80  and  257,  iircsentrd  delinite 
evidence  of  recent  inllammation — in  the  former  lymph  on  the  surface  of  the  hi'mis]dieres,  in  the  latter  on  th<^  base 
of  the  brain  and  in  both  in  the  ventricles.  The  brain  or  its  niemliranes  were  aliected  in  seven  of  tliirtci-n  typho- 
muluridl  cases  in  which  they  were  examined:  In  208  attention  was  <liri'i^ted  to  thi'  brain  only  as  cont:iining  a  tumor; 
in  264  and  297  the  condition  of  the  brain  was  not  stated,  probably  because  in  neither  did  it  prisent  .-my  abuorudty — in 
both  the  meningeal  vessels  were  engorgi'd;  in  99  and  109  the  membranes  were  anuMuic,  In  the  latter  the  cerebral 
matter  was  also  anaunic,  in  the  former  white  and  soft;  in  86  there  was  general  congestion  with  eli'nsion  into  the 
subarachnoid  spaces  and  ventricles,  while  in  111  eli'usion  into  the  ventricles  was  associated  with  thickening  and 
opacity  of  the  arachnoid  over  the  interpeduncular  space.  The  brain  or  its  inendnanes  were  normal  or  healthy  in 
twenty-eight  of  the  mixed  cases,  and  in  two  others,  140  and  148,  the  iirmness  of  the  cerebral  substance  may  not  be 
regarded  as  morbid.  Changes  from  the  normal  were  reported  in  twenty-one  instances:  In  202  the  cerebral  ves.sels 
were  engorged;  in  four  the  condition  of  the  brain  alone  was  stated — as  firm  and  congested  in  its  ])osterior  ])arls  in 
304,  congested  and  with  a  small  quantity  of  bloody  lii|uid  in  the  ventricles  in  301,  congested  and  softi'Ui'd  in  281, 
and  congested  to  a  crimson  color  in  its  upper  and  anterior  portions  in  194;  in  1.5(1  there  was  sonu^  roughni'ss  of  the 
ventricular  lining  but  no  meningitis.  In  eight  cases  the  condition  of  the  membranes  alone  is  stated,  the  brain  sub- 
stance inferentially  beinj,  nornud;  in  four  of  these,  1(>8,  208,  313  an<l  319,  there  was  a  slight  subarachnoidal  ellusion; 
in  344  the  meningeal  vessels  were  ana'mic  and  seemed  to  contain  air-bubldes;  in  KiO  and  180  these  vessels  were  con- 
gested, and  in  117  there  was  a  slight  degree  of  arachnitis,  but  the  facts  on  which  this  conclusion  w  as  based  were 


The  rKKF.i{!t.\i.  mfmiiranks. — Four  cbkcs  liail  twii  <»r  tliroo  siiiall  (sjiooiifuls  of  cWnr  wM-um  in  tlio  ii]i|ict  part  nf  tlio  arat-loiuitl ;  anil  in  inio  of  tliono 
somo  allmniiiuiuK  particlofi  ailliorod  to  tlio  viriooml  layer,  whiio  in  a  fifth  rase  tlio  oorrosiKiiiiliriK  part  of  tlio  imrii'ta!  lu\or  was  Kiniiliiriv  alTortoil.  In  four 
casos  tlioro  was  Knnio  opai-ity,  hut  no  otTiision,  at  tho  nppor  part  of  tlio  nionilmino,  a  losioii  ropinloil  by  Loris  asantoilatin^  tho  typhoiil  attaok.  Tlio  siil.- 
arachnoid  cellular  tissue  eoiitainoil  serosity  in  twenty -<'iKht  ea-sos;  oopious  in  four  hut  sliy:ht  in  the  otliern,  ami  in  winio  (H-oupyin;;  only  theix-oipital  suloj. 
In  no  oimo  was  there  aiihesion  iK'tween  the  araohiioiilal  layers.  The  jiia  mater  was  iiijoi'tod  in  a  nnrnhor  of  eases  atid  reiimrkaldy  so  in  eleven,  in  most  of 
which  tho  upper  ccrohral  veins  were  distenileil ;  in  one  can-  some  air-hnht>les  were  observed  in  these  veins. 

The  oEREBRl'M. — The  cortical  sutistance  was  of  ft  uulform  roseate  hue  in  seventeen  ca.ses,  siwekleil  with  Maekish  points  in  one  caw,  and  in  two 
others  darkened  almost  to  violet;  the  medullary  suhstance  was  deejily  eoiigesttsl  in  seven  easi'sand  sli>;litly  iiijeeled  in  thirty-two.  In  peneral  this  coii;res- 
tion  of  the  hniin-tissue  was  projiortioiied  to  the  injection  of  the  pia  mater.  The  ccrohral  matter  was  tinner  than  usual  in  six  ca.ses,  softer  than  usual 
in  five ;  but  these  alterations  hail  no  relation  to  existiii;;  conilitions  of  conjiestion.     Ijot-is  lieiiee  concluded  that  increasisl  firmness  represcntiil  merely 

physiological  differences  in  the  tissues  of  the  orpiii,  but  that  diuiinislied  consisti'iice,  whi»di  was  more  distinctly  marked,  niiclit  1m nsidercd  a  niorbid 

lesi^in  analaj;ous  to  the  softening  found  in  many  eas-'S  in  the  liviT  and  liealt.  No  si-ro-ity  wa.s  found  in  the  third  ventricle  in  any  of  the  cases ;  in  the 
lateral  ventricles  tlicre  w.as  in  six  c.i.scs  no  effusion,  in  twenty-eight  slight  ctfiision  and  in  twi-lve  s..veral  s] nfiils  of  li.piid  which  in  two  was  tiirldd. 

The  CEREBELLUM  particii«ted,  but  not  in  all  cjuM-s,  in  the  changed  which  alTeeted  the  reri'brum.  Similar  encephalic  lesions  and  in  nearly  the 
Bame  proportion  were  found  in  patients  who  died  of  acute  diseaiK'S  other  than  typhoid. 


482  PATHO].(^<UCAL    ANATOMY     A  N  1 1    I'ATIK  il.OGY 

not  recoi'Uetl.  Jii  four  casus,  llilt,  175,  IKi  ami  :il7,  in  wliicli  (lie  lnuin  was  reported  Jieulthy,  llieie.  was  injection  of 
tbo  pia  mater  with  subaraclmoid  cifusioii.  Lastly,  in  three  eases  in  which  the  brain  and  its  inenil)ranes  were  liotli 
nientioued  as  having  undergone  alteration,  tlu're  was  in  2S10  etfusion  into  the  snbaraclmoid  spaces  and  ventricles,  with 
congestion  of  the  brain-tissue,  in  379  some  exudation  on  the  arachnoid,  with  engorgenient  of  tlio  brain-substanc(^ 
and  distention  of  the  hitcral  ventrich's  with  blood-tinged  serum,  and  in  30;!  lymph  at  the  base;  of  the  brain,  witii 
injection  of  the  nu'inbranes  and  turbid  serum  in  the  ventricles. 

The  liLooi>  was  found  in  an  unusually  lluid  condition  in  the  typhoid  aisi-  25,  in  the  inahirhd  case  70,  in  tin!  li/pho 
muhirial  cases  i>6  and  264  and  in  ease  150  of  the  iiiixid  series;  in  201  of  the  last  series  the  blood  was  said  to  have  con- 
tained few  white  corpuscles. 

CEdema  was  noted  in  few  cases:  the  neck  was  affected  in  12  and  tlie  legs  in  'M  of  the  tijpluiid  series;  tlie  iowiT 
extremities  in  70  and  78  of  the  maJariul  series  ;  the  han<ls  and  feet  in  ol(i,  and  the  body  generally  in  H07  of  the  mixid 
series. 

Puuui.KNT  IXFILTKATIOXS  AND  DEPOSITS. — In  one  of  the  lijphcnd  cases,  38,  pus  was  deposited  in  the  greater 
pectoral  muscle  and  in  th(^  knee,  elbow  and  wrist  joints.  The  articular  cartilage  of  the  knee  was  destroyed  and  the 
joint  and  synovial  bursa  filled  with  lymph  and  pus  in  289  of  the  mularUd  series.  Turulent  deposits  were  found  in 
several  of  the  mixed  series:  Within  the  sheath  of  the  rectus  abdominis  in  151;  in  the  abdominal  walls  in  241;  in  the 
subperitoneal  cellular  tissue  on  the  left  side  a  little  below  the  diaphragm  in  199;  in  the  muscles  of  the  arm  and 
shoulder  in  253;  in  the  jiectoral  region  opening  into  the  pleural  sac  in  383;  along  the  track  of  the  i)Soas  nuignus 
in  382;  between  the  muscles  of  the  lower  extremities  in  125;  in  the  right  buttock,  connnunicating  e.xternally  by  a 
small  aperture  near  the  anus,  in  185,  and  in  the  prostate  in  239. 

Extravasations  ok  hlood  ix  tke  voluxtaky  mx'Scles. — Blood-clots  were  found  within  the  sheath  of  the 
rectus  abdominis  in  248  of  the  malarial  series,  in  63  of  tlie  tijpho-mahirial  and  157  of  the  mixed  series ;  the  ujjper  third 
of  the  muscle  was  affected  in  63,  the  lower  third  in  the  others.  To  these  may  be  added  136  of  the  last-mentioned 
series,  in  wliicdi  the  anterior  abdominal  wall  was  said  to  have  presented  contusions  and  subperitoneal  blood-clots, 
and  98  of  the  tyjilio-iiialiirinl  series,  in  which  au  emiihysenuitous  and  engorged  condition  of  the  tissues  of  the  left 
side  of  the  neck  was  believed  to  have  been  the  result  of  an  ante-mortem  blow. 

Petechial  ok  ecciiymosed  spots  or  blotches  on  the  skin  were  noted  in  the  post-mortem  records  of  t  wo  of 
the  typhoid  eases,  36  and  45;  but  in  six  others  the  clinical  history  refers  to  their  existence  during  the  course  of  the 
disease:  Thus,  in  5,  21  and  49  there  were  petechiie  on  the  chest,  abdomen  and  thighs;  in  16  a  few  minute  re<ldish 
spots  which  did  not  disappear  on  jiressure;  in  2  blotches  on  the  face,  abdomen  and  chest,  and  in  34  vil)ices  on  the 
abdomen.  In  eight  of  the  maUirial  cases,  260,  261,  289,  292,  293.  295,  386  and  387,  the  surface  of  the  trunk  or  of  the 
body  generally  was  more  or  less  ecchymosed;  in  292  and  293  the  skin  was  re])orted  also  as  dingy  or  bronzed.  Of  the 
lijplio-malurial  series  273  is  the  only  case  in  which  the  record  notes  the post-iiwrttin  appearance  of  spots  of  this  char- 
acter, in  this  instance  situated  on  the  abdomen  and  chest;  but  the  clinical  history  of  86  and  114  indicates  their  exist- 
ence, while  that  of  93  shows  the  body  generally,  except  the  face  and  neck,  covered  with  vibices.  In  the  mixed  series 
of  cases  only  nine  instances  were  recorded  of  ecchymosed  or  purpuric  spots  on  the  skin.  In  two  of  these,  205  and 
235,  the  clinical  history  is  the  source  of  the  information  that  ecchymoses  appeared  on  the  chest  and  abdomen.  In 
the  others  the  post-mortem  records  show  diffused  ecchymoses  on  the  bodj'  in  201,  a  few  faint  reddish  spots  or  petechia; 
on  the  chest  or  abdomen  in  202  and  203,  purpuric  spots  in  351,  354  and  perhaps  303,  and  a  purple  pustular  eruption  in 
334,     Petechia'  were  noted  on  the  epigastrium  in  the  typhtis  case  389. 

liED-sORES  formed  on  the  back  and  hips  in  cases  5,  23  and34  of  the  lyplioid  series,  in  289  and  36(i  of  the  malarial 
series  and  in  101  of  the  lypho-maUirial  series;  in  the  last  case  they  were  developed  also  over  the  angles  of  the  ribs 
ou  the  right  side,  hi  the  mixed  series  the  clinical  history  of  117  and  166  states  that  the  skin  over  the  sacrum  became 
red  and  painful,  manifesting  a  tendency  to  slough;  in  125,  199  and  300  large  sores  were  developed  over  the  sacrum 
and  trochanters,  and  in  218  the  skin  is  said  to  have  been  excoriated  and  denuded. 

G.\ni.;renous  spots  appeared  on  a  blistered  surface  in  case  93  and  in  connection  with  parotitis  in  103  of  the 
typho-maluriul  series. 

G.\XGRENE  OF  THE  FEET  is  recorded  in  six  of  the  cases:  27X,  a  malarial  ca.se  in  which  amputation  was  per- 
formed at  the  mctatarso-jihaiangeal  arti<ni!ations;  112.  typho-mulariul,  in  which  amputation  was  effected  by  the  cir- 
cular method  above  the  ankle,  and  138,  143,  163  and  164  of  the  mixed  series.  In  all  the  cases  both  feet  were  affected; 
in  the  three  first  mentioned  the  condition  was  attributed  to  frostbite. 

SupruR.^Tlox  IX  THE  EAi!  occuricil  in  many  cases,  but  in  56,  typho-malarial,  it  appeared  to  l>e  intimately  con- 
nected with  the  fatal  event. 

Ulcer.\tiox  of  THE  coiiXEA  was  mentioned  in  but  one  case,  49,  of  the  typhoid  series.  , 

In  connection  with  the  tiljovc  tlie  following  iibstract  of  a  synopwiH  of  autopsies  in  thirty- 
five  typho-malarial  ca.ses  is  submitted.  The  examinations  were  made  by  Assi.stant  ISur- 
geoiis  H,  Ai.lI':n  and  Geoegp:  M,  McGill,  U,  S.  Army,  at  the  Lincoln  liosjiital,  AV^ish- 
iiigton,  D.  C,  during  1863  and  1864.      The  report  was  filed  in  the  Burgeon  General's  Office, 


Tlio  SKIN  was  jauufliced  in  two  eases,  affected  with  ery-iipi-las  in  fuiir  cases  ainl  witli  csehurs  in  eight.  The  eellular  tissue  nf  the  necl;  wa- 
emphysematous  and  the  pliin  of  the  itart  greenish  in  one  ease.  Tlti.s  eomiition  was  f.juntl  in  ei<;ht  4-ases  of  eh'atli  fnun  other  aeute  (ihiii>.>;  atel  in 
Bonie  of  these  the  emphysema  was  pieneral,  hut  speciaUy  marlied  in  the  interrnuseiilar  sejjta  of  tlie  hiwer  extremities.  ,\s  the  heai't  and  Ii\i|-  wrii-  soft- 
ened in  all  these  eases  and  the  latter  organ  itself  emphysematous  in  three,  Locis  attriliuted  theconilirion  to  a  niorbiii  elian^^e  in  the  fluids  of  the  hodv 

The  voLUNT.^RV  MCSCLES  Were  healthy  in  all  of  the  forty -six  ruses, 


OF    THE    CONTINUED    FEVEK?.  433 

but  the  general  r<-.<nlt:^  of  the  observations  werr  |iiibli>lie'l  in  tlif  Aincricirn  Journal  oj  fJie 
Medical  )Srie)icf><.'''  It  niav  be  stated  that  most  ot'  these  cases  are  to  be  toinul  in  the  post- 
mnrfi'm  records  that  have  just  been  analw.ed. 

In  one  case  the  fa  uax  anil  <j}i<iltilti>i  were  ('(ivficil  uitli  diplu  licrilic  iiifiiiluancs.  tlir  iiuu;;in«  (if  the  epif;l(iltis 
antl  liiiini;  of  tlie  Uiri/nx  ukerateil :  in  another  there  was  thickening  of  the  membrane  but  no  ulceration.  In  one 
instance  the  traiheo  was  decidedly  inflamed,  but  without  coincitient  larynfjitis  or  ]ineumonia.  The  a'nophn<iiiK  and 
phiirynx  were  liealthy  in  twenty-seven  cases,  infiamed  in  three  and  ulcerated  in  live.  Several  of  the  ulcers  were  cov- 
ered with  a  greenish  exudation,  and  two,  which  had  perforated  the  mucous  coat,  exhaled  a  gangrenous  odor.  In 
one  of  the  cases  of  inflammation  without  ulceration  an  abscess  about  the  size  of  a  hazelnut  was  foiind  wliere  the 
tube  is  crossed  by  the  left  bronchus. 

The  liinija  were  mottled  in  every  case,  owing  to  the  deposit  of  black  pigmentary  matter;  congestion  was  found 
in  fifteen  and  red  hepatization  in  ten.  Under  the  lu'adiug  of  <'ongest  Ion  is  embraced  every  variety  of  engorgement 
from  simple  excess  of  blood  to  a  turgidity  of  the  |)arencliyuia,  absence  of  irepitatioii  and  the  presence  of  an  excessive 
amount  of  sero-sanguineous  liijnid;  all  the  sjiecimens  on  section  gave  issu(^  to  a  thin  dark-red  and  frothy  tliiid. 
This  condition  differed  from  splenization,  as  under  jiressure  the  lung  c(dla|)sed  when  the  li(|nid  was  expressed,  while 
a  splenified  lung  would  break  down  when  subjected  to  this  treatment.  Hut  splenization  was  frecjueutly  found  asso- 
ciated with  this  sero-sanguineous  engorgement.  In  three  of  the  ten  ])neumonitic  cases  both  lungs  were  all'ected  and 
in  seven  one  only;  of  the  latter  two  were  on  the  right  side  and  live  on  the  left.  One  case  was  tuberculous,  one  showed 
capillary  bronchitis  and  the  remaining  eight  were  nornnil.  I'lriirisi/  was  oliserved  in  tliree  cases,  in  two  of  which  it 
was  simple  and  in  the  other  complicated  with  pneumonia. 

The  heart  was  generally  pale;  in  twenty-nine  cases  tirm  and  in  six  soil.  It  contained  ('lots  in  all  except  three 
cases,  and  the  larger  clots  were  invariably  a.ssociated  with  imeumonic  complications.  Pericardial  adhesions  were 
found  in  two  eases;  the  (piantity  of  efl'nsed  li(iuid  varied  from  one  fluid  drachm  to  three  fluid  ounces. 

The  lircr  wan  lirni  in  twenty-tVnir  cases  and  llabby  in  eleven,  but  tluei^  were  fatty,  four  congested  and  two 
bronzed.  Bile  was  generally  jnesent,  in  (inautity  from  two  to  twenty  fluid  drachms.  It  was  usually  black,  thick 
and  tar-like,  occasionally  dark-greenish,  brown  or  ochre-colored,  and  in  other  cases  of  a  nnue  yellowish  tinge. 
While  freiiuently  viscid  it  was  sometimes  thin,  with  a  light  flocculent  dejiosit. 

The  splien  in  twenty-one  cases  was  Arm  and  liealthy;  in  fourteen  flabby  or  pnltaceons.  It  was  generally  gray- 
ish-purple externally  and  bluish-gray  or  dark-brown  internally.  In  some  the  softening  was  so  extreme  that  the 
organ  would  break  under  the  handling  necessary  to  remove  it  IVom  (he  body,  and  when  sipu'ezed  the  pnlj)  would 
flow  out  in  a  thick  c(mtinned  stream  as  from  a  sponge. 

The  intisliinn. — lu  twenty-eight  cases  the  morbid  conditions  were  confined  to  thl^  xmatl  iiitrnthic;  in  seven  the 
colon  was  also  involved.  The  mucous  mendirane  was  more  or  li'ss  softened,  and  in  ]irotracted  cases  of  illness  its 
folds  in  the  lower  tliir<l  of  the  ileum  were  obliterated.  '1  he  parts  immediately  around  the  ileo-ca'cal  valve  were 
uniformly  the  scat  of  greater  )iathological  changes  than  else w  here.  From  this  point  the  glandular  eviden<'e  of  disease 
extended  several  feet  up  the  canal,  in  one  instance  reaching  the  distance  ot  ten  feet  above  the  valve.  No  ulceratiiui 
was  detected  above  I  lie  jejunum.  The  greater  lesions"  were  invariably  observed  in  the  closed  glands.  These  in  the 
earlier  stages  were  tumid,  tliickened,  of  a  whitish  color,  with  high  abrupt  walls.  Of  the  whole  number  of  specimens 
eighteen  presented  ulceration  in  tumefled  patches;  fourteen  in  ]iatches  not  tumetied;  in  three  the  condition  of  the 
patches  was  unnoticed.  The  character  of  the  ulcer  varied  as  it  existed  in  the  swollen  or  the  shrunken  gland:  In 
the  former  its  walls  were  high,  its  liase  red,  its  form  generally  circular  or  suli-oval,  with  occasionally  a  low  form  of 
exudation  on  its  surface.  This  form  was  never  confluent,  and  in  no  instance  was  the  entire  surface  of  a  patch  the 
seat  of  ulcerative  change.  Several  distinct  ulcers,  however,  were  seen  in  one  patch,  and  in  three  instances  the  w  hole 
area  was  pitted  w  itii  punctate  ulcers,  giving  the  gland  a  honey-conibed  appearance.  'I'his  condition  of  the  agmi- 
nated  glands  was  always  accompanied  with  a  similar  change  in  the  solitary  follicles;  the  enlarged  follicles  were 
frequently  so  numerous  as  to  give  the  surface  of  the  gut  a  niammillated  a])pearance.  In  the  shrunken  gland  the  ulcers 
were  always  of  a  duller  hue,  the  walls  seldom  high,  and  if  so,  only  in  the  periphery  of  the  aflected  patch,  forming 
a  rounded  subeverted  border,  the  area  within  const itut  lug  the  nicer.  The  base  was  chiefly  of  a  dark-blackish  color, 
due  to  the  presence  of  pigment.  The  form  of  the  nicer  ans.  as  a  mle,  irregular,  a  condition  resulting  from  the 
unequal  ravages  of  the  undermining  nrocess  which  had  taken  place  at  the  base  of  the  individual  follicles.  In  eight 
cases  the  borders  of  the  patches  were  sccMiped  out  to  the  depth  of  a  line  by  this  action  ;  in  two  perforation  of  the 
intestine  had  taken  jilace  in  ulcers  near  the  ileo-ca'cal  valve,  and  in  both  of  thes<i  peritonitis  was  extensive.  The 
niUiii  was  congisted  in  seven  cases,  in  four  of  which  there  was  follicular  enlargement  and  in  three  ulceration;  in  one 
case  its  mucous  meiiibrane  was  thickened  and  its  solitary  glands  ulcerated,  anil  in  another,  in  w  hich  the  immediate 
cause  of  death  was  heniorrl;age,  large  quantities  of  blackberry  seeds  were  found  in  the  actively  inflamed  tissues  of 
the  alimentary  canal. 

Gluteal  abscess  was  observed  in  one  case.  The  parotid  glands  weie  inflamed  in  six  cases,  in  two  of  which  sup- 
puration was  noticed.  Inflammation  of  the  thyroid  gland  with  thyroid  apoplexy  and  abscess  of  the  salivary  glands 
was  observed  in  one  case.  In  another  an  abscess  containing  a  drachm  of  healthy  pus  was  detected  In  the  cellular 
tissue  beneath  the  diaphragm  at  the  e))igastrium. 

The  scattered  tacts  juvsented  bv  the  records  n|'  nidiviibbil  cases  liaving  been,  for  con- 


•  Vol.  Xl.l.X.  p.  Ilili  .1  mi. 

Med.  Hist.,  Pt.  Ill— 5.5 


434  PATHOLOrirCAL    ANATOMY    AND    PATirOLOGY 

veiiii'iu-i;  in  .stm.ly,  eon.-ulklutcd  iii  llu'  aliovc  analytical  .summary,  .some  remarks  suggested 
liv  tiii'ii'  cnnsidiM'ation,  auil  i\'run.'nc(.'s  to  mattfrs  of  interest  uutuuclied  upon  in  tlic  analysis, 
aiv  lit-'n-witli  sulmiitted. 

n.— THE  ALIMENTARY  TRACT  AND  ABDOMINAL  VISCERA. 

The  SALIVARY  cMjANDS. — Tlic  jiai'otid  gland  was  inllamcd  in  1.1  per  coat,  of  the  cases. 
No  predilection  was  shown  for  (athci'  side,  and  in  several  instances  IkiIIi  glands  became 
involved.  In  some  cases  the  iidlainniiition  snlisidud  alti'r  a  t'ontuuunu'e  ol  many  days;  but 
in  the  greater  nundjer  purulent  inliltration  speeddy  resulted.  As  an  illustrati(jn  of  the 
rapidity  with  which  this  was  eirecte<l  case  31  may  Ihj  instanced, — the  gland  was  observed 
to  be  swollen  on  the  eleventh  ilay  of  the  month,  and  on  the  fourteenth,  when  death  occurred, 
disorganization  had  already  taken  place.  In  222  the  matter  escaped  by  the  ears;  in  193 
by  apiertures  in  the  mouth  Ijetween  the  I'oot  of  the  tongue  and  the  inferior  maxilla,  and  also 
externally  a  little  below  the  mastoid  process.  Parotid  swelling  occurred  only  after  a  pro- 
longed attack  of  fever,  and  was  I'ecorded  among  the  malarial  as  well  as  the  typhoid  cases. 
It  must  therefore  be  considered  a  result  not  so  much  of  the  direct  action  of  the  fever-poison 
as  of  the  lessened  vitality  and  detei'iui'ated  condition  of  the  blood  produced  by  the  con- 
tinuance of  the  fel.irile  slate.  Its  occurrence  in  the  later  stages  of  typhus*  also  indicates 
its  independence  of  a  specific  febrile  cause.  The  frequency  of  parotid  swelling  in  the  con- 
tiiuicd  fevei-s  of  llu^  war,  as  compared  with  those  of  civil  life,  has  already  been  noticed  in  the 
section  on  symptomatology. f  It  seems  of  interest  as  one  of  several  morbid  phenomena 
that  occurred  in  our  camp  fevers  intimating  a  tendency  to  typhus,  or  rather  to  a  return  of 
the  clinical  features  that  characterized  the  fevers  of  the  unsanitary  camps,  ships  and  pjrisons 
of  the  middle  ages.  The  rarity  of  notable  inflammation  of  the  submaxillary  (suppuration 
having  occurred  in  this  gland  in  but  one  ca,se,  384)  or  sublingual  glands  or  of  the  pancreas 
was  in  marked  contrast  with  the  frequency  of  these  parotid  abscesses.  HoffmannJ  ascribes 
the  destructive  character  of  the  inflammation  in  the  parotid  after  typhoid  to  peculiarities  in 
the  anatomical  situation  of  the  gland.  The  density  and  inelasticity  of  its  fascia  and  the 
bony  structures  among  which  it  is  embedded  prevent  expansion  during  the  congestion  and 
corpuscular  accumulation  attending  the  process,  so  that  impaction  and  necrobiosis  are  more 
readily  produced.  But  although  this  is  true  in  part,  and  corresponds  with  our  knowledge 
of  inflammatory  results  in  similarly  situated  localities,  as  in  the  familiar  example  of  paro- 
nychia, the  febrile  poison  appears  to  exercise  a  certain  influence  on  the  progress  of  parotid 
swellings  in  view  of  the  infrequency  of  suppuration  as  a  result  of  the  inflammatory  condi- 
tion in  mumps. 

That  the  pharynx  and  cesophaous  were  not  more  frequently  observed  to  have  suffered 
from  inflammatory  action  appears  due  to  the  fact  that  their  condition  was  seldom  examined 
by  our  medical  officers.  Dr.  Harrison  Allen's  notes  aff'ord  the  only  data  for  estimating 
the  frequency  of  their  morbid  appearances.  The  mucous  membrane  was  normal  in  twenty- 
seven  of  his  thirty-five  cases, — when  altered  its  changes  were  such  as  have  been  recorded 
by  Louis  in  his  typhoid  cases;   it  was  inflamed  in  three  and  ulcerated  in  five.      The  post- 

*  MritrHist.N,  |).  21'j,  rcp(»rts  tlic  itfiiK^aranrt"  of  parotiil  swcl!iii<r..*  in  211  u\  14,1176  patients  a.lniitt.'il  into  tin-  Lonii.m  Ffvcr  n<.K]iitiil  in  tin*  ten  ypars 
Isr.l-Ti),  uti.l  nf.Ts  to  their  (.ri'MLMifo  in  the  t.vplinrt  of  military  writyrH,  iw  not«-'d  by  Mosho  in  the  British  army  ufwrating  in  Germany  in  HGl  and  liy  Jaoqvot 
tri  tile  t.vphns  of  the  French  army  in  tin;  Crimea. 

f  See  xtipni^  p.  20S. 

I  Vntvmn.-hnnfit'n  ilher  di^'  Palhitlfjisch-Anatomixchm  Vfnin'Ifnntilf^n  der  orrfiutf  hehii  Ahdinniu'dliJlihnK. — C  E.  K.  Hoffmann.  Leipzig,  IHC'.t,  p.  ISO, 


OF    THE    CONTINUED    FEVERS. 

mortem  recoixk  )iro,sented  above  show  in  a<iditiun  tlie  occurrence  of  eechymoses,  diphtheritic 
exudation  and  abt^cess. 

The  observations  v\i  the  stomaih  were  not  numerous.  This  organ  W'^^  ahered  in 
appearance  in  7'")  per  cent,  of  si.x:teen  tvjihi'id  cases,  in  51.7  per  cent,  of  twenty-nine  nialariah 
in  62.0  per  cent,  of  sixteen  typlio-niahirial.  and  in  50  per  cent,  of  seventy-four  mixed 
febrile  cases.  In  most  of  these  there  was  more  or  less  congestion,  sometim<?>''  general,  at 
otljer  times  circumscribed  in  patches  and  in  a  few  cases  punctiform;  this  w^is  often  asso- 
ciated with  softeniiiiT  and  tlnckeniny;  of  thf  mucnus  membrane  and  in  three  cases  with 
ulceration.  Tlie  ulcers  were  minute  and  situated  along  the  small  curvature  i'l  bS6,  near 
the  middle  of  the  large  curvature  in  354  and  near  the  pylorus  in  96.  The-'^e  hypfmemic 
conditions  are  essentially  the  same  as  those  found  by  Louis  in  his  typhoid  cnses,  and  con- 
sidered by  him  to  be  of  secondarv  importance  as  he  liad  encountered  them  in  death  from 
acute  diseases  other  than  typhoid  fever.  But  it  is  evident  that  the  changes  lound  in  the 
malarial  series  of  continued  fevers  were  occasionally  of  a  more  intensely  congestive  cliar- 
acter  than  those  of  the  typhoid  series;  ecchymoses  and  tliorough  disinteg'''^tion  of  the 
mucous  lining  of  the  stomach,  which  was  filled  with  a  dark  grumous  liquid,  '"iiy  be  men- 
tioned in  illustration.  Similar  conditions  were  observed  in  the  cases  submitted  in  the  last 
chapter  as  belonging  to  the  paroxysmal  fevers.  There  ajipears,  therefore,  soine  warmnt  for 
referring  them  to  the  presence  of  the  malarial  ])oison  when  they  are  discovered  in  certain 
cases  of  the  typho-malarial  and  mixed  series. 

The  eniidition  of  the  lining  membrane  of  the  ditodenum  was  seldom  specially  recorded, 
but  when  noted  in  the  typhoid  cases  the  lesions  were  similar  to  those  observed  by  Louis 
and  regarded  by  him  as  of  minor  importance  since  they  liad  been  found  with  equal  frequency 
in  other  acute  diseases.  The  duodenum  was  seldom  ailecteil  alone;  generallv  '^  participated 
in  the  morbid  affection  of  the  stomach.  Thus  ImiIIi  n|'  these  portions  of  the  alimentary 
tract  were  inflamed  in  29,  116  and  354,  uh-eratetl  in  ^)&,  and  disintegrated  in  71  and  243. 
When  only  a  part  of  the  duodemnn  was  afleeted  the  morbid  action  was  restricted  to  the 
upper  tliii'd;  and  even  when  the  whole  of  this  poition  of  the  canal  was  implicated  the 
jejunum  was  frecpiently.  as  in  317,  healthy.  <  )n  the  other  hand  there  occurred  some  cases, 
as  276  and  354,  in  which  the  duodenum  was  affected  while  the  stomach  was  considered  in 
a  healthy  condition;  in  these  the  morhid  action  had  extended  from  below.  Briinner's 
glands  were  noted  as  enlarged  in  some  instances  and  in  one  case,  ;'><)7,  as  ulcerated 

The  .lE.iUNTM  was  mentioned  with  sufficient  frequency  to  show  that  it  became  altered 
by  tin;  extension  of  the  diseased  action  iVoiii  below  and  not  from  above.'''  The  lowest  part 
of  the  tube  was  affected  when  onlv  one  poi'tioii  was  saiil  to  have  suffered,  and  when  the  whole 
was  implicated  the  action  in  its  lower  pait  was  more  diffuse  and  intense  than  in  its  upper. 
In  addition  to  congestion  there  was  sometimes  a  softened  and  thickened  condition  of  the 
membrane  with  enlargement  of  the  solitary  glands,  and  in  rare  cases  ulceration.  In  many 
instances,  however,  in  which  the  record  states  only  an  ulcei-ated  condition  of  the  small 
intestine,  it  is  probaljle  that  the  ulceration  affected  the  jejunum  as  well  as  the  part  of  the 
canal  lying  below  it. 

Intussusception  of  the  small  intestine- was  occasionally  found,  but  not  with  the  fre- 
quency recorded  by  Louis  in  his  tvj'hoid  cases.     It  cannot  be  regarded  as  having  a  special 

*HuFF>l.\NN — Ojji.  cU.,  p.  06 — saTS  that  he  ha.s  !>iit  scldnm  found  disr.iR('  uf  the  jVjnmim  in  typhoiil;  that  wlien  it  does  m'cur  it  is  extremely  rare  f-r 
its  upper  portion  to  be  involved,  and  that  the  duodenum  is  e.\empt  in  a  still  greater  deprce. 


-\'^C)  PATH(»LO(iirAI.    ANATOMY    A  X  li    PATFlOLOiiY 

rrlatKMi  to  tin;  febrile  cabe.s,  us  it  wuh  IbiiiiJ  with  perluijivS  equal  frequency  in  the  diarrhoea] 
sei'ies.''' 

Iji;mi;i;ji'()11)  \vui;ms  were  also  noted  in  a  few  cayes,  but  it  does  not  a|i|iear  that  they 
had  any  special  cniiiiection  with  the  CDiitiniied  fevers. f  In  o7<S  a  worm  erawded  into  the 
larynx  of  the  patient  and  caused  death  liy  suHucatiun.  Specimen  iJ'dO,  Army  Medical 
Museum,  exhibits  this  wurm  extended  in  the  larynx,  trachea  and  right  brmichus.  In  o48 
the  intestinal  canal  was  extensively  colonized. 

A  tumefied,  inflamed  uv  ulcerated  condition  of  the  PATCliKS  of  Peykr  or  deep  and  cir- 
curnscrilie([  ulcerations  of  the  mfestine  whi(di,  in  view  of  our  knowledge  of  the  typhoid  intes- 
tinal lesidii,  might  lie  ascribed  to  the  ilestruction  of  these  patches,  were  found  in  all  the  cases 
of  continued  lever  except  those  that  have  been  separately  presented  as  probably  due  solely 
to  the  action  of  the  malarial  poison  and  two  of  those  that  were  regarded  clinically  as  typhus. 
It  is  evident  that  the  glands  in  the  vicinity  of  the  ileo-ceecal  valve  were  especially  prone  to 
become  affected,  for  in  some  cases  it  is  stated  that  the  diseased  action  was  in  progress  only 
in  those  occupying  the  lower  part  of  the  ileum;  while  in  cases  in  which  the  whole  of  the 
intestine  was  involved  the  ulcerative  process  had  made  greater  progress  in  the  glands  near 
its  termination  than  in  those  of  the  jejunum.  This  is  illustrated  by  many  of  the  specimens 
tliat  have  been  pi'eserved  in  the  Museum.  Three,  four  or  more  pieces  from  different  con- 
volutions of  the  same  ileum  invariably  show  a  progressive  increase  of  the  diseased  action  as 
the  ileo-ctecal  valve  is  approached.  Thus  the  seven  successive  portions  of  the  ileum  con- 
stituting specimens  171-177  present  the  most  gradual  transitions  from  the  slightest  thick- 
ening of  Peyer's  patches  in  the  first  piece  to  the  large  ulcerations  just  above  the  valve  in 
the  last.  Thus  also  the  five  portions  of  the  ileum,  specimens  376-380,  present  from  above 
downwards  a  gradual  enlargement  of  the  agminated  glands,  the  summits  of  which  are  more 
or  less  ulcerated  in  the  last  three  pieces;  many  of  the  solitary  glands  are  also  diseased, 
forming  in  the  lower  pieces  oval,  ulcerated  elevations  similar  in  character  to  those  in  the 
[latches  of  Peyer  but  smaller  in  size.  The  plate  facing  this  page,  prepared  from  a  water- 
color  drawing  of  the  fresh  intestine,  reproduces  the  appearance  of  the  second  and  last  of 
these  epecimens.  The  section  of  the  intestine  on  the  left  side,  taken  from  high  up  in  the 
ileum,  shows  two  of  Peyer's  patches  somewhat  thickened,  rising  from  the  surface  of  the 
mucous  memlirane  with  abrupt  edges,  the  lower  decidedly  thicker  than  the  upper,  but  neither 
ulcerated;  the  tawny-yellow  mucous  membrane  is  considerably  injected ,and  a  few  slightly 
enlarged  solitaiy  follicles  are  scattered  over  its  surface.  The  section  on  the  riglit  side  of  the 
plate,  taken  from  just  above  the  ileo-csecal  valve,  shows  in  its  lower  part  a  large  patch  much 
thickened,  witli  abrupt  edges,  its  surface  ulcerated  and  stained  with  biliary  pigment;  eight 
similar  but  smaller  ulcerations  of  various  sizes  seem  to  have  originated  in  the  solitary  glands, 
and  a  number  of  these  glands  are  enormously  enlarged  but  not  ulcerated;  the  pale  cream- 
colored  mucous  membrane  is  highly  injected  in  patches,  which  appear  as  irregular  red 
stains.  The  case  from  wdiich  these  specimens  were  obtained  is  given  as  336  of  the  po-'^t- 
mnricm  recoi'ds.J  Prints  from  negatives  of  the  mounted  specimens  are  submitted  (facing 
pages  410  and   112)  tor  comparison  witli  the  chromodithographs  of  the  fresh  intestine. 

It  is  also  I'vident  that  the  diseased  action  had  a  ]>rogressivo  upward  movement,  for  in 
liut  few  instances  were  the  upper  glaiuls  allected  while  those  below  were  in  a  healthy  cou- 


*  Sri'  p.  :il:i.  I'art  Sti  1.11.1  ..f  tliit  work.  t  Si'i!  iii/rcr,  J>.  591.  X  See  mite,  p.  410. 


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OF    TIIK    CONTINUKD    KEY KRS.  437 

dition.  In  case  29(i  i\\v\\;  wwc,  thirty-two  jiatclicM  of  IVyor  varying  from  half  an  inch  to 
three  inches  in  length,  and  twenty-seven  of  these  were  niucli  tliickc^ned  and  generally 
inflamed  but  not  ulcerated;  the  first  two  patches  of  the  series  were  not  thickened;  a  large 
patch  dotted  with  black  pigment  but  otlierwise  healthy  was  found  on  each  fold  of  the  iloo- 
caical  valve,  and  the  next  patch  above  these  appeared  to  be  healthy.  In  another  exceptional 
case,  200,  the  twelve  upper  patches  were  liealthy,  the  thii'teenth  ulcerated,  the  fourteenth 
healthy  and  the  remainder  ulcerated  and  sloughing,  some  even  through  to  the  peritoneum. 

The  afl'ected  patches  in  the  continued  fever  cases  were  usually  circular  or  oval,  from 
half  an  inch  in  diameter  to  three  or  four  inches  in  their  longest  measurement,  that  parallel 
with  the  long  axis  of  the  tube.  Occasionally,  however,  they  were  of  unusual  size.  Thus 
specimen  399,  Army  Medical  Museum,  from  case  198,  exhibits  in  the  ileum  immediately 
above  the  ileo-ctecal  valve  a  patch  eight  inches  long,  the  upper  extremity  of  which  is  covered 
with  minute  ulcerations. 

The  thickening  of  the  patches  varied  from  a  just  perceptible  tumefaction,  such  as  is 
seen  in  the  upper  part  of  specimen  377,  to  a  prominent  node  rising  gradually  from  the  sur- 
face of  the  surrounding  mucous  membrane;  but  in  many  instances  the  margins  of  the  nodes, 
as  seen  in  the  plate  of  specimen  380,  were  abrupt,  and  in  some,  as  in  565  (see  plate 
facing  page  380),  the  patches  were  so  constricted  at  the  base  as  to  present  the  appearance 
of  flat  sessile  fungoid  growths.  The  enlargement  was  opaque,  soft  and  of  a  white,  yellow 
or  grayish  color,  more  or  less  reddened  by  congestion.  In  some  the  mucous  membrane 
covering  the  patch  presented  a  slightly  reticulated  appearance  from  the  irregularity  of  the 
underlying  surface;  this  is  well  seen  in  the  lower  part  of  specimen  377,  as  shown  in  the 
photographic  print. 

When  the  morbid  action  had  made  further  progress  in  such  plaques,  ulcers  appeared  on 
the  prominences  and  afforded  escape  to  the  softened  and  broken-down  portitm  of  the  con^ 
tents.  These  ulcerations  became  enlarged  by  the  destruction  of  the  inti'rlying  glamlular 
and  mucous  tissue  and  the  coalescence  of  adjoining  ulcerations  until  the  greater  part  or  whole 
of  the  node  was  removed,  leaving  a  shallow  cavity  containing  the  remains  of  the  ghunls  and 
the  infiltrated  submucous  tissue  usually  stained  of  a  dark  or  greenish  color  by  the  intestinal 
contents.  Patches  seen  in  various  stages  of  this  destructive  process  piesented  a  vai'iet}'  ot 
appearances:  In  some  a  few  iniimte  ulcerations  on  thi;  apices  of  individual  glands;  in  others 
one  or  more  larger  ulcerations  at  some  points,  witli  (lie  I'eniaining  surface  intact  or  onlv 
minutely  penetrated;  and  in  others  again  a.  large  irregular  uK-eraleil  surface  more  or  less 
stained  and  pei'haps  liridged  in  jtart  oi' overlaid  by  fragments  of  the  softened  nuicous  covering. 
The  edges  of  the  com])leted  ulcer  were  sometimes  ragged  from  the  persistence  of  shreds  of 
the  mucous  mendirane,  but  generally  they  were  well  d<'lined  hy  a  thickening  of  this  mem- 
brane and  its  undiM-lying  tissue.  Rome  of  these  appearances  are  admirably  shown  in  the 
chromo-lithographs  of  specimens  177,  185  and  189,  Army  Medical  Museum,  hei-ewith  sub- 
mitted. The  first,  of  these  has  already  lieen  i-eferred  to  as  one  of  seven  successive  portions 
of  the  ileum  showing  a  gradual  transition  from  the  slightest,  thickening  of  the  patches  of 
Peyer  in  the  upper  part  of  the  canal  to  extensive  ulceration  in  the  lower  part.  It  is  from 
the  case  of  a  soldier  of  the  6th  Pennsylvania  Cavalry  who  was  admitted  into  the  .ludiciai'v' 
Square  hospital  Api'il  2(),  1863,  and  died  May  2.  The  de|;\ils  of  the  case  were  not  fur- 
nished. Tht?  chromo-hthograph  facing  page  440  represents  the  ilenm  in  the  vicinity  of  the 
ileo-ctecal  valve;  the  mucous  membrane  is  reddened  by  congest  ion  except  near  the  valve, 


438  TATIIOI.OOICAL    ANATO>rY    AND    PATHOLOGY 

where  it  is  gniyisli,  with  ofcasioiuil  wtains  of  Itrowiiisli  pigmoiit;  tho  ]iatches  of  Pcyer  ami 
sevei'al  of  tlic  KoHtary  gluiids  are  tliicki'iifd  and  idcerated,  the  contour  and  surface  of  tlie 
ulcers  Ijciiig  irregular  from  tlic  iin])(n-fect  destruction  of  the  overlying  iiiuc(jn8  nienibi'ane. 

The  specimens  185  and  189,  phite  facing  tliis  page,  were  taken  from  a  soklier  who  died 
of  fever  iti  tlio  Finley  liospital,  Wasliington,  D.  C,  during  the  summer  of  1863.  His  history 
was  not  recorded.  The  left  piece,  representing  a  portion  of  the  upper  pai't  of  the  ileum, 
shows  four  ty|>hoid  ulcers,  two  evidently  l)ased  on  Peyer"s  patches  and  two  apparently  on 
diseased  solitary  glands.  A  nundier  of  slightly  thickened  follicles  are  scattered  under  the 
cream-colored  mucous  membrane,  wliicii  is  lightly  streaked  with  an  arborescent  redness. 
The  contour  of  tlie  ulcers  is  irregulai-ly  I'ounded  or  oval,  their  surfaces  dark  coloi-ed  witli  a 
greenish  tinge  and  their  edges  thickened  and  jialo  but  in  parts  somewhat  injected.  The  right 
piece,  taken  from  just  above  the  ileo-ctecal  \alve,  shows  two  large  ulcerated  Peyer's  patches 
and  five  ulcers  apparently  due  to  disease  of  the  solitary  glands.  The  mucous  membrane  is 
thickened,  of  a  livid  crimson  coloi-  and  raised  at  several  points  into  small  rounded  elevations 
by  enlargement  of  the  solitary  cryj)ts.  The  contour  of  the  ulcers  is  irregularly  round  or  oval, 
but  in  some  of  the  smaller  lesions  tlie  long  diameter  is  at  rigiit  angles  to  the  axis  of  the 
tube.  The  surface  is  stained  of  a  dai'k-greeu  color,  but  in  the  lowest,  the  largest  ulceration, 
there  are  some  spots  of  reddish  congestion.  The  edges  are  abrupt  and  thickened  and  par- 
ticipate more  or  less  in  tlie  dark  injection  of  the  mucous  lining. 

In  many  cases,  however,  some  of  the  ulcers,  })articularly  in  the  lower  part  of  the  ileum, 
extended  through  the  submucous  tissue  and  exposed  the  transverse  fibres  of  the  musculai' 
tunic  in  the  bottom  of  the  cavity.  In  many  cases,  also,  the  muscular  coat  became  involved 
m  the  process  of  disintegration,  and  the  serous  covering  of  the  intestine  gave  way  at  the 
weakened  point.  But  in  a  smallproportion  of  the  cases  the  nodes,  instead  of  breaking  down 
in  tliis  gradual  manner,  sloughed  away  en  'laasse;  or  a  part  of  the  tliickened  patch  became 
subject  to  progressive  ulceration  wdiile  another  part  was  removed  by  sloughing.  The  patches 
are  sometimes  stated  in  the  record  to  have  been  converted  into  soft  pultaceous  sloughs. 
Thus  in  cases  13  and  14  of  the  typhoid  series  the  so-called  typhoid  de|H)sit  was  removed 
by  sloughing,  as  also  in  cases  200  and  385  of  the  mixed  series.  In  20U,  aiTurding  to  the 
record,  one  of  tlie  patches  of  Pever  was  converted  into  a  blac'kish-ljrown  irregular  eschar 
one  and  one-fourth  inches  square  and  one-fourth  of  an  inch  thick.  In  385  the  patches  were 
blackisli  in  color,  marked  with  livid-red  and  their  margins  indistinctlv  detiiicd.  Pho- 
tographic prints  of  a  portion  of  the  ileum  in  each  of  the  last  two  cases  acconi))anv  this 
report,  facing  pages  388  and  418.  Tlie  first,  representing  specimen  241.  Arniv  Medical 
Museum,  shows  a  larsie  irregular  pulpv  slouj-di.  its  transverse  diameter  measuring-  three 
inches  and  its  longitudinal  diameter  one  inch  and  a  half;  several  small  shallow  ulcerations 
may  also  be  observed  on  the  specimen.  The  second,  representing  specimen  182,  shows  a 
large,  thickened,  sloughing  patch,  several  oval  ulcers  based  on  the  solitary  glands  being  also 
present.  When  the  destructive  process  was  efiected  in  this  rapid  and  general  way  the  tend- 
ency to  perforation  was  obviously  increased. 

In  the  analysis  given  above  of  the  post -mortem  records  of  the  series  of  fifty  pure 

.typhoid  cases  there  is  ample  ground  for  the  assertion  that  the  raucous  membrane  of  the 

small   intestine  was   affected  chiefiy,  and   not   unfrequently  solely,  over  and  immediately 

around  the  tumefied  or  ulcerated  patches  of  Peyer.     The  absence  of  a  general  congestion 

ot  the  mucous  membrane  in  some  cases  proves  that  its  presence  was  not  essential  to  the 


'  Grs;  cnromoHtn  """r^' 


OK   THI<;    COMIX L'KD    FEVERS.  439 

diseased  condition  of  the  dands.  Their  afliection  must  therefore  be  considered  the  primary 
lesion,  and  any  extension  of  inflammatory  processes  to  the  general  mucous  surface  must  be 
regarded  as  secondary  and  as  much  a  consequence  of  the  morbid  action  in  the  glands  as  its 
extension  to  the  serous  membrane  after  the  destruction  of  the  muscular  tunic.  This  secondary 
congestion  of  tlie  membrane  between  the  ulcerated  patches  was  usually  confined  to  the 
lower  part  of  the  ileum,  where  the  diseased  action  had  made  most  progress.  In  some 
cases,  however,  it  was  more  generally  diffused,  but  in  these  it  was  invariably,  so  far  as  the 
records  show,  less  intense  in  proportion  to  its  distance  from  the  ileo-csecal  valve.  Speci- 
mens from  some  of  the  cases  of  this  series,  as  from  10,  43,  48  and  50,  were  received  at  the 
Museum  and  have  been  preserved,  but  unfortunately  none  of  them  were  subinitted  to  the 
artist  for  the  preservation  in  colors  of  their  appearance  when  recent.  Nevertheless  the 
absence  of  a  diffuse  congestion  of  the  mucous  membrane  in  the  vicinity  of  typlioid  ulcer- 
ations, at  least  in  the  upper  part  of  the  ileum,  is  shown  by  the  chromodithograj)]i  of  speci- 
men 185  on  the  left  side  of  the  plate  facing  page  438.  As  the  history  of  the  case  from 
which  this  specimen  was  obtained  is  not  on  record,  it  is  uncertain  whether  it  was  or  was 
not  modified  by  a  malarial  element.  But  even  had  the  case  been  so  modified  the  value  of 
the  drawing  as  an  illustration  of  typhoid  ulceration,  unaccompanied  by  diffuse  inflainina^ 
tion  of  the  lining  membrane,  is  by  no  means  impaired.  As  will  be  seen  directly,  a  dllhisdy 
congested  or  infiamed  condition  of  the  membrane  was  more  fretpifutly  met  with  in  mod 
ified  than  in  unmodified  cases;  hence,  wliile  the  general  congestion  of  189,  shown  on  tlir 
right  sid(>  of  the  same  plate,  may  bo  viewed  as  due  to  a  malarial  complication,  th(;  alisencc 
of  a  similar  congestion  in  185camiot  be  ascribed  to  an  inlei'feri'nce  of  tliat  nature. 

In  the  malarial  sci-ics  of  rontinucd  fcvci'  I'ases  pn^senling  adynamic;  symptoms  the 
condition  of  (lie  fiatclu's  of  Pe\-i'r  was  not  reported  in  twenty-six  instances;  and  as  in  most 
of  these  some  details  are  gu'eii  ol  (lie  appearances  pi'eseiited  by  the  mueoiis  memhraiie  of 
the  small  iii(es(ine,  it  may  be  inferred  tliat  the  patches  were  not  so  alt,ered  as  to  attract 
special  attention,  or  in  other  words,  that  they  or  the  memlirane  covering  thorn  wei'e  heaJthv, 
congested  or  iiifiame(l  according  to  the  condition  of  the  general  mncoiis  lining.  Thev  were 
healthy  in  seven  cases  a,iiil  not  ulcerated  in  two  cases,  although  in  six  of  these,  257,  2()0- 
263  and  367,  the  membrane  was  more  or  less  conges(ed  or  inllamed,  and  in  the  las(-men- 
tioned  case  ulcerated  at  oni^  point  (o  perforation.  When  sjiecial  attention  was  given  by 
the  reporters  to  the  condition  of  the  patches  they  were  generally  said  to  l>e  ivddriied  or 
altered  in  color  by  d(^p(jsits  of  black  or  lilnish  pignuMit,:  They  were  reddened,  coin^csled 
or  iiiHame(l  in  ten  cases,  in  four  of  wliieh  the  state  of  the  miu'oiis  membrane  of  the  small 
mtestine  remained  unnoted,  while  in  six  it  was  more  or  loss  hyperremic;  it  is  to  lie 
observed  also  tliat  in  one  <jf  these  cases,  37"x  contrary  to  what  is  found  in  typhoid  fever, 
the  glands  and  mucous  membrane  ol  the  ujiper  [)ail  ol  (he  intestinal  tract  wt-vo  the  seat 
of  the  congestion.  In  case  84,  in  whii'h  (In'  agminated  glands  wen^  repor(ed  pale  the 
mucous  membrane  of  the  small  in(es(ine,  aldiongli  showing  some  streaks  of  cono-,.sti(>n 
was  generally  bloodless.  In  :')S(')  most  of  the  glands  were  healthy,  bu(  a.  few  were  inllamed 
and  slightly  thickened,  while  the  ileum  was  infiamed  in  patches,  some  of  ^vlliel|  were 
intensely  affecteil.  In  M.S7  the  glands  were  opaque-white  ;ind  slightly  thickened,  but,  did 
not  appear  jiosilively  diseased,  and  the  mucous  membrane  generally  was  of  a,  iiale-cream 
color.  In  (he  remaining  fifteen  of  the  sixty-three  cases  tln'  patehes  of  Peyer  Were  colored 
by  deposits  of  pigment,  which  wdl  be  more  particularly  referred  to  hereafter.* 

»S.>i'  lu/r.i.  ]>.  153. 


440  PATHOLOGICAL    ANATOMY    AN!)    TATHOLOOY 

The  mucous  liniiiir  <>(  tlii>  ili'iim  was  congested  in  nearly  two-iliiids  nf  the  cases  of 
this  series.  In  some  the  cdnu'estinii  t'oinicil  streaks  and  ])atches,  ami  in  these  there  appeared 
no  marked  partiality  inr  tlu'  iDwer  part  ol'  the  intestine;  generallv,  however,  the  congestion 
was  diffused  througliont  the  whole  df  the  ih'um.  The  mucous  membrane  was  frequently  dark- 
ened by  the  intensity  of  the  eno-orgement  and  occasionally  spotted  with  ecohjnnosis;  in  one 
instance  the  ileum  is  said  to  have  keen  gangrenous;  nevertheless  ulceration  Avas  varidy 
present.  In  a  few  cases  the  memln'ani'  was  sultened,  thickeiii'd  or  thinned.  In  st)me  it  is 
stated  that  there  was  no  congestion  of  the  membrane,  and  in  otiiers  the  absence  of  anv 
statement  with  regard  to  its  condition,  although  the  changes  in  its  glands  were  noted,  leads 
to  the  belief  tliat  it  was  not  materiallv  affected.  In  fact  the  condition  of  the  mucous  lining 
of  the  ileum  in  these  continued  malarial  fevers  did  not  ditfer  from  that  I'ound  in  the  par- 
oxysmal malarial  cases  submitteil  in  the  preceding  chapter.  The  hyperemia  of  the  mem- 
brane in  the  malarial  series  ditl'ered  from  that  met  with  in  the  typhoid  cases  not  only 
in  its  greater  extent  and  intensity  but  in  its  motle  of  development.  In  the  latter  it  was 
a  secondary  result  of  the  morbid  action  in  the  closed  glands;  in  the  former,  on  the  contrary, 
it  must  be  regarded  as  a  direct  result  of  the  virulence  of  the  iebrile  cause, — a  ]irimary  lesion 
l.iecause  unconnected  with  any  antecedent  focus  of  intlammation.  The  agminated  and  soli- 
tary glands  were  frequently  healthy  or  pai'liei}»ated  only  in  the  general  congestion.  In 
one  exceptional  case  tlie  gut  was  perforated,  but  usually  no  circumscribed  areas  of  special 
activity  appear  to  have  lieen  developed,  although  the  engorgement  was  suck  that  in  two 
cases  ecehymotic  blotches,  and  in  one  gangrenf',  were  recorded  as  its  consequences.  In  fact, 
while  the  inflammation  in  tiie  ty|ihoid  cases  was  conliued  to  the  glands,  penetrating  deeply 
on  account  of  their  anatomical  relations,  and  spreading  laterally  along  the  continuity  of  the 
membrane  to  but  a  limited  extent  froni  these  primary  foci,  the  kypertemia  in  the  malarial 
cases  was  general  and  primary,  differing  as  much  in  appearance  and  distribution  from  that 
in  the  typhoid  cases  as  the  tleyelopnieiits  on  the  skin  in  e'rvthema  or  erysipelas  differ  from 
those  in  small-pox  during  its  period  of  maturation. 

In  the  sixty-one  cases  of  the  tvph(j-malarial  series  the  patches  of  Peyer  wei'e  tumefied 
and  more  or  less  congested,  as  in  the  earlier  stages  of  the  progress  of  typhoid  fever,  in  twenty- 
one  instances.  They  were  ulcerated,  as  in  tlie  later  stages  of  typhoid,  in  thirty  cases; 
in  some  of  these,  as  56,  93,  110  and  298,  they  were  in  process  of  healing,  Avkile  in  one. 
92,  their  disorganized  condition  is  suu'ii'estive  of  that  removal  ky  slougking  wkich  has  been 
mentioned  as  occasionally  occurring.  In  ten  cases  in  which  the  condition  of  the  patches 
was  not  entered  on  the  record,  the  ileum  or  .small  intestine  was  congested  or  ulcerated  and 
in  several  instances  perforated.  Deposits  of  kkn-k  pigment  were  found  in  some  of  tke  glands 
in  three  of  these  typho-malarial  cases. 

In  this  series  the  raucous  memf)rane  of  the  ileum,  exclusive  of  tliat  covering  the  affected 
glands,  was  generally  congested  or  inflamed  through<.)ut  its  whole  extent;  but  in  a  few 
cases  the  liypersemic  condition  was  confined  to  its  lower  p>ortion,  and  in  one  it  was  reported 
as  forming  only  an  areola  around  each  enlarged  and  iih.'ei-ated  patch.  In  a  few  cases,  also, 
softening,  tfiickening,  thinning  or  piLiiin'iitatiou  was  neited. 

Conditions  of  tlie  mucous  meinbraiu'  and  |iatehr>s  of  the  ileum  similar  to  those  observed 
in  the  typli(.i-inalarial  cases  were  found  in  the  mixed  series,  k^oiiie  ilifleivnce  in  the  li'^quency 
of  certain  (ib^^ervations  may,  lioWe\er,  k^  noted.  Thus,  it  has  been  seen  th;.it  twf'Uty-one 
of  the  sixty-one  typho-nialarial  cases  proved  fatal  at  a  time  when  the  disease  ot  the  agmi- 


H  ('ab«r  pinx' 


rMorat  •ronoliih  PhilaJ' 


taken  near  the  Ileo-coeca!  valve. 


OF   THK    CONTINUED    FF.VER8.  441 

iiateil  glands  liad  not  ailvanci'il  liey(.iii(l  the  slage  of  livjU'raMnia  and  tmntdaction.  Death 
occuiTed  in  thesi^  modilied  (vjiliuiil  r-ases  at  an  carliiT  ].ita'iod  of  the  typlmid  career  than 
is  usual,  and  this  I'i'sult  nmst  he  asciil.ird  to  iju'  inlhiciicc  of  a  concuiTent  and  })robahiy 
antecedent  malarial  fever.  .But  uidy  t  wchc  of  t  wn  lumdred  and  thirteen  eases  of  the  mixed 
series  are  reported  as  having  presentt-d  tuniched  but  unuleerated  glands.  This  accords  with 
our  knowledge  of  the  constitution  of  this  group  of  cases.  It  consisted  of  pure  and  modified 
typhoid  eases  in  unknown  |)roportiiiiis,  Imt  the  propoiiion  of  coincident  malarial  fevers  was 
necessarily  less  than  in  the  typho-malarial  sei'ies,  in  wliirh  everv  case  was  moditied  by  a 
malarial  complication.  The  relative  inl'rcquencv  of  umdcerated  patclu's  of  Fpvfr  in  the 
mixed  series  of  cases  may  tlnis  be  readily  understood. 

The  LAKQK  INTESTINE  was  recorded  as  more  or  less  altered  from  the  normal  or  healthy 
condition  in  35.4  per  cent,  of  the  typhoid  cases,  68  per  cent,  of  tlie  malarial  and  in  f)!  per 
cent,  of  the  typho-malarial  and  the  inixed  series  of  cases.  These  figures,  however,  express 
only  approximately  the  relative  fi'equency  of  the  implication  of  the  large  intestine,  as  in 
many  cases  in  which  its  condition  was  not  stated  there  is  an  uncertainty  as  to  whether  or 
not  it  was  examined.  The  appearances  indicated  tliat  congestive  or  intianimatoiy  processes 
had  been  in  progress  during  the  fatal  sickness  or  at  some  period  shortly  anterior  to  it.  The 
mucous  membrane  was  reddened  in  eiythematous  patches  or  more  difl'usely  and  deeply  con- 
gested. The  latter  condition  was  frequently  found  at  or  near  the  extremities  of  the  gut;  the 
former  in  tiie  intermediate  parts.  With  t)r  without  this  congested  condition  in  their  vicinity 
the  solitary  glands  were  in  many  instances  observed  as  prominences  sometimes  as  large  as  small 
shot  and  frequently  ulcerated.  Occasionally  the  presence  of  larger  ulcerations  was  recorded, 
but  whether  these  were  based  upon  the  glandular  substance  or  a  result  of  the  inflammation 
of  the  membrane  independent  of  the  condition  of  its  crypts  is  uncertain.'"  Tn  some,  how- 
ever, as  in  case  23,  it  is  said  that  the  ulceration  was  miconnected  with  the  state  of  the  soli- 
tary glands.  (Sometimes  the  more  deeply  congested  parts  were  spotted  with  ecchymoses,  and 
in  a  few  cases  the  canal  contained  exti-avasated  bhjod.  Those  parts  of  the  nuicous  mem- 
brane tliat  were  but  slightly  congested  were  frequently  mottled  with  patches  and  streaks  of 
a  slate-gray,  bluish,  greenish  or  other  dark  color.  Frequently,  also,  and  particularly  in  these 
cases  of  mottling,  the  solitary  glands,  whether  prominent  or  not,  presented  points  of  black 
pigmentary  deposit  in  their  apices.  In  a  i'ew  cases  softening  with  thickening,  or  rarely 
thinning  of  the  mucous  membrane,  was  recorded.  LUceratioii  without  specially  noted  con- 
gestion appears  frequently  in  the  reports  of  the  tvphoid  cases,  while  congestion  without 
ulceration  seems  to  have  characterized  the  majoi'ity  of  the  malarial  cases.  Only  30  per 
cent,  of  the  large  intestines  that  were  observed  in  the  tvphoid  seiies  presented  congestion 
without  ulceration,  while  35  jier  cent,  presented  ulceration  witliout  jiartieularized  congestion; 
but  in  the  malarial  series  03  jier  cent,  showed  C(_)ngestion  willioiit  ulcenilion,  while  onlv  16 
per  cent,  were  ulcerated,  and  the  mucous  iiiembi'ane  in  these  was  inflamed,  eechvmosed, 
congested  or  mottled  with  slate-colored  patches. 

It  may  reasonably  be  supposed  that  the  lesions  of  the  large  intestine  m  a  few  of  the 
cases  Were  those  i->t  diphtheritic  <lysi'iifi->ry,  ;is  I'or  instance  in  1)23,  in  whudi  tlie  intestine 
was  soft>-ned  and  "Jista-ganizid;  in  SO,  m  wliieh  it  w;is  s;ud  to  have  b.'i-n  disease<],  and  in 
31 1  and  3>1().  in  winch  its  l(.iwer  end  and  lining  membrane  were  reported  respectively  as  gan- 
grenous and  converted  into  a  J)ulj)y  mass.      Dr.  WooDW.VRD  has  instanced  cases  141,  192,  226, 


*  Si-l'  ,:ifr,l,  (I.  4-.". 

Med.  Hist..  I't.  Ill— 56 


442  I'ATHOLOGTCAL    ANATOMY    AXP    PATirOI.OGY 

278  and  ."^OO  (if  liis  diarrlioeal  series  as  examples  of  the  eoinciJence  of  typlioid  fever  and 
diplitlieritic  dysentery. 

The  SOLITARY  GLANDS  were  reported  altered  from  the  normal  or  healthy  condition  in 
20  per  cent,  of  the  typhoid  cases,  38  per  cent,  of  the  malarial,  24.6  per  cent,  of  the  typho- 
malarial  and  23.5  per  cent,  of  the  mixed  series.  These  iigures  cannot  be  regarded  as  accu- 
rate expressions  of  the  frequency  of  such  changes  in  the  glands  owing  to  the  obvious  imper- 
fection of  some  of  the  records.  Nevertheless  a  more  frequent  involvement  in  the  malarial 
cases  seems  to  be  indicated.  This  deduction  may  be  accepted  the  more  readily  as  it  has 
already  been  shown  that  in  these  cases  the  congestion  of  the  nuicous  membrane  was  more 
diffuse  and  intense  than  in  unmoditied  tyi»hoid.  Not  that  the  aflection  of  the  glands  was 
always  associated  with  existing  congestion,  for. in  many  instances  their  tumefaction  or  ulcer- 
ation is  the  only  abnormity  mentioned,  and  in  the  chromo-lithograph  of  specimen  185,  facing 
page  438,  they  may  be  seen  enlarged  on  a  mucous  surface  which  is  not  reddened;  but  from 
our  knowledge  of  the  histology  of  catarrhal  diarrhcea  it  is  certain  that  tumefaction  of  the 
follieles  originates  in  hypera^mic  conditions  of  the  membrane,  which  at  a  later  period  may 
subside  before  the  glands  have  returned  to  their  normal  condition.  Aloreover,  pigmentation 
of  the  glands  was  more  frequently  found  in  the  malarial  cases  than  in  the  typhoid;  thus, 
whih^  in  the  latter  deposits  of  pigment  were  reported  in  but  two  of  thirteen  cases  in  which 
attention  was  given  to  this  point,  they  were  noted  in  ten  of  twenty-eight  malarial  cases,  in 
five  of  Hfteen  tvpho-raalarial  cases,  and  in  nine  of  fit'ty-one  cases  of  the  mixed  scries;  and, 
as  will  be  sliuwn  hereafter,  this  pigmentation  was  dependent  on  an  antecedent  congestion. 

The  records  show  also,  with  some  uncertaintv,  however,  owing  to  tlieir  occasional  want 
of  precision,  that  the  glands  of  the  ileum  were  more  commonly  affected  than  those  ot  tlie 
lai'ge  intestine,  and  that  while  the  former  were  altered  with  nearly  equal  Ircqucncy  in  all  the 
Series  of  cases  tln^  latter  apjieared  more  liable  to  become  changed  in  tlie  malarial  than  m  the 
t\  |>liiiid  cases.  Thus,  the  solitary  glands  of  the  small  intestine  wdo.  in  an  abnormal  or 
unliealtliy  condition  in  S4.6  per  cent,  of  thirteen  tvi^hoid  cases,  in  92  per  cent,  ol  twenty- 
iwur  malarial  cases,  in  70  per  cent,  of  seventeen  typlio-malai'ial  cases  and  in  78  per  cent,  ot 
lil'ty  of  the  mixed  series  ;  while  those  of  the  large  intestine  were  similarly  altered  in  38.4  per 
cent,  of  the  typlioid,  G2.5  per  cent,  of  the  malarial,  35.5  per  cent,  of  the  typho-uuilarial  and 
40  per  cent,  of  the  mixed  cases. 

Louis,  while  setting  aside  the  changes  in  the  patches  of  Peyer  as  peculiar  \(>  the  typhoid 
affection,  regarded  the  congested  or  inflammatory  condition  of  the  intestinal  rming,  inehi.ling 
also  the  enlargenient  ami  ulceration  of  tlie  solitary  glands,  as  of  an  accidental  or  secdii  lirv 
charac-ter,  since  he  had  observed  tliem  in  cases  of  death  Irom  other  a(atle  diseases.  in  tlie 
present  section  they  jiave  iH'en  iVuind  of  even  more  frequent  oc<-uri'i.'nce  m  fevers  that  did  not 
exhiliit  the  specihc  lesions  of  tvphoid  than  in  tliose  that  did,  but  evidently  constituting  an 
essential  of  the  disease  in  neither  of  these  classes.  Dr.  Woodward,'''  however,  has  shcnvn 
tlie  invariable  presence  of  coiTgestion  and  the  frec^uent  occurrence  of  an  affection  of  the 
solitary  glands  in  catarrhal  diarrlujea;  ami  since,  in  the  cases  of  continued  fever  which  were 
characterized  by  these  appearances,  there  hael  invariably  been  an  antt'cedent  diarrhcea,  it  is 
not  sur|)rising  to  find  tliat  the  changes  in  the  solitarv  glands  in  these  cases  were  precisely 
thuse  that  have  fieen  described  as  characteristic  of  the  simple  diarrlioeal  afi'ecfioii.  In  fact 
the  case  reiiorti  d  as  olH)  of  the  poHt-morfcni  records  of  the  continued  fevers  fiirnislied  tht:' 

*  Page  321),  Sciun.l  I'urt  nf  tin:-  w.nk. 


OF   THF.    CONTINUED    FKVERS.  443 

specimen  which  was  used  in  the  iniiTusco|iie  JeHueation  of  the  chaii<:;;es  in  the  mucous  mem- 
brane anil  its  solitary  ghtnJs  in  cases  ol"  acute  diarrhci'a, — see,  in  tlie  SecdUil  Part  <A'  tliis 
work,  the  steel  engraving  t'aeing  jiagc  Sl^ii  and  llie  [iholdii-raiihie  ju-iiit  I'acinu;  [la^e  !V_*S.  The 
patient  died  of  a  complicating  dysentery  associateil  witli  a  fehrile  muvenn'ut  of  a  [lamxysmal 
character. 

The  plate  lacing  page  3S0  of  the  present  volume  shows  the  solitary  glands  enlargi'd  to 
the  size  of  small  peas.  The  portion  of  the  ileum  rrpresfuted,  eonstituling  specimen  i')6i), 
Army  Medical  Museum,  was  taken  i'rom  neai'  the  valve,  the  case  Ix'ing  that  reported  as  147 
of  the posf-morte III  records.  The  jiatch  of  aggregated  glands  in  the  lower  half  of  the  specimen 
is  much  and  irreuularlv  thickened,  and  the  villi  are  so  enlarsjrod  as  to  ifive  the  mucous  sur- 
iace  a  pluslidike  aspect.  In  connection  with  the  marked  i^dargenKMit  of  both  the  solitary 
and  agminated  glands  in  this  case,  it  may  be  st;ded  that  in  geiu-ral  the  solitaiy  glands  in 
typhoid  cases  presented  characters  similar  to  those  ol'  the  patches  of  Peyer,  as  if  they  had 
been  involved  in  the  same  morbid  action;  when  the  latter  were  largely  tumeHed,  extensively 
ulcerated  or  in  a  sloughing  condition,  the  former  were  in  most  instances  similarly  atlected. 

But  tumefaction  and  ulceration  connneiicing  in  the  solitary  glands  of  the  ileum  not 
unfrequently  extended  beyond  their  boundai'ies.  The  suri'ounding  nuicous  and  submucous 
tissues  became  involved,  and  by  the  coalescence  of  neighboring  morbid  areas  ulcers  of  com- 
paratively large  size  were  produced.  When  small  the  ulcers  were  round  or  oval,  when 
large  they  were  less  regular  in  form  and  not  unfrequently  their  greater  diameter  lav  ai-ioss 
rather  than  along  the  intestine.  Their  edges  were  usually  abrupt  and  their  cavities  staim-d 
like  those  resulting  iVom  the  disorganization  of  the  patches  of  Peyer, — see  the  chronio  lith- 
Ggiaplis  of  the  specimens  submitted  on  the  right  of  the  plates  facing  pages  4.'>6  and  4^)S 

The  morbid  action  in  the  solitary  follicles  of  the  colon  resulted  in  similar  enlar'ji ments 
and  ulcii-ations.  In  some  cases  the  mucous  surface  was  raised  by  nnmitc  i-oundrd  pi'omi- 
nences;  m  otbei-s  i>in-liole  apei'tui'es.  produced  by  the  sloughing  of  tlie  apic<'s  of  i\\f  Liiamls, 
permittcil  then-  softened  stroma  with  its  recent  abnormal  deposit  to  b(>  extruded.  Ii'aving 
small  cavities  in  its  place;  in  othc'rs  airain  the  extension  and  coalescence  of  iifitrbborinix 
ulcers  gave  risf^  to  larger  patches  of  irregular  outline,  sometimes  even  an  inch  in  tliaun-ter, 
and  in  tlipse  ih^  muscular  coat  was  frequently  exposed.  Tlie  ajipeai-anc  of  llic  ruli.n  when 
alt^-rcd  hv  follicular  ulceration  has  been  illustrated  in  the  kSecond  Part  of  this  W'»rk,  —<ri'  the 
photographic  prints  of  specimens  206,  Arn^y  Medical  Museum,  facing  page  51().  ami  cf  195, 
facing  page  526.  The  former  exhibits  ulcers  varying  in  size  from  a  mere  |»unciur.-  to  a 
break  one-tenth  of  an  inch  in  diameter,  with  a  series  near  the  centre  of  the  spiM-im.-n  *'ularge<l 
by  progressive  ulceration  and  coalescence  to  a  diameter  of  over  half  an  inch.  Thr  latter 
shows  a  more  extensive  ulceration,  which  originated  apparently  in  a  morhid  ronditii.n  of  the 
solitary  glands. 

The  changes  in  tlie  minute  anatomy  of  tlie  mucous  membrane'-'  in  tvphoid.  whether 

*To  permit  ofreaily  r.*jii]iiiri>i.ii  witli  tin-  >t;ti*-nifiit-^  in  th.-  i.\t.  ;t  >iiiiitii.try  til"  tli.-  vit-u.-.  ;in<l  i.l.s.-rviiti.nis  ..f  si.iii.-  i.-c.nt  iiiv<-stiu':»tnrs  is  hi-n-witli 
gulimitte'l.  R<JKiT.\N>iKY — l.rhrhiirh  >lrr  P,ithnh"]is<lii'ii  Aiuitnmit;  Viciiriii,  Isiil,  V..I.  Hl—favs  that  two  st;»tr*'s  iiiay  In-  nlis.-iv.il  ill  till-  tyjihoi'l  iiruc^s 
atlcrtiiiir  till*  imir.tus  mPTiibraiu'  uf  tin-  sniiill  intestine.  In  the  tirst  there  is  an  aenle  catjirrhal  iriHarninatinn  of  the  ileum,  «  hit-tly  uf  its  hiwer  half;  the 
niemhraiK'  ix  iiij<-rti'<l.  its  villi  tnr^re^.!  tiit  ari<l  its  aL'^miiiateii  itn<l  SM|ji;ir.v  ^'htmls  visihly  enlarL'^eil.  In  the  seruiiil  th*-  hy[>er:>-nii:i  is  euiircntiate>|  ii|Mtii  the 
^latnis.  whieh  Ijernme  switlhn  in  innseqiu'noe  nf  exudatinii  and  liyperidasia  of  their  stnirtural  ek-nu'Ttts.  An  injeete.i  vasrular  network  siinoim.ls  the 
jvatchej*.  whicli  are  thiekeiied  and  hare  an  ahrujitly  ri.-ing  inurLnii  -.  rionn-times  a  eonstri'-tion  around  tlie  hast-  jiives  them  n  funirns-like  apiK-arance. 
The  glands  are  tirni  antl  havo  a  gntyish,  yellowish  in-  juile-red  eolor,  visible  not  only  tlin.ntjrh  the  niui-uuji  coal  hut  also  thnniirh  the  ..uter  layers  of  the 
intestine  :  or  they  tire  puftir.  move  yieldiiiix  anil  of  a  darker  "V  Mnish-red  eolor.  A  seetion  of  ..m-  of  these  tnnn-fied  pat'-he.s  shows  a  uniform  deweneration 
(»f  its  jrlandnlar  strurture  and  its  hed  of  connective  ti^>ne  into  a  niarmw-like  snh^tancl■.  uhich  invades  the  uverlyint:  menihram-.  and  in  some  instances 
penetrates  beyond  the  ?nbmnc(tus  layer  into  the  niuscnlar  nat.  Thi:=  degeiieratiun  it>  the  result  of  an  excessive  developnient  of  the  exnded  plastic  ele- 
ments. The  isolitary  folliclet*  are  in  like  manner  enlarged,  firm  and  Anrrountled  by  a  va.fcnlar  zone.  The  diseased  process  has  two  modes  of  terminatiou — 
resolution  and  sloughing.     Mlien  resolution  takes  place  the  swollen  glands  become  less  dense  and  resistant ;  a  gniyi-h  t-jiafjue  liipiid  replaces  the  firm 


444  PATHOLOilOAL    ANATOMY    AND    PATiruLOGY 

pure  ol-  inodified,  apj>ear  to  liave  depended  wliolly  on  a.  condition  of  hyperplasia.  The  first 
of  tlie  observed  rlianges  was  a  congestion  of  the  capiHaries  and  small  veins,  particularly 
noticeable  in  the  vascular  circlets  sui'rounding  tlie  closed  glands.  This  was  followed  by 
an  increase  of  the  lymphoid  elements  of  the  adenoid  tissue  of  the  mucosa  and  the  submucous 
connective.  These  elements  accumulated  in  the  mucous  membrane  between  the  follicles  of 
Lieberkuhn,  which  Avere  pushed  apart,  and  in  some  instances  occluded,  giving  rise  to  the 
appearance  of  closed  cysts  embedded  in  the  prominent  mass  of  the  new  elements.  They 
accumulated  also  in  the  solitary  and  agminated  glands  or  at  particular  points  in  or  beneath 
the  membrane,  which,  when  thus  raised  into  prominence  by  the  newly-developed  mass, 
were  undistinguishable  from  eidarged  glands.  Numerous  swarms  of  these  lymphoid  cor- 
puscles were  found  also  around  the  swollen  glands  or  pseudo-glands  in  the  vicinity  of  the 
small  veins,  and  disposed  in  ii'regular  stellate  grou])S  corresponding  in  outline  to  the  serous 
canals  of  the  connective  tissue.  Accompanying  these  aggregations  of  the  corpuscular  ele- 
ments was  an  infiltration  of  plasma  which  relaxed  the  cohesion  of  the  reticular  matrix  and 
increased  the  size  of  the  lymph-sjiaces. 

The  tumefaction  caused  by  this  accumulation  of  the  lymphoid  elements  disappeared 
gradually,  the  site  of  the  aggregation  resuming  its  normal  aspect  as  resorption  of  the  plasma 
and  broken-down  corpuscles  was  effected;  or  the  swelling  continued  to  increase  until  by 
pressure  on  the  nutrient  vessels  a  necrosis  occurred  at  various  points,  leading  to  the  devel- 
opment of  ulcers  varying  in  size  with  that  of  the  necrosed  tissues.  In  some  instances  these 
ulcerations,  beginning  as  mere  points,  became  extended  and  coalesced  into  larger  areas  by  the 
progressive  infiltration  of  the  surrounding  tissues  and  the  concomitant  interference  with 
nutrition.     In  other  cases  in  which  tumefaction  was  suddenly  developed  the  whole  mass 

i-lements  anil,  ul'ti-r  the  iilinciiijtii.u  i:f  tliis,  tliciv  rcniiiiiis  a  Blati-(;ray  or  Mark  iiiginentation  of  the  imicous  membrane  and  glandular  plexus.  Slougli- 
ing  of  the  agminateil  glaluls  not  only  involves  wholly  or  in  iHirt  the  menil.rane  i-overing  them,  hut  also  other  and  otherwise  normal  adjacent  tiK>ues 
through  which  the  typhous  pro*luct  has  I.ecoine  diffused.  The  i.ortii>n  to  he  thrown  t»ff  has  meanwhile  been  converted  into  a  yellow  or  yellowisli-hrown 
substance  like  yellow  tubercle,  deriving  its  surface  coloring  from  the  presence  of  bile.  The  prticess  seizes  upon  the  part  uniformly  throughout,  or  fre- 
i|uently  distinct  portions  of  a  patch  are  removed  by  sloughing  while  other  parts  undergo  a  simple  resolution.  The  siditary  glands  pursue  the  same 
course  ;  but  they  ale  slower  in  their  progress  and  their  sloughs  ar.'  small  and  round.  When  the  muscular  coat  is  involvi'd  the  peritoneal  coat  thus  laiil 
bare  soon  beconns  gangrenous  and  |ieritonitis  ensues  ;  even  when  the  muscular  coat  has  not  been  originally  implicated  a  necrosis  of  its  tissue  in  layers 
may  take  place  at  a  later  iK'riod  and  the  process  extend  to  the  serous  coat  with  tile  same  consecpieuces.  Perforation  is  generally  effected  at  some  distance 
above  the  ileiwa'cal  valve.  Sometimes  the  development  of  the  agminated  glands  is  inconsiderable;  the  swellings  do  not  rise  mneh  above  the  geuernl 
surface ;  they  are  relaxed,  anil  occasionally  their  indiviilnal  lysts  become  disorganized  and  burst  through  the  mucons  menibnuie,  giving  by  the  uumer 
ous  resulting  ilepressions  a  md-like  anoearame  to  the  surface.  In  rare  rasi's  only  a  single  group  of  glands  attains  to  an  extreme  stage  of  the  typhoid  pro- 
ces.s,  while  in  others  there  is  no  glandular  involvement  and  the  intestinal  affection  is  limited  to  a  catarrh  of  the  muc.ius  membrane.  In  other  cases 
there  are  present  thick,  hard,  glandular  tunu'rs  [mssing  into  a  fungoid  condition  at  the  intestinal  surface  and  a<'com|ianied  with  intense  hyi'era'Uiia  of 
the  surronniling  |iarts,  wliiih  gives  rise  to  hemorrhage  ;  or  in  some  instances  the  tyidioid  matter  developing  towards  the  exterior  peni^trates  the  mir.-^c  cilar 
tunic  ami  gives  origin  to  a  pseudomembranous  etHoresc'ence  on  the  peritoneal  surface.  After  the  separation  of  the  slough  the  nrucous  membrane  around 
the  margin  of  the  ulcer  sinks  to  the  level  of  the  latter  and  apjiears,  in  proportion  to  the  original  thickness  of  the  gland,  as  a  nioie  en-  less  broad,  free 
and  movable  border,  at  first  rather  elevated,  red  and  injected,  and  afterwards  more  relaxed  and  of  a  dark-gray  color.  Healing  proceeds  fiom  tin-  lir- 
cnmferenie  towards  the  centre;  the  overlying  mucous  border  unites  with  the  exposed  layer  of  submucous  cellular  tissue,  from  which  a  cell-grow tli 
springs  uii  and  the  surface  becomes  transformed  into  a  facet  having  a  lustre  like  that  of  a  serous  membrane.  Over  this  the  advjiming  iMlgi^s  of  the  sur 
rounding  nnnoiis  mendjrane  are  gradually  extended,  th.ingh  not  with  equal  rapidity  from  all  |>arts,  until  they  finally  meet.  Occasional  in.-ifances  are 
met  with  in  which  a  mendirane  furnished  with  villi  and  crypts  is  found  to  cover  an  extraordinarily  large  area  wlii're  loss  of  substance  had  takeu 
place,  and  imperlei't  villi  may  be  observed  in  the  very  centre  of  the  facet-like  cicatrix  ;  these  circumstances  render  it  probable  (bat  a  mucous  formation 
lakes  plac  e  from  the  cicatrix  itself     .\fler  the  healing  of  the  ulcers  a  shallow  depressi.in  remains,  duo  to  the  thinned  mucous  inembram-  adhering  more 

intimately  t..  the  defective  laverbe ith  ;  uTiil  not  unfrei|uently  there  is  seen  in  the  autre  a  small  jiortion  of  the  smooth  lustrous  cicatrix  still  uncovered 

by  luu.  ons  membrane  ;  in  other  iustames  the  mucous  coat  is  snnioth,  without  folds,  less  pliable  and  in  coniiiarismi  with  the  surn.nnding  tissue  less  vas- 
cular, and  in  patch.s  less  rich  in  villi.  These  api.carancc^s  are  sometimes  found  after  a  lal.se  of  thirty  years.  Only  in  rare  cases,  in  which  there  has  been 
an  extensive  loss  id'  substance,  does  contraction  of  the  cicatrix  give  rise  to  a  noticeable  stenosis.  Occasionally  the  niuioiis  margin  around  the  ulcers 
becomes  hypertrophied  and  remains  pennarently  raised,  contributing  nothing  to  the  covering  of  the  cicatrix,  while  sometimes  it  lias  no  connection  with 
the  subjacent  layer  and  proj,.,ts  into  the  hollow  of  the  bowel.  H.^rley— in  Knim.l.l'H  ,s>7.«,  „/  3fc,(i,iiie,  Vol.  I,  London,  MX,  p.  .-.Vli  el  sc/.— says  that  in 
the  earliest  stage  of  typlioi.l  iuHammation  the  patches  of  IVyerare  slightly  swollen  ami  a  little  ni..re  vascular  than  in  health.  The  swelling  implicates 
Ihe  netw.,rk  of  mucons  membrane  chielly,  the  ridges  between  the  crypts  bec-oniiiig  i v  vascular,  wider  and  pr.iminent,  and  the  intervening  depres- 
sions more  contracted  and  ilcejier,  while  the  glands  them.selves  aiijiear  unaltereil.  The  ijillai.iiii.ilory  products  are  therefore  formed  around  the  closed 
glands  and  not  in  their  interior.  Careful  observation  leads  him  to  speak  posit  ive  I  \  .,n  this  point;  bnf  an  examination  of  the  illustration  on  page  449, 
infra.  sutHces  to  disprove  this.  He  has  never  seen  the  glands  project  on  the  surface  ..r  Ibc  patih ;  tliey  are  placed  helow  and  between  the  swollen  mucous 
ridges,  and  in  the  later  stages  are  completely  buried  beneath  the  iuftamed  surface.  When  this  covering  becomes  disintegrated  they  are  discovered  lying 
deeply  in  the  abundant  submucous  tissue  and  exhibitiuL'  little  or  no  increase  of  size.  The  cellular  texture  is  infiltrated  with  finely  granular  corpuscles 
of  various  sizes,  chiefly  spherical  and  averagitiL'  jj'jj,  of  an  inch  in  diameter.  In  the  more  advanced  and  ulcerated  patches  the  cells  are  eijually  numer- 
ous, but  are  large  and  of  more  uniform  size,  averaging  jj^j  of  an  inch,  and  a  little  more  darkly  granular.    In  still  more  advanced  stages  the  enlargsd 


fiowi^r-o/iA/;/'/-  k^ Dr.S  'iirn'',  17.  S. A 


,v^vffF,M 


TBPuEE  PEEPE^[DICra^^(  SECTIONS  OE  rLHlP/ 

enlax,s;eiiieiit  softening" andiilceration. 
o£tb_p  solitary  gle^nds 

I'^iv^mfiai  12  E^-meter;' 


o 


445 

OF    THK    CONTINUED    FKVKKS.  ^^"^ 

J  an  infiltrated  and  impacted  patch,  with  mucli  of  the  underlying  and  surrounding  submu- 
cous tissue,  was  involved  in  the  necrosis  anrl  separated  as  a  slough.  Many  of  the  micro- 
scopic sections  tlnit  hav*'  Ih'.'M  pr^s.-rvr-l  sliuw  the  vessels  of  the  atTected  j^ai'ts  filled  with 
blood  corpuseles  and  their  pci'iphciy  sunoiuided  b)'  swarms  ef  the  new  corpuscular  elements, 
but  in  none  of  these  sections,  nor  in  those  recently  cut  for  examination,  were  those  plugs  of 
micrococci  observed  which  Klein  invested  witli  the  important  role  of  causing  the  death  of 
the  tumefied  parts. 

Enlargement,  softening  and  ulceration,  as  affecting  the  solitary  glands  of  the  ileum  and 
their  site  in  the  mucous  and  submucous  tissues,  are  illustrated  by  the  plate  facing  page  444. 
This  is  an  engraving  on  steel  from  pliotographs  of  specimens  in  the  n"iicroscopic  collection. 
The  section  on  the  left  of  tlie  plate  represents  specimen  1745,  the  middle  section  1747  and 
that  on  the  right  1750.  These  are  three  of  a  series  of  six  specimens,  1715-1750,  showing 
various  stages  of  the  ulceration  of  a  sulitary  gland  in  the  ileum  from  a  cas(»  the  hist<av  of 
which  is  unknown,  but  in  which  the  patches  of  Peyer  were  thickened  at  their  edges  and 
destroyed  in  their  interior  by  eroding  ulcers,  and  tlie  solitary  glands  the  subject  of  what  has 
been  called  pinhead  enlargement  and  ulceration.  The  gland  in  the  section  on  tiic  left  of 
the  plate  is  slightly  enlarged  and  elevated,  and  embedded  in  a  mass  of  the  new  lymplioid 
cells  which  appear  as  a  well-defined  and  darkened  sotting.  In  tlie  middle  section  the  out- 
line of  the  gland  has  become  obscured  by  the  impaction  of  the  surroinxling  tissue  with 
corpuscular  elements,  which  liave  also  extended  througli  the  submucous  connective  in  more 
or  less  dense  swarms  as  far  as  the  muscular  tunic.  In  the  section  on  the  right  the  mucous 
membrane  lias  given  way,  forming  an  ai)erturc  into  a  small  cavity  containing  and  surrounded 
by  the  altered  tissues  of  the  mucous  and  submuciuis  coats. 

capsiiIoR  contain  siihomles  of  nil  and  there  is  iinich  intiTntrpus.iiljir  nioliTiiljir  niatliT.  Swrlliiij;  of  the  indivhliml  glaiifli^  at  thJH  imthhI  in  due  tn  the 
pnlarpi'nuMit  of  tlie  cnrpusrlcs  forming  tlmir  parflHliyina.  II"KF>i  \s\^f'iilrrsnihnti'fii  i'lhrr  iitc  1'nfhi>Jn,jisrh-Aniilnwisrhpn  n'n'itnltriiii'f'H  W- r  Orgun^  hpim 
Ahtlinniiiol  fijiihus,  IiiMp/i^i,  isOH.  \k  iH'i  c/  K,^q, — states  tli;tt  tyiilmiil  fi-vir  is  iisln'n-<I  in  hy  arnti'  catarrtial  rlianjrfs  in  tlie  int'-slinal  ninioni*  im-niliraiH',  the 
capillariew  bfcoiiiin;;  ililatcil  and  the  circulation  rftard<''l,  wliili-  tnarlicd  i-xuilatinn  tak*'s  place  in  tlic  iniiions  tissue.  Fre(|Ufntly  aClcr  death  the  affi'cted 
capillarieH  of  the  earlier  stagcfi  of  the  diseaw-,  together  with  thos4>  of  the  derjH'r  hiyers  of  the  nnicoiiH  citat  with  which  they  cuntiect,  are  wt  ill  found  enlarced 
and  filled  witli  Mood  ron)Uscles,  the  rod  aw  a  rule  pn-dnniinating,  although  smnetinies  white  corpnsi-h-s  aggregatid  in  tJpot^  are  ohserved  in  eonsiderahle 
nuniherf.  Towanlts  and  within  the  folli«des  the  vesxel-*  diniinisli  in  calihre.  The  thickiiefn  of  tlie  vasnilar  walls  cnrresponds  to  their  enlargenienl.  so 
that  while  the  veswds  in  the  iniiuediate  vicinity  of  the  follicdes  tthow  a  duulde  contour,  in  thoH-  more  distant  this  couilition  l>e<'oTnert  less  distinrt  and  is 
often  wanting.  V\Hm  the  dilatation  of  tlie  vessels  and  the  engorgement  in  couTiertion  with  it  dt'p''ud  in  part  the  niorhid  appearaeices  in  tlie  early  stages 
of  the  disease  ;  the  turgid  vascular  network  around  the  follirh-s  and  other  fully-charged  vessi-is  tlii"oiit;honl  the  tnruflicd  tissues  givf  to  the  mucons  sur- 
face its  red  cidor.  Resulting  from  these  vascular  louditions  is  a  slowness  of  circulation  with  a  eorn-sponding  exudation  into  the  runeons  tisstu's,  pro- 
moting an  abundant  slifnlding  of  the  epithelium.  The  dilated  state  of  the  vessels  is  often  associated  with  small  e\lravasations,  and  occasionally,  iii  severe 
cases,  with  more  extensive  ecchyuiotic  hlotchrs  ;  nioreovtT,  the  pigmeutation  frei|ncntly  oltsi-rvi-d  in  th*  l.tter  stages  points  to  tli«-  fact  that  smh  extrava- 
sations had  occurred.  AVhilc  this  enlargennnt  of  the  capillaries  is  fmnnl  v.ry  gt-n. -rally  in  the  early  peiin.!  it  sn  I 'sides  gradually  as  tnniefaelinn  inereiises. 
Although  the  Bwelling  of  tlie  glatuls  is  ufihered  in  with  an  exudation  into  the  mucous  tissue,  it  is  de|K'udent  up<ui  this  only  in  a  slight  degree ;  it  is  due 
in  great  pan,  to  the  excew*ive  developnuMit  and  increase  of  the  strmtural  elements.  In  recent  cases  large  cell-structures  are  seen,  some  similar  in  appear- 
ance to  lymph  corpuBcdes,  hut  twice,  three  times  and  even  eight  times  as  large,  and  others  poly-nucleated  and  mensjoually  notche<l  in  one  or  mon'  plac*^s 
ae  if  in  the  act  of  division.  This  occurring  not  only  in  the  jwitehes  of  peyer  and  solitary  follitdes,  hut  also  in  the  adjacent  nuicous  tissue,  seems  to  point 
to  an  enormous  increase  and  enlargement  of  the  original  lymph-<'ells  ;  the  new  cell-structures  am  the  progeny  of  the  old  lyinjdi  corpuscles  and  possess 
nothing  P(»ecitic.  The  enlarge<I  follirdes  eh-vate  the  nir'mhrane  covering  them  and  impart  to  the  surfac**  a  mammillate'I  asiteet ;  souietimes  they  pntject 
60  much  as  to  at*ume  a  polypoid  apifcarance,  and  occasionally  hy  their  enlargement  in  an  oppot-ite  direction  they  i»ress  upon  the  uLuscular  coat  and  give 
rise  tu  an  infiltration  of  cell  elements  through  its  interstices  to  tlo'  serous  coat,  wliere  they  form  small  grayi.-<h  hiMlies  beneath  the  peritoneum.  To  this 
infiltration  of  the  cell  elements  is  also  due  the  uccasiuual  tid'crcnlated  routliti-'U  of  the  edges  of  nherated  patches.  Resolution  is  ushered  in  with  a 
diminished  afflux  of  bloml.  Its  simplest  form  is  observed  in  the  upper  imrtion  of  the  Im.ucI  and  itrejerably  in  tlie  least  tumefied  piitches,  where  it  on  iirs 
as  ft  rule  in  connection  with  others,  and  may  even  be  ho  assr>ciated  v  itli  them  that  one  jtart  of  a  phopn'  is  sul'Je.  t  to  it  and  the  rest  to  another,  or  what  is 
of  more  conmion  tHcnrreuce  different  jiortions  of  th-'  bowel  are  respectively  subject  to  different  forms  of  retrograde  change.  In  the  simpler  pri«i'ssgre;it 
numbers  of  celln  undergo  disintegration;  among  these  are  included  the  large  structures  so  abundant  in  tlm  follicles  and  contiguous  tis-ue  befor-  the  dis- 
eased process  had  reached  its  height.  Wlieii  i-esorption  goes  on  with  unifnrnnty  throughout  all  the  structural  elenieuts  i_if  a  pateli  the  tumcfactioti  sul)- 
eides  evenly;  hut  when  the  contmry  obtains  ineipialities  remain  on  its  surface.  Absorjttion,  for  iustame,  may  go  on  more  energetically  within  the  b'ili- 
cles  than  in  the  intervening  tliickeued  areolar  tissue,  which,  through  the  sinking  in  of  the  more  rapidly  dinnnishiug  follielcs.  ln'eomes  more  proininent 
and  thus  gives  rise  to  a  retic\ilated  ap|M'anince  of  the  surface  of  the  phnpie.  8v»metimes  the  contents  of  the  glands,  including  th«  stroma  as  well  as  the 
altered  mass,  undergo  fatty  degeneration,  become  dissolved  and  are  evacnattil  ;  the  pmall  cavities  whieh  result  also  give  rise  to  the  reticulated  apiH'ar- 
aiice  just  noted.  After  the  evacuation  of  the  fullii  les  numerous  minute  hloiKlvesstds  are  seen  to  imiss  through  their  cavities  like  vessels  traversing  the 
iiollnw  of  i)  pulmonary  abscess.  This  condition  has  an  intimate  c-innection  with  tlie  punctiite  pigmentati<iii  freijuently  seen  in  the  glands.  This  color- 
ation isdm>  to  little  bleedings  into  the  empty  foUii  les  from  rupture  of  the  minute  permeating  vess.  Is  during  the  process  of  disorganization  and  evacua- 
tii-n  ;  and  the  cxtravawttions,  at  first  of  a  red  color,  beconie  later  dark-ldue,  prohably  from  the  at  linn  of  the  intestinal  pases.  The  process  of  follicular 
dcstrncthm  just  descrilied  constitutes  one  of  the  less  grave  f..ruis  of  ulcer-fonnation.  Sometimes  fatty  'h-eu.  ra(i<ui  ciiiiMences  at  suiN-rficial  points  of 
limited  nize,  wher«  Bej»aration  from  the  tissues  beueath  takes  place  and  a  more  extensive  ulcer  is  formed,  wlii(  h  tinds  its  limit  ultimately  in  neighliorinL" 


446  PATHOLOaiPAL  AXATOMY  AXP  PATHOLOGY 

The  plate  facing  this  page  shows  an  extension  of  the  folUcular  ulcer  m  all  directions 
by  tlie  impaction  anJ  subsequent  necrosis  of  the  tissues.  The  interior  layer  of  the  muscular 
coat  has  been  almost  reaclied.  Laterally  the  morbid  action  has  progressed  more  rapidly  in 
the  submucous  tissue  than  in  the  mucous  membrane,  so  that  the  latter  is  left  as  a  thickened 
edi^e  overhanging  the  cavity  in  the  former.  This  is  a  steel  engraving  of  a  photograph  of 
specimen  1756  of  the  microscopic  collection,  the  section  having  been  derived  fi'om  the  same 
.source  as  the  three  that  have  just  been  presented. 

In  the  colon  the  solitary  glands  usually  began  to  ulcerate  before  any  considerable 
enlargement  or  protrusion  above  the  surface  of  the  mucous  membrane  had  taken  place. 
When  the  corpuscular  elements  were  set  free  a  minute  cavity  was  formed,  which  became 
enlarged  by  progressive  ulcerative  action  in  the  infiltrated  submucous  tissue  and  the  caving 
in  of  the  undermined  mucous  membrane.  This  process  has  already  been  illustrated  by  the 
plates  facing  pages  568,  570  and  572  of  the  Second  Part  of  this  History. 

The  changes  in  the  agminated  glands  were  essentially  of  the  same  character.  The  plate 
facing  page  448,  infra,  shows  the  typhoid  thickening  of  a  patch  the  mucous  membrane  over 
which  has  been  in  a  great  measure  destroyed,  wdiile  the  glands  and  submucous  connective 
are  converted  into  a  somewhat  uniform  cellular  mass  by  the  dense  aggregation  of  the  cor- 
puscles. This  plate  was  engraved  from  a  photograph  of  specimen  1704,  one  of  a  series  of 
thirty-two  perpendicular  sections  of  the  ileum  of  a  dai'k  mulatto  woman  who  died  in  the 
Freedman's  hospital,  Washington,  D.  0. 

Tliis  patient,  twenty-six  years  of  aj;e  anil  niirsin}.;  an  infant  three  niontli.s  old,  was  admitted  Sept.  5,  1865,  with 
typhoid  fever.  Slie  liad  lieen  snfferinf^  for  four  weeks  from  fever,  headaelie,  anorexia,  thirst  and  pain  in  the 
abdomen;  pulse  feelile  and  rapid,  120;  skin  hot  and  dry  and  tongue  coated  with  a  thick  yellow  fur;  tlie  howels 
were  moved  once  daily,  the  i)a8sage»  lieing  of  a  fjreenish  color,  but  diarrlupa  set  in  prior  to  death  <ni  the  13th.     At  the 


niiir()n.<<  (itnicturea  HUltpIicil  with  nttriiiiillj'  Jilmriil:ilit  IdotHlvrsscIs  ami  orpiriiciilly  uriiiUereil.  Sufli  llli-crs  liavc  ninderatfly  cli'vattMlt'dfics  ami  arc  often  of 
(■iilisi(liTal)lp.  exti'lit  ;  (HcaHionally  thi'y  iii-ni-tratt'  tlip  iiinscular  turiir  ami  li'ad  to  |MTforation.  AVlieu  ill  jirocfss  ut' liealilig,  tliiTt!  s|)riii{;  ii]!  cti  the  flixir  of 
tlio  uU-fTati-d  cavities  filif  ^raliulations  \vlii<h  ln'coniorovcnHl  with  a  transparent  ami  HnnK'tiliifMiii^incntcil  inenihrant'.  The  liKtro  frequent  anil  danperon,- 
prwertd  of  uleer-forniatiitn  jiroeeedis  w  itii  greater  energy:  The  tissues  wiiieh  liy  eell-iniiltiplieatioii  and  enlargement  have  Iteeu  deprived  of  tlieir  nutrition 
separate  in  defineil  patches  hy  sloiigliilig.  Aft<>r  the  detaeliinent  of  the  slough  the  Bilrfare  is  in  many  i-ases  niodr-rately  red  with  strongly  in.jerted  edges; 
in  others  dark-ri'd  and  often  eeeliyniosed  from  the  jireseiiee  of  u  eapillary  network  on  the  siirraee  of  an  extremely  delicate  granulating  tissue  in  which  a 
lesion  ri-adily  leads  to  heiiiorrliiige.  These  sloughing  ulcers  soinelinies  extend  to  the  Huhrnncons,  iiin.sciilar  and  even  to  the  serous  coat  of  th"  Iiowid, 
Sometimes  Ihe  two  modes  of  ulcer-formiltion  occur  in  the  s;ime  plaque,  the  milder  attaiking  tli(^  margin  of  sloughing  ulcers  ami  foiniing  confluent  sores 

of  large  size.     S'Unetinies,  too,  the  ilestriiclive  and  reparative  prr sses  are  present  in  the  sane-  ulcer,  the  former  going  i>n  in  the  centre  and  the  latter  at 

the  cireumfereliee.  While  this  is  generally  dilliciilt  to  deuionstrate,  inslanees  have  heen  ohserved  in  which  the  inarginal  structure  hears  so  decidedly  the 
characters  of  new  tissue  that  there  can  hardly  lie  any  donht  of  attempts  at  repair.  The  tissues  which  horder  the  ulcers  towanls  the  exterior  aspect  of  the 
howel  have  generally  tlieir  natural  firmness  increased  hy  the  efriisioii  of  jplastic  elements,  hut  occasionally  these  structures  heconie  hrittle  or  gangrenous 
and  either  lead  to  is-rforation  or  predispose  to  |H-riloneal  intlanimation.  Typh'>id  cii-atriccs  present  themselves  iii  the  form  of  smooth  formations,  red  at 
tir.st  liut  later  deeply  pigmented,  a  |»'<-uliiirity  iM-casi<iiially  oliserved  even  after  the  lapse  of  yi-ars.  No  villi  are  found  on  these  <-icatrici'S,  and  evi-n  the 
mucous  tissue  itself  fails  to  he  developed  from  the  graiilllating  niaterial  when  the  ulceration  had  penetrated  to  the  niilscillar  coat,  fiangreiie  as  a  rule 
makes  its  ajtls-a ranee  iii  spots  of  limited  size  in  jKirts  that  have  Im'cii  excessively  iutlltrati-d.  In  sonieca.ses  of  extensive  ulceration  diphtheritic  intlanima- 
tion complicates  the  typhoid  process  and  alTecIs  hotli  the  small  and  large  intestine  to  a  variahle  extent.  This  is  seldom  conlined  to  one  locality,  hiit  flxe> 
at  Ihe  same  time  upon  several  jiortions  of  the  digestive  tnhe  ;  frequently  it  starts  from  the  larger  ulcers  and  is  a  cause  of  recurring  liemorrhages  ; 

sometimes  U.I  relation  to  existing  nlcer«  can  he  determined,  ami  in  these  instill s  si'coiidary  ulcerations,  i-esulting  from  tlie  dil>htlieritie  intlamniation. 

often  ap|»>ar  at  a  late  js-riisl.  .Xccording  to  liiMin.Klscii  — ZW/ei/.yiV.i/ ifiV../..,/;/,  .Vein  ,<;(./eii/,.o«  Srhlii,  London,  IHTJ.  Vol.  T,  p.  4:iS  c(  sc.;.— the  closed 
glands  of  the  small  and  large  intestine  participate  in  a  catarrhal  iutlainmation  of  the  iniicoiis  lueml.rane.  The  eiditary  glands  ajipcar  as  dull-gray 
licarl.v  nodules  the  size  of  a  jiililiead,  surroiindi'd  hy  ii  hyiiera-mic  plexus  of  vessels  ;  and  each  of  the  individual  glands  of  the  jiatches  of  IVyer  hecoine 
similarly  affecte.l.  After  this  the  glands  |iass  into  the  stage  of  medullary  inflltratioti  in  which  the  solitary  follicles  attain  a  size  even  six  times  greater 
than  the  normal,  and  tin'  jierifollicnlar  rouucctivu  l.ecomes  iiiflllrated.  The  aggregated  folli.-les  of  a  patch  coalesce'  with  the  interstitial  tissue  to  form 
a  soft,  rose-colori'd,  seemingly  honiogeneon.< mass  resenihling  the  medullary  suhstance  of  the  fietal  lilliiu,  the  entire  iiatcli  appearing  as  a  flattened  eli'va- 
tion  two  lines  in  height,  of  an  elongateil  oval  outline  iilid  marked  off  from  tiie  Kurroiindiiig  inncous  luenihrane  liy  a  jireciliitous  edge.  The  infiltration  is 
composed  of  a  numerical  increase  of  the  corpn.si-iilar  elements  and  an  increase  in  the  size  of  these  individually.  Tiiey  contain  a  larger  proportionate 
ipuintity  of  Jirotoplasiii  than  the  simple  lynilih  coijaisclc'  ;  the  ]irotoplasiu  of  the  latter  scarcely  equals  the  contained  nucleus  in  anioiiiit,  hnt  in  the 
typhous  cell  it  usually  takes  uji  more  space  than  the  nucleus.  The  inorhid  luiHliict  is  removed  hy  a  prcK'ess  of  colliquative  softening,  the  cell.s  hecom- 
ingdisiiilegnited  into  oily  matters  wliicli  areahsorheil  ;  or  failing  this  thedcpiisit  jKisses  into  a  state  of  clieesy  necrosis  and  is  removed  liy  ulcerative  action. 
Kl.riN— ill  his  lliiK.il  mi  III,-  /»/oi,..(c  .l,i„(..„/ic.i(  Cliiimjrs  ill  Kiihrii:  or  Tjiphniil  F-rri;  in  the  li.qiort  of  the  Local  C.ivernmeiit  Hoard,  Ijoiidoii,  1«7.^,  pp.  Kll~124 
— ilescrihes  Ihe  cliaiiges  in  tile  iiilestiiial  iiiiicous  nieiiihiaiie  as  la'ginniug  with  a  distention  of  the  vi'ssels  enrrouiidiug  tlic>  lymphatic  follicles.  This  is 
lollowed  hy  swelling  ..f  the  s  .lilaiy  glaiids  diK'  to  ail  ac.iimulatiou  of  ordinary  iincleati  d  lymph  i  i.r]inscl.-s.  Similar  aecnninlations  in  the  mucosa  exer- 
cise a  destrii.tive  compression  on  lie- crypts  of  Lieherkiihii,  .hlaehing  their  epitheliniii  and  convi-rtilig  it  iiit i.sses  of  cells,  which  In  the  oc.  asiomil 

occlusion  of  tile  follicular  aperture  ap|»ar  s.ini.tim.s  to  he  contain. '.1  in  a  closi-.|  .yst.  Th..  lyniplioid  corpus,  l.'s  ar.'  als.i  inir.'as.il  in  the  sulimu.-.isa, 
|>arti.  ularly  in  an.l  around  the  lias..s  of  the  s.ililary  ami  agniinal..!  glamls.  But  this  ol.s.>rv..r  olij..t...l  t.i  .■onsider  all  th.'  niinnte  prominein-.'S  on  th.' 
mucous  ni.-mhrane  to  ho  enlarg.-.l  glali.ls,  as  li.-  hail  tii.ni  al.le  to  trace  ha.k  tli.-ir  d.vilupne-nt  to  Hiiall  ac.nmnlations  of  th.-  lymph  c.rpuscles  in  the 
niil.-..sa,  an.l  niop'ov.  r.  th-  solitary  glaii.ls  an-  not  s.i  numerous  in  man  as  are  frequently  th.-  minnle  tnmelactions  foiinil  in  tyi'li"i.l  fever,     rollowing 


PERPEIIDICULAR  SECTIOlsr  OF  ILEUM 

skowuLg  a. 

FOLLICULAR  ULCER, 

whiclilias  penetratedn.eaxh/'tothLe  iTiiisciiLax  coat 
]Vka3ified  E  rliauieiers 


OK    THE    CONTINUED    FEVEKS. 


447 


pont-mortem  examination  sixteen  hours  after  death  great  emaciation  and  marked  rigor  mortis  were  noted.  The  lower 
lobes  of  the  lungs  were  somewhat  congested.  The  duodenum  and  ileum  were  iiitlamed  througliout,  the  jejunum  in 
patches.  The  agmiuated  glands  were  enlarged  and  tliickened  gradually  from  above  downwards;  each  of  those  in 
the  lower  third  of  tlie  ileum  presented  one  or  more  points  of  ulceration;  Komi>  near  the  valve  were  completely  ulcer- 
ated away,  leaving  the  fibres  of  the  muscular  coat  exjiosed.  while  on  the  valve  and  for  aliout  four  inches  above  it  the 
whole  mucous  surface  was  a  mass  of  enlarged  and  thickened  patches,  each  presenting  several  points  of  ulceration. 
The  ascending  colon  was  inflamed  and  deei)ly  ulcerated  in  transverse  oval  patches,  some  of  them  two  inches  in 
diameter  and  with  overhanging  edges, — there  were  also  a  few  enlarged  solitary  follicles  the  size  of  peas,  some  of  which 
were  ulcerated  on  the  apex;  the  transver.se  colon  presented  a  few  small  round  ulcers  which  had  penetrated  to  the 
niuacular  coat;  the  descending  colon  was  inflamed  in  patches  and  had  in  the  sigmoid  flexure  a  group  of  small  oval 
ulcers  and  slightly  enlarged  solitary  follicles  with  specks  of  pigment  in  each:  the  rectum  also  presented  a  few  small 
ulcers. —  lloxpitiil  Slrwiird  A. ./.  Slm/hirt,  V.  .S'.  Army,  Frcedmun's  Hospital,  Wanhin<iton,  D.  C. 

Till'  [)hotu-f ii;.;;r;iviim-  wliicli  folluw.s  this  paragraph  ilhistratiis  the  appearance  of  a  per- 
pendicuhir  section  of  a  patch  when  its  superficial  kxyers  have  been  removed  by  necrobiotic 


processes.     The  section  shows  a  si 


lallow  ulcer 


leer  with  abrupt  edges,  involving  the  whole  patch. 


The  glandular  stroma  and  intervening  submucous  tissue  are  indistinguishable  on  account 
of  the  great  accumulation  of  the  corpuscular  elements.  The  tissues  around  the  impacted 
portions  are  freely  beset  with  swarms  of  new  cells  and  liberally  supplied  with  vessels 
which  are  generally  filled  with  blood  corpuscles. 


Section  of  a  t.vplioid  patrli :  SiH'rhiicu  Ttsll.  mu  r  >^i  .pu       II     ti   ii    \rni\  MmIkjiI  Mii-^tuni,  niaKuilicd  l:i  (liiiinctcrs  atirl  siihseijin'iitly  reiiin-M  oiie-tliinl. 

The  record  of  the  case  tVuin  wliirh  this  specimen  was  obtainetl  reads  as  follows: 

Private  (Jeorge  Hayes,  Co.  H,  Ijltli  V.  S.  Inf.;  age  25;  was  admitted  from  Russell  Harracks,  Washington,  D. 
C,  Aug.  2."),  IStiti,  with  typhoid  fever.  [He  had  been  confined  to  the  guardhouse  at  the  barniiks  from  May  10. 
About  August  1  he  complained  of  diarrhiia  and  was  excused  from  fatigiu^  duly.  Afterwards,  symptoms  of  tyjihoid 
fever  having  appeared,  he  was  sent  to  the  jiost  hospital.  ]  On  admission  he  was  (juite  stiiiiid,  Imt  could  readily  be 
aroused.  On  tht^  afternoon  of  the  2(;th  he  became  delirious  and  during  the  night  reiiuiied  constant  watching  and 
restraint  to  keep  him  in  bed.  This  continued  until  the  forenoon  of  the  27th,  when  almost  complete  loss  of  sensi- 
bility ensued.  Ho  could  not  swallow;  an  a1tcm]it  was  made  to  give  him  a  spoimful  of  beef-tea,  but  it  nearly 
strangled  him.  Heavy  stupor  continued  until  about  noon  of  the  2Sth,  when  death  took  place.  Posl  miirlim  exami- 
nation five  hours  after  death:  There  was  an  op;iclty  of  the  iiiachnoid  at  the  liasi^  of  the  brain,  with  some  ettiision  of 
lymph  just  below  the  medulla  oblongata  on  the  posterior  portion  of  the  spinal  cord.  Player's  patches  were  much 
thickened  and  ulcerated,  especially  in  the  lower  part  of  the  ileum:  the  villi  were  hypeitrophied  and  the  .solitary 
follicles  enlarged  to  the  size  of  peas,  many  of  them  ulcerated  at  their  apices.  The  solitary  follicles  of  the  large 
intestine  were  similarly  affected. 


tliis  onliirgoim'iit  tluTf  apitrai-  in  lin>  ^wnll.-n  li-;-ii'-^  M'lric  fi']]s  w>"  t.«  fniii'  liiii''^  a>  la  !:_'■■  ;i>  til.'  1\  iiipli-ii.!  .  .irpiiMlf-,  1ml  with  a  larjr'-r  ntu-li'iis  than 
the  lattfi- ;  aint  wonu'timcs  tliis  iiii'-lnis  is  ajiiiar-iitly  itieli  i^'niii::  ilivi.-imi.  ,\>  iiil<Tnn'iliat<'  (nnii>  an-  i.i.M-ivi'i  1.v(\vim-ii  these  larp-  eells  alel  tie-  lyiii- 
phatie  eorpuscles  it  seems  tlial  th.'  wiu'li-  'if  tie'  e.Tpiis'-iilai-  mass  "ri^riiiat's  in  lie'  Ivmphei'l  elfiie  ills.     liiailiiall\  tlie  nnliimry  Ivmphati'' e'.i  piisrle.s 

heeome  eulargeil  or  theenlai-j.'"!  "'lis  iie'.'ip.'ial.    tie-  smallir  -.  iinril   ih.'  aileiiei.l  tissue  e'Hil.iiiis  .mly  cells  el  Ihi'  larpT  si/e,  la'li  'le  l"-in-  an 

nvoiil,  transparent  llileleiis  siliiate<l  p-'ripleraliv.  aiel  a   vaiiahli'  iiihmIm  i    .il"  spleriea!  iim'lei  ,'itlier  i><.|ale.l  er  in  ;ir.-iii.s  eml>"M''i  in   tii'    ^nl'-laii-" 

,if  tlieeell  ureiiel.is.'.:  ill  11  va.'U.'le.      In  111.'  .'.nlr.    "f  tin   tnm.li.'.l  j;laii,|  manv  ,.f  the  eells  assunie  llie  iharaeteis  ,.t  trii"  Kianl-i  ells,  ear  h  ...ntai u 

Inini  ten  t..  thirty  nnelei  ;  l.iil  tlie  giant-.. Us  ..t  typln.i.l  liim.l'a.li lifl.r  In.iii  lli...s..  ..f  till..'r.l.'  in  that  tlnir  slr..|na  is  |.r..\ii|..|  with  l.l.a.lv'  -.s.  Is. 

,\  .'liaiigi'  was  also  i.l.sirve.l  to  take  jiliie,.  in  .s.,nie  of  the  art. rial  eapilliui.-s  „(  tli,-  iiiiparl.'.!  r..|li.'l.'s  ;  lli.'y  l..'.'aiii.'  iin.r.'  ..r  1. -s  ol.slni.t.'il  hy  it  il. 'posit  of 
vi'lloMish  eiill..iil  siihstan.  .'  h.'t^ve.'n  th.'  liiiini;  I'n.lotli.lium  an.t  an  a.h.iitilial  thin  inn  l.'at.-.l  in.  nil. ran.- ;  lie  ir  walls  w-v  tlii.'k.n.il  an. I  tli.-ir  lillnina 
;(istorte<i.     In  ail.liti..n  t..  th.'se  appearances  in  llii'  stage  of  tiiinela.tii.n.  I\i  i.is  i.liserve.1  in  th.'  .  lypts  i.l   l.iil'.  iKiilin  si'iie-  higlily  nlia.  live  gi.'.'uish- 


448 


PATHOLOGICAL    A^'ATOMY    AND    PATHOLOCtY 


A  section  of  a  patch,  constituting  No.  7479  of  the  microscopic  collection,  from  the 
case  just  reported,  IS  represented  below.  The  lymphoid  elements  are  densely  packed  in  the 
glands  and  adjoining  stroma,  and  freely  distributed  in  the  mucous  and  submucous  layers  of 
the  surrounding  parts  of  the  intestine;  the  vessels  in  the  submucous  tissue  are  distended 
with  coagulated  blood. 


-  ^i 


Sfrtinti  nf  ii  typhnid  imtrli  :  Spccimi'ii  717'.(,  inirnisri>|ii.-al  cnllfrtiuti.  Army  Mrdi'-rtl  IVIiisenni. 

The  illustrations  submitted  above  show  the  afTi'ction  ol'  the  interlying  tissue  of  the 
submucosa  to  be  as  strongly  marked  as  that  of  tiie  glands  themselves,  so  that  had  necrosis 
taken  place  it  would  have  afliected  the  patch  as  a  whole,  the  surface  continuing  to  break 
down  and  be  carried  away  with  the  intestinal  contents  until  the  disintegrated  mass  was  com- 
pletely removed.  But  it  is  evident  from  the  reticulated  appearance  of  many  ulcerated 
typhoid  patches  that  certain  jvirts  were  more  susceptible  to  the  morbid  process  than  others. 
The  parts  specially  liable  to  impaction  and  consequent  necrosis  were  the  follicular  compo- 
nents of  the  patches.     This  is  illustrated  by  the  following  photo-engraving  of  a  specimen, 

ypllnw  rnrpiiscli's.  vHTyiii,^  fn-ni  th»>  size  of  a  jiK-re  ;rrariiiliM-  [i.'iiit  tn  thut  of  a  hunnin  rfd-blond  rorpnwic.  Tlit-y  wcp'  nmstly  (^plu'riial,  linur-glasii  or 
kiiliicy-slifipcil,  .-mil  f^'i-in*'il  I-i  1..'  Iirlit  (<i^'-Iln-r  by  a  traiisjian-iit  ciMirn-.-lhi.:;  ^iib.-ta?i»i' ;  ^nim-  of  tli''nt,  iiartirnlarly  lln-  tiTuiiiial  c'lN,  rniifaiui-'l  inilllltf 
hollies  ri'si'mbliiiK  s|iotv«  m-  niirrniocii.  IIi'  roKiinliil  iIhso  as  .joints  of  tin-  iiiyiolial  throails  of  an  orKaiiisiii  niiiiilar  to  the  I'li-notliiix  polysipom, 
ilfsi-ribeil  liy  IVihn  tn  1»<7II  a.s  chaiaitiTislii-  of  ilir  vi-ptation  liiwovi-ivil  tiy  Iiiin  in  tin-  wi'll-watir  of  a  illslriit  of  Hn-slaii  noti'il  for  tlji'  prcvalenci'  of 

ent'Tii-  fi'viT.     Kl.Kiv  founil  tin-  rniinmnii  as  zoo-laa  Ilia— I  >  ill  till'  lvni|'li->pi sailjoiniiiK  tin-  liiluilar  foMii'los.  ami  also  inipaiting  tli>>  veins  mid 

Tenuus  capillaries  of  the  afTeetiil  solitar\  ainl  ai;niiiiMliil  ulainN  ami  of  lli..  ailia.  .nl   inii.  <.ii>  ami  siilmoi s  li,~Mi.v- ;  lie  foiiml  llieiii  also  in  the  alviue 

diwhar};es.     When  the  tuniefaetion   riaiiml  its  liei-lit   the  i  .ir|'ii~rii|.ir  eli m-  ap|"iiie.l  |..  fa.le.  Iipal,  ih.un  ajnl  l.eionie  ah-orlieil  or  ilelaeleil  as  a 

slongh,  while  the  stroma  was  eonnrte.l  into  a  ilensi'  felt-work  of  stilf  hlKhly  refraetive  lil.iv^.  lie  iliil  not  eon^il|l  r  this  iliie  wholly  to  coniiiression  of  the 
blofKlvciisels  liy  the  snrronnilinj;  ai-euninlatioii  of  new  eleinenfs  ami  tin-  eneii.aehnienis  on  the  ir  lamina  hy  theeolloiii  ile|iosit;  on  the  eontrary,  as  he  hail 

observed  a  failin.ir  of  the  eorpiisenlar  elenients  and  other  signs  of  a  retrograde  ehaiig--  sj tally  marked  in  the  neighl.orliood  of  vessels  iniiijteteil  with 

micrococci,  he  regarded  these  organisms  as  the  chief  causp  of  the  neerotie  developinents. 


^h'?!^r/ri/J:'ka/  iy  VrKCwU-    L  ' SA 


?tnli-:  JI.FcU' 


PFRFKNDJCUl.AR    SKCTluN  01''  ll.i-irM 

Showing,' 
Typ'lioKi  Oiirkoniiic-;  oi' ci  f'eyera  I'atch. 
Mripnn'icd    !■.'  duiineiea;. 


OF    THE    CONTTNUED    FEVER?. 


449 


7454  of  tlie  microscopical  scries,  contributed  by  Dr.  W.  W.  Joiix.STOx,  of  Washington,  D.  C. 
The  cellular  elements,  while  freely  scattered  throughout  the  raucous  layer  and  the  adenoid 
tissue  of  the  submucosa,  are  so  densely  aggregated  in  the  glands  that  each  is  converted  into 
a  distinct  and  separate  cellular  tumor. 


^&^ 


..i"^,* 


""if     ■ 


Section  of  n  typhoid  ])atrl»  :  Specimen  74r.t,  microseopical  enllt'rtion,  Army  Meilieal  Musenm. 
The  case  from  which  this  Biieciiiicn  was  ohtainert  was  that  of  a  cliild  tliroe  years  of  age,  who  had  snft'erod  for 
alin.^st  a  week  with  sliglit  fever  ami  dianluva.  lie  died  aiipareiitly  of  syncope  about  an  hour  after  swallow  in?;, 
through  the  carelessness  of  attendants,  eighteen  sugar-coated  pills  each  said  to  contain  three  grains  of  <iuinine. 
ront-morkm  examination  found  tho  heart  relaxed,  the  right  cavities  empty,  the  left  containing  fluid  blood.  The 
Jungs  were  congested  posteriorly.  Tho  liver  and  pancreas  were  normal;  tho  Malpighiaii  bodies  of  the  spleen 
were  well  marked.  Tho  stomach  was  congested  and  ecchymosed;  the  duodenum  and  .jejunum  congested,  their 
glands  conspicuous  and  villi  liypertrophied.  In  the  ileum  also  tho  villi  were  hyiiertro|iliied;  the  solitary  and  agmi- 
nated  glands  were  progressively  enlarged,  and  the  serous  surfoco  corresponding  to  tho  bases  of  the  latter  was 
jiatehed  with  arborescent  congestion ;  the  contents  of  the  intestinal  glands  were  dark  and  graniibir.  The  mucous 
membrane  of  the  large  intestine  was  congested  and  its  follicles  enlarged.  The  examination  was  niaile  by  Dr.  I).  .*<. 
L.VMi!,  of  the  Army  Medical  Museum,  .Surgeon  General's  Oliice. 

Tho  plate  facing  page  450  further  illustrates  the  special  liabiHty  of  tlie  glaiiils,  as 
distinguished  from  that  of  the  surrounding  adenoid  tissue,  to  impaction  and  disintegration. 
It  is  etched  on  steel  from  a  photograph  of  specimen  455  of  the  microscopic  collection,  one 
of  a  scries  of  nine  perpendicular  sections  of  the  ileum,  showing  the  ulcers  to  have  origi- 
nated in  the  individual  glands  of  the  j)atch.  These  sections  are  from  the  case  submitted 
as  32o  of  the  poHf-niortem  records  of  the  continued  fevers.  They  show  admirably  the 
softening  and  discharge  of  the  glands  each  by  its  own  aperture,  the  gradual  enlargement 
of  the  resulting  cavities  and  the  coalescence  of  these,  embracing  the  whole  ot  the  patch 
in  the  irregularly  ulcerated  area. 

To  illustrate  the  minute  anatomy  of  the  corpuscular  eleiiients  the  two  figures  on  the 
following  page  have  been  introduced.  The  lower  represents  the  deeper  portion  ot  a  section 
of  an  enlaro-ed  ao-minated  o-luiid,  from  the  case  which  furnished  the  specimen  delineated 
in  the  figure  on  this  page;  the  upper  is  a  view  of  a  more  superficial  portion  ot  the  same 
section.  These  were  drawn  under  a  magnifying  power  of  700  diameters  by  Dr.  J.  C.  ^IcCoN- 
NELL  of  this  oflice,  and  afterwards  reduced  by  the  photo-electrotype  process  to  two-thirds 
the  size  of  the  oriLi'inal  drawing;'.  In  the  deeper  poi'tion  tho  endotlielial  ctlls  are  jn'incl- 
pally  confined  to  the  vessels;  the  intervascular  spaces  are  occupied  by  a  variety  of  lymph 
corpuscles,  some  of  which,  by  their  aggregation,  suggest  a  multiplication  by  fission,  while 
others  are  possibly  passing  into  the  round,  mononucleated  vesicular  form  which  is  the  pre- 
vailing type  in  the  superficial  parts  of  the  atlVcted  patches.  Instances  suggesting  the  tran- 
.sition  of  the  ordinary  lymphoid  corpuscle  into  the  nucli'at<,'d  cull  may  be  observed  on  the 
field  This  transition  seems  the  more  probable,  as  nearer  the  surface  or  in  more  advanced 
stages  the  true  lymphoid  cells  are  found  to  have  bucu  tj  a  great  extent  replaced  by  the 
Med.  Hist.,  Pt.  111—57 


450 


PATHOLOGICAL  ANATOMY  AND  PATHOLOGY 


Matter  fn.m  tli( 


iiil  iiiiit  uf  a  tyjiliuid  I'littli. 


Vt!     C 


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MiitttT  fnini  till'  dii|»r  j/arts  nf  m  t.vpliuij  piili  li. 


larger  nucleated  and  granular 
cellular  bodies.  These  appear 
to  become  larger,  hazier  in 
outline  and  ultimately  to  dis- 
integrate into  a  molecular  or 
granular  mass. 

Erosion  of  thk  intes- 
tinal MUCOUS  MKMHRANK.' — • 
In  case  23  of  the  jwd-mor- 
tcm  records  it  is  stated  that 
the  ulceration  of  the  mucous 
membrane  was  unconnected 
with  the  state  of  the  solitary 
(flands.  It  seems  that  the 
aggregation  of  the  corpuscu- 
lar elements  in  the  mucous 
membrane,  aside  from  tlie  sit- 
uation of  the  closed  glands, 
sometimes  gave  rise  to  aa 
erosion  of  the  membrane. 
The  destruction  of  the  epithe- 
lium left  the  underlying  infil- 
trated tissues  with  an  abraded 
surface,  which  became  ex- 
tended and  deepened  by  the 
removal  of  tlie  softening  and 
disintegrating  corpuscles. 
When  such  ulcers  were  small 
and  shallow  their  mode  of 
origin  could  usually  be  deter- 
mined; but  when  large  and 
deep  it  was  often  impossible 
to  discriminate  between  them 
and  those  that  followed,  the 
separation  of  a  diphtheritic 
slough  or  the  necrosis  of  a 
follicle  and  its 
tissue. 


surroundini!; 


HeMORRHAGK,  PKRFOR-. 
ATION  and  PERITONEAL  IN- 
FLAMMATION.— The  necrobi- 
otic  processes  occurring  in  the 


diseased  agminated  glandis,  or  in  patches  usually  involving  one  or  more  of  the  solitary  glands, 
were  atti'nded  in  their  progress  by  an  increasing  liabilitv  to  hemorrhage  from  the  intestinal 


J^/ictr^.7rar'Ae£/  tr/J?"  ^k/r^s  ^ 7.^. 


jY^'-v   /: ,  _*  /'  yf?rr 


PERPEXDICULAP.  SECTIOK  OF  ILETJli 

'Tiroiiglr  dii 

ULCERATED  PEYF;.r's  EAI'CH. 

TLe  sciumed  conteirts  uf  ,?fr/era],  iaDides iavp  escaped  Eoni  tke  p^cton 
Maopiiied  12  diajixeler.;- 


OF  THK  CONTINUED  FEVERS.  451 

vessels  ami  to  an  extension  of  the  inflamraatorv  action  to  tlie  serous  lining  of  the  abcloni- 
inal  cavity.  Manifestly  these  dangers  were  proportioned  to  the  rapidity  of  the  processes, 
for  although  the  records  are  not  sufHcientlv  explicit  to  give  a  numerical  expression  to  this 
proportion,  the  disorganized  condition  of  the  intestine,  in  many  cases  characterized  by  clini- 
cal or  pcM-mortem  evidence  of  hemorrhage  or  peritonitis,  indicates  that  a  sloughing  of  the 
diseased  patches  rather  than  a  progressive  ulceration  was  under  observation. 

In  some  cases,  particularly  sucli  as  were  due  Avholly  or  chiefly  to  the  malarial  intlu- 
ence,  the  occurrence  of  hemorrhage  mav  be  ascribed  to  that  extreme  congestion  ot  the  parts 
which  led  to  the  extravasation  of  blood  even  into  the  submucous  tissues.  In  cases  also 
that  were  purely  typhoid  it  is  probable  that  the  slight  hemorrhages  which  were  observed 
in  the  early  period  of  the  disease  were  due  to  congestion.*  But  when  bleeding  took  place 
later,  and  especially  when  it  was  profuse,  it  could  with  propriety  be  ascribed  to  no  other 
cause  than  a  break  in  the  walls  of  the  vessels  by  the  sej^arating  tissues  of  the  small  intestine 
in  typhoid  cases  and  of  the  large  or  small  intestine  in  those  due  to  malaria  or  complicated 
by  dysenteric  processes.  Hemorrhage  from  the  bowels  was  probalily  the  cause  of  death  in 
the  cases  21,  27,  110,  176,  32:^,  32r)^xnd  335. 

Peritoneal  inflammation  in  continued  febrile  cases  was  sometimes  due  to  other  causes 
than  tlie  extension  of  the  intestinal  ulcerations.  The  condition  of  the  mesenteric  glands 
was  in  some  instances  the  determining  cause:  this,  however,  may  be  regai'ded  as  an  indirect 
extension  from  the  ulcerated  mucous  nuMubrane.  The  degeneration  of  the  abdominal  recti 
muscles  in  cases  63  and  151  proljably  gave  rise  to  the  peritonitis  from  which  tlie  patients 
suflered,  while  in  249  it  resulted  from  the  rupture  of  a  degenerated  spleen.  When  due,  as 
was  nsuallv  the  case,  to  an  extension  of  the  morbid  action  from  the  ulcerated  intestines, 
the  peritoneal  inflammation  was  generally  associated  with  perforation  of  the  intestinal  wall. 
Nevertheless,  a  number  of  cases  have  been  instanced  in  the  analytical  summary  in  which 
peritonitis  was  present,  although  none  of  the  ulcers  had  perforated;  and  several  specimens 
preserved  in  the  museum  show  {)lastic  exudation  on  the  peritoneal  surface  in  cases  which 
had  no  record  of  perforating  uleers,  Ijut  wliile  in  some  cases  a  local  peritonitis  may  have 
preceded  the  perforation  with  which  general  pi'ritonitis  was  usually  found  associated  after 
death,  the  sudden  advent  of  acute  pain,  tenderness,  vomiting,  hiccough  and  extrone  pros- 
tration indicates  that  the  serous  coat  seldom  became  largely  involved  until  the  occurrence  of 
perforation  and  extravasation  of  the  intestinal  contents.  On  the  other  hand,  perforation 
sometimes'occurred  without  giving  rise  to  the  symptoms  ov  pod-moriem  appearances  of  peri- 
toneal inflammation.  Either  the  perforation  was  effected  while  the  patient  was  in  his  dying 
agony,  so  that  there  was  no  time  for  the  development  of  the  morbid  appearances  that  gen- 
erally attend  extravasation  of  the  intestinal  contents,  as  may  have  been  the  case  in  32,  or 
the  adhesion  of  contiguous  serous  surfaces  strengthened  the  point  of  impending  rupture 
and  limited  the  area  of  inflanmiation  by  preventing  communication  with  the  peritoneal 
cavitv,  as  appears  to  have  been  the  case  in  385. 

From  what  has  been  said  of  the  circumscribed  character  of  the  diseased  processes  in 
typhoid,  as  compared  with  the  extent  and  difiusion  of  the  hypergemia  in  the  cases  attributed 
to  malaria,  it  is  not  surprising  that  perforation  should  have  proved  so  frequent  a  result  in 
the  former  and  so  rare  in  the  latter.  Case  367  is  the  oidy  exampL'  of  perforation  in  whi<-h 
tvt^lioid  ulceration  of  the  jwtches  of  Peyer  was  not  discovered  at  the  posf-mork'/a  exam- 

*St'e  mtpra,  p.  21*4. 


452  PATHOLOGICAL    A^TATOMY    AXD    PATHOLOGY 

ination.  Forty-three  cases  of  perforation  have  been  submitted  to  analysis,  and  as  these 
occurred  in  three  hundred  and  eighty-nine  cases  of  continued  fever,  perforation  took  place  in 
11  per  cent,  of  the  cases.  But  if  the  sixty-three  malarial  cases  which  furnished  but  one 
instance  of  perforated  bowel  be  withdrawn  from  the  calculatioii  the  frequency  of  tliis  acci- 
dent in  probably  typhoid  cases  will  be  increased  to  12.9  per  cent.  Murchison,  as  the  result 
of  a  tabulation  of  1,721  cases  recorded  by  various  observers,  found  tliat  perforation  occurred 
in  196  or  in  11.38  per  cent.*  In  twenty  of  the  forty-three  cases  the  site  of  the  perforation 
was  reported  to  have  been  the  patches  of  Peyer;  in  eighteen  the  ileum;  in  two  the  small 
intestine;  in  one  the  intestine;  in  one  the  caecum,  and  in  one  the  sigmoid  Hexure  of  the 
colon.  It  is  evident  from  these  figures  that  ulceration  of  the  agminated  glands  was  gener- 
ally, and  of  the  solitarv  glands  rarelv,  the  cause  of  the  perforation,  notwithstanding  the 
frequency  with  which  the  latter  were  affected  by  the  murbid  processes.  Had  perforation  at 
the  site  of  the  solitary  glands  been  a  common  occurrence  it  would  have  been  reported  in  the 
large  intestine  with  greater  frequency  than  twice,  cases  33  and  300,  in  forty-three  cases. 

As  the  sloughing  or  ulcerative  action  progressed  at  so  many  points  in  the  same  intes- 
tine it  not  unfrequently  happened  that  more  than  one  break  was  found  at  the  post-mortem 
examination.  Thus,  in  the  series  of  pure  ty2)hoid  cases  there  were  two  perforations  in  16, 
three  in  32,  five  in  19  and  several  in  17,  18  and  50.  Furthermore,  on  account  of  the  irreg- 
ularity of  the  advance  of  the  destructive  process  in  the  same  area  of  ulceration  it  sometimes 
happened  that  more  than  one  break  was  found  on  its  floor,  as  may  be  seen  in  one  of  the 
ulcers  represented  in  ttie  plate  facing  page  382.  The  specimen,  370,  Army  Medical  Museum, 
from  which  this  was  photographed  was  taken  from  the  patient  whose  case  appears  as  159 
of  i\\Q  jiost-mortcm  series  already  submitted.  The  clinical  record  says  that  this  soldier  had 
well-marked  symptoms  of  typhoid  fever;  he  was  delirious  and  extremely  prostrated,  and  there 
was  much  distention  and  tenderness  of  the  abdomen,  but  no  diarrhoea  until  a  few  days  before 
death.  Five  of  the  ulcers  in  the  ileum  had  perforated.  Five  specimens,  369-373,  Army 
Medical  Museum,  from  this  case  have  been  preserved.  The  first,  taken  fron;i  high  up  in  the 
ileum,  presents  live  irregular  ulcerations  from  one-quarter  to  half  an  inch  in  diameter, 
penetrating  nearly  through  tlie  muscular  coat.  The  second,  represented  in  the  plate  to  which 
attention  has  been  invited,  shows  three  irregular  oval  ulcers,  each  about  an  inch  in  diameter, 
their  edges  thickened,  their  bases  formed  by  the  muscular  coat  except  where  perforation  has 
been  effected;  the  perforation  in  the  upper  ulcer  is  small,  but  a  little  to  the  left  is  a  point 
at  which  a  break  through  the  serous  coat  was  about  to  take  place;  the  middle  ulcer  presents 
an  oval  perforation  nearly  half  an  iucli  long,  having  shreds  of  the  peritoneal  cuat  attached 
to  its  margin,  while  immediately  above  the  perforation  is  u  point  whfre  the  serous  coat  has 
been  exposed;  the  lower  ulcer  presents  in  its  centre  an  oval  patch  one  inch  in  its  h.ing  diam- 
eter, in  the  upper  part  of  which  the  serous  coat  retains  its  ]iosition,  forming  the  fluor  of  the 
cavity,  while  in  its  lower  portion  this  coat  has  given  way,  forming  four  oval  apertures  sep- 
arated from  each  other  by  shreds  of  the  serous  membrane;  the  solitary  follicles  are  slightly 
prominent,  and  there  is  pseudomenil)ranous  exudation  on  the  peritoneal  surface  of  the  speci- 
men. The  third  and  fourth  specimens,  371  and  372,  present  ulcers  similar  to  those  repre- 
sented in  the  plate,  one  of  which  in  each  instance  has  perforated  the  intesiinal  wall ;  some 


*  IIi^  table  slniws  tluit  tlii.-s  limli'^iralilr  result  was  ^^^  moi-e  frequent  ui  inrreiiie  in  tlie  e\p.-rieiiee  nf  Kiii'Iish  oliservi-rs  tliaii  in  that  "f  CuntiTuntul 
physieijuis.  Tims,  of  41-.i  fatal  eases  reenriied  by  liimself,  ItiilsTuwK,  .iKNNKU  iiliil  Watkrs.  perfuratiMii  was  fi.iiiul  in  .so  eases  iir  I'.'.ll  Jier  eent.:  nf  270 
cases  liy  the  Frelieli  observers,  Lmcis,  Bkethnnkav,  t'll'iMKl.,  Mh.ntaii.t  ami  Feu.;KT,  perforation  was  dise.jvered  in  25  ur  *J.25  per  cent.,  ami  of  l,u:!ll  eases 
by  the  German  observers,  Geiesingkb,  Hoffmann,  Lebebt  aud  others,  91  or  B.75  per  ceut.  had  the  iutestine  perforat«d.    See  his  treatise,  p.  566. 


OF  thp:  coxti^ukd  ff.vers. 


453 


minute  puncheJ-out  ulcerations,  corresponding  to  the  solitary  glands,  are  also  seen  in  these 
sections.  The  last  specimen.  373,  taken  from  just  above  the  valve,  has  the  mucous  mem- 
brane considerablv  thickened  and  studded  with  enlarged  solitary  follicles;  there  are  also 
several  irregular  ulcerations;,  one  of  which  measures  fully  two  inches  in  its  long  diameter, 
the  floors  formed  bv  the  muscular  coat  of  the  intestine.  These  specimens  maybe  accepted 
as  illustrations  of  the  fact  that  the  part  of  the  ileum  usually  perforated  in  typhoid  fever  lies 
more  frequently  some  distance  above  the  valve  than  immediately  adjacent  to  it. 

Perforation  of  the  site  of  the  agminated  glands  is  also  illustrated  by  the  plate  facing 
page  343.  The  specimen,  452,  Army  Medical  Museum,  from  -which  this  was  photographed 
was  obtained  from  the  patient  whose  case  is  recorded  as  4)5  of  the  post-mortem  records  of  the 
continued  fevers.  In  this  instance  the  perforated  part  of  the  ileum  was  not  far  above  the 
ileo-cffical  valve.  The  aperture,  small  and  oval,  appears  near  the  centre  of  a  large  irregularly 
shaped  ulcer  with  overhanging  edges  and  a  smooth  and  even  floor,  formed  by  the  muscular 
coat;  its  margins  are  as  sharply  defined  as  if  the  piece  had  been  punched  out.  The  speci- 
men shows  also  some  small  ulcers  of  the  solitary  glands  situated  between  the  transverse 
mucous  folds  and  extending  through  the  submucous  tissue  to  the  muscular  tunic,  while  on 
its  peritoneal  surface  is  a  coating  of  pseudomembranous  lymph. 

The  inflammatory  condition  of  the  ileum  in  a  case  of  death  from  peritonitis  consequent 
on  perforation  is  well  shown  on  the  cliromo-lithograph  facing  page  391.  The  specimen,  147, 
Armv  Medical  !A[useum,  from  which  this  drawing  was  made  was  taken  h-om  the  case 
recorded  above  as  224  of  the  post-inortci/i  records.  The  peritoneal  cavity  contained  a  large 
quantity  of  pus  and  serum.  The  serous  membrane  was  generally  thickened  and  congested; 
over  the  intestine  in  some  parts  it  was  of  a  brilliant  red  color,  in  other  parts  deep  red  or 
almost  black.  The  ileum  for  five  feet  above  the  ca3cum  was  more  or  less  ulcerated,  and  at 
a  point  about  eighteen  inches  above  the  valve  it  was  perforated.  The  drawing  on  the  right 
of  the  plate  shows  the  mucous  surface  iiL  the  vicinity  of  this  point:  The  perforation,  large 
and  oval,  occupies  nearly  the  whole  of  the  site  of  the  original  ulceration,  and  the  mucous 
membrane,  of  a  livid-brown  color,  lies  in  closely  set  transverse  folds  and  shows  several 
ulcerated  patches  above  and  below  the  })erforated  point.  The  drawing  on  the  left  of  the  plate 
represents  the  serous  surface  of  the  same  specimen:  The  intensely  injected  peritoneunr  is 
coated  in  vellowish  patches  with  pseudomembranous  lymph. 

Rkparation  (.)F  tiik  intestinal  ulcerations. — But  when,  instead  (if  extension  and 
penetration  through  the  walls  of  the  intestine,  a  reparative  process  was  initiated  after  the 
removal  of  the  necrosed  and  disintegrated  tissues,  the  vessels  adjacent  to  the  lesions  became 
enlarged  and  tin;  uh'erated  cavities  filled  with  grantilations  over  which  the  mucous  membrane 
advanced  from  the  edges  to  the  centre  as  a  thin  and  glistening  covering.  The  area  of  the 
cicatrized  surface  was  much  less  than  that  of  the  original  ulceration,  as  the  mucous  mem- 
brane became  drawn  over  it  by  the  subsequent  contraction  of  the  connective  tissue  of  the 
granulations.  In  the  solitary  glands  the  cicatrix  appeared  as  a  smooth  central  spot  around 
which  the  mucous  membrane  between  the  tubular  follicles  was  thrown  into  radiating  ridges, 
giving  the  whole  a  stellate  appearance,  which  has  been  illustrated  liy  the  photograph  of 
specimen  G03,  Army  Medical  Museum,  facing  page  528  of  the  Second  Part  of  this  work. 
The  contraction  of  cicatrized  patches  of  Peyer  was  manifested  by  puckering  of  the  surrounding 
membritne  and  occasionally  Ijv  the  disposition  of  the  transverse  folds  in  the  neighborhood 
of  each  to  radiate  from  it.     Cicatrices  left  in  the  intestines  after  the  healing  of  ulcerated 


454  PATHOLOGICAL  A^' ATOMY  AM)  PATHOLOGY 

patclii^s  luivc  been  illusinxted  liy  five  jilates, — one  a  cliromo-litliograpli  of  a  recent  specimen, 
and  tlic  others  pliotoL^'rapliic  rc])n)ilu(;tions  of  preserved  specimens. 

Xotliinii'  is  Icnown  of  the  liistory  of  the  case  representr'(l  by  tlie  chromo-hthop:raph. 
The  plate  facing  this  pagx*  sliows  the  lower  portion  of  the  ileum  and  part  of  the  caecum. 
On  the  mucous  surface  of  the  former  arc  a  number  of  oval  ulcers  similar  to  those  frequentlv 
left  after  typhoid  fever;  the  cream-colored  membrane  is  injected  in  reddish  patches:  the 
colon,  also  somewhat  injected,  shows  several  follicular  ulcers. 

The  photograjihic  rejiroduction  of  specimen  597,  Army  Medical  ^Museum,  lacing  |)age 
456,  shows  a  portion  of  the  ileum  with  the  ile()-«pcal  valve  and  part  of  the  cfemim.  A 
Peycrian  patch,  one  and  a  half  inches  aliove  the  valve,  presents  an  oval  cicatrix  wliich  is 
somewhat  obscured  by  the  pseudomembrano  covering  the  whole  of  the  mucous  surface;, 
there  arc  some  small  ulcerations  near  the  valve.  This  specimen  was  taken  from  a  soldier 
who  died  of  dvsenterv,  apparentlv  subseQuent  to  his  recovery  iVom  an  attack  of  typhoid  fever. 

I'livate  William  Uemy,  Co.  G,  *<tli  N.  V.  Cav.:  age  18:  was  admitted  July  22,  1865,  with  chronic  diarrlinpa. 
[This  man  apiicars  on  tiie  records  of  the  Au}j;nr  hospital,  near  Alexandria,  \'a.,  as  adnntted  from  regimental  hospital 
June  24  with  acute  rhenmatisni,  aixl  sent  to  Slough  liospital  July  21'.]  lie  died  on  the  29th.  Poxt-mnrtem  examina- 
tion: Body  not  much  emaciated.  The  lungs  were  collapsed,  of  a  gray  color  and  without  pleuritic  adhesions.  The 
heart  was  normal.  Externally  the  liver  was  clay-colored;  internally  it  presented  the  nutmeg  ai)j)earance.  The 
spleen  was  lake-red  on  section.  The  sigmoid  flexure  was  folded  down  against  the  anterior  wall  of  the  pelvLs,  to 
which  it  adhered  hy  a  layer  of  yellow  semi-transparent  lymph.  Portions  of  the  ileum  were  also  adherent,  the 
adhesions  enclosing  a  little  yellow  serunv  in  the  lower  part  of  the  pelvic  cavity;  the  peritoneal  surface  of  the  last 
foot  of  the  ileum  was  much  injected  and  it.s  mucous  membrane  coated  with  whitish  pseudomembrane;  I'eyer's 
patches  were  tumid  and  reticulated.  The  large  intestine  was  thickened  and  its  mucous  lining,  which  was  dirty 
and  blackish,  presented  a  number  of  shallow  irregular  ulcers  and  patches  of  pseudomembrane. — Act.  Ass'f  Siiry. 
IT'.  C.  Minor,  SloiKjli  ltox2>il(il,  Alrxandriti,  I'a. 

Specimen  459,  Army  ]\Iedical  ^luseum,  which  is  rejiresented  in  the  plate  facing  page 
404,  is  from  the  case  reported  as  300  of  the  pod-mortcm  records  of  the  continued  fevers. 
The  large  intestine  was  said  to  have  been  thickened  and  ulcerated,  and  in  the  sigmoid  flex- 
ure  perforated,  while  the  mucous  lining  of  the  ileum  was  ei'oded  and  the  agminated  and 
solitary  glands  ulcerated.  The  portion  of  the  ileum  represented  was  taken  from  just  above 
the  ileo-cfecal  valve.  It  shows  cicatrices  in  four  of  the  patches  of  Peyer, — in  the  up|>er  two 
the  process  has  been  completed;  in  the  lower  two  the  ulcers  are  not  wholly  cicatrized.  The 
solitary  glands  are  enlarged  and  prominent.  Sections  ef  tlie  follicles  from  this  specimen 
have  been  presented  in  the  plates  facing  pages  326  ami  328  of  the  Second  Part  of  this 
History  as  illustrative  of  the  follicular  changes  in  acute  diarrhcea. 

The  plate  facing  page  401  represents  a  portion  of  the  ileum  from  the  tract  of  the  val- 
vuhe  conniventes,  taken  from  the  patient  whose  case  is  reported  as  298  of  the  post-mortem 
records  of  the  continued  fevers.  The  record  states  that  the  mucous  membrane  of  the  ileum 
was  of  a  grayish-slate  color,  its  villi  hypertrophied  and  dotted  at  their  apices  with  black 
pigment,  and  that  the  patches  of  Pever  were  in  everv  stage  of  cicatrization,  tlie  ulcers 
smooth  and  the  gut  around  them  puckered.  On  the  specimen  represented  liy}ierti'ophied 
villi  are  seen  on  all  ])arts  except  the  cicatrices,  which  are  marked  by  their  smoothness  and 
the  breaks  in  the  transverse  folds  of  the  mucous  membrane.  Three  sections  of  u  cicatrized 
j)atch  from  this  iltnmi,  constituting  specimens  470-472  of  the  microscopic  collection,  show 
it  to  consist  of  condensed  connective  tissue,  embedded  in  which  are  a  few  of  the  original 
glands  of  the  locality. 

The  contraction  of  the  cicatrix  is  so  stronglv  marked  in  the  plate  facing  page  458 
that  the  interrupted  and  adjacent  valvulee  tend  to  radiate  from  the  newly-formed  tissue; 


*Ti  «t  i(3vwr'-\vrti*^fc»«n*"'"'*«"' 


"MS^r^^TOiiM  ©IF  lUi  DILI 


m]B  gmcum 


yA 


OF    THE    CONTIXUED    FEVERS.  ■  455 

801110  Kinall  tuLorcles  are  situated  on  the  peritoneal  surface.  The  sj^ecimen,  887.  Army  Med- 
ical !Museiim,  which  furnished  this  illustration  has,  unfortnnately,  no  recorded  historv. 

riGMEXTATioi-.'  OF  THE  INTESTINAL  LINING. — There  remain  fur  consideration  the  pig- 
mentary deposits  sometimes  oljserved  in  tlie  intestinal  walls.  This  pigment  was  seen  only  on 
tlie  fresh  intestine;  it  disappeared  under  the  treatment  adopted  for  tlie  preservation  of  the 
specimen.  Usually  it  occurred  in  streaks  or  patches  of  a  gray,  greenish,  bluish  or  other 
dark  color,  affecting  the  general  surface  of  the  mucous  mendjrane  of  the  small  or  large 
intestine.  Sometimes  it  was  aggregated  in  the  apices  of  tlie  hvpertrophied  villi  of  tlie 
small  intestine,  giving  a  dark  tinge  to  its  ])lushdike  surface.  Laro-e  accumulations  were 
found  in  the  solitary  follicles  and  in  tlie  glands  of  the  patches  of  Pever,  constituting  what 
was  known  as  the  shaven-heard  appearance  in  the  affected  area  of  the  latter. 

The  diffused  streaks  of  pigment  on  tlie  general  surface  of  the  mucous  membrane  con- 
sisted of  minute  brown  granules  deposited  in  the  lymphoid  cells  of  the  stroma  between  the 
follieles  of  Lieborkulin,  and  most  abuiulant  about  midwav  between  the  ei)itlielial  layer  and 
the  muscle  of  Briicke.  The  deposits  in  the  solitary  and  aggregated  glands  consisted  of 
similar  granules  in  the  cells  of  their  parenchyma.  But  in  all  these  instances  the  pigment  was 
occasionally  observed  in  larger  agglomerations,  situated  appan^itly  between  the  corpuscular 
elements  rather  than  within  them. 

Dark  colorations  of  the  mucous  membrane  had  long  been  recognized  as  due  to  ante- 
cedent hypenemic  conditions.  Louis  regarded  tliem  as  vestiges  of  an  e.xtinct  enteritis, 
find  assigned  a  similar  oriu-in  and  meanino;  to  the  dark  color  of  the  mesenteric  elands  after 
typhoid.  But  the  shaven-beard  patches  were  wholly  misunderstood  by  our  medical  officers 
during  and  after  the  war.  They  were  regarded  as  pathognomonic  of  the  malarial  form  of 
tyjilio-malarial  lever.  Indeed  a  chromo-lithograph,  reproduced  in  th.e  ju'esent  volume,  ami 
facing  page  4(30,  was  pufilislied  in  Cirotdar  Xo.  6,  Burgeon  (jreneral's  Office,  Washington, 
I).  C,  ISTov.  1,  1865,  as  an  illustration  of  the  characteristic  lesion  of  this  form  of  fever.'-'' 
The  plate  represents  the  congested  condition  of  the  membrane,  the  injection  of  the  vessels, 
the  enlargement  of  the  solitary  follicles  and  the  shaven-beard  appearance  of  the  patches  of 
Peyer.  The  case  from  which  tliis  specimen  was  taken  is  reported  as  89  of  the  post-mor- 
ieni  records  of  the  continued  fevers. 

Xo  further  light  was  thrown  upon  this  pigmentation  of  the  closed  glands  of  the  intestine 
until,  in  his  remarks  on  typho-malarial  fever,  read  before  the  Section  of  Medicine  of  the 
International  Medical  Congress,  Philadelphia,  1876,  Dr.  Woodward  gave  an  outline  of  what 
he  considered  to  be  the  clinical  course  of  the  malarial  form  of  typho-malarial  fever,  to  which 
was  added  an  acknowledgment  that  post-mortem  examination  of  the  diseased  intestines 
in  these  cases  showed  no  other  lesion  than  those  which  were  the  invariable  accompaniment 

*  "'TIk'  most  oharacti'i'istic  spocimeiKs  may  bo  thus  dcs<'rilnMl :  In  tlu*  frt-sh  inti'stiiio  as  rcccivi-ii  at  the  Jliisviim  tin-  ik-iim  itrcsciits  patrlics  of  deep 
congestion  of  variablo  e.Yti'iit ;  the  solitary  follidos,  enlarged  to  the  size  of  large  pinheads,  are  frequently  blaek  with  I'ignieiit  deposits.  The  Peyer's  luitches 
fit^metimes  quite  healthy  are  more  generally  the  seat  of  pigment  deposits  in  the  individual  follicles  composing  the  i)atidi,  which  appears  of  a  gray  color 
dotted  over  with  blackish  points,  i)reseiiting  a  resemblance  to  the  freshly-shaven  chin.  The  name  "shaven-beard  aiijiearance  "  has  In-en  quite  cur- 
rently bestowed  ni>on  this  condition.  In  other  cases  the  IVyer's  patches  are  somewhat  thickeiu'd  and  oi-iasionally  as  ninch  so  as  in  ordinary  cases  of 
enteric  fever.  In  the  preparations  as  presei-ved  in  the  ^Inseuin  the  color  of  the  pieces,  including  that  of  the  itigment  deixisit,  gradually  disapiiears.  The 
enlarged  solitary  foIliLdes  and  the  altenitions  iti  the  Peyer's  liatches  are,  however,  well  lu-escrved.  The  stditary  fLdlicles  are  not  ulcerated  in  these  cases 
exee|it  rartdy  some  of  the  largest,  vvhi(dl  may  jiresent  a  minute  iioint  of  ulceration  on  the  ai>ex.  The  form  of  fever  from  which  these  siiecinnms  are 
obtained  is  that  whhdi  attracted  attention  in  1802,  under  the  designation  of  (.'hickahomiuy  fever,  but  which  before  and  since  luis  prevailed  v^-henever 
our  armies  have  operated  in  nmlarial  regions.  It  is  a  contitnu-il  fevei-  which  presents  also  a  more  or  less  decidedly  remittent  type  at  the  beginning  at 
iea-t.  Jt  is  aecompanied  by  diarrhoa  and  abih>minal  tenderness,  but  usually  without  tympanites.  Cerebral  and  puUuonary  complications  are  connuou 
as  in  ordinary  enteric  fever.  Enlargement  of  the  spleen  is  freqiuMit  ami  often  excessive.  The  fever  usually  lasts  from  three  to  five  weeks  and  terminates 
in  a  lingering  and  protracted  convalescence.  This  variety  I  have  projioseil  to  ilesignate  as  the  Malarial  form  of  Typho-nialarial  Fever." — Dr.  "\Vooltw.\RD 
in  Circular  No.  i'.,  p,  1  lo. 


456  PATHOLOGICAL  A^-ATOMY  AND  PATHOLOGY 

of  V.  smart  intestinal  catarrli,  to  wit:  Patches  of  congestion,  enlargement,  with  sometimes 
ulceration  and  pigmentation  of  the  solitary  follicles,  and  frequently  a  slight  tumefaction  of  the 
patches  of  Peyer  with  such  pigmentary  deposits  as  gave  them  the  shaven-beard  appearance.''' 

The  next  reference  to  the  meaning  of  these  accumulations  is  contained  in  the  Second 
Part  of  this  work.-j-  publisjiod  in  1S79.  At  this  stage  of  his  investigation  Dr.  Woodward 
showed  officially  the  connection  of  the  pigment  with  those  hypenemic  conditions  of  the  mem- 
brane that  are  manifested  clinically  by  continued  diarrhceal  attacks.  In  view  of  tlie. tes- 
timony then  presented  there  appears  no  ground  for  doubting  the  oi'igiu  of  the  de])osits  in 
minute  extravasations  into  the  mucous  membrane  or  in  the  plugging  of  its  capillary  loops. 
They  were  of  more  common  occurrence  in  the  patches  of  Peyer  than  in  the  solitary  follicles, 
notwithstanding  the  frequent  and  decided  enlargement  of  the  latter.  The  former,  although 
seldom  much  swollen,  were  often  more  distinct  than  normal  from  jiarticipation  in  the  general 
hypera?mia  of  the  mucous  and  submucous  tissues.  Occasionally,  indeed,  a  diarrhoeal  case 
presented  such  morbid  changes,  including  ulceration  of  the  agminated  glands,  as  were  sug- 
gestive of  the  })resence  of  typhoid  fever:  In  the  plate  facing  page  300  is  a  thickened  patch 
which  appears  as  a  dark  elliptical  spot  two  inches  long  by  an  inch  in  its  transverse  meas- 
urement, its  surface  not  materially  elevated  above  that  of  the  surrounding  membrane,  but 
thicker  than  normal,  and  by  transmitted  light  more  opaque  than  any  of  the  other  patches 
observed  in  this  subject.  In  the  plate  facing  page  302  is  a  plaque  which  shows  a  greater 
advance  towards  a  morbid  condition;  its  surface,  which  is  not  materially  raised  above  the 
surrounding  level,  is  marked  by  narrow  broken  lines  studded  with  hypertrophiod  villi  similar 
to  those  on  the  general  surface  of  the  specimen,  and  between  these  are  irregular  areas  which, 
being  destitute  of  villi,  seem  depressed  below  the  adjacent  level  and  give  the  patch  a  some- 
what reticulated  appearance;  in  its  centre  is  a  shallow  oval  ulcer  an  eighth  of  an  inch  in 
diameter;  half  an  inch  below  this,  near  the  right  margin,  is  a  similar  tilcer,  and  a  third  may 
be  observed  near  the  upper  end  of  the  patch.  But  in  cases  of  non-specific  intestinal  con- 
gestion pigmented  villi  and  the  sluu'cn-beard  appearance  of  the  patches  were  more  frequent 
post-vio7'tc7n  observations  than  tumefaction  and  ulceration  of  the  glands  of  Peyer. 

These  lesults  of  a  completed  studv  of  the  accumulated  material  relating  to  diarrhc^a 
necessai-ilv  deprived  lliis  pigmentation  of  tlie  patclies  of  its  assumed  signiiicance  in  connec- 
tion with  typho-malarial  fever.  I)r.  Woodward  was  prompt  to  recognize  this  fact.  He 
observed  :t  "The  discussion  of  the  interesting  question  of  the  relation  of  the  lesion  just 
described  to  a  particular  forna  of  malarial  fever  must  be  postponed  to  a  stibsequent  chapter; 
it  must  suffice  at  jireseut  to  express  the  conviction  that  the  intestinal  lesion  in  the  class  of 
fever  cases  referred  to  presents  nething  by  which  it  can  be  distinguislioel  from  the  lesions 
observed  in  other  cases  in  which  the  febrile  phenomena  are  not  well  mai'ked  or  at  least  pre- 
sent no  specific  characters.  " 

This  intimates  that  there  is  no  specific  intestinal  lesion  by  which  the  malarial  lorm  of 
typho-malaiial  fever  may  be  distinguislied  from  the  malarial  fever  which,  beginning  as  an 
intermittent  or  a  remittent,  becomes,  like  typhoid,  subcontinuous,  and  in  its  later  stages  is 
attended  with  typhoid,  ;'.  c,  adynamic  symptoms. 

IFad  Pr.  WoODWAP.D  been  spared  to  complete  his  work  one  or  other  of  two  courses  was 
open  id  him  in  the  discussion  of  his  malarial  grouj>  of  tvpho-nialarial  fevers:  Either  to  rele- 
gate this  group  to  tlie  class  of  jiuivlv  malarial  fevers  or  to  argue  that  typln^id  fever  is  non- 

*  Sw  lui^'i-  :l.'.  i.f  Ih..  i.iuiiiihl.t,  rliilaili-lphiii,  INTO,  t  Sfc-  1>1>-  i»8  it  mq.  *  I'iife'i'  ;ill2. 


Am.  Photo-Relief  PHnting  Co., 


10O2  Arch  St.,  FhiladelpMa. 


CICATRIX  OF  AN   ULCERATED   PEYERS   PATCH. 

No.  597       MEDICAL  SECTION. 


OK   THE    CONTINUED    FEVERS.      '  457 

specific  ill  its  cliuracter  and  may  supervene  on  an  intestinal  congestion  sucli  as  may  be  due 
to  tlie  incidence  of  tlie  malarial  poison  when  sufficiently  prolonged  to  involve  the  patches  of 
Peyer,  or  in  the  presence  of  constitutional  abnormities  or  peculiarities  in  the  environment 
tending  to  tlie  development  of  that  typhoid  state  which  is  the  usual  accompaniment  of  an 
ulcerated  condition  of  these  patclies. 

It  is  needless  to  say  that  the  correct  course  appears  to  the  writer  to  be  that  first  indi- 
cated, as  he  has  been  led  to  adopt  it  by  a  clinical  and  pathological  analysis,  the  various  pro- 
cesses of  which  have  been  carried  on  in  full  view  of  the  reader  of  the  preceding  pages.  More- 
over, if  the  argument  be  continued  on  the  basis  of  the  similarity  between  the  condition  of 
tlie  patches  in  intestinal  catarrh  and  in  the  malarial  group  of  the  typho-malarial  fevers  it  is 
equally  conclusive:  The  cases  in  question  were  either  examples  of  a  subcontinued  malarial 
fever  with  adynamic  symptoms,  showing  on  post-mortem  examination — if  the  intestines  were 
implicated,  which  was  by  no  means  the  case  in  every  instance — the  anatomical  lesions  which 
characterized  cases  of  intestinal  catarrh  and  not  those  of  typhoid  fever,  or  they  were  cases  of 
typhoid  fever  so  modified  by  the  presence  of  malaria  that  the  full  action  on  the  aggregated 
glands  was  prevented.  But  while,  as  lias  been  shown  in  the  course  of  this  report,  there  is 
ample  testimony  in  support  of  the  former  alternative,  tlie  latter  is  based  on  the  assumption 
that  typhoid  fever  may  be  present  without  showing  its  existence  by  its  usual  action  on  the 
aggregated  glands  of  the  intestine.  If  this  assumption  were  allowed,  tyj^hoid  fever,  as  known 
to  the  medical  profession  for  the  past  sixty  years,  would  itself  cease  to  exist,  and  in  the 
clinical  and  pathological  chaos  that  would  result  it  would  manifestly  be  useless  to  attempt 
the  identification  of  a  typho-malarial  fever  when  its  tvphoid  element  was  acknowledged  to 
be  unrecognizable.  Fortunately  the  assumption  is  suggested  by  facts  which  may  be  used 
instead  to  strengthen  and  sustain  views  that  are  in  accord  with  our  present  knowledge  and 
past  experience  :  Undoubted  malarial  fever  m.ay  assume  clinically  the  appearance  of  typhoid, 
while  at  the  post-mortem  examination  the  lesions  of  typhoid  are  not  present.  The  gen- 
oral  experience  that  has  found  a  particular  lesion  in  all  cases  of  typhoid  naturally  concludes 
that  in  these  malarial  cases  there  was  no  typhoid  element.  It  requires  a  forced  rendition 
of  the  facts  to  construe  them  into  a  proof  of  tlie  modification  of  the  typhoid  lesion  by  the 
coexisting  malaria.  If  malaria  exert  such  an  interference  in  one  case  it  should  do  so  to  a 
greater  or  less  extent  in  all  the  cases  of  typhoid  which  it  complicates;  yet  the  post-mortem 
records  that  have  been  submitted  contain  many  cases  in  whicli,  although  the  malarial  com- 
plication was  strongly  marked  clinically,  the  typhoid  lesions  were  as  distinct  as  in  a  specially 
selected  case  of  unmodified  typhoid.  It  must  therefore  be  concluded  that  the  absence  of 
the  typhoid  lesion  implies  an  absence  of  the  febrile  condition  which  is  its  cause,  and  not 
an  interference  with  the  development  of  morbid  changes  in  glands  that  are  known  to  be  not 
recessarily  aflfected  by  the  poison  which  is  assumed  to  iiave  caused  the  interference. 

The  only  course  open  for  an  attempt  to  sustain  the  malarial  group  of  the  tvpho- 
malarial  fevers  in  their  position  of  modified  typhoid  fevers  is  to  deny  the  specific  character 
of  typhoid  fever  and  show  that  there  is  a  more  intimate  relationship  between  malarial  and 
typhoid  fevers  than  has  hitherto  been  allowed.  This  involves  the  subversion  of  the  generally 
acce})tcd  views  of  typhoid  fever  and  the  establishment  of  typho-malarial  fever  as  the  typical 
and  central  figure  of  the  subcontinued  fever  series,  which  becomes  paroxysmal  or  continued 
acciii'ding  as  certain  inflammatory  processes  are  restricted  to  the  general  surface  of  the  intes- 
tinal mucous  membrane  or  invade  the  substance  of  the  agminated  glands,  results  which  are 

Mkt..  Hist.,  Pt.  Ill— .5« 


458  .  PATIIOLOiirAL    ANATOMY    AND    rATIIOT.OGY 

due  not  to  specific  (liffei'cnces  in  tlio  febrile  canse  but  to  accidental  ciivunistances  pertaining 
to  the  constitution,  aire  and  livti'ienic  surroundino-s  of  the  aiiccted  individuals.  To  sustain 
tliis  position  in  the  faci'  ol'  our  present  knowledge  of  the  malarial  and  tvpboiil  ffbiile  cuu- 
ditioiiK  is  impossible.  Tlie  natural  history  of  the  causes  of  these  conditions  must  Ik;  shown 
to  lie  whiilly  at  variance  with  our  present  conceptions  before  any  attempt  of  this  kind  can 
be  otlii'r  than  a  work  of  the  imauination. 

If  the  eases  that  have  been  instanced  in  the  analytical  summarv  as  presenting  pigmen- 
tation of  the  mncous  membrane  of  the  intestine  bo  examined  it  will  be  found  that,  where 
the  patient's  condition  for  some  time  before  death  is  mentioned,  diarrhoeal  attacks  form 
invariably  a  part  of  his  history.  Notable  ])igmcntation  was  of  much  greater  frequencv  in 
the  continued  malarial  cases  than  in  those  which  presented  a  distinct  tvphoid  element;  in 
the  former  pigmentation  existed  in  nearly  one-tbird  of  the  cases,  and  in  the  greater  proportion 
of  these  the  deposits  were  specially  marked  in  the  patches  of  Peyer.  This  corresponds  with 
what  has  already  been  observed  concerning  the  intensity  of  the  congestion  in  such  cases. 
In  the  true  tvpho-malarial  and  the  mixed  series  the  proportion  of  pigmented  cases  was  much 
smaller;  while  in  the  ty]ihoid  series  there  occurred  no  instance  in  which  deposits  had  formed 
in  the  patches,  and  but  two  in  which  the  solitary  glands  were  their  site,  although  the 
mucous  membrane  of  the  colon  presented  in  five  cases  an  alteration  of  coloi' wdiicli  must  be 
ascribed  to  an  antecedent  hypera^mia.  This  absence  of  the  shaven-beard  appearance  from 
the  patches  in  typhoid  is  susceptible  of  explanation  on  the  one  hand  ]>y  the  rarity  of  that 
intense  congestion  which  tends  to  I'elief  liv  extravasation,  and  on  the  other  by  the  removal 
of  each  ecchyraosed  spot  by  subsequent  ulceration  or_sloughing. 

The  prevalence  of  the  pigmented  intestine  in  the  continued  malarial  fevers  that  were 
reported  as  typhoid  or  typho-malarial  is  worthj'of  remark  as  compared  with  its  infrequency 
in  the  fatal  cases  of  paroxysmal  fever.  Thus,  wliile,  as  has  l)een  stated,  31.7  per  cent,  tA 
the  former  presented  pigmentary  deposits  in  which  the  aggregated  glands  were  generally 
participants,  only  one,  case  98,  of  twenty-tlve  paroxysmal  cases,  in  which  the  intestines 
were  morbidlv  affected,  had  the  patches  of  Peyer  blackened,  and  in  only  two,  57  and 
94,  was  the  mucous  membrane  of  the  large  intestine  the  site  of  these  deposits.  It  will  be 
rem(,'mbered,  howevei',  that  death  in  the  paroxvsmal  cases  occurred  usually  after  a  short 
illness,  while  in  tlie  continued  malarial  cases  that  were  reported  as  typhoid  or  typho-malai'ial 
the  fatal  attack  was  prolonged.  Time  was  afforded  in  the  latter  for  the  development  of  a 
pigmented  condition,  which  in  the  former  was  represented  by  an  existing  congestion  such  as 
led  to  ecchymoses  in  the  pernicious  cases  97-99,  or  gave  a  deeper  color  to  the  apices  of  the 
solitary  glands  in  69,  or  produced  in  59  an  extravasation  of  blood.  If  these  cases  are  taken 
into  consideration  as  presenting  the  earlier  stages  of  the  development  of  the  pigmented 
condition  it  will  be  found  that  the  proportion  of  such  cases  in  the  paroxysmal  fevers  did  not 
differ  from  that  in  the  continued  malarial  series. 

TiiK  MESENTERIC  CfLANDS. — The  wu'iters  of  the  post'Viortem  records  seldom  gave  a 
detailed  account  of  the  condition  of  the  mesenteric  (ilands;  but  enouo'h  has  been  said  to 
show  tluit  tlirir  afiVctioii  was  similar  to  that  observed  by  Louis""-'  in  his  classical  typhoid 

=■■'■  >i->-  iioti',  p.  -IJii,  Ncj"".  Rmkitanskv,  "11.  rit.^  s}i}ir<i,  piiiire  44;i,  dt.'!ii^ril»i*s  the  nifsontfric  glaiuU  as  cuuyeritc-il  and  swullea  during  the  iuitiiil  stage 
of  in-iil''  rutiirili;il  tTitluiiiniJiliiiii  nf  t!i<-  ilcmn.  Tlu-ir  tiitnrliiitimi  is  iiruKi'ei'J^ivL'  witli  that  uf  the  clorir-d  glands  of  thr-  inti'stiiial  lining.  Tliey  attain  tin' 
si/.'.'  iif  11  hiati  i>r  piir'-iiii's  viXix  and  snnn-tirni-'  that  of  a  lien'si  cgj;,  thuiii'  ncart-st  tin-  Itowtd  slinwing  tin-  most  enlargmuMit ;  their  gri-att-st  riizi?  is  ivuL-ht'd 
during  the  (■i»ng«\-*tioii  att'-nduig  tin-  il'->trnitiun  i>f  iht*  intestinal  fullirlcs,  when  they  an;  ofti-n  jin  !*«.ift  as  to  flmlnati'  under  jtre:isur'\  They  ajijR'ar 
to  d'';r''n<Tate  into  a  ni'-dn!!;uy  suh^taiii-<-,  SMinetiiii'T*  firm  and  \vliir<-.  at  utlnT  tinir-^  sufti-r  ami  uf  a  grayish-red  or  pale-red  color.  The  areolar  tissue 
fcuvid'ipiiig  Ihi'iit  >liou-'  It  vnriro-e  Vii^eiilar  netwoik  ;  uerasiunally  their  serun^  cuvei-ing  Itecome??  inflamed  and  ji'-rhap!*  niptured,  giving  rise  to  lieinor- 
rliage  and  perituneul  inllaniniation,  and  their  iiarenchynia  is  couverti'd  into  a  yellow  or  yellowish-red,  thick  and  diffluent  mass.    When  tlio  necrosed 


Heliotyp€. 


y antes  R.  Osgood  &^'  Co.-,  Boston. 

CICATRIX    OF    AN    ULCERATED    I'EYKR-S     PATCH. 
No.  SS7.    MKDICAI.  SECTION. 


OK    THK    CONTIXrEI)    FFA-KRS.  459 

cases  Their  increasing  tumefaction  and  redness,  their  dark  coloration  and  subsequent 
softening  absorption  and  pigmentation  as  tlie  general  result,  with  rarely  the  formation  of 
pus  and  its  escape  into  the  peritoneal  cavity,  or  its  inspissation  and  transformation  into  a 
calcareous  deposit,  liave  all  been  illustrated  by  the  cases  submitted.  The  occasional  exce])- 
tions  to  the  o-cneral  rule,  that  the  most  severely  affected  glands  were  those  in  direct  com- 
munication with  the  diseased  patches  of  Peyer,  have  also  been  noted  in  the  analytical 
summary.  Sections  of  the  diseased  glands  liave  been  prepared  in  the  ]\Iuseum  showing 
the  occlusion  of  the  lyn:iph  passages  by  corpuscular  elements  differing  in  no  respect  from 
those  found  in  the  closed  glands  of  the  intestinal  mucous  membrane/'* 

The  splken. — The  enlargement,  softening  and  occasional  darkening  of  the  spleen  found 
by  Louis  in  his  typhoid  cases  were  observed  also  by  our  medical  officers  in  their  fatal  cases 
of  that  disease;  and  as  he  found  one  instance  of  diminished  volume  in  his  forty-six  cases, 
so  in  the  fifty  cases  that  have  been  reported  in  this  work  there  also  occurs  an  exceptional 
case  of  this  character.*}* 

la  a  majority  of  their  continued  malarial  cases  our  medical  officers  reported  the  spleen 
as  large,  soft  and  darkened,  and  their  records  bear  testimony  to  the  existence  of  more  actively 
destructive  changes  in  these  cases  than  in  those  of  the  typhoid  series.  Thus,  in  three  of 
the  cases  noted  in  the  anatomical  summary  there  were  purulent  or  caseous  cysts  or  circum- 
scribed sero-purulent  infiltrations,  with  escape  in  one  instance  of  the  morbid  product  into 
the  cavity  of  the  peritoneum.  Specimens  325  and  326,  Army  Medical  Museum,  two  per- 
pendicular sections  of  the  spleen,  from  a  case  recorded  as  87  of  this  series,  show  the  organ 

[lurtions  of  the  intestinal  patclies  liave  lioon  removed  tlie  mesenteric  glands  bcf^in  to  decrease  in  size,  tliongli  still  retaining  an  almormul  darlv  lilnisli- 
red  i'(dur  ;  but  by  tlie  tinir  that  the  intestinal  ulcers  are  heab-il  t  lie  glands  havt*  rrj^ahicd  tln-ir  in)rinal  k'v/.v,  ami  an-  frcipniitly  snialler  tiian  usual,  vviltfd, 
tough,  pale  and  often  pigmented.  The  swnllcn  glands  are,  acfurding  to  Haiu.kv,  alninst  entircdy  icnistitutvd  of  ei'rpusrlrs  nf  various  sizes,  for  tin-  uutHX 
l>art  spherical  and  nui  U'at<'d;  the  most  numerous  average  jgVc  *'^  ""  i"*"^'  '"  diameter;  the  lurgiT  jfresent  weU-furmed  nuclei  anil  average  5^5  "'  »" 
inch.  Hoffmann  states  that  the  locality  of  the  glands  most  deejdy  implicated  docs  not  always  eorrespund  with  that  of  the  bowel  in  like  eoudition,  fur 
iu  some  instances  the  mesenteric  glands  may  be  decidedly  enlarged  while  the  intestinal  aflTection  is  slight,  and  in  others  the  tumcfii-d  glands  may  be 
found  higher  up  and  away  from  the  seat  of  the  intestinal  disease.  The  tumefaction  is  often  bo  rajtid  that  in  a  few  days  the  glands  acquire  double  tlieir 
natural  size,  and  by  the  time  the  disease  has  reached  its  height  it  is  not  uneonnnon  to  find  them  as  large  as  a  hazidnnt  or  walnut,  and  in  soim-  instances 
even  as  large  as  a  hen's  egg.  In  the  initial  stage  they  are  hypera-mic  ;  internally  the  periphery  is  of  a  deejier  tinge  than  the  renuiinder  of  the  section,  but 
more  frequently  the  interior  is  of  a  uniform  rose-color,  or  of  this  color  mottled  with  lighter  shades  of  the  same  tint  or  with  gray.  The  coloration  and 
swelling  contiuue  for  some  time,  and  then  decline  ;  as  a  rule  the  fading  of  the  medullary  substame  procoe<ls  towards  the  corti<'al  )iortion,  and  the  latter 
commonly  retains  its  pronounced  red  coloring  after  the  centre  has  become  pale-gray;  gradually,  liuwever,  tlie  redness  of  the  entire  gland  disappears  and 
the  tumefaction  becomes  reduced,  constituting  the  most  simple  and  frei|ueut  motle  of  resnlution.  In  many  cases,  however,  the  glands  take  on  a  yel- 
lowish or  even  an  intense  yellow  color,  developing  foci  of  purifonu  wdtening,  mostly  small  except  in  the  centn-,  where  they  often  acipiire  greater 
dimensions.  AMien  the  softening  is  of  limited  extent  absorption  readily  takes  place  ;  but  when  consiilerable  the  liquid  components  disa).pear  leaving 
a  dry,  cheese-like,  yellow  mass  in  which,  at  a  later  period,  calcareous  matter  may  Ite  depositei).  All  the  structural  elements  of  the  gland  are  subject 
to  enlargement,  the  stroma  as  well  as  the  other  constituents;  large  cells,  resendding  those  found  in  l*4'yer's  patches,  are  oltserved  in  all  jMirts  of  the 
glandular  tissue,  but  most  abundantly" in  tjn*  lymph  sinnses.  Atrophy  may  follow  both  forms  of  resolution.  As  the  changes  coincide  in  general  with 
those  in  the  intestinal  follicles,  and  as  both  are  developed  simultaneously  and  in  corresjionding  localities,  Hoffmann  suggests  a  pathological  connection 
between  the  processes, — that  the  changes  iu  the  mesenteric  glands  are  caused  by  matter  brought  into  them  by  the  lymph -current.  According  to  Rind- 
FLEisCH  the  histological  characters  of  the  primary  infiltration  are  faithfully  reprcxluced  in  the  mesenteric  glands.  Catarrhal  swelling  is  followed  by 
excessive  -enlargement  from  nu'dullary  infiltration.  The  follicles  and  their  prolongaticus  are  the  jirincijial  seats  of  the  morbid  changes,  while  the  lymph 
sinuses  and  the  connective  are  only  modenitely  infiltrated.  The  vessels  are  enlarged  an<t  many  t)f  the  capillary  loops  plugged.  The  trabecula;  become 
three  ur  four  times  thicker  than  usual,  the  uodal  j)ointa  esiH.'cially  are  swollen  and  the  nuclei  vesicular.  Proliferation,  chiefly  fii^siparous,  but  also 
endogenous,  so  fills  every  sjiace,  not  already  occujtied  by  the  vessels,  with  corpuscular  eh^ments  that  it  is  impossible  to  inject  the  lymphatic  path  of  the 
gland.  Degeneration  and  absorption  follow,  leaving  the  gland  shrunken  and  sometimes  i)igmented  by  extra  variations  that  had  occurred  during  tlie  ante- 
cedent congestion.  Cheesy  necrosis  is  regarded  as  a  rare  phenomenon.  Peritonitis  may  be  caused  by  the  resulting  suppurative  inflammation,  or  the  pus 
may  become  inspissated,  calcareous  and  encysted.  The  cluinges  obs<?rvetl  in  the  mesenteric  glands,  according  to  Klein,  were  similar  to  those  described 
as  occurring  in  the  closed  glands  of  the  mucous  membrane  of  the  intestine ;  micrococci,  fonned  in  the  proi>er  glandular  tissue  and  in  the  capillary 
branches,  were  always  connected  with  the  necrotic  changes. 

*See  siijjm,  jiage  44U. 

t  KoKiTANSKV  desf^Tibes  the  spleen  in  tyjihoid  as  sometimes  enlarged  to  six  times  its  nomial  size,  its  pnlp  consisting  of  a  soft  pultaceons  matter, 
cherry-red  or  jKile-red  in  color  and  similar  to  that  uf  the  tyi>hoid  substance  of  tli<*  mesenteric  glands ;  otTcasiimaily  the  splenic  parenchyma  becomes  reduced 
tou  fluctuating  mass.  IIarlkv  detected  under  the  higher  powers  only  "  minute  granular  cori)US(.de8,  fibre-cells  and  molecular  branched  fibres."  Hoffmann 
says  that  changes  in  the  spleen  are  as  regularly  observed  in  autopsies  in  typhoid  fever  cases  as  changes  in  the  intestines,  and  among  them  an  increase  of 
volume  is  the  most  freqiUMit  and  striking.  Nevertheless,  in  every  epidemic,  cases  occur  in  which  this  condition  is  not  present,  particularly  in  persons 
over  forty  years  of  age,  in  whom  ex|iansion  is  restrained  by  the  firmness  and  thickness  of  the  stroma  ;  similar  restraints  are  imposed  when  a  cai)snle  has 
become  thickened  and  unyielding  as  a  result  of  previous  disease,  and  when  extensive  adhesions  between  the  organ  and  its  surroundings  have  previously 
taken  place  ;  hut  it  sometimes  liapjiens  that  in  young  persons  B]>lenic  enlargement  is  wanting,  even  in  the  culminating  stagi-  of  the  disease,  without  tlie 
apiiearanee  of  any  conditions  that  might  be  considered  as  explanatory.  In  general  the  spleen  in  typhoid  gains  rapidly  in  size  at  an  early  iKTiinl,  and 
continues  to  increase  until  the  height  of  the  liisease  is  reached,  when  it  remains  without  change  for  a  time,  and  tlien  eubsidesby  a  slower  process  than  that 


460  PATHOLOGICAL  ANATOMY  AND  PATHOLOGY 

enlarged  and  considerabl}'  infiltrated  with  metastatic  masses.  When  fresh  this  spleen  was 
so  soft  as  to  be  easily  torn  with  the  finger;  it  was  partly  bluish-black  in  color  and  partly 
of  a  livid  blood-color,  while  the  so-called  metastatic  masses  were  bright  yellow;  these  foci 
consisted  of  granular  matter  in  which  were  embedded  the  partly  disintegrated  anatomical 
elements  of  normal  sjilenic  structure.  Nevertheless  the  proportion  of  cases  in  which  the 
spleen  was  small  or  normal  in  size  and  consistence  was  greater  in  the  malarial  than  in  the 
typhoid  cases.  Similar  conditions  were  found  in  the  fatal  cases  of  the  paroxysmal  fevers.* 
The  spleen  presented  abnormal  changes  in  93.3  per  cent,  of  those  typhoid  cases  in  which  its 
condition  was  observed  and  recorded  and  in  only  65.4  per  cent,  of  the  malarial  cases.  In 
the  typho-malarial  and  mixed  series  a  medium  as  to  frequency  is  found,  the  former  furnishing 
81  and  the  latter  75  per  cent.;  but  although  the  proportion  of  abnormities  in  these  cases 
was  greater  than  in  the  continued  malarial  series,  the  proportion  of  cases  in  which  a  pulta- 
ceous  or  purulent  degeneration  had  taken  place  was  not  so  great. 

The  LIVER  in  our  typhoid  cases  differed  from  that  of  Louis's  observations  in  the  very 
general  presence  of  an  augmentation  of  volume:  Although  noted  in  but  five  of  his  fortv-six 
cases,  enlargement  is  mentioned  in  a  majority  of  such  of  our  records  as  call  attention  to 
abnormities.  The  somewhat  enlarged,  pale,  perhaps  fatty,  softened  and  sometimes  con- 
gested state  of  the  liver  in  typhoid  was  present  also,  to  a  certain  extent,  in  the  malarial 
cases,  a  result  probably  due  in  both  instances  to  the  action  of  the  disease-poisons;  for 
since  these  manifest  their  operation  by  similar  pyrexial  symptoms  and  disordered  secre- 
tions a  similarity  in  the  secondary  morbid  lesions  might  naturally  be  expected.  But  among 
the  malarial  cases  was  found  a  larger  proportion  of  congested  livers,  and  instances  of  adhe- 
sion and  suppuration  give  evidence  that  the  inflammatory  conditions  were  more  intense  as 
well  as  more  general ;  there  was  also  found  that  darkening  or  bronzing  of  its  substance 
which  was  observed  in  the  paroxysmal  but  not  in  the  typhoid  fevers.  The  liver  was  altered 
in  eighteen  of  twenty-nine  typhoid  cases  in  which  its  condition  was  observed  and  recorded, 
I.  e.,  in  62  per  cent.,  in  thirty-two  of  fifty-three  cases,  or  60  per  cent,  of  the  malarial,  in 
twenty-six  of  forty-five  cases,  or  58  per  cent,  of  the  typho-malarial,  and  in  eighty-seven  of 
one  hundred  and  Ibrty-two,  or  61  per  cent,  of  the  mixed  series.  The  bronzing  and  occa- 
sional disorganization  found  in  continued  malarial  cases  were  found  also  in  the  typho-mala- 
rial and  mixed  cases. 


tiy  wliii  h  its  nuKHu'ntiition  was  offectoil.  Vliile  enlarging  tlio  organ  is  tense,  firm  and  uniformly  dark  bluish-red,  with  the  trabecular  structure  barely  seen 
in  the  outswelling  pulii-inass;  but  as  the  disease  advances  its  substance  becomes  softer,  the  pulp  assumes  a  piiltaceous  character  and  the  stroma  has.less 
cohesion.  Later  the  capsule  becomes  wrinkleil,  white,  cloudy  and  thickened,  while  the  spleen  itself  diminishes  in  size.  These  changes  depend  upon  an 
alti'ratiou  of  the  blood-contents  and  of  the  constituent  elements  of  the  spleen.  In  their  entire  character  they  exhibit  great  similarity  to  those  observed  in 
the  lymphatic  system  of  the  small  intestine.  There  appear  single  nucleated  lympU-cells  of  normal  size  and  larger,  together  with  great  numbers  of  large 
nuiTiy-nucleated  cells,  which  latter  compose  in  great  part  the  contents  of  the  venous  sinuses  and  are  prgfusely  distributed  in  the  larger  splenic  veins. 
This  is  especially  the  case  in  the  commencing  stage  of  the  splenic  swelling ;  in  the  second  and  third  weeks  the  large  cells  are  found  in  vast  numbers  in  a 
state  of  [Kirtial  division,  while  in  later  stages  the  single  nucleated  cells  preponderate.  The  original  lymph-cells  are  supposed  to  be  the  source  of  the 
cellular  development.  Coincident  with  the  increased  cell  formation  the  trabecule  become  extended  and  the  vessels  tense.  The  Malpighian  bodies  are 
nu>stly  distinct,  somewhat  enlarged  and  well  supplied  with  blood ;  at  first  they  are  abundantly  filled  with  cells,  among  which  are  a  moderate  number  of 
the  larger  many-nucleated  corpuscles.  As  long  as  cell  proliferation  continues  active  the  firmness  of  the  splenic  tissue  is  maintained,  but  when  it  begins 
to  subside,  abiiut  the  end  of  the  third  week,  the  tissue  becomes  soft.  With  the  evacuation  of  the  cell-structures  the  tension  and  volume  of  the  splenic 
substance  diminish  and  the  larger  tralM'cuhv  contract ;  hut  the  fibrous  reticulum  and  capsule  remain  thickened  during  the  further  progress  of  the  resolu- 
tion. The  cell  elements  leave  the  spleen  by  the  vessels  leading  from  the  organ  ;  but  as  comparatively  few  of  the  large  many-nucleated  cells  are  seen  in 
those  vessels  it  is  inferred  that,  considering  their  abundance  in  the  splenic  tissue,  they  are  broken  up  into  small  cells  in  the  efferent  channels.  At  this 
peri.Kl  dark-nvl  ami  even  bla.k  hemorrhagic  foci  are  occasionally  found  scattered  throughout  the  substance  of  the  organ.     Infarction  is  generally  con- 

8. '  '"  ""*'  •"■■•tion,  a  wedge-shaped  mass,  having  its  base  directed  towards  the  splenic  periphery.     So  long  as  the  infarcted  portion  continues  firm  its 

tissue  preserves  its  ability  to  uud.>rgo  a  progressive  fading,  shrinkage  and  isolation  from  the  surrounding  parts  bv  a  dense  capsule  of  connective  tissue ; 
but  when  the  infarction  is  large  it  is  prone  to  become  softened  into  a  pultaceuus  grayish-brown  mass.  If  the  capsular  tissue  has  alrijadv  been  formed 
the  portion  witiiin  it,  as  a  nil.-,  alone  be.-omes  disorganize.!,  but  if  it  is  unformed  the  softening  process  may  extend  beyond  the  infarction  and  lead  to 
peritonitis.  According  to  Ki.kix.  the  cells  in  t\w  distended  blood-paths  of  the  spleen  in  typhoid  cases  resemble  lymphoid  cells  changed  in  the  same 
manner  as  those  of  tiie  intestinal  and  mesenteric  glauds. 
*  :See  (0(^',  page  14G. 


^\ 


/ 


^ 


WW^^'W^'^^MW    rn^.T?  ^TSTTJ!    ^IT.I^rflM 


OF   THE   CONTINUED    FEVERS.  *  461 

The  two  cases  111  and  199  are  of  interest  in  connection  with  that  rare  post-mortem 
condition  emphysema  of  the  liver.  In  the  first  case,  which  occurred  in  the  service  of  Surgeon 
E.  B.  l^ENTLEY,  U.  S.  Vols.,  at  the  Slough  hospital,  Alexandria,  Va.,  the  patient  had  recurring 
chills  followed  by  fever,  sleeplessness,  delirium  and  jaundice,  with  death  on  the  ninth  day 
after  admission.  The  patches  of  Peyer  and  mesenteric  glands  were  enlarged  and  the 
liver  increased  in  size,  its  right  lobe  honey-combed,  "full  of  air  and  of  a  very  peculiar  appear- 
ance," and  its  left  lobe  normal  in  texture  but  of  a  yellow  color:  the  kidneys  were  normal. 
Specimen  639,  Army  Medical  Museum,  is  a  section  of  the  I'ight  lolie  of  the  liver  from  this 
case,  showing  the  honey-combing  of  the  organ  by  dilated  ducts  which,  according  to  the  state- 
ment of  the  Catalogue  of  the  Museum,  was  filled  when  recent  with  a  yellowish  serum-like 
fluid.  This  statement  makes  no  mention  of  the  presence  of  emphvsema.  The  second  case 
was  reported  by  Assistant  Surgeon  IIaerison  Allen,  U.  S.  Ar)ny,  in  charge  of  the  Lincoln 
hospital,  Washington,  D.  C.  The  patient  died  on  the  seventh  day  after  admission,  but  the 
existence  of  bed-sores  over  the  sacrum  and  trochanters  showed  that  he  must  have  been  sick 
for  several  weeks.  He  suffered  from  high  fever  and  delirium,  frequent  retching  and  violent 
diarrhoea.  The  patches  of  Peyer  were  ulcerated;  the  mucous  membrane  at  the  ileo-cfecal 
valve  thickened,  indurated  and  blackened  and  in  the  colon  pale  but  dotted  with  spots  of 
black  pigment.  On  the  left  side  of  the  abdomen,  about  two  inches  below  the  diajiliragm, 
was  a  subperitoneal  abscess  containing  four  drachms  of  jtus.  The  surface  of  the  liver  was 
generally  of  a  grayish-blue  color,  but  anteriorly  the  right  lobe  had  a  more  healthy  appear- 
ance; minute  collections  of  air  were  disseminated  through  its  parenchyma,  which  was  soft, 
of  the  color  of  sanious  pus  and  possessed  of  a  disagreeable  odor;  the  air-cavities  and  the 
transverse  sections  of  the  portal  veins  gave  a  honey-combed  appearance  to  the  interior.  The 
kidne3^s  were  in  a  similar  emphysematous  condition,  the  distinction  between  the  pynuniilal 
and  cortical  portions  being  almost  obliterated. 

Perhaps  to  these  might  be  added  case  137,  as  presenting  the  color,  odor  and  consistence 
of  the  fuUv-developed  emphysentatous  case,  although  no  air  is  mentioned  as  present  in  the 
tissues.  This  case,  also  reported  by  Dr.  Allen  of  the  Lincoln  hospital,  died  on  the  third 
day  after  admission,  but  no  clinical  history  has  been  preserved.  The  patches  of  Peyer  in 
the  lower  part  of  the  ileum  were  surrounded  by  congestion  and  had  ragged  surfaces  and 
purplish  edges.  The  liver,  of  a  dull  greenish  color,  evolved  a  peculiar  chicken-coop  odor 
and  was  so  soft  that  the  linger  could  be  passed  through  it  in  every  direction;  the  gall- 
bladder contained  an  ounce  of  dark  ochre-colored  bile.     The  kidneys  were  congested. 

Fkeeichs*  refers  to  emphysema  hepatis,  and  cites  CtEAVf:s  and  IIaspel  as  instancing 
cases  in  which  an  abscess  or  hydatid  cyst,  after  the  discharge  of  its  contents  into  the  stomach 
or  intestine,  became  filled  with  gases  from  the  gastro-intestinal  canal  owing  to  pressure 
exerted  by  the  abdominal  walls  or  muscitlar  tunics  of  the  intestine;  but  he  acknowledges 
that  it  is  more  difficult  to  account  for  those  cases  in  which  air-cavities,  from  the  size  of  a 
millet-seed  to  that  of  a  pea,  are  found  permeating  the  hepatic  substance.  He  met  an 
instance  of  this  kind  in  the  body  of  a  woman  who  died  from  purulent  inflammation  of 
the  joints,  death  having  been  preceded  a  short  time  by  abortion  and  the  appearance  of 
petechias  He  also  cites  some  cases  observed  by  others, — by  Stokes  in  a  person  who  died 
from  the  rupture  of  an  aneurism  into  the  oesophagus,  by  Louts  in  a  tubercular  patient,  by 
Cambav  after  dysentery  and  peritonitis  and  by  Piorry  after  small-pox. 

*  .1  I'liiiiotl  Treatm-  <iit  Ilismiu'*  «>/  Ihf^  Lirer — New  Sydenliani  Si>ci<'ty,  Lomlol),  ISfil,  Vol.  11,  p.  :jfl9. 


462  PATHOLOGICAL    ANATOMY    AND    PATHOLOGY 

In  addition  to  Ins  tubercular  case  above  cited  Lour.s'-'  found  this  emphysema  ot"  the 
liver  in  certain  cases  of  acute  disease;  but  in  the  typhoid  affection  he  never  encountered  it, 
and  he  comments  with  astonishment  on  what  seems  to  him  a  fact,  that  this  apparently  juitre- 
factive  condition  of  the  liver  should  be  absent  in  a  disease  which  has  been  long  known  as 
putrid  fever  while  jiresent  in  other  acute  maladies  that  are  not  so  intimately  associated  with 
the  idea  of  putridity.  Emphysema  of  the  liver  in  his  cases  coincided  with  a  similar  condi- 
tion of  the  neck  and  limbs. 

J.  Forsyth  Meigs  has  reported  a  case  in  which  the  liver  was  found  in  this  condition 
after  typhoid  fever. "j"  In  this  case  there  was  much  exhaustion,  which  was  regarded  as  due 
to  an  unusual  destruction  of  the  red  corpuscles  of  the  blood  indicated  by  the  amount  of  their 
coloring  matter  in  the  urine.  The  patient  died  after  profuse  hemorrhage  from  the  bowels 
about  the  eighteenth  day  of  his  attack.  The  patches  of  Peyer  and  many  of  the  solitary 
"lands  were  ulcerated  and  the  mesenteric  "lauds  enlara;ed,  vascular  and  softened.  The 
liver  was  much  enlarged,  brownish-yellow,  spongy  and  crepitant,  so  light  as  to  float  in 
water  and  so  soft  that  the  finger  could  readily  be  thrust  through  it ;  on  pressure  much  dirty, 
frothy,  thin  liquid  escaped,  Avhich  looked  like  ichor  but  not  like  pus;  the  gall-bladder  was 
filled  with  thin  yellowish  bile.  The  kidneys  were  enlarged,  dark  colored  and  congested; 
thev  crepitated  distinctlv  but  did  not  float  in  water.  There  was  subcutaneous  emphysema 
of  the  sides  of  the  neck  and  thorax,  and  much  discoloration  from  stasis  in  the  dependent 
parts  of  the  body.  On  microscopic  examination,  the  liver  was  found  to  be  fatty;  fat  in  large 
drops  was  scattered  over  the  field,  and  all  the  small  angulated  a«d  irregular  cells  contained 
much  fat  in  minute  refractive  points.  (.)n  the  other  hand,  the  kidneys  were  not  fatty,  but 
the  tubes  were  large,  swollen  and  crowded  with  dark  cloudy  cells.  Dr.  Meigs  remarks  that 
there  was  no  emphysema  of  the  neck  before  death,  or  at  least  none  was  observed,  as  he 
believes  it  would  have  been  had  it  existed;  but  he  con^siders  it  difficult  to  suppose  that  the 
singular  cribriform  and  spongy  character  of  the  liver  could  have  been  produced  in  the  eleven 
hours  and  a  half  which  elapsed  between  death  and  post- inor tern  observation,  especially  as 
there  was  no  decomposition  of  the  tissues  in  other  parts  of  the  body,  and  assuredly  none  in 
the  kidney,  which  also,  although  to  a  less  extent,  was  emphysematous. 

The  honey-combing  of  the  liver  in  case  111  was  certainly  due  to  dilatation  of  the  ducts, 
by  a  serum-like  fluid,  according  to  the  statement  in  the  Catalogue,  connected  with  which 
was  the  jaundice  of  the  clinical  history;  but  the  language  of  the  reporter  leaves  no  room 
for  doubt  that  emphj^sema  was  associated  with  this  condition.  Without  additional  cases 
and  more  precise  details  it  is  difficult  to  say  what  may  have  been  the  origin  of  the  emphy- 
sema; but  in  yiew  of  similar  conditions  in  the  kidneys  in  some  of  these  cases,  and  in  the 
muscles  of  the  neck  in  case  98,  it  seems  probable  that'  it  was  the  result  of  post-mortem 
changes.  In,  tissues  that  have  become  so  profoundly  altered  from  the  normal  condition 
during  life  it  is  not  surprising  that  chemical  reactions,  in  advance  of  bacterial  or  putrefactive 
changes,  should  have  given  rise  to  the  evolution  of  gaseous  products  as  soon  as  vitality 
ceased  to  act  as  a  preservative. 

*  Paris,  isi'.i,  t.  I,  11.  SIX). 

f  PliUadflplii'i  Me'tUitl  Thuen,  1872-73,  Vol.  Ill,  p.  1. — Referring  to  the  rarity  of  tliid  condition  of  the  liver  Dr.  Meigs  says  :  "In  that  great  treasure- 
house  of  putliulogical  medicine,  Rokitansky's  Pathological  .\natoniy,  I  cannot  find  a  single  sjiecific  reference  to  it.  I  have  loolied  tlirongit  seven  vol- 
umes of  the  Ycar-Books  of  the  Sydeiiluim  Society  and  did  not  tind  a  case.  Bambf.rokk.  in  Viucuow's  Hand-Iiook  of  Pathology  and  Thi-niiientics,  in  the 
chapter  on  the  liver,  makes  nn  mention  of  it.  Neither  liritn  in  his  Treatise  mi  the  Liver,  hur  Watson  in  his  Practice,  nor  Gravfs,  who  saw  nn  ninch 
typhus  in  Duldin,  in  his  great  work  on  the  Science  of  Medicine,  nor  the  \^■riters  on  Typhoid  Fever  and  Diseases  of  tile  Liver  in  JIevnolo's  System  of 
Medicine,  nor  the  Compendium  de  Medecine  Pratique  even  ghiuce  at  it.'' 


OF    THE    CONTI.XUED    FEVERS. 


163 


The  GALL-BLADDER  ill  tlio  contiuueJ  fever  eases  presented  no  speeial  characteristics.  It 
was  Lirge  or  small,  emptv,  (.listenJeJ  or  charged  with  various  quantities  of  bile,  usually 
dark-Cdlored  and  viscid,  but  sometimes  thin.  >traw-colored  or  watery.  As  accidental  com- 
plications may  be  mentioned  the  perforation  of  its  walls  m  case  1*5,  m  which  constant  nausea 
ami  vomiting,  jaundice  and  snbsecjuent  jieritoiiuis  oltscured  the  svmptoms  of  tvphoid,  and 
its  disorganization  in  ?y'27  as  the  result  of  its  participation  in  a  general  peritonitis. 

The  PANCREAS  was  normal  in  twenty-seven  of  forty-one  observations  and  but  slightly 
altered  in  the  rcmainiim-  fourteen,  the  alteration  consisting  of  an  asserted  hardness,  softness 
or  change  of  tint.  The  resistance  of  this  gland  to  the  ty])hoid  and  malarial  poisons  maj'  be 
fairly  assumed  from  a  consideration  of  the  many  cases  in  which  it  was  healthy,  although 
the  other  abdominal  organs  v\"ere  extensivelv  diseased.  Even  when  the  parotid  gland  became 
aiTected  it  does  not  ajipear  that  the  suscej)tibility  of  the  pancreas  was  increased,  for  while  the 
condition  of  the  latter  was  stated  in  but  one  of  the  cases  in  which  the  parotids  were  inflamed 
it  was  normal  in  that  case,  263.  ]kit  the  inference  that  on  this  account  there  is  a  greater 
dift'erence  between  these  glands  than  is  generally  supposed  is  hardly  warranted,  since  tlie 
submaxillary  glands  were  so  rarely  affected. 

The  KIDNEYS  were  less  frequently  affected  in  the  continued  fevers  than  the  liver  or 
spleen,  but  the  morbid  changes  that  were  observed  were  of  a  similar  character.  The  large 
number  of  instances  in  which  their  condition  was  not  stated  detracts  from  the  value  of  the 
statistics  for  certain  purposes;  but  of  the  cases  that  were  examined  about  one-half  were 
reported  as  in  a  healthv  oondition.  In  oi  })er  cent,  of  the  tyjdioid  series  the  kidneys  were 
more  or  less  altered;  in  57  per  cent,  of  the  continued  malarial  cases;  in  35.7  of  the  typho- 
malariahand  42.6  of  the  mixed  series  of  cases.  It  is  inferred  from  these  figures  that  although 
an  altered  condition  of  the  kidneys  was  as  frequent  an  attendant  of  malarial  as  of  typhoid 
fever,  the  conjunction  of  these  was  not  expressed  by  an  increased  frequency  in  the  lesions 
of  this  organ.  Xevertheless  an  examination  of  the  analytical  summary,  by  showing  a 
somewhat  greater  prevalence  of  acutely  inflamed  cases  in  the  typho-malarial  and  mixed 
series,  suggests  that  the  coincidence  of  the  febrile  poisons  may  have  been  manifested  by  an 
increased  gravity  of  the  lesions.  The  kidneys  were  congested,  in  inany  cases  soft  and  flabby 
and  in  some  pale  and  fatty;  occasionally  the  congestion  resulted  in  ecchymoses,  and  at 
times  the  inflammatory  action  proceeded  to  suppuration.  The  emphysematous  kidney  in 
case  199  has  already  been  referred  to  in  speaking  of  the  lesions  of  the  liver. 

As  has  been  shown  in  a  previous  jxirt  of  this  chapter,*  no  general  connection  was 
observable  between  dysuria  or  retention,  and  delirium  or  stupor,  although  it  is  probable,  as 
argued  by  MuRCHisoN,  that  cerebral  symptoms  are  in  some  instances  the  result  of  an  accu- 
mulation of  urea  in  the  blood. 

in— THE  ORGANS  OF  RESPIRATION  AND  CIRCULATION. 

As  the  condition  of  tlie  larynx  and  trachea  was  observed  in  so  few  of  the  cases,  the 
relative  frequency  of  their  lesions  can  be  ascertained  only  by  the  figures  supplied  by  Dr. 
Harrison  Allen. f  In  only  three  of  his  cases  of  camp  fever  was  the  trachea  or  larynx 
implicated.  In  one  the  fauces  and  epiglottis  were  covered  with  false  membrane,  and  the 
margins  of  the  latter  and  mucous  lining  of  the  larynx  were  ulcerated;  in  a  second  there  was 
thickening  of  the  membrane  but  no  ulceration,  and  in  the  third  a  decided  inflammation  of 

*  See  oiite,  pages  298  and  308.  t  See  axle,  page  433. 


464  PATHOLOGICAL    ANATOMY    AND    PATHOLOGY 

tlie  tracliea  uiiaccoinpanicd  by  laryngitis  or  pneumonia.  From  the  paucity  of  such  lesions 
in  tliirty-tive  oases  it  seems  probable  that  the  reason  why  the  larynx  and  trachea  were  not 
more  frequentlv  mentioned  in  our  posf-morfcm  records  was  the  absence  of  morljid  appear- 
ances in  tliese  parts.  Observations  were  made  in  six  of  tlie  typhoid,  eight  of  the  malarial, 
four  of  the  tvpho-malarial  and  seventeen  of  the  mixed  cases.  The  alterations  consisted  of 
thickening  of  the  lining  membrane  by  congestion,  oedema,  exudation  into  the  submucous 
tisstie  or  the  develojjinent  of  false  membranes  on  its  surface;  not  unfrequently  the  membrane 
was  ulcerated, ''■  and  occasionally  small  abscesses  were  formed  in  connection  witli  the  laryn- 
geal cartilages.  Unquestionably  tliese  conditions  were  frequently  the  causes  ot  the  alter- 
ation or  loss  of  voice  and  the  dysphagia  that  were  at  times  present  in  the  progress  of  the  fever. 
CEdema  w^as  a  dangerous  lesion  in  some  instances,  as  in  339,  in  which  it  caused  death  by 
occluding  the  rima  glottidis.  Perliaps  also  this  was  the  cause  of  the  sudden  death  in  36; 
in  this  case,  as  there  was  oedema  of  the  lower  extremities  and  effusion  into  tlie  serous  sacs, 
the  fatal  result  may  have  been  occasioned  by  the  jiericardial  etlusion,  whicli  suffices  to  account 
for  the  masking  of  the  heart-sounds,  the  dyspncea  and  prfCcordial  pain;  but  it  is  not  certain, 
in  the  absence  of  post-mortem  observations  directed  to  the  larynx,  that  an  ccdematous  con- 
dition of  the  glottis  arising  from  the  anseraia  may  not  have  been  the  immediate  cause  of  death. 
Generally,  however,  cedema  glottidis  was  connected  with  local  congestive  processes.  Occa- 
sionally pseudomerabranes  were  the  proximate  cause  of  the  fatal  issue,  as  in  cases  122  and 
308;  but  it  does  not  appear  that  diphtheria  was  specially  a  complication  of  typhoid  or  other 
continued  fevers,  for  it  appeared  in  patients  enfeebled  by  other  diseases  and,  indeed,  by  gun- 
shot wounds.  Its  occurrence  seems  to  have  been  determined  by  the  deteriorated  condition 
rather  than  by  the  specific  cause  of  the  deterioration. f 

Emphysema  of  the  neck  has  been  attributed  to  the  existence  of  ulcers  in  the  laryn.\;J 
but  ill  the  only  instance,  case  98,  in  wdiich  this  condition  of  the  cervical  cellular  tissue  was 
noted,  the  larynx  does  not  seem  to  have  been  examined,  and  the  emphysema,  on  account  of 
a  coexisting  ecchymosis,  was  referred  to  a  hypothetical  ante-mortem  violence.  In  case  12 
the  cedematous  condition  of  the  neck  was  apparently  connected  with  processes  affecting  the 
throat,  as  the  epiglottis  was  much  swollen. 

The  condition  of  the  bronchial  tubes  was  seldom  observed  or  noted,  but  they  occa- 
sionally appear  to  have  been  congested  irrespective  of  the  condition  of  the  pulmonary  tissue. 
In  a  few  cases,  as  281,  331  and  362,  there  were  distinct  evidences  of  inflammation. 

The  condition  of  the  lungs  was  variously  reported  by  our  medical  officers  as  engorged, 
congested,  oedematous,  splciiified  or  hepatized.  They  weighed  more  than  in  the  healthy 
state  from  the  affiux  and  stagnation  of  the  blood  and  tlie  subsequent  exudation  or  transuda- 
tion of  its  elements  in  certain  parts,  generally  their  lower  and  posterior  portions.  Undoubt- 
edly this  comlition  arose,  in  many  instances,  during  the  great  prostration  that  iinnirdiately 
preceded  death,  fur  it  was  found  in  cases  in  whicli  there  had  been  no  symptomatic  manifesta- 
tion of  its  presence;  but  in  other  cases  the  morbid  action  was  of  a  more  active  charactei', 
leading  to  a  true  hepatization.     Generally  the  sanguineous  condensation  was  difTuse,  but  it  was 

*  Acronling^  to  Likrermelster,  ZinusseHs  Cifi^hpetUa,  Am.  Ed,,  Vol.  1,  p.  160.  hin-^npeal  ulcern  are  itf  romparatively  frequent  (iccurrenco  in  typhoid. 
He  litis  IIuFFM.^NN  a^  having  found  them  in  2.S  uf  250  autopsie.'i  of  ty[)hi,;iil  fuver,  and  (iRiE^iMiKu  in  2']  jicr  f.'nt.  of  liis  fatal  casi'ft. 

t  Si-e  diplitht-ria,  in/i-'t.  p.  730. 

J  Mi'RCiiTSuN  reft'r^  to  Wilks  as  having  dfoionstrati'd  the  associatiun  of  L^mphysenia  of  tin-  neck  with  nh-er.  '".V  lioy,  ageil  12,  becanur  cniphys.Tma- 
tou^  on  thf  twelfth  diiy  of  an  attack  of  enterit-  fever,  the  emjihyseniaronimoncing  in  the  neck,  spreading;  tn  the  faee.  arms  and  i  IteHt,  and  greatly  im]ieiling 
doghitition.  Death  oi-currod  on  the  twenty-)ii'C(jniI  day,  when  it  was  fnund  that  th''  air  liiid  I'srap'-d  tliruuu'Ii  a  sl.iniching  nlitr  i»f  the  hiryn.x,  r^ituated  at 
the  iHjsterior  junction  of  the  vocal  cords." — Op.  '('.,  p.  So^. 


OF    THE    CONTIiS'VKlt    FEVERt^.  465 

occasionally  eir<:'UiTiscribeJ  in  lobular  ina.s^cs  as  if  ili.'  result  nt' catarrhal  pro(>es,ses.  Owing 
lo  want  of  definition  in  the  records  it  is  um'crtain  t'l  what  extent  lieniorrhagie  infarction  con- 
duced to  the  production  of  the  iiiorlml  aiipearaiicfs. 

The  lungs  presented  a  larger  |in.ijiiirtion  of  niorliid  changes  in  the  typlioid  than  in  the 
malarial  cases.  Tliey  were  altered  froin  the  normal  in  So.)^  per  cent,  of  thirty-four  typhoid 
cases  in  which  their  condition  was  notccl,  and  in  hut  5o.2  per  cent,  of  fifty-eight  malarial 
cases,  the  typho-nialarial  and  iaixe<l  cases  taking  a  middle  position  in  this  respect,  the  former 
presenting  62.7  per  cent,  of  fifty-one  cases  and  the  latter  71.2  jier  cent,  of  one  hundred  and 
sixty-three  cases;  but  while  the  lungs,  like  the  spleen,  were  less  frequently  affected  in  con- 
tinued malarial  than  in  t\plioid  fever,  they  presented  in  the  individual  cases  of  the  former 
more  extensive  or  aggravated  diseased  conditions,  as  manifested  by  the  occurrence  of  ecchy- 
mosis  with  congestion  and  by  the  greater  frequency  of  purulent  collections.  Hurried  respira- 
tion, although  generally  due  to  local  hypertemic  conditions,  was  in  some  instances  attributable 
to  nervous  agitation,  to  febrile  excitement,  to  pressure  on  the  lungs  by  the  tympanitic  abdomen, 
or,  as  in  case  25,  to  a  combination  of  these  conditions. 

The  pleura. — As  compared  with  the  frequency  of  congestive  and  inflammatory  pro- 
cesses in  the  parenchyma  of  the  huigs,  morbid  changes  in  the  pleural  membrane  were  of 
great  rarity.  Adhesions  unconnected  with  the  febrile  attack  are  of  course  excluded  from 
the  list  of  abnormal  appearances.  The  pleural  cavity  sometimes  contained  a  serous  etl'usiun, 
due  in  some  instances  to  a  transudation  from  engorged  capillaries,  but  in  others  to  more 
active  processes,  as  may  be  inferred  from  the  flakes  of  Ivmph  or  purulent  tm-bidity  described 
as  present;  recent  lymph  appeared  occasionally  on  the  surface  of  the  membrane  and  the 
serous  effusion  was  sometimes  tinged  with  blood. 

This  rarity  of  the  pleural  aflPection  in  continued  fevers  among  the  white  troo[)s  is  strongly 
contrasted,  according  to  the  published  statements  of  Surgeon  Roibert  Reyhurn,  U.  S.  Vols., 
by  its  irecpiency  and  fatality  among  the  negroes.  In  a  report*  which  gives  the  results  of 
the  treatment  of  7,949  cases  of  sick  and  wounded  freedmen  in  the  District  of  Columbia  from 
June  1  to  December  31,  1865,  he  states  that  ty[>hoid  fever  constituted  the  most  fatal  although 
by  no  means  the  most  immerous  class  of  cases;  there  were  one  hundred  and  sixteen  cases, 
of  which  forty-nine,  or  nearly  41  per  cent.,  proved  fatal.  lie  considered  that  pneumonia, 
which  so  often  occurred  in  the  progress  of  typhoid  fever  aflfecting  the  Caucasian  race,  became 
in  the  negro  pleuro-pneumonia  of  a  low  grade,  and  was  generally  accompanied  witii  a  large 
serous  or  sero-sanguineous  effusion,  which  after  death  was  found  filling  the  pleural  cavities. 
In  fact,  inflammation  of  the  serous  membranes  seemed  to  be  more  frequent  and  dangerous 
among  negroes  tlian  among  whites.  That  the  effusion  was  not  n  post-mortem  transudation 
was  2>roved  by  its  quantity,  which  entirely  j)recluded  that  idea,  and  by  the  fact  that  in 
many  of  tlie  cases  percussion  revealed  its  existence  during  life. 

The  PERICARDIUM  was  less  frequently  affected  than  the  pleural  Sometimes  an  excess 
of  serum  was  present,  and  occasionally  this  w^as  tinged  with  ]<\oud  or  associated  with  a  slight 
redness  of  the  membrane.  Rarely,  as  in  90,  206,  276  and  307,  there  were  stich  indications 
of  inflammatory  action  as  fibrinous  flocculi  in  the  eihiscd  li(|uid,  exuded  lymph  on  the  serous 
surlace  or  a  thickening  of  the  membrane.  Many  of  the  cases  j)resenting  these  jtericardial 
changes  had  the  lungs  or  pleural  cavities  in  a  morbid  state,  but  in  some,  as  170,  206,  262 
and  328,  there  was  no  coincident  implication  of  these  jiarts. 

*Se«  AmericoH  Journal  of  the  Mediral  l:?i-uiuft,  1866,  p.  3«i4  el  tea. 

Meu.  Hist.,  Pt.  HI— 59 


466  PATHOLOGICAL    ANATOMY    ANP    PATHOLOOY 

The  condition  of  the  heart  was  mentioned  in  less  tlian  one-half  of  the  cases;  and  in 
these  it  was  frequently  said  to  have  been  normal  or  healthv,  as,  for  instance,  in  82  per  cent, 
of  twenty-two  typhoid  cases,  in  75  per  cent,  of  forty-eight  malarial  cases,  in  77  f>  per  cent. 
of  forty  typho-malarial  and  in  77  per  cent,  of  one  hundred  and  thirty-five  cases  of  the  mixed 
series.  Usually,  when  described  as  altered  from  the  normal,  the  words  pale,  anaemic,  soft, 
flabby,  flaccid  or  atrophied  were  employed  to  express  its  condition;  in  a  few  cases  it  was 
said  to  have  been  fatty.  From  these  observations  it  would  bo  dithcult  to  infer  the  frequency 
and  great  importance  of  the  degenerative  changes  in  the  muscular  tissue  of  the  heart  induced 
by  the  continuance  of  the  febrile  movement  as  demonstrated  by  the  investigations  of  IIayem,* 
Vallin^}"  and  others;  but  it  is  known  that  these  changes,  involving  a  cloudiness  of  the 
striae  of  the  muscular  tissue  apparently  by  albuminous  granules  in  the  fll)res  and  inter- 
fibrillar  protoplasm,  and  even  a  fatty  degeneration  of  the  muscle,  arc  gradual  in  their  progress 
and  may  be  shown  by  microscopic  examination  to  be  notably  advanced  although  the  organ 
may  not  attract  attention  by  changes  in  its  macroscopic  characters. 

But  although  the  heart  was  so  frequently  reported  in  a  healthy  condition  by  the  po.sf.- 
mortevi  observers,  the  attending  medical  officers  recognized  in  the  symptoms  a  tendency  to 
a  failure  in  the  powers  of  this  organ,  and  were  inclined  to  attribute  cases  of  sudden  or  other- 
wise unexplained  death  to  this  cause.  Nevertheless,  in  the  series  of  cases  that  have  been 
submitted  there  is  not  one  case  that  may  with  certainty  be  instanced  as  having  proved  fatal 
by  the  sudden  failure  of  a  degenerated  heart.  In  case  184,  which  had  a  suddenly  fatal  ter- 
mination during  an  apparently  favorable  convalescence,  the  heart  was  flabby.  In  the  largo 
number  of  cases  in  which  death  was  the  result  of  progressive  prostration,  ainl  which  were 
unmarked  at  the  autopsy  by  the  presence  of  a  particular  lesion  known  to  be  mortal,  it  is 
possible  that  the  heart  was  materially  implicated,  but  the  records  do  not  say  so.  Thus,  in 
cases  13  and  14,  in  which  it  is  stated  in  terms  that  the  cause  of  death  was  asthenia,  the 
condition  of  the  heart  is  not  mentioned.  On  the  other  hand,  while  there  is  no  certainty 
that  this  degenerated  condition  of  the  heart  was  the  cause  of  death  in  the  cases  in  which  it 
was  present,  it  is  deserving  of  note  that  in  a  large  proportion  of  them  there  was  no  lesion 
of  the  viscera  that  could  l)e  cited  as  the  immediate  cause  of  the  fatal  result.  In  about  one- 
third  of  the  three  hundred  and  eighty-nine  cases  that  have  been  presented  the  cause  of  death 
could  bo  ascribed  to  some  particular  complication  or  lesion,  as  coma,  hemorrhage,  perforation, 
pneumonia,  etc.;  but  of  the  thirty-nine  cases  in  which  the  heart  was  stated  to  liave  been 
pale,  anaemic,  softened,  flabVjy,  atrophied  or  fatty,  a  lesion  t(j  which  death  might  with  proba- 
bility be  assigned  was  found  only  in  six  or  seven  cases, — gangrene  of  the  feet  in  112  and 
278,  gangrene  of  the  intestines  in  311,  perforation  of  the  bowds  in  .S47  and  pneumonia  in 
243,  333  and  perhaps  182.  In  view  of  what  is  known  concerning  the  degeneration  of  the 
muscular  tissue  of  the  heart  in  continued  fevers  it  is  not-  uiiliki'ly  that  death  in  many  of 
these  thirty-nine  cases  may  have  been  due,  to  a  certain  extent,  to  the  special  influence  of 
this  morbid  change. 

Physiological  considerations  lead  to  the  expectation  of  a  greater  frequency  of  congestion 
of  the  lungs  in  connection  with  a  degenerated  condition  of  the  heart  than  in  those  cases  in 
which  this  organ  was  reported  healthy;  but  this  expectatimi  is  not  sustained  l)y  an  examination 

*  Hf^cheri:heit  stir  les  Rapportu  eJistant  entre  /«  Mort  SubUe  et  hs  (Utiratiow  vasculaires  du  Ctxur  rfniw  la  Fittre  Tiiphouk^  par  Georges  Hayem. — Archives  de 
rhysiolopii!  Scirmalo  ct  Pathologiquo,  Paris,  1809,  t.  2'',  p.  6a0. 

t  ^**-'  .4/(tm/w)ji»  Ui'^oloijiiiiKu  dn  Ijvur  et  ties  lUuKle^  VolotUaireH  dam  letiji-:rres peniU-iemen  et  r'  itiUleiU^n,  par  >l.  K.  V.vLLlN. — Meniuires  do  Medeciue,  Ac, 
Militaries,  3""  serie,  t.  XXX,  Paris,  1S7I, 


OF    THE    CONTINITKD    FKVERS.  467 

of  the  records.  The  condition  of  rhe  hinij:^;  wa.*  not  statt-d  in  four  of  the  thirty-nine  cases  in 
which  the  heart  was  said  to  have  been  degenerated:  in  twelve  tlie  lungs  were  normal  and 
in  twenty-three  congested  or  more  activelv  diseased;  thrv  were,  therefore,  altered  in  tipper 
cent,  of  the  cases  in  whii-h  their  condition  was  repnrl<d.  (hi  the  otlit^r  hand,  in  looking  at 
the  cases  in  wlndi  the  records  do  not  state  the  heart  to  have  presented  this  Halihy  comhtion 
of  its  walls,  tile  lungs  were  hv|)eriemie  in  one  hundred  and  eighty-six,  normal  in  eighty-five, 
while  in  seventy-nine  their  condition  was  not  stated,  /.  ''.,  they  were  congested  or  otherwise 
altered  in  68.7  per  cent,  of  the  cases  in  which  tlieir  condition  was  recorded.  In  view  of  these 
figures,  showing  the  association  of  a  larger  proportion  of  congested  lungs  with  hearts  that  did 
not  attract  attention  by  their  morbid  conditions  than  with  those  that  were  reported  as  more 
or  less  degenerated,  it  is  to  be  inferred  that  j)ulmonary  congestion  in  these  fevers  was  uncon- 
nected with  the  condition  of  the  heart  or  that  the  naked-eye  appearances  of  the  latter  organ 
gave  by  no  means  a  true  impression  of  its  actual  condition. 

The  contents  of  the  chambers  of  the  heart  were  noted  in  ninety-six  of  the  three  hun- 
dred and  eighty-nine  cases  of  continued  fever.  In  nine  of  these  it  is  stated  that  no  clots 
were  present:  In  48  the  heart  was  pale;  in  329  tliin;  in  137  flabby;  in  165  and  277  it  was 
said  to  have  weighed  nine  ounces;  in  96  it  was  repoiled  large,  the  left  ventricle  empty  and 
the  right  containing  uncoagulated  blood;  in  150  and  190  the  blood  was  uncoagulated ;  in 
191  there  was  a  thin  wafer-like  formation  on  the  tricuspid  valve.  Manifestly,  fi'om  the 
small  number  of  cases  in  which  the  heart  was  reported  as  having  been  found  free  from  clots, 
its  contents  were  specially  noted,  as  a  rule,  only  when  the  attention  ot  the  recoi-der  was 
attracted  by  these  coagula. 

Clots  occurred  with  greater  frequency  in  the  cavities  of  the  right  side  than  in  those  of 
the  left.  In  a  few  instances  the  records  do  not  specify  whether  the  coagula  or  fibrinous 
(joncretions  were  formed  in  the  right  or  left  side  or  in  both  sides,  the  statement  being  simjily 
as  to  their  presence  in  the  heart.  But  if  their  existence  in  the  chambers  of  both  sides  be 
assumed  in  these  cases,  it  will  be  found  that  of  eighty-seven  recorded  cases  of  heart-clot  both 
sides  were  afifected  in  forty-nine.  Of  the  remaining  thirty-eight  cases  tlie  right  side  con- 
tained clots  in  thirty-five  and  the  left  in  three  instances.  Of  those  containing  clots  in  the 
righ  chambers  only,  the  lef''  side  contained  fluid  blood  in  two  and  no  clot  in  two,  while  in 
thirty-one  assurance  isj  conveyed  of  the  absence  of  clots  by  the  fact  that  their  presence  was 
not  recorded.  In  the  cases  containing  clots  in  the  left  chambers  only,  the  right  sid(>  con- 
tained fluid  blood  in  one  instance  and  no  clot  in  another;  in  the  third  no  statement  of  its 
contents  is  given.  The  greater  liability  of  the  right  side  of  the  heart  to  the  accunuilation 
of  coagula  may  be  gathered  from  these  figures.  Clots  were  noted  in  the  right  cavities  of 
eighty-four  an<l  in  the  left  cavities  of  fifty-two  hearts. 

But  the  character  of  the  coagulum  had  a  tendency  to  vary  according  as  the  right  or 
left  chambers  of  the  heart  were  its  seat.  Of  the  eighty-four  coagula  noted  in  the  ri'dit 
cavities  fifty-six  consisted  of  fibrinous  concretions  or  deposits,  frequently  filling  the  cham- 
bers and  projecting  into  the  great  vessels,  eight  were  venous  or  black  clots,  six  a  mixture 
of  fibrinous  deposits  and  venous  coagula,  while  in  fourteen  the  api)earance  of  the  clot  was  not 
entered  on  the  record.  Of  the  fifty-two  coagula  in  the  left  cavities  twenty-five  were  fibrin- 
ous, eight  venous,  seven  mixed  and  twelve  of  unstated  appearance. 

Dr.  WooDWAKij  has  discussed  tlie  general  question  of  heart-clot  in  connection  with  if/. 


468  PATHOLOGICAL    ANATOMY    AND    FATHOLOaY 

occurrence  in  diarrlicna  ami  dysentery.*  He  concluded  tliat  altliougli  iibrinous  coagula  may 
be  formed  during  life  tliey  must  be  regarded  in  ilie  vast  majority  of  instances  as  occurring 
during  tlie  death  agony.  He  pointi^d  out  that  no  facts  had  been  presented  to  sliow  that 
clots  were  formed  men.'  frequently  in  cases  of  sudden  death  than  in  cases  of  the  same  disease 
in  which  death  took  place  in  the  usual  way  and  without  any  symptoms  referable  to  the 
heart;  and  that  there  was  no  evidence  that  the  clots  in  tlio  one  group  of  cases  differed  from 
those  that  occurred  in  the  others  as  to  size,  texture,  adhesions,  etc.  Di'.  Woodwakd  dealt 
with  this  question  before  the  whole  of  the  data  relating  to  it  had  been  submitted.  It  is 
true  the  further  evidence  contained  in  the  records  does  not  unsettle  his  conclusions;  but  if 
there  had  been  before  him  the  cases  of  lieart-clot  recorded  in  the  chapter  on  the  paroxysmal 
fevers,f  with  cases  271  and  377  of  the  continued  fevers  and  34  of  the  secondary  pneumonias, | 
it  is  probable  that  he  would  have  given  a  more  emphatic  acknowledgment  of  the  existence  of 
heart-clots  of  ante-mortem  development,  and  conceded  them  as  a  whole  a  higher  place  in  the 
scale  of  importance.  The  clots  being  manifestly  of  ante-mortem  formation  in  some  cases,  it 
is  assumed  that  they  must  have  had  a  similar  history  in  other  cases  unless  it  can  be  shown 
that  in  the  latter  they  were  of  post-mortem  origin.  It  is  admitted  that  in  most  instances 
these  clots  were  formed  when  the  patient  was  about  to  succumb.  The  question  at  issue  is 
their  relation  to  the  death  agony.  If  they  w^ere  formed  during  the  agony  and  because  of  it, 
they  had  only  a.  post-mortem  value;  but  if,  as  seems  likely  from  the  cases  presented,  they 
were  due  to  some  cause  which  induced  a  temporary  stasis  or  retardation  of  the  flow  of  the 
blood  through  the  chambers  of  the  heart  and  brought  about  the  agony  by  the  rapidity  of 
their  development,  they  become  of  importance  as  the  determining  cause  of  the  fatal  issue  in 
a  large  number  of  cases  and  as  indicating  the  necessity  of  preserving  i)atients  from  such 
influ(>uces  as  are  known  to  be  efficient  in  precipitating  the  deposition.  When  the  predis- 
iiosing  conditions  were  not  strongly  marked,  as  in  a  case  of  typhoid  in  which  the  patient 
apparently  retained  strength  sufficient  to  enable  him  to  help  himself  in  many  of  the  neces- 
sities incident  to  his  condition,  a  notable  impress  on  the  system  might  be  required  to  con- 
stitute the  immediate  or  determining  cause  of  the  fibrinous  deposits,  as  the  faintness  which 
followed  the  exertion  of  rising  to  stool  in  cases  271  and  379,  or  the  chill  in  96  of  the 
paroxysmal  series.  But  on  the  other  hand,  in  the  presence  of  strongly  predisposing  condi- 
tions, such  as  were  constituted  by  the  prolonged  duration  of  the  fever,  the  existence  of 
pulmonary  livpenemia,  the  exhaustion  of  diariiioea  or  hemorrhage  or  the  collapse  attendant 
on  perforation,  the  agency  that  determined  the  deposit  and  the  closely-following  fatal  result 
mifj-ht  have  been  so  slight  as  to  have  passed  unnoticed;  yet  it  may  not  bo  allowed  that  there 
was  no  exciting  cause  to  occasion  tlie  deposit  and  death  at  that  particular  time. 

In  the  majority  of  cases  in  whicli  heart-clots  were  formed  there  was  no  lesion  of  the 
abdominal  viscera,  brain  or  lungs  obviously  inconsistent  with  tli(!  continuance  of  life.  To 
no  one  in  particular  of  the  niorliid  changes  iu  these  organs  could  the  role  of  executioner  be 
assii'ned.  The  patients  died  from  the  totality  of  the  morbid  changes  produced  l)y  the  fever, 
tvphoid  or  malarial,  as  the  case  may  have  been,  or  from  the  asthenic  conditions  bearing  on 
the  thread  of  life  in  the  diarrhoeal,  pneumonic  or  other  cases  in  which  heart-clot  was  iound 
as  ii  2'>ost-mortem  a}:)pearance ; — or  tliey  died  from  heart-clot.  But  while  the  totality  of  the 
morl)id  changes  w^as  an  inconstant  quantity  and  of  an  uncertain  value,  the  heart-clot  was 
constant  and  efficient.      In  view  of  these  considerations  it  is  not  surprising  that  our  medical 


*  Seo  p.  SKI  rl  »('.;.  of  the  Si'ivrtul  I'art  "f  tilis  work.  fSee  snjira,  page  138.  J  See  iii/rn,  page  788. 


OF    THE    CONTTyUET)    FEVERS. 


469 


officers  came  to  regard  the  fibrinous  coawula  as  the  immediate  cause  of  tlie  fatal  issue  in  the 
cases  presenting  them.  If  a  patient  manifestly  died,  as  in  llU,  from  exhaustion  con- 
sequent on  rejieated  hemorrhage  from  the  bowels,  Avliat  may  lie  conceived  to  have  been  the 
modus  oj)erandl  of  the  cause?  The  hemorrhage  preilis|ioscd  to  death  by  syncope,  but  the 
patient  did  not  die  until  a  clot  liad  formed  in  his  heart.  He  might  liave  lingered  for  some 
time  longer,  notwithstanding  the  weakened  action  of  the  heart  and  the  altered  condition  of 
the  blood,  had  not  some  slight  exciting  cause  determined  the  deposition  of  the  fibrinous 
coagulum,  which  speedily  interfered  with  the  continuance  of  the  cardiac  flow.  In  case  112, 
in  which  the  patient  may  be  said  to  have  died  of  gangrene  of  the  feet,  there  was  no  condition, 
so  far  as  is  learned  from  the  record,  to  occasion  the  immediate  extinction  of  life  until  the  depo- 
sition of  fibrin  was  effected  by  some  trifling,  but  under  the  circumstances  all-sufficient  cause. 
In  some  of  the  cases  of  peritonitis  from  perforation,  as  45,  106,  156,  245  and  347,  or  that  in 
which  the  gall-bladder  was  perforated,  case  95,  there  appears  no  cause  for  the  destruction  of 
life  at  one  particular  moment  ratlier  than  at  another,  if  the  fibrinous  coagula  in  the  heart  are 
excluded  from  consideration.  So,  too,  in  such  pneumonitic  cases  as  62,  198,  281,  357  and 
369,  in  the  pleuritic  effusion  of  340,  and  in  the  cases  217  and  304,  which  passed  into  death 
from  a  condition  of  coma,  the  agency  that  determined  the  occurrence  of  the  fatal  event  at  one 
time  rather  than  anotlier  must  be  conceived  to  have  been  the  development  of  these  clots, 
owing  to  some  temporary,  and  but  for  this  not  necessarily  permanent,  stasis  in  tlie  passage 
of  the  blood  through  the  chambers  of  the  heart.  Even  in  such  a  case  as  122,  in  which  the 
occlusion  of  the  larynx  by  diphtheritic  membranes  may  be  readily  assigned  as  the  cause  of 
death,  it  is  probable  tliat  the  immediate  cause  was  the  fibrin  deposited  in  the  heart  during 
the  stasis  occasioned  by  the  last  of  the  suffocative  paroxysms;  since,  if  this  had  not  occurred, 
the  patient  might  have  lived  to  have  added  another  to  the  suffocative  paroxysms  that  he  had 
already  experienced.  The  proposition  that  certain  cardiac  concretions  are  formed  during  life 
does  not  therefore  rest  exclusively,  as  it  appeared  to  Dr.  Woodward,  upon  the  anatomical 
characteristics  of  the  concretions;*  but  in  some  cases  very  clearly  on  tlie  symptoms,  and  in 
others  less  clearly  on  positive  and  negative  pathological  evidences.  These,  indeed,  suggest 
that  sometimes  the  ordinary  black  coagulum  may  have  an  ante-mortem  formation  and  be  the 
cause  of  the  death  agony."]" 

Theoretically,  one  of  the  conditions  provocative  of  the  deposition  of  fibrin  in  the  heart 

*  Page  .■>41,  Part  II. 

fThe  three  folhfwing  cases  are  briefly  presented  as  illustrating  the  ante-mortem  occurrence  of  all  the  varieties  of  clots  that  have  been  found  iu  tiie 
beart :  1st.  Fibrillated  clots  with  central  softening  and  arterial  iirojections  into  their  roots,  which  manifest  with  certainty  their  aute-niortem  origin; 
2d.  Fibrinous  clots  which  sonictiiues  by  their  symptoms,  as  in  the  cases  already  given  in  the  text,  are  known  to  precede  and  cause  the  death  agony  ;  3d. 
Ordinary  blood  coagula,  which  are  usually  ascribed  to pmt-un>rt<fm  changes,  but  which  may,  in  some  cases,  be  the  itiimediate  cause  of  death.  The  first  is 
related  by  John  G.  M.  Kesorok,  Ediuhiinjh  Meil.  Joiir.,  Vol.  XV,  1800,  p.  3ilf..  The  patient,  a  woman  of  1'.),  was  admitted  Feb.  2:!,  180!1,  ami  died  .March  1. 
She  was  low-spirited  and  anxious,  but  complained  only  of  slight  cough  and  frontal  headache,  particularly  towanls  evening.  The  most  remarkable  phe- 
nomenouofthecase  was  a  constant  moaning  of  the  patient  during  sleep,  which  was  usually  disturbeil  by  frightful  dreams.  Nothingrelieved  this  distressing 
symptom  except  propping  her  head  and  shoulders  high  with  pillows.  One  morning,  having  been  iu  her  usual  state  till  breakfast  time,  she  smldenly 
became  worse,  dying  at  10  a.  m.,  ajiparently  from  congestion  of  the  lungs.  In  the  right  auricle  there  was  a  w  liite  irregularly  pear-shaped  clot  about  the 
size  of  a  large  walnut,  attached  by  several  baud-like  prcKes-ses  at  its  narrow  end  to  the  mnsculi  pectiuati  in  the  apex  tit  the  appendage.  This  clot,  of 
firm  consistence  and  slightly  tloccnlar  apjiearance,  had  a  cavity  iu  its  centre  conuuunicating  with  the  exterior  by  a  snuill  rent  in  its  substance.  In  the  left 
auricle  a  firm  white  clot,  attached  to  the  colunuue  carnea',  divided  into  two  branches,  one  of  which  mclnded  the  mitral  orifice  and  the  other  extended 
into  the  aorta.  Hy[»ertrophy  of  the  left  ventricle,  thickening  of  the  anterior  Hap  of  the  tricuspid  valve  and  iuip<'rfect  closure  of  the  forauieu  ovale,  were 
also  observed.  The  lungs  were  much  congested,  and  a  few  ounces  of  .serum  were  found  in  the  left  pleural  cavity  together  with  a  little  serum  in  the  p«ri- 
cardium,  l)Ut  there  was  no  pericarditis.  The  clots,  on  microscopical  examination,  were  found  to  be  of  fibrillated  structure,  boldiug  in  its  meshes  tunnerous 
corpuscular  bo<lies  with  corrugated  edges  ;  several  minute  lilocslvessels  from  the  endocardium  entered  the  root  of  one  of  the  band-like  pris-esses  of  the  clot 
iu  tliB  right  auricle,  liut,  as  far  as  could  be  observed,  did  not  penetrate  its  substance  ;  the  ei)ithelial  layer  of  the  endoiardium,  with  the  subjacent  one  of 
elastic  tissue,  seemed  to  be  reflected  upon  the  root  of  the  clot  and  to  run  along  with  it  for  a  few  lines.  The  second  case  is  given  by  Hr.  I'lAVr.MTi.  in  tie- 
Trati".  Pidlt.  .S^c.  Loudon,  Vol.  .Will,  l.sfiT.  pp.  l>.s-7(l,  as  having  .scurredat  King's  t'ollege  h.'>pital.  The  patient  liati  complailii^  of  (Kiin  in  the  right  knee, 
but  there  was  no  swelling  or  tenderness  of  the  part,  nor  feverishiu-ss.  .\n  alkaline  mixture  was  prescribed.  She  was  not  seen  next  clay.  On  the  third 
morning  she  expressed  herself  free  from  pain  and  said  she  had  i»asseil  a  good  night  ;  but  shortly  aftci'  this  she  complained  of  feeling  weak,  and  asked 
for  a  bed-pan  that  she  might  not  have  to  leave  her  bed.  She  was  tln-n  seized  with  hurried  breathing  and  died  befoi'e  tlie  house  physician,  who  was 
sent  for,  could  arrive..    On  poiU-niortem  examination  all  the  organs  and  structures  of  the  body  were  found  to  be  healthy.     A  finn  solid  clot  of  fibrin  of 


470  PATHOLOGICAl.   ANATOMY   AND    PATHOLOGY 

is  that  degeneration  of  its  muscular  tibre  which  in  prolonged  fever  gives  rise  to  the  cluirac- 
teristic  feebleness  of  the  pulse.  But  the  records  do  not  show  a  greater  frequency  of  clots 
in  hearts  reported  pale,  flabby,  flaccid,  etc.,  than  in  those  reported  healthy  or  which  did  not 
attract  attention  by  any  abnormal  appearances.  Of  thirty-nine  cases  in  which  a  degenera- 
tion of  the  heart  was  noted  it  was  free  from  clots  in  two  cases,  its  contents  were  not  stated  in 
twenty-nine  cases,  and  it  contained  clots  in  eight  cases,  or  in  20.5  per  cent,  of  the  number 
observed.  The  eight  cases  were  75,  276  and  347,  in  which  fibrinous  clots  were  present  in 
both  sides  of  the  heart;  112  and  184,  in  which  they  were  confined  to  the  right  side,  and  148, 
154  and  219,  in  which  coagula,  the  character  of  which  was  not  specified,  were  found,  pre- 
sumably, in  both  the  right  and  left  chambers.  Of  three  hundred  and  fifty  cases  in  which 
the  condition  of  the  heart  was  not  stated  or  stated  to  be  healthy,  seventy-nine,  or  22.5  per 
cent,  of  the  whole  number,  contained  clots.  In  view  of  what  has  already  been  advanced 
concerning  the  difficulty  of  deciding  upon  the  actual  condition  of  the  heart  from  its  micro- 
scopic appearances,  this  similarity  in  the  percentages  of  heart-clot  in  the  two  sets  of  cases 
might  1)e  construed  as  indicating  that  the  heart  was  possibly  as  much  weakened  in  the  cases 
in  which  its  condition  was  not  stated  or  said  to  have  been  healthy  as  in  those  in  which  the 
observers  considered  it  flabby  or  otherwise  degenerated. 

As  congestion  of  the  lungs  was  so  commonly  present  in  the  final  hours  of  continued 
fever,  occurring  in  as  many  as  68.3  per  cent,  of  the  cases,  the  frequent  coincidence  of  clots  in 
the  heart  with  such  congestion  was  to  be  expected.  On  questioning  the  cases  for  a  possil>le 
connection  between  the  presence  of  fibrinous  clots  in  the  right  chamber  of  the  heart  and  an 
engorged  or  other  condition  of  the  lungs  interfering  with  the  circulation  of  the  blood  through 
their  tissues  the  following  information  is  obtained: 

III  the  five  cases  of  typhoid  in  which  separation  of  filniii  took  place  there  were  pulnioiiary  conditions  during 
the  last  stage  of  the  fatal  illness  involving  stasis  of  the  blood-current. 

In  four  of  the  fourteen  cases  of  the  walarial  series  in  which  there  were  fibrinous  coagula  in  the  right  chambers 
the  luni's  were  not  seriously  affected:  In  2^>U  some  injection  and  a  small  nodular  consolidation  was  recorded,  but 
the  weight  of  the  lungs  was  inconsistent  with  any  material  engorgement;  in  71  the  lower  ]iart  of  the  pleura  on  one 
side  was  said  to  have  been  intlamed.  whence  it  may  be  inlVried  that  had  the  i)ulinonary  tissue  i>resented  any  notable 
abnormity  it  would  have  been  observed  and  recorded;  in  the  two  cases,  2!t2  and  29;^,  the  lungs  were  exi>ressly  stated 
as  having  been  in  a  healthy  condition. 

Of  the  ten  typho-nialarial  cases  presenting  libiinous  clots  in  the  right  side  the  lungs  were  nmnial  in  four,  77, 
95  102  and  271,  while  in  a  fifth,  2(it>.  old  pleuritic  adhesions  constituted  the  only  abnormity.  Moreover,  106,  in  which 
clots  of  an  unspecified  character  were  found  in  the  heart,  liad  the  lungs  in  a  healthy  state. 

Lastly,  of  the  thirty-one  cases  of  the  mixed  series  in  which  filirinoiis  or  partly  fibrinous  clots  were  observed 
in  the  right  side  of  the  heart,  the  lungs  were  normal  in  four,  1(!7,  220,  221  and  347,  while  in  a  fifth,  llifi,  the  pulmonary 
disease  consisted  merely  of  a  few  softened  tubercles  in  the  apex  of  each  lung. 

From  the  above  figures  it  may  be  calculated  that  congestion  of  tlie  lungs  was  present 
in  75.4  per  cent,  of  those  fever  cases  in  which  the  heart  was  found  to  contain  fibrinous  or 
mixed  clots  in  the  cavities  of  its  right  side.  This  increase  in  the  percentage  of  lung 
disease  in  the  heart-clot  cases  may  be  considered  an  expression  of  the  infiuence  of  pulmonary 

a  pale-yellow  cnlor  was  fonml  in  tin-  right  siilf  i.f  tlie  heart  and  ipiilnioiiaiy  artery,  adhering  tu  the  valves  and  fleshy  ruluuins.  If  this  elut  was  formed 
during  the  death  agony,  why  did  the  death  agony  wcur?  If  the  wonmn  did  nut  die  of  heartnlot,  what  was  the  eanse  of  death  ?  Ilr.  Pi.avkair'k  theory 
was  that  the  clot  had  i.robably  heen  forming  during  the  night  preceding  the  fatal  result,  and  that  so  long  as  the  |iatient  remained  quiet  sufficient  blood 
passed  through  the  obstructed  vessels  to  carry  on  the  organic  functions,  but  when  she  was  obliged  to  exert  herself  there  was  a  sndtlen  call  for  blood,  which 
could  not  be  supplied  through  the  included  artery,  anil  death  resulted.  Dr.  John  A.  LuiEl.L,  ..f  New  y..rk,  gives  the  third  case,— .Im.  Jour.  ,./  Med.  Sci., 
Vol.  XLIV,  18TJ,  p.  3iS.— that  of  an  inteui(«Tate  woman,  who,  whi'n  recovering  from  an  attack  of  epileptic  convulsions,  was  seized  with  dyspnoea,  and  died 
in  an  hour.  The  left  pulmonary  artery  was  obstructed  w  itii  coagula,  Th.'  heart  was  enlarged,  fatty  exbrnally  arjd  flabby;  its  cavities  were  dilated  and 
those  of  tin-  right  side  filled  with  dark-iolored  clotte.1  blo.xl.  The  right  lung  was  njnch  congested  and  .edematousand  the  left  intensely  crmgested.  It  was 
SUPIHJS.-J  that  the  coagula  iu  the  artery  had  at  first  formed  a  part  of  tlie  mass  r,,„ud  in  the  right  side.. f  the  heart,  whi.h  wascoiueive.1  to  have  originated 
in  the  stasis  of  the  blood  att.n.ling  the  epileptic  convulsion,  and  that  tlies.-.  altir  the  i.atient  hail  recovered  her  consciousness,  had  b.-eu  carried  to  the 
point  where  they  were  found.  It  is  true  the  opinions  of  PnvrAiR  and  I.toKi  I.  are  merely  conjectures,  but  they  are  conjectures  founded  on  posl-morlem 
and  negative  pathological  evidenc.-,  in  view  of  th.'  history  of  the  patient  during  the  later  hours  of  life. 


OF    THK    CONTINUED    FEVF.RS. 


471 


conditions  as  predisposing  to  the  formation  of  clots;  but,  in  view  of  the  rehxtively  harge 
number  of  these  cases  in  which  tlie  luugs  were  in  a  liealthy  or  comparatively  liealthy  con- 
ditiun,  the  clots  may  not  be  referred  for  causation  to  the  pulmonary  congestion  alone. 

The  opinion  is  very  generally  entertained  that  in  the  course  of  continued  fevers  the 
blood  becomes  progressively  altered  by  the  diminished  nutrition  of  the  patient  and  the  abnor- 
mal action  of  the  various  organs  concerned  in  elaboration  and  elimination,  irrespective  oi 
the  morbid  changes  that  may  be  produced  in  it  by  the  more  or  less  direct  action  of  a  specihc 
fever-poison.  But  tlie  character  of  the  blood-changes  has  not  been  sufficiently  studied. 
When  inflammatory  conditions  prevail  in  the  system  tlie  fibrin,  as  is  well  known,  becomes 
largely  augmented,  hi  such  cases  there  would  be  no  difficulty  in  appreciating  the  existence 
of  a  predisposition  to  coagulation.  But  the  deterioration  in  fevers  that  are  not  symptomatic 
of  acute  inflammatory  pi'ocesses  seems  rather  to  tend  to  a  difsHolutio  sangiii/iis  manifested 
by  the  fluid  and  disorganized  condition  in  which  the  blood  is  sometimes  found  after  death, 
and  by  the  ecchymoses,  hematuria,  epistaxis  and  other  hemorrhages  that  appear  in  the 
])rogress  of  the  disease.  The  one  series  of  changes  oflTsets  the  other  so  far  as  relates  to  the 
proportion  of  fibrin  in  the  blood,  and  involves  the  occm'rence  of  fibrinous  coagula  in  the  heart 
in  corresponding  obscurity. 

Since  post-mortem  observations  on  the  pale,  weak  and  flaccid  heart  fail,  as  has  been  seen, 
to  connect  it  as  a  strongly  predisposing  element  with  the  heart-clot  of  fever;  since  ])ulmonary 
congestion  and  inflammation  give  but  a  slight  increase  in  the  percentage  of  these  clots, 
and  since  the  condition  ol'  the  blood  itself  does  not  appear  to  be  notably  favorable  to  their 
development,  it  follows  that  for  their  production  there  is  needful  an  immediate  or  exciting 
cause  of  an  intensity  pro[)ortioned  to  the  inadequacy  of  the  predisposing  factors.  Generally, 
no  doubt,  this  is  constituted  by  some  unusual  exertion  on  the  ])art  of  the  patient,  perhaps 
sometim(\s  by  mental  im]>rossi()ns;  but  accurate  details  of  death  scenes  in  fever  are  nec- 
essary to  complete  our  knowledge  of  the  immediate  causes  and  j)rogress  of  these  fibrinous 
depositions. 

Thk  blood. — Few  observations  were  made  on  the  condition  of  the  blood  in  the  con- 
tinued fevers.  Tt  was  said  to  have  been  thin,  uncoagulated  or  unusually  fluid  in  the  five 
cases,  25,  70,  96,  150  and  264.  It  is  singular,  in  view  of  the  general  belief  in  the  connec- 
tion between  a  disorganized  condition  of  the  blood,  such  as  exists  in  scurvy,  and  cutaneous 
Ijlotches  of  a  hemoiThagic  nature,  tliat  in  none  of  these  cases  is  there  a  record  of  petechial  spots 
or  cutaneous  or  internal  ecchymoses.  In  one  case,  70,  the  liquidity  of  the  blood  was  asso- 
ciated with  oedema  of  the  lower  extremities.  In  case  204,  in  which  a  decrease  in  the  num- 
ber of  white  corpuscles  was  recorded,  it  is  observed  that  the  spleen  was  remarkably  liloodless 
and  the  thyroid  gland  enlarged. 

According  to  the  records  ecchymoses  of  the  internal  organs  were  _'arely  coincident  with 
ecchymoses  of  the  skin;  whence  it  may  be  inferred  tliat  the  former  were  in  general  the 
result  of  local  congestions  rather  than  of  a  deteriorated  condition  of  the  blood,  and  similarly, 
tliat  the  latter  were  frequently  due  to  local  rather  than  general  conditions.  Tiius,  in  the 
typhoid  series  there  were  blood-clots  in  the  pleural  cavity  in  31  and  a  bloody  or  reddish  serum 
in  the  jtericardium  in  26.  In  the  malarial  series  the  lungs  were  ecchymosed  in  258  and  288, 
and  in  the  former  the  pleura  contained  a  quantity  of  bloody  serum;  the  stomach  was  ecchy- 
mosed in  262,  the  intestines  in  91  and  365,  and  the  upper  surface  of  the  cerebral  hemis- 
pheres in  287.     In  the  typho- malarial  series  the  ileum  was  affected  in  273,  and  in  this 


472  PATHOLOGICAL    ANATOMY    ANT)    PATHOLOGY 

instance  tlie  skin  also  was  implicated.  In  the  mixed  series  of  eases  the  pericardium  con- 
tained reddish  serum  m  182  and  183;  a  similar  effusion  was  i'ound  in  the  pleural  cavities 
in  168,  338  and  310;  the  oesophagus  was  ecchyraosed  in  301  and  329,  the  stomach  and 
bladder  in  342,  the  ileum  in  203,  the  colon  in  162,  301,  318  and  370,  the  liver  in  380  and 
the  kidneys  in  181  and  187.  But  in  none  of  these  cases,  except  203  and  273,  was  the  pas- 
sage of  the  blood  from  the  vessels  of  the  internal  organs  associated  with  a  similar  leakage 
from  those  of  the  skin.  The  post-mortem  records  are,  however,  very  defective  so  far  as 
relates  to  the  condition  of  the  skin.  This  is  shown  by  the  number  of  typhoid  cases  in 
which,  altliough  petechije  were  present  according  to  the  clinical  record,  no  mention  was  made 
of  their  existence  by  the  post-viortcm  observer.  It  may  be  claimed,  therefore,  that  in  tlie 
case.s  instanced  above  there  is  no  evidence  that  the  skin  was  free  from  petechise,  purpuric 
spots  or  ecchymotic  blotches. 

If,  however,  the  cases  which  presented  such  spots  or  blotches  be  examined  for  concur- 
rent leakage  in  the  internal  organs,  it  will  be  found  that  few  instances  of  coincidence  are 
recorded.  The  eight  typhoid  cases  in  which  the  skin  was  more  or  less  spotted  hiul  no  inter- 
nal ecchymoses.  The  eight  malarial  cases  that  presented  superficial  blotches  showed  similar 
internal  appearances  in  but  one  case,  386,  in  which  the  heart  and  the  colon  were  affected. 
Of  the  four  cases,  86,  93,  114  and  273,  of  the  typho-malarial  series  that  had  the  skin  eccliy- 
mosed,  tlie  last  mentioned  had  the  ileum  also  spotted.  Finally,  of  the  nine  casos  of  the 
mixed  series  that  showed  purpuric  spots  on  the  cutaneous  surface  only  one,  203,  had  ecchy- 
moses of  the  internal  organs.  Although  petechise  or  other  superficial  colorations  may  have 
been  overlooked  by  the  recorders  in  cases  presenting  internal  ecchymoses,  it  is  not  likely  that 
the  latter  would  have  been  overlooked  wliere  the  record  preserves  the  existence  of  the  former. 
Thus  it  may  be  concluded  that  internal  ecchymoses  were  not  invariably  associated  witli 
cutaneous  transudation,  and  that  in  inanv  instances  each  of  these  was  due  rather  to  local 
conditions  than  essentially  to  the  deteriorated  condition  of  the  blood. 

But  perhaps  the  facts  would  be  expi-essed  with  greater  accuracy  by  the  statement  that 
wliile  the  situation  of  the  extravasations  and  transudations  was  dependent  on  local  condi- 
tions their  existence  was  renderctl  possible  only  by  the  changes  wliich  had  taken  place  in 
the  blood.  An  abnormal  state  of  the  l)l(Hid,  fi'equently  manifested  bv  petechia',  vihices, 
blood-colored  urine  and  passive  hemorrhages  lias  already  been  noted  as  characterizing  per- 
nicious cases  of  the  paroxysmal  fevers.  In  ca^^es  of  continued  fever  of  malarial  origin  a  sim- 
ilar condition  miglit  naturallv  be  expected.  In  typhoid  cases  it  is  ditiicult  to  assume  a 
healthv  condition  of  the  blood,  in  view  of  the  prolonged  interference  with  the  normal  action 
of  the  various  organs  concerned  in  its  preservation  at  a  ]>articular  standard.  A.ssinniug  this 
unhealthy  condition  to  have  existed,  it  would  probably  have  been  especially  marked  in  pro- 
longed or  pernicious  cases;  but  since,  as  has  been  shown  by  the  records  of  the  Seminary  and 
other  hospitals,  it  was  precisely  in  such  cases  that  petechia  and  vibices  were  of  frequent 
occurrence,  it  may  be  concluded  that  a  connection  existed  in  typhoid  between  the  condition 
of  the  blood  and  these  ecchymotic  appearances,  although  the  Uiw  observiitions  on  the  blood 
in  the  post-mortem  records  of  the  continued  fever  fail  to  show  it.  This  view  is  sustained  by 
the  liemorrhagic  blotches  of  scurvy,  which  are  known  to  deiiend  on  a  deterioration  of  the 
blood  constituting  the  essence  of  the  disease,  by  tlu;  ecchymoses  of  typhus  and  by  the 
transudations  which,  occurring  in  association  with  a  liipiid  and  uncoagulable  state  of  the 
blood,  gave  the  name  of  spotted  fe\'ei-  to  those  febrile  cases  characterized  by  a  special  impli- 


OF    THE    CONTINUED    FEVERS. 


473 


cation  of  the  ccrebi'o-spinal  systoin.  It  is  sustained  al^^o  by  tlie  extravasatioi;s  of  altered 
blood  observed  in  the  paroxysmal  fevers;  and  as  in  these  there  was  the  same  want  of  coin- 
cidence between  external  and  internal  hemorrhagic  manifestations  tliat  was  found  in  typhoid, 
it  follows  that  ecchymotic  spots  were  probably  as  nim-h  due  to  an  altereil  condition  of  tlie 
blood  in  tlie  latter  as  in  the  former  cases. 

But  althouo-h  the  connection  between  a  deirenerated  blooil  and  its  escape  Iroiu  the  ves- 
sels  may  require  argument,  in  view  of  the  non-coincidence  of  superliclal  and  inti-rnal  ecchy- 
moses  in  the  recorded  cases  of  the  continued  fevers,  it  is  scarcely  nccdfid  to  argue  the  exist- 
ence of  an  abnormal  condition  of  the  blood  in  them.     This  has  been  siiown  in  tlie  malarial 
cases  to  have  been  the  immediate  consequence  of  the  pervasion  of  the  system  \)y  the  iebrile 
poison.     Not  one  of  the  typhoid  cases  that  have  been  presented  demonstrates  the  disorganized 
condition  of  the  blood  as  the  direct  result  of  the  febrile  cause;   but  this  was  observed  in 
the  following  i-apidly  fatal  case  which,  in  this  respect,  was  ])recisely  analagous  to  the  per- 
nicious malarial  cases  that  have  been  submitted.     The  patient  died  after  a  delirious  attack 
of  twenty-four  hours,  and  'post-mortem  observation  discovered  the  blood  in  a  liquid  state, 
the  skin  covered  with  purpuric  spots,  the  patches  of  Peyer  thickened  and  some  of  those 
near  tlie  ileo-cfecal  valve  remarkable  for  their  pultaceous  character,  the  spleen  enlarged 
and  the  lungs  engorged  or  hepatized.     In  this  instance  the  disease  did  not  last  long  enough 
for  the  blood  to  become  deteriorated  by  gradual  }irocesses  based  on  the  imperfiH't  operations  of 
the  organic  functions.     The  fluidity  of  the  blood  must  th(>refore  be  referred  to  the  action  of 
the  fever-poison.     The  case  has  already  been  published*  as  163  of  the  iliari'lueal  siM-ies. 
l)r.  Woodward  presented  it,  along  with  several  otiier  cases  of  fever  that  had  been  similarly 
recorded  as  diarrhoea,  in  order  to  illustrate  a  class  of  errors  of  diagnosis  which  were  no  doubt 
of  frequ(Mit  occurrence  ;f  but  as  it  illustrates  matters  of  greater  consequence  J  than  these 
errors,  its  presentation  in  this  connection  has  been  deemed  advisable: 

rri\  uti!  Thomas  Kelley,  Co.  A,  I'JItli  X.  Y.;  admitted  Deo.  12,  1862.  Diarrhtra.  The  patient  was  uot  confined 
to  l)fd.  On  the  llSth  ho  was  iiioving  about  and  in  the  eveninfj  ate  his  siijipor  with  other  jiatients.  The  same  night 
he  was  slightly  delirious.  Died  Deeembcr  19,  at  11  P.  M.  Aulopnij  next  <lay:  liody  not  emaciated;  ai)|)aient  age  about 
28  years;  njioii  the  body.  esi]ecially  the  thighs,  there  were  a  number  of  irregular  spots  of  imrjuira  from  the  sl/e  of  a 
tlea-bite  to  that  of  a  diiiie.  The  blood  was  very  licpiid  and  jiuured  forth  from  incisions  of  the  skin  and  all  the  internal 
organs.  'l"he  brain  was  examined  but  exhiliited  no  unhealthy  marks.  Pleuritic  adhesions  throughout,  on  both  sides, 
of  not  very  old  date ;  left  lung  crepitant  but  engorged  with  a  bloody  li(|nid;  the  ujipcr  hdie  of  the  right  lung  hepa- 
tized, the  lower  lobe  congested.  There  was  slight  atlieronui  throughout  the  courseof  the  aorta.  Liver  soft,  Indian- 
red  in  <()lor  and  large;  siileen  large,  tlabby  and  on  section  dark  ln<lian-red,  its  convex  surface  exhibiting  the  remain* 
of  a  Icirmer  intlanunation.  Stomach,  pancreas,  kidneys  and  sn]>rarenal  bodies  healthy.  SnuiU  inli'stine  ])ink  in 
color;  the  agminated  glands  thickened  and  mostly  liright-red  in  color;  th(<  lower  glands  were  a  line  in  thickness  and 
contained  a  white  cellular  deposit;  none  of  them  were  ulcerated.  Mesenteric  glands  somewhat  enhuged.  Mucous 
membrane  of  the  huge  intestine  dirty  slate-colored,  with  streaks  of  iuHamnuition  here  and  there. — Ad.  Ahs'I  •Surij. 
•Itisfpk  Lndij.  [Nos.  88  to  HO,  Med.  Sect.,  Army  Medical  Museum,  from  this  case,  are  successive  portions  of  the  ileum, 
in  each  of  w  liich  is  a  large  thickened  Peyer's  patch;  in  9(1  the  i)atch  is  renuirkable  for  its  great  si/e  and  the  |)ulta- 
ceous  character  of  the  thickening,  there  are  also  several  large  solitary  follicles  in  this  sjiecimen.] 

MuR0HlS0N§  recognizes  two  conditions  of  the  blood  in  tyqihoid  lever:  One  rare,  in  which 
it  is  dark-colored  and  liquid,  the  other  of  more  frequent  occurrence,  in  whiih  it  is  disposed 
to  concrete  in  firm  white  coagula.  He  conceiA'es  that  a  close  relation  exists  lietween  the 
state  of  the  blood  and  the  symptoms  during  life;  that  when  death  has  been  jireceded  for 
some  days  by  the  typhoid  state  the  blood  is  usually  dai'k  and  fluid;  while  in  other  ca.ses, 
as  when  due  to  perforation  or  pneumonia,  it  often  contains  tibrinous  coagula.  The  first  of 
these  observations  does  not  apply  to  the  typhoid  cases  observed  during  the  war;   for,  of  those 

*  In  t\v:  Si-.-uliJ  J'art  ..f  this  wuik.ifage  117.  -f  Id.,  pafrc  5-21.  \  See  iufm.  page-  480.  g  Pafc;  l',:il  uf  his  Treatise. 

Med.  Hist.  Pt.  Ill— 60 


474  PATHOLOGICAL    ANATOMY    AND    PATHOLOGY 

submitted  as  constituting  the  post-mortem  records  of  tlie  continued  fevers,  many  presenting 
fibrinous  heart-clots  were  not  cut  off  by  pneumonia  or  peritonitis,  but  died  wliile  in  the 
typhoid  state.  The  dark-colored  and  Huid  condition  of  tlie  blood  appears  rather  to  have 
been  characteristic  of  rapidly  fatal  cases,  such  as  that  given  in  tiie  preceding  paragraph; 
and  this  observation  is  sustained  by  analogous  changes  found  in  fulminant  cases  of  mala- 
rial, cerebro-spinal  and  typhus  fevers. 

The  condition  of  the  blood  in  typhoid  fever  has  not  been  made  the  subject  of  special 
study  by  medical  observers  or  physiological  chemists.  Chomel,  while  recognizing  that  tlie 
blood  in  this  disease  differed  from  that  of  pneumonia  and  other  acute  inflammations,  con- 
cluded from  his  observations  that  its  changes  did  not  constitute  a  primitive  lesion  whence  the 
symptoms  of  the  disease  were  derived,  nor  even  a  secondary  phenomenon.*  Lehmann 
states  that  during  the  first  eight  days  of  a  typhoid  attack  the  blood  is  like  that  of  plethora, 
in  which  the  corpuscles  are  increased,  the  fibrin  normal  and  the  albumen  but  little  above 
the  usual  proportion ;  but  that  later  it  resembles  the  blood  of  antemia,  in  which  the  corpuscles 
are  diminished  in  number  and  the  serum  watery  and  deficient  in  albumen  and  other  organic 
constituents  although  richer  in  salts. f  ViECHOW  holds  that  in  typhoid  the  fibrin  is  dimin- 
ished; but  as  he  states  also  that  an  increase  of  the  colorless  corpuscles  may  be  looked  for 
in  diseased  conditions  attended  with  a  notable  swelling  of  the  glands  of  the  lymphatic  sys- 
tem, this  increase  must  be  inferred  as  present  in  typhoid.  In  cases  presenting  a  large  black 
spleen  he  found  pigment-cells  resembling  colorless  blood  corpuscles,  spherical,  often  elon- 
gated and  having  granular  contents,  among  Avhicli  appeared  black  particles  of  various  sizes; 
these  pigmented  bodies  were  observed  also  in  other  diseases  attended  with  a  rapid  exhaus- 
tion of  the  vital  properties  of  tlie  blood  and  productive  of  cachectic  and  anssmic  conditions. | 
Alonzo  Clark  is  of  opinion  that  the  most  important  of  the  lesions  of  typhoid  fever  is 
foiuid  in  the  blood;  and  from  some  experiments  at  Bellevue  hospital  he  concludes  that  the 
blood-change  is  characterized  by  a  progressive  loss  of  coagulability. § 

But  although  so  few  observations  on  the  quality  of  the  blood  in  typhoid  fever  appear 
in  the  records  of  medicine,  the  belief  is  generally  entertained  that  a  depraved  condition  is 
invariably  present  in  this  and  other  continued  fevers.  Sir  William  Jenner  deduces  the 
existence  of  a  deteriorated  condition  of  the  blood  from  the  sup}>urations  which  are  consecu- 
tive to  the  disease.  He  argues  that  the  exudation  of  a  blastema  possessing  the  same  prop- 
erties in  so  many  places  at  the  same  time,  indicates  the  existence  of  a  definitely  diseased 
condition  of  the  fluid  from  which  that  blastema  is  ibrmed,  just  as  the  deposit  of  many  masses 
of  cancer-blastema  in  the  same  body  at  the  same  time  is  held  to  indicate  the  existence  of  a 
definite  disease  of  the  blood  in  the  person  who  is  the  seat  of  them.|| 

The  degeneration  of  the  blood,  at  first  due  to  the  more  or  less  direct  influence  of  the 
fever-poison,  becomes  afterward  increased  and  modified  by  the  retention  in  the  system  of  the 
products  of  that  retrogressive  metamorphosis  of  the  tissues  which  aj)pears  to  constitute  the 
essential  of  the  febrile  condition,  no  matter  what  may  have  been  its  exciting  cause.^     Urea 

*  He  drew  blood  from  thirty  i)atieuts,  eacli  of  whom  was  in  the  early  stage  of  the  disease.  In  six  the  ch>t  was  firm  and  buffed  ;  in  twenty  it  was 
firm  but  not  eoated  ;  in  four  diffluent  and  curdled.  His  eoiulusiun,  as  ^ven  in  the  text,  was  based  on  the  small  number  of  cases  in  which  tlie  blood 
was  dipueitt  el  fiiHi'h>>li\  and  tlie  fait  that  a  similar  condition  is  found  in  dis.ases  other  than  typboid,  some  of  which  indeed  are  not  of  a  serious  character. 
From  the  firmness  i.f  tin-  clot  in  the  twenty-six  cases  he  oi»jiosed  the  belief  of  those  who  held  that  in  grave  cases  of  fever  the  blood  suftered  a  loss  of  coagu- 
lability.—A.  F.  CnoMF.i.,  /.c,„„«,/,.  I'liai./if  M.,li,;h—fi.iif  Tiij.liuKlr,  Paris,  ISW,  p.  fni. 

ft.'.  O.  Lehmann  — //.oiiifciicA  i/er  Plnj^i"tn,fm-lifn  rlmtne,  Leipzig,  185'J,  pp.  2:10  and  2:J2. 

{  VlKCHOVl— (V;fi((<(rfil(/lu/"!//V,  Berlin,  IS.'iS,  p.  2111. 

gSeeil/«/ic.,(  lter„r,l.  New  York,  Vol.  XIIl,  ISTs,  p.  •2C2. 

I  JirediVui  Tim,-::in,l  (iazetle.  Vol.  XXVII.  I..ind..n,  1S.W.  p.  413. 

\  J.  MiLNER  FoTHEBuiLL  has  a  suggestive  article  ou  IVi«  Tgyhoid  CotuiUiun,  in  the  Kdiuburyk  Medical  JourtitU,  ltil\i.  Vol.  XIX,  Pt.  1,  p.  225. 


OF   THR    CONTINUED    FEVF.RS.  ,  475 

and  carbonic  acid  are  tlic  ultimate  [midiicts  ot'  this  metabolism;  but  between  these  and  the 
organized  albuminous  matters  of  the  living  system  ai'c  a  vast  uuudjcr  of  complex  transition 
products  concerning  which  little  is  known  either  chemically  or  physiologically.  When  the 
skin  and  kidneys  are  inactive,  as  is  generally  the  case  during  tlu-  tebrile  cdutinuance,  these 
products  accumulate  in  the  blood,  and  coincident  with  this  acrunuilatiou  the  patient  falls 
into  what  is  known  as  the  typhoid  condition.  As  urea  is  susceptible  of  quantitative  deter- 
mination, its  retention  in  the  blood  and  its  |)ernicious  iuHuenee  on  the  system  can  be  dem- 
onstrated. The  poisonous  action  of  carbonic  acid,  or  of  the  concomitant  deprivation  of 
oxygen,  as  shown  by  the  circulation  of  yenous  blood,  is  manifested  by  the  insensibility  and 
convulsions  of  asphyxia.  Other  products  of  tissue-waste,  concerning  which  our  knowledge 
is  meagre,  are  plausibly  assumed  to  be  detrimental  to  the  system  in  which  they  are  retained. 
There  is  no  proof  that  they  are  the  cause  of  the  typhoid  condition ;  but  the  inyariable  appear- 
ance of  the  latter  after  a  prolonged  period  of  unusual  change  in  the  tissues  and  its  more  rapid 
development  when  the  eliminative  organs  are  inactive,  are  strongly  suggestive  of  a  causative 
relation  between  the  metabolic  products  and  the  typhoid  state.  If  this  view  of  the  occur- 
rence of  the  typhoid  condition  be  correct  there  is  no  diiliculty  in  understanding  the  super- 
yention  of  the  so-called  typhoid  symptoms  in  malarial  or  other  fevers"^'  uncomplicated  by  the 
special  poison  of  typhoid  fever. 

The  great  prostration  which  was  characteristic  of  the  contintied  fevers  not,  only  in  their 
early  stages  but  even  from  their  onset,  must  be  attributed  to  the  condition  of  tht^  blood, 
depraved  primarily  by  the  influence  of  the  fever-pnison  and  secondarily  by  the  disorder  of 
the  functions  of  the  body.  The  latter  will  readily  bo  admitted  as  a  debilitating  cause.  '^Plie 
former  has  been  well  argued  by  Louis  as  regards  specific  tyjihoid  cases,  in  which  the  primary 
debility  was  more  marked  than  in  malarial  cases:  We  cannot  attribute  it  to  the  diarrluea,  as 
it  is  often  jiresent  befoi'e  the  llux  has  developed,  nor  to  the  abdominal  ]>ain,  which  is  often 
slight,  no]'  to  the  cephalalgia,  which  is  generally  dull  and  which,  when  severe  in  other  acute 
affections,  is  not  accompanied  l,)y  a  like  loss  of  strength,  nor  to  any  appreciable  lesion  of  the 
brain  or  stomach,  as  shown  hy  'j>o.it-')nortem  observations;  hence  it  is  needful  to  recur  for  its 
explanation  to  the  s|iecial  changes  in  the  small  intestine  as  acting  sympathetically  on  the 
brain,  oi'  still  fui'ther,  to  the  typhoid  fever-poison  which  produced  these  changes.-}- 

The  intense  prostration  of  the  later  stages  of  continued  fever  is  the  result  of  a  complexus 
of  causes  originating  in  the  disordered  state  of  the  blood.  Prominent,  however,  among;  them 
is  that  degeneration  of  the  muscular  sv'stem  which  has  already  been  mentioned  in  the  par- 
oxysmal and  continued  fevers  as  afl'ecting  the  substance  of  the  heart.  Zknkkk|  first  called 
the  attention  of  the  ])rofession  to  the  iVerpiency  and  extent  of  these  changes  in  the  muscles. 
He  considered  them  wholly  uneonnected  with  inflammation;  hut  by  Waldkykk§  and 
HayfmII  thej  were  on  the  contrary  viewed  as  resulting  fi'om  inflannnatory  processes. 
The  latter  attributed  them  to  the  morbid  condition  of  the  blood,  placintr  them  amonir  those 


*S«'«  PiiiMiilionic  Fever,  infni,  IKi^e  C13.  f  See  liis  IWilniihi"^  t.  n,  p.  -ii;i. 

J/knkf.k  —  l'eh4-r  die  ytriiiiilvrniKjeit  ilfi- iviUkihlifUt'U  mtiikt^lti  int  TifphumbdinuituiUs,  l.eip/ifr,  lr<t',4. 

g  Wai.dkvkU— II(V  Vfruit<hntii'l'>i  tl<r  tpi^riji'^f'ij'Un  Mit^L'hi  hfi  drr  EttUiimlKnij  ii„d  dftii  Tjiidiiisi.ru::,'^,  fir.     VlKrHuw's  .4re//.,  t.  XXXIV,  Isth't,  p.  47:1. 

^H.WKM—Khul^  mr  Ifs  Mi/ogi/in  SiiiHi'l"iii'ili,iii,x—.4riliiii^  ill-  Pl,!i^i:.l;,ii.;  Paris,  IKTii.      lie  ,-,.iisiilers  diiigi'  TiSli  thiit  he  hiia  ealalilWieil  tlirre  ik'grees 

or  succe^-sive  phases  in  the  prujrivss  uf  the  iiiuseiilur  lesions.     The  (irst  is  »-Iiaraeteri/.et!  I.\  h^peneitiia,  th nniieneenient  t.f  vitreous  tiinl  granular 

ilegeneratidii.s  of  the  tibres  and  .sunii'tiines  a  slight  tiej;i-ee  of  alteration  of  the  walls  of  the  vessels.  In  the  seeunil  is  found  the  cttuiplete  development  of 
the  vitreous  and  jrranular  degenerations  of  the  striated  ectntents.  with  u  pndiferation  of  the  eellnlai-  elenn-nts  in  the  interior  of  the  sarioleninia,  which 
activity  sometimes  e.xteud.s  to  the  vase-ular  walls.  The  thii'd  degree  ineludes  on  the  one  hand  tin'  atrophy,  disorganizatitjii  and  complete  disap|tear- 
anee  of  the  degem-rati'd  fibres,  and  on  the  other  the  woik  of  n-geiiei-ation  or  rejiaration,  invoUing  the  retniii  of  the  nniscles  to  their  normal  condition. 
The  new  inu.scular  tihres  formed  during  this  last  jieriod  originate  in  pre-existing  uniscniar  cells,  llo-  jiroliferation  of  which  wad  evident  in  the  second 
plittse  of  the  morbid  changes. 


476  PATHOLOGICAL    AJTATOMY    AXD    PATHOLOGY 

disorders  of  nutrition  that  are  pnxluced  in  many  of  the  tissues  1:iy  diseases  attended  with  a 
notable  dyscrasia. 

Connected  with  the  deterioration  of  the  blood  and  the  degeneration  of  the  muscles  were 
those  eccliymoses  simulating  contusions,  and  the  large  extravasations  that  were  in  some  cases 
found  in  the  voluntary  muscles,  particularly  in  the  lower  part  of  the  rectus  abdominis  and 
in  the  muscles  of  the  neck,  as  in  63,  98,  136,  157  and  248.  To  these  causes  may  also  l)e 
attributed  the  purulent  infiltration  of  the  muscles  sometimes  observed,  as  in  151,  in  wliii  li 
the  sheath  of  the  rectus  abdominis  was  the  afifected  locality,  and  in  other  instances  noted  in 
the  analytical  summary. 

Scurvy  has  been  by  some  considered  a  very  important  cause  of  the  peeidiar  characters 
exhibited  by  the  fevers  that  affected  our  troops;  but  this  opinion  is  not  sustained  by  the 
records  that  have  been  preserved.  In  but  one  case,  316,  was  a  nota])le  scorbutic  element 
present.  If  the  ecchymoses,  purpuric  spots  and  hemorrhages  that  supervened  during  fever 
be  regarded  as  symptoms  of  scurvy,  this  complication  was  of  frequent  occurrence;  but  there 
is  no  ground  for  supposing  that  these  phenomena  were  dependent  on  the  scorbutic  taint, 
except  in  so  far  as  it  formed  one  of  many  influences  which  tended  to  their  production,  the 
determining  factor  being  the  great  and  sudden  impress  on  the  blood  ett'ected  ])y  the  febi'ile 
poison.  Certainly  these  extravasations  occurred  in  ca.ses  in  which,  prior  to  the  febrile  attack, 
there  was  no  suspicion  of  scurvy.  They  may  not  therefore  be  regarded  as  scorbutic  symp- 
toms when  observed  in  the  progress  of  fever.''" 

Diminished  vitality  resulting  from  disordered  nutrition  led  to  the  formation  of  slouglis 
and  gangrenous  patches  in  situations  detei'mined  by  local  conditions  of  impeded  circula- 
tion, as  on  the  sacrum  and  hips  ii'om  continued  pressure,  in  the  parotid  region  and  on  blis- 
tered surfaces.  Probably  the  absorption  of  morbific  detritus  from  tliese  gave  rise  to  pyemic 
developments  in  some  instances,  as  bedsores  were  present  in  three  of  the  cases,  125,  199  and 
289,  in  which  purulent  dejiosits  were  found  in  other  parts  of  the  body.  In  some  pytemic 
cases,  liowever,  as  in  38,  wliicli  presented  purulent  collections  in  the  joints  and  pcctoralis 
major  muscle,  there  is  no  record  of  the  existence  of  bedsores  or  pai'otid  abscess.  Excluding 
these  cases  of  purulent  accumulations  in  the  joints,  there  is  no  instance  of  disease  of  the 
bones  following  continued  fever  to  be  found  among  the  post-mortem  records,  althdUgli  the 
clinical  accounts  of  severe  rlieumatic  pain  endured  by  convalescents  render  it  iirobable  tlial. 
the  periosteum  and  bones  occasionally  became  affected,  and  that  the  lai-ge  bui-mwiiiu- 
abscesses  sometimes  observed  were  associatecl  with  caries  or  necrosis. f     A  sinu'le  instance  of 


*  Sii-  ij/lV.i,  ]i.  022. 

tSir.lAMKS  I'A.iET  liiis  i.lisorv.-.l  that  i..ti..>litis  follnwiiig  (.vpli.iia  iVvi-riri-n.Tallv  alT.-.l.-.l  tli.-  tihiii,  Init  occasioniilly  the  leiiiiir.  ulna  and  iwiii-tal 
bones.  It  was  always  cireuniscrnicd  in  a  simh-)-  uf  one  to  tiirr<-  imln-s  in  jirca.  M'ln-n  nn  i-u^is  MCfiirri*d  its  cxti-nt  was  less  tlian  that  nC  the  inHannna- 
tion  ovtT  it.  anil  gt-nerally  only  the  rurn|iaet  striH-lun-  it  outer  table  iMTisliei] ;  it  uas  never  atteujeil  with  the  ilelirinin,  fever  or  other  sevej-e  symp- 
toms assoeiateil  with  acute  necrosis.  Periostitis  of  ttie  rihs  so  resemhies  urilinury  srrnfuluiis  jKU-iostitis  that  lie  sonietimes  thoujiht  it  shoulil  he  reganleil 
as  an  evidence  of  si-rofula  ednceij  Iiy  the  fi-cl.li  iiess  of  the  nutrition  consei|ueiit  on  the  fever ;  hut  it  has  occnrriil  after  tyiihoti!  in  patients  of  so  rohnst 
and  ap^itirently  unldeniished  constitutniiis  that  it  woulii  seem  absurd  to  inipnte  scrofula  to  tln-tn.  The  swellinji,  {laitiful  and  tendei-,  is  usually  on  the 
front  of  the  chest,  and  sujipliratioti  slowly  occurs  in  it,  ttie  thin,  Jiah'  pus  niakini;  its  exit  throujrh  small  openings  in  the  skin  ;  hut  he  has  seen  pus  hur- 
row  l)etween  the  ahiliuninal  muscles,  fonninj;  a  ^reat  ahscess,  which  had  to  he  oiwiied  in-the  irroin.  See  SI.  lUt.ih'-town-'s  }l<sj,il,tl  /^■^».r^,  Vol.  Xll, 
London,  ISTii,  (i.  2.  Kf.fn,  jiaj^e  12  of  his  pa]ier  cited  in  note,  jw^re  2'.tT,  niii>ni,  says  that  of  47  eases  of  disease  of  the  tioiies  to  arose  duriiij;  the  iirst  two 
weeks  of  the  fever,  27  in  from  three  to  six  weeks  and  Hi  followed  ten  months  after  the  fever.  He  attrihiitcd  the  earlier  cases  to  throutliosis  or  einholism, 
and  the  later  cases  to  enfeehled  nutrition,  whose  effects,  especially  in  structures  which  vary  so  slowly  as  the  hones,  may  readily  extend  over  such  lon^ 
periixls.    Quotin;^'  Aitkfn's  n-inark  that  "N'o  tuan  can  he  considered  fit  for  «  ork  or  for  general  military  service  for  three  or  four  nmnths  after  ati  attack 

of  severe  typhoid  t\-\t-l\"  —  HuluitH'  t>nstein  of  Siirtj'-ni,  1st  ed.,  Vol.  IV,  p.  '.n.— In-  ^rjvt.^  n  case  in  which  i-\ti-nsi\c  ro^is  of  the  loii;;  hones,  disahling  the 

patient  for  three  or  four  years,  was  the  result  of  hard  work  in  the  use  of  a  teri-jioulul  hanmuT,  undertaken  h.-foie  tin-  system  had  sufficiently  recovered 
from  the  effects  of  the  febrile  attack.  lie  also  describes  a  nninarticular  form  of  intlainniation,  a  suliacute  synovitis,  which  affects  the  lareer  .joints  and 
especially  the  liip,  where  the  swellini;  is  sometimes  obscured  by  the  muscles.  Vsnally  it  arises  spontaneously,  but  occasionally  from  periostitis  or 
necrosis  invadine'  the  .joint.  It  rarely  |iroduces  suppurative  or  fistulous  iipeliiugs,  the  result  being  ireiierally  a  gradual  return  to  usefulness.  These  joint 
troubles  are  very  infrequent.     He  cites  GlxEiiBocK  as  responsible  for  the  statement  that  in  the  Charite  tlierliuj  and  in  the  Hamburg  Iiospitals  not  a  case 


OF    THE    CONTIXrEli    FKVKRS.  477' 

dt\^tr'irtinii  tA'  buiie,   possililv  cuiniri-ti'il  with   t'e\iT,  is  fiin]i.-li(.'(l   liy  tlie  ca.se  of  Carleton 
Bergiin,  jirivutc  Cc  1>,  Purin'll's  Mar\lan(l  l/'ii'icii.''' 

When  admitted  into  liosjiital  Ml  Fiodiriili,  Md..  tliis  piitifiit  liad  a  brdsuivoviT  tliesai  rum  ;  his  liody  was  bathed 
ill  sweat  and  ciivi'icd  with  sudaiiiiiia  :  l(iiii;iir  drv  and  iim-rcd  with  siinh's.  It  was  rc]iiiiied  that  he  liad  been  treated 
in  camp  with  laige  doses  (if  meremial.s,  but  tlie  lerciid  does  not  sliow  tliat  lie  was  salivated  on  admission.  Two  days 
at'feiwards  a  ra^p'd  iileer  was  observed  on  the  lijllit  edge  of  the  tongue,  wliieh  in  ten  days  extended  to  the  cheek  and 
idof  of  the  inoiith,  exposinj;  by  sloughing  tlie  entile  upper  max  ilia.  Six  weeks  later  the  w  hole  of  tliis  bone,  the  ver- 
tical plate  of  the  palate  bone  and  a  narrow  strijiof  the  left  maxilla  were  reiiioveil.  they  being  at  the  time  iinile  sepa- 
rated from  the  healthy  bone.  The  right  eye  was  destroyed  and  sunken;  the  right  half  of  the  iijiper  li]i,  the  right,  ala 
of  the  nose,  the  adjacent  portion  of  the  cheek  and  the  right  superior  maxillary  bone  were  gone,  leaving  an  extensive 
opening  directly  into  the  cavity  of  the  iiiouth  and  right  nasal  fossa. t 

But  tlie  most  striking  ut"  the  uncoiuiiiuii  rcsiills  ni'  the  clisoi'ik'red  coiulition  of  the 
blood  was  the  gangrene  of  the  feet,  recorded  in  six  of  the  three  hundred  and  eighty-nine 
cases  constituting  the  post-mo7ic7n  records.  These  numbers  perluips  exaggenite  the  fre- 
quency of  this  occurrence,  inasmuch  as  the  unusual  nature  of  the  complication  may  have 
led  to  the  preservation  of  the  cases  nrescntiiig  it,  when  otherwise  they  might  have  remained 
unnoticed.  Its  uncommon  character  is  evidenced  by  the  iact  that  in  one-half  of  the  cases 
in  wliich  it  occurred  it  was  regarded  as  the  result  of  exposure  to  cold. 

Spontaneous  gangrene,  usually  of  parts  in  which  the  circulation  is  languid,  is  rare  in 
the  general  experience  of  typhoid  fever,  but  of  greater  frequency  in  tyiiluis.  In  some  epi- 
demics the  nose  has  been  the  site  of  the  gangrenous  attack,!  in  others  the  feet  have  sufleretl, 
as  in  the  cases  from  our  war  records. § 


orc-tirn'tl  in  ;i  Ht-ricK  iif  years,  and  in  tlu.  V'it^nna  Gi-iirral  linspital  from  IHUK  ti>  IS71  only  i\\  m  caHC^H  aniimg  ;i,i:{0.  MrucMlsns  doi'H  nut  inrntitui  tliin  nun- 
l>li<-iitlnn,  iicr  any  ottuT  nf  our  tt'Xt  writiTs  <in  Kiirp'ry  tir  praftict'  <'Xri-pt  Vhi.kmann,  wliu  ^M\..f*  a  frw  tini-s  lo  it  in  J'ithn  v,„l  HiUf<>lli\  Ihtn'thtirl,.  Snrii..- 
tirnrs  t)i!'  ilistcnsinn  of  tin-  Kyni»vial  cavity  jiivcs  rise  t't  tiinilitiniiM  in  wliich  spuiitant-onrt  (tistoratiim  occurs,  ami  in  a  niajurity  of  tlic  cases  sluilicil  Him 
a.tiial  ilislncation  was  llic  first  filet  iilisiTVcil  rclativi.  In  tlic  ciiiiililii>n  of  tin'  joint;  this  arose  froiu  the  siiliaeilte  liatnie  of  tlic  lesion  ami  tlie  atiatbetir 
slate  of  the  patii'lit. 

*  An  accoinil  of  this  casi-  is  ^'ivm  in  lhc>  l-'iist  Part  "f  Ihe  Sniirieal  volmne  ..I  tliis  Ilist..ry.  pp.  in'.-llTT. 

t  This  rrishtlnl  .leloriiiily  was  snccessriilly  Ir.'ate.l  l.y  Hr.  (Il  nMex  l!i  cK.— See  •;V,i,i«.(.«"h,<  of  llie  S,-u-  V,;k  Mrili,„l  ,s„e,W;/,  tsill,  p.  17:'.. 

j  M.  .1.  c:i  rHKiu,KT-/V)»T  ,/ic  W.o.c  .V„»f  )„;  ,/,„,  7>;./oi.< 'W/ic„.<_in  lli,/cl,i,i,r>  .h.nni'il,  li.l.  XI, II,  Is] II,  part  VI,  p.  Inl --ays  that  Mie  "l.lne  nose" 
was  seen  only  in  overerow.i.-,!  niilitary  hospitals  infectcil  w  illi  the  typhus  coiitafrion.  Exposiiri'  to  cohl  was  not  concerned  in  its  priHlintion.  It  was  met 
w  ith  during'  the  hottest  loontlis  of  ISU'.I  in  the  Austrian  hospitals  at  Nickolshiiry: ;  during  tlie  mild  damp  winter  of  lS0tl-l(l  at  Kriau  in  iipiter  Hungary, 
ami  titirinj;  the  riy:or"tis  uinlcr  of  lHl;i-l  I  in  the  military  hospitals  near  Wlir/hurg.  The  patients  were  geiierally'ronvalesi-ents  from  fever  who, 
althoiij;]i  so  far  improved  as  to  Iiiive  a  j^ood  appetite,  did  not  pain  ill  stroiiptli ;  they  had  at  the  same  time  an  excited  pulse,  a  hot  dry  skin,  and  were 
always  lire.l,  languid  anil  disiiiiline.l  to  leave  their  hcils  even  in  the  warmest  weather.  Some  wore  soldiers  with  their  systems  completely  exiiaiisteil  by 
cidliipiative  diarrlnca  of  many  weeks  or  months  contilinance  ;  these  were  attacked  immediately  on  their  admission.  Nurses  were  seldoin  alTected,  even 
though  tlic-y  had  hy  a  long  stay  in  hospital  acquiri'd  the  .sallow,  cachectic  apjiearalice  or  so-call-'d  "  hospital  complexion."  The  graver  symptonis  of  ner- 
vous fever,  such  as  (hdiriiiin  anil  stupor,  never  a(.conilianied  the  "blue  nose."  The  assucuited  fever  was  not  severe  ;  the  patient  was  languid,  inditTerent, 
spoke  little  and  niiwilliiigly,  hut  answen-il  ijnestioiiH  correctly;  he  hail  mostly  a  frequent  watery  hut  not  imrticiilarly  offensive  diarrlitea,  and  always  a 
hxed  ttiongli  not  very  severe  pain,  iiicre».sed  hy  pressure  in  the  umhilical  region  ;  he  made  no  complaint,  hut  his  countenance  was  anxious  and  he 
oh.j.-cted  to  any  tactile  examination  of  his  ahdomi-n,  which  was  sunken,  retracted  and  had  a  soft  doughy  feel ;  respiration  was  mostly  thoracic.     The  ilis- 

ea.se  did  not  spriad  from  the  particular  hospital,  hnt  its  occnrreiiie  was  regarded  as  a  sign  of  the  presence  of  a  high  degr >f  the  typhus  contagion. 

(il'TBEKI.KT  saw  hctweeii  two  Illld  three  hnildri.d  l-ases  during  the  years  18(10  and  ISlll,  and  suhseqilelltly  during  the  winter  of  lMl;i-lt,  all  of  irhit-h  irere 
f'lhil.  Death  generally  ensued  in  from  twenty-four  to  thirty-six  hours  after  the  attack,  hut  sometimes  it  was  delayed  to  the  thinl,  hmrth  or  fifth  day. 
No  p'fKl-inminn  oli.s(.rvatiolis  were  made,  hut  the  disease  was  thought  to  he  connected  with  a  gangrenous  aflectiou  of  the  intestine.  In  Harkfr  and 
t'llEVNK's  .Iccf.ii)//  of  Ihe  Feter  lati'hl  Epiilfmit;  in  frrhiid — I.-ondon,  Is-Jl — Dr.  Br.vcken  of  Waterford  reports  from  his  hospital,  during  the  winter  of  1818-l;i, 
eighteen  cases  in  which  death  quickly  follow(.d  a  lividity  which,  affecting  first  the  nose,  extended  in  a  short  time  over  the  face  and  ears.  The  fever 
prevailing  in  IrelamI  at  this  time  had  lieen  preceded  hy  excessively  rigorous  winters  and  cold  damp  snmmers.  During  the  first  of  these  unproiiiticns 
harvest  se;i.soiis  much  of  the  grain  remained  iiiicnt  and  was  altogether  lost ;  and  a  greater  part  of  that  which  was  saved  had  germinated  in  the  husk  and 

hecoine  in  |iroportioii  impaired  as  an  article  of  foml.     The  potatoi-s  of  that  year  were  small,  wet  ami  .letiiii-iit  in  nntrii t  ;  turf  or  peat,  constituting 

the  chief  fuel  of  the  ) ■,  could  Hot  he  ciit  aiid  dried,  SO  that  dampness  of  chillies  and  iH'dililig,  imperh'ct  cooking  of  foisl  and  viiililation  id'  aimrtioent.s, 

il.ticient  cleanliness  of  isTsoii  and  dwelling,  co-o|».iated  with  a  detieiency  of  fisid  in  lowering  the  vitality  of  the  ].eople.  "The  failure  of  tlii-  crops  iu 
ISIO  was  not  muih  felt  till  the  spring  of  tlie  following  yi'ar,  hnt  scarcity  then  hecomiiig  general,  attained  its  greatest  height  ahont  midsummer,  and 
extending  to  all  the  priMliictions  of  the  earth  iK-ea-sioned  extreme  distress.  In  some  places  the  poorer  classi.s  were  comiielled  to  the  sid  necessity  of  col- 
lecting various  esculent  wild  vegetahles,  nettles,  wild  mustard,  navew  and  others  of  the  same  kind  to  sustain  life  ;  and  in  places  distant  from  I>iihlin 
w  retched  lieings  were  often  seen  exploring  the  fl(.|cis  with  the  hope  of  ohtainilig  a  supply  of  this  misenil.li>  f.i.'d.     In  districts  contiguous  to  the  sea  various 

niarilK.  plants  wi  re  hail  recourse  to  tortile  pnrposii  of  allaying  the  cravings  of  huiig.r  ;  and  we  have  1 n  iiiforiiied  that  on  the  seacoiist  of  llally.shannou 

many  of  the  poor  during  several  months  at  this  iH.riinl  suhsisted  either  chiefly  or  altog..|her  on  cinkles,  muscles,  limiK'ts  or  even  the  piilr.fyiiig  tisli  they 
could  priH'ure  on  the  shore.  Iirsomi*  districts  seed-potatoes  were  taken  up  from  the  ground  and  the  holies  of  the  future  year  tlius  destroyed  for  the  relii^f 
of  present  neiessity;  and  the  IiIoihI  drawn  from  the  cattle  in  the  ti.lds  and  mixed  with  oatmeal,  when  this  eonld  Is-  pns-nred,  has  not  uiifre.|neiitly  snp- 
plicl  a  meal  to  a  starving  family.  So  general  was  the  distress  and  insnllicieiit  the  supply  in  some  jiarts  of  the  country  that  a  few  nnlia|.py  snfli.reix  are 
said  to  have  died  of  alisolnl.-  want  of  foinl,  and  many  must  have  sunk  under  the  coniliineil  impre.s,sioliB  of  hunger,  damp,  .-..lil  and  the  anguish  of  mind 
nece.s.sarily  attendant  on  sad  anticii«itions  of  the  future."— Op.  ril.,  pp.  :(4-.5.— The  conm.ction  hetween  these  conditions  and  the  nniisual  prevalence  and 
peculiarities  of  the  continued  fevers  that  nlterwards  scourged  the  country  was  acknowledged  hy  all  the  reporters. 

?. Mortification  of  the  toes  and  fct  occurred  in  a  few  instances  in  the  epidemic  descril.ed  l.y  H.vrkeh  and  Chevxe.— See  Vol.  I,  page  340.  .1.  .\. 
EsTL.v.M.Ell,  iu  an  article  in  Uini/eHbeck'a  ArMr.  far  KUauclie  L'hinmjk,  Berlin,  Vol,  XH,  Iip.  4o»-517— on  Uuiigreue  <ij' tlie  hirer  exIinuUiet  in  Tufhm  Fci-er— 


478  PATHOLOGICAL   ANATOMY    AND    PATHOLOGY 

An  impoverished  condition  of  the  blood,  resulting  from  a  deficiency  of  food,  and  the 
other  co-operating  influences  to  which  a  poverty-stricken  people  are  subject  have  been  so 
generally  present  not  only  in  epidemics  but  in  individual  cases  of  fever  characterized  by 
gangrenous  tendencies,  that  the  appearance  of  the  latter  warrants  a  strong  belief  in  the  pre- 
existence  of  the  former.  The  deprivations  and  exposures  to  which  our  soldiers  were  liable, 
together  with  the  prostration  incident  to  repeated  attacks  of  antecedent  diarrhcea  or  other 
lowering  diseases,  render  it  probable  that  in  occasional  febrile  seizures  the  specific  cause  of 
the  fever  found  the  patient  in  a  condition  as  favorable  for  tlio  development  of  spontaneous 
gangrene  as  if  he  had  undergone  the  preliminary  course  of  starvation  so  common  in  Ireland 
during  the  years  of  famine  and  fever.  On  this  view  of  the  conditions  associated  with  gan- 
grene Dr.  Keen's  summary  of  the  causes  may  be  accepted  as  accurate.  He  attril)uted  it 
to  an  altered  blood,  a  weakened  heart  and  the  mechanical  difficulties  in  carrying  on  the  circu- 
lation, especially  in  distant  parts;  Init  in  view  of  the  usual  seat  of  the  affection  in  the  lower 
extremities  he  concluded  that  the  last  two  causes  were  the  more  immediately  determining 
factors.*  To  these,  perhaps,  should  be  added  exposure  to  cold,  as  the  six  reported  cases 
occurred  during  months  when  frostbite  from  exposure  on  active  field  service  was  not  uncom- 
mon, although  uidcnown  amid  the  comparative  comforts  of  camp  and  hospital  life.  A 
degree  of  coldness  of  the  feet  resulting  from  displaced  blaidvets,  which,  under  ordinary  con- 
ditions, would  have  been  immediately  succeeded  by  healthy  reaction,  may  in  these  devi- 
talized cases  have  sufficed  to  determine  the  development  of  gangrenous  phenomena.f 

Nevertheless  it  is  to  be  noted  that  in  none  of  the  six  cases  is  there  any  record  of  special 
depi'ivations;  on  the  contrary,  in  one,  164,  the  body  of  the  patient  was  said  to  have  been 
not  emaciated.  Hence  it  is  probable  that  in  certain  cases  something  more  than  depression 
of  the  vital  powers  was  needful  to  the  occurrence  of  gangrene.  MurchisonJ  si^eaks  of 
spontaneous  gangrene  as  a  result  of  arterial  thrombosis,  and  P^stlander  found  the  clot  in 
many  of  his  cases.  Case  112  of  our  post-mortem  records  is  the  only  instance  in  which  the 
arteries  are  said  to  have  been  occluded. 

IV.— THE  BRAIN  AND  ITS  MEMBRANES. 

Cases  of  tlie  continued  fevers  in  which  the  condition  of  the  brani  aiul  its  monibrancs 
was  examined  constitute  but  a  small  percentage  of  the  whole  number,  in  some  of  the  hos- 
pitals where  posl-raorti'in  investigations  were  svstematicallv  lairsued  tlie  lu'ain  was  examined 

based  upon  nlwervatioDs  ma'Ic  ilifrinj^  an  cpiilcmic  wiiicli  prcvailort  in  Finnland  during  thp  famine  of  18(>G-0S.  states  that  tlie  aifeetinn  wart  no  donbt  dun 
to  t^e  intensity  of  ttie  tvpliu?  ((.iritaj^ion,  af:j;ravatod  Jiy  a  want  of  foo<l  and  proiwr  rare  dnrinp:  the  disease.  AVitli  rcf^anl  to  its  immediate  cause  it  is  said 
that  of  twenty-one  eases  nn-t  witli  there  were  tlironihi  in  tiie  prineipiil  artiTV  of  tlie  linili  in  fourteen  ;  and  it  is  held  that  these  were  plainly  the  cause  of 
the  gangrene,  as  tlieir  presence  was  estatdished  h\  examination  of  the  artery  during  life  atid  after  death,  flenerally  no  pulsation  could  he  felt  in  the 
Tessel  of  the  affected  linih,  while  that  of  the  vessel  of  the  opposite  siile  could  tie  readily  detected.  The  obstructed  artery  felt  like  a  hard  cord  antl  was 
wholly  without  sensation.  Now  and  theti,  below  the  knee,  it  would  feel  harder  and  tlKire  resisting  than  usual,  and  in  the  vicinity  of  Poupart's  liga- 
ment would  still  pulsjtte  feebly  and  obsciu'ely.  yet  so  evidentl,v  as  to  render  it  uiuertain  whether  any  obstruetion  actnally  existed  ;  but  on  amputation 
the  hemorrhage  was  trifling, — no  blooil  carnc  from  the  femoral  or  pitpliteal,  and  only  a  little  from  the  smaller  nniscnlar  bram;hes,  while  a  fibrinous 
plug  filled  thr*  vessel  and  projected  lieyond  its  retracted  end.  Most  <if  the  thrombi  were  examined  ;  they  generally  terminated  below  where  an  abrupt 
narrowing  occurred,  as  at  the  division  of  the  popliteal  artery,  or  as  was  the  case  in  one  instance,  at  the  origin  of  the  pn>f'unda  femoris,  from  which  thu 
thrombus  exteTided  upward.  In  one  case  in  which  the  part  rennived  b,v  amputatio?i  was  mit  wholly  disorganized  and  a  ping  was  formed  at  the 
tiifurcation  of  the  popliteal,  the  vessels  below  this  jioint  were  com[detely  free  anil  sound  ;  in  another  case  in  which  amputation  had  been  perbirmed  at 
the  upi>cr  mird  of  the  leg,  the  anterior  anil  posterior  tibial  and  the  peroneal  arteries  were  finnd  empty.  Estlanukk  was  of  opinion  that  when  the 
oliBtrnctingcoagulumdid  not  <>xtend  from  the  popliteal  artery  higher  than  the  tendon  of  the  adductor  niagnus  gangrene  either  did  not  result  or  involveil 
only  a  Un^  or  a  small  portion  of  tin*  foot ;  but  when  it  extended  beyond  the  origin  of  the  profunda  fenmris  the  disease  involved  the  upiH'r  third  of  the  leg  ; 
this  was  illustrated  in  eight  or  ten  cases.  The  emboli  were  believed  to  have  originated  in  the  left  ventricde  of  the  heart  when,  owing  to  debility,  con- 
trat'tion  was  imiwrfect  and  evacuation  incomplete,  .\fterwards,  when  the  heart  became  stronger,  the  coagula  were  expelled  ami  iiccluded  the  yessc-ls. 
This  gangrene  from  obstruction  was  observed  only  at  the  end  of  the  fever  or  after  the  eoumiencement  of  r'onvalescence.  Gangrene,  where  no  obstniction 
was  found,  showed  itaidf  by  iieeuliar  symptoms  even  at  the  beginning  of  the  fever  and  attacked  both  sides,  being  confined  generally  to  some  of  the  tuea 
or  to  other  small  |iortioTts  of  the  foot  and  only  in  the  severest  cases  extending  as  far  as  the  ankle-joint. 

*  t*ee  Jiage  :\r,  of  his  Lfrtiire,  cited  sej»rr(,  note  to  page  2'.»7, 

t  See  report  of  Surg,  ,1,  11,  Tavlok,  V,  S,  V.,  mprn,  p,  310,  t  ''"K"  •''^'J  of  his  Treatise. 


OF    THE    COXTIXUKD    1•KVKH^;.  479 

as  a  matter  of  course,  but  in  otlnTs  where  apparently  the  oViject  of  the  examination  was 
merely  to  verify  a  diagnosis  or  Hud  an  aderjuate  cause  for  death,  the  intracranial  examina- 
tion was  frequently  omitted  unless  sjiecially  called  iur  hy  clinical  manifestations.  Hence  it 
may  be  assumed  that  the  cases  in  which  time  was  devoted  U)  upeiiing  the  calvariaand  exam- 
ining its  contents  were  as  a  whole  characterized  by  a  prominence  of  the  cerebral  symptoms. 
Nevertheless,  in  a  large  proportion  of  these  no  abnormal  appearance  was  observed.  The 
brain  and  its  membranes  were  considered  normal  in  45.5  per  cent,  of  the  purely  typhoid 
cases;  congestion  and  efl'usidii  were  present,  but  none  of  the  cases  presented  undenialde  evi- 
dence of  tlie  existence  of  inflammatory  action.  Of  the  malarial  cases  in  which  the  cranium 
was  opened  almormal  appearances  were  observed  in  61.7  ]>er  cent.  The  hyperfcmic  tendency 
attained  a  higher  development  in  these  cases  than  in  typhoid;  and  this  was  shown  as  well 
by  the  intensity  of  its  manifestions  as  by  their  frequency,  for  in  one  case,  287,  the  cerebrum 
was  ecchymosed,  and  in  two,  80  and  257,  the  active  character  of  the  hyperemia  was  evi- 
denced by  the  lymph  that  had  been  exuded.  Morbid  changes  were  found  in  54  per  cent,  of 
the  typho-malarial  cases  and  in  41.2  per  cent,  of  the  mixed  series  of  cases. 

In  a  large  number  of  cases  in  which  the  brain  and  its  membranes  were  said  to  have 
presented  a  healthy  appearance  nothing  is  known  of  the  associated  symptoms;  in  certain 
other  of  these  cases,  as  23,  36,  106,  112,  ll(i,  289  and  380,  no  mention  was  made  of  head 
symptoms,  although  what  nuist  1)0  regarded  as  the  clinical  characteristics  of  each  case  were 
stated  by  way  of  preface  to  the  post-mortem  record.  There  remain,  however,  some  important 
observations  which  show  that  very  notable  distui'bances  of  the  cerebral  functions  occurred 
without  leaving  in  the  brain  or  its  membranes  any  trace  by  which  their  existence  could  have 
been  jiredicated.  Thus,  in  7,  24,  29  and  199  delirium  was  present,  prolonged  in  the  last- 
meiitiniicd  case  for  a  week  before  death;  in  370  the  patient  was  deaf  and  unconscious;  in 
3(xS  he  fell  into  a  lethargic  state  twenty-four  hours  before  death;  and  in  56  coma  and 
delirium  were  reported,  apparently  in  connection  with  inflammation  of  the  middle  ear. 

Looking  now  at  tlie  cases  in  which  some  abnormity  was  discovered  in  the  brain  or  its 
mendii'anes,  it  is  found  that  in  many  of  these  no  record  of  the  associated  symptoms  has  been 
preserved,  while  in  others,  as  42,  80,  99,  264  and  276,  although  certain  symptoms  were 
reportetl,  no  mention  was  made  of  any  referable  to  the  encephalic  lesions.  Delirium  was 
mentioned  in  ten  cases,  8,  109,  111,  117,  247,  278,  281,  287,  291  and  297,  as  the  prom- 
inent cerebral  symptom.  Generally  it  occurred  as  the  precursor  of  death,  sujiervening,  as 
in  287,  a  few  hours  before  the  fatal  issue,  or  lasting,  as  in  278,  for  several  days  with  occa- 
sional lucid  intervals.  This  was  associated  in  the  majority  of  those  instances  with  con- 
gestion of  the  pia  mater,  leading  in  case  287  to  ecchymosis,  with  or  witliout  congestion  of 
tlie  cerebral  substance  or  effused  serum  in  the  subarachnoid  space  and  ventricles.  In  one 
case.  111,  in  which  delirium  was  associated  with  insomnia,  the  arachnoid  at  the  base  of 
the  brain  was  thickened  and  opaque  and  the  ventricles  filled  with  effused  liquid.  But  in 
contrast  with  these  hy])era'mic  appearances  the  brain  and  its  membranes  in  109  were  pale 
and  ansBmic,  and  in  291,  in  which  delirium  lasted  for  several  days,  the  brain  was  normal 
and  the  pia  mater  anseniic,  opaque  and  wrinkled. 

In  nine  cases,  9,  26,  45,  47,  86,  104,  257,  303  and  304,  the  cerebral  implication  was 
marked  by  unconsciousness,  usually  succeeding  to  delirium  or  insomnia,  and  passing  into 
death  by  coma:  In  45  and  47  the  only  abnormal  ajipearancc  consisted  of  a  serous  transu- 
dation into  the  arachnoidal  sac  or  ventricles,  and  in  26  and  104  of  a  simple  injection  of 


s 


480  PATHOLOGICAL  ANATuMY  AND  PATHOLOGY 

the  membranes,  while  in  9  and  86  \hA\i  injectiuii  and  effusion  were  said  to  have  been  pres- 
ent. In  .'U)l  tlic  foniUtion  of  tlie  membranes  was  not  stated,  but  the  cerebral  substance  was 
firm  and  slightly  congested  posteriorly.  In  two  cases  only,  257  and  303,  were  definite  sign.' 
of  inflammatory  action  presented — a  coating  of  lymph  on  the  base  of  the  brain  and  a  turbidity 
of  the  ventricular  serosity. 

In  two  cases,  343  and  349,  the  encephalic  symptoms  were  said  to  have  been  those  of 
meningitis,  but  the  prominent  post-morfein  lesion  in  each  case  consisted  of  subarachnoid 
effusion.  In  299  signs  of  cerebral  congestion,  noted  clinically,  were  verified  hy  po-'if -mor- 
tem examination.  In  160,  in  which  the  cerebral  disturbance  was  manifested  by  craziness, 
the  usual  hy})er£emia  of  the  membranes  and  subarachnoid  effusion  wei'e  observed.  Lastly, 
in  379,  in  which  death  overtook  the  patient  suddenly  and  quietly  while  in  bed  and  supposed 
to  have  been  asleep,  the  brain  and  its  membranes  were  engorged  with  bright  blood  and  the 
ventricles  distended  with  sero-sanguinolent  serum. 

Although  headache,  dizziness,  insomnia,  delirium,  dulness,  stupor  and  coma  were  in  some 
instances  associated  with  changes  in  the  brain  and  its  membranes,  to  which  they  might  witli 
propriety  be  attributed,  the  encephalic  lesions  were  in  other  cases  wholly  incommensurate 
with  the  intensity  of  the  cerebral  symptoms;  and  in  many  cases  noted  the  latter  were,  indeed, 
unaccompanied  by  any  observed  lesion.  Loris  long  ago  demonstrated  that  the  existence 
of  delirium  in  typhoid  could  not  be  in  all  cases  explained  by  the  condition  of  the  brain.  He 
argued  also  that  the  intestinal  lesion  could  not  be  regarded  as  the  cause  of  the  delirium, 
for  although  there  is  delirium  in  pneumonia  there  is  no  concomitant  intestinal  lesion,  and 
it  isnnlikoly  that  the  sympathetic  action  on  the  brain  of  organs  so  different  in  function  ami 
structure  as  the  lungs  and  alimentarv  canal  should  bt;  similar.'"'  He  attributed  the  delirium 
to  the  pyrexia,  as  it  was  the  only  pathological  factor  common  to  all  the  cases.  It  has  already 
been  shown,  in  speaking  of  the  alteration  of  the  blood  resulting  from  the  persistence  of 
fever,  that  the  febrile  condition  may  develop  delirium  by  an  accumulation  in  the  blood  of 
the  noxicms  transition  products  of  tissue-waste.  The  coma  that  was  the  frequent  prelude 
of  death  may  also  liave  been  due  in  manv  cases  to  this  altered  blood,  for  free  effusions  were 
often  discovered  in  the  serous  and  subserous  sj^aces  without  a  concomitant  congestion. 
Effusions  unconnected  with  inflammatory  processes  were  observed  in  other  serous  cavities, 
particularly  in  the  pericardium,  and  these  must  be  referred  to  that  watery  condition  of  the 
blood  which  occasioned  ffidema  of  the  legs  in  the  paroxysmal  fevers  and  in  some,  as  70  of 
the  malarial  series,  of  the  continued  fevers. 

But  cerebral  symptoms  unconnected  with  notable  hypersemic  conditions  of  the  brain  or 
its  membranes  wei'e  not  in  all  cases  due  to  that  alteration  of  the  blood  which  resulted  from 
the  continuance  of  the  fever,  for  in  some  instances  they  were  developed  from  the  beginning 
of  the  attack.f  The  patient  in  the  case  presented  on  J>agc  473,  supra,  died  after  an  illness 
of  twenty-four  hours  marked  by  slight  delirium ;  and  while  the  brain  exhibited  no  mdiealthy 
aj)pearances  the  blood  was  so  liquid  that  it  had  become  extravasated  subcutaneously  in  irreg- 
ular jnirpuric  spots  and  issued  freely  from  post-mortem  incisions  into  the  skin  and  internal 
organs.  Here  the  disordered  condition  of  the  blood  was  evidently  a  primary  lesion  mani- 
fested by  cerebral  phenomena. 

*L"1-IS,  — /,V,7..T.*r»,  ,h:,  t.  II,  p.  ITU. 

f  Spfakilitf  ordfliriiim  in  typhoiii,  U  uiti.ktt,  in  his  Trratu'c  im  iin-  Fn-rrs  <•/  Ihf  I'tiihiJ  Stales.  P1iila<tolpIii:i,  IS.'.-J,  p.  t!.",,  siivs  :  "In  a  siriall  ininilM-r  of 
casP8  tliissyinpf  >rn  ispp-'iit  at  tli--ruliinu'liiclrn'nt  or  very  early  in  tlifili.scasi'.  *  *  *  Asa^eniTal  rule,  it  ai»pt^iri*  early  in  proportion  to  the  gravity  ami 
rai>i<l  i»ro;rrfss  of  tin-  ili^-a<i-,'  MtionisoN  giveri  two  cases,  one  of  wliieli  was  fatal  on  the  first  ami  th4i  other  on  the  wM-ond  <lay.  "Tlie  sytnptonis  in 
these  ra]  i'i  lases  are  iisnally  >.v<  re  hea<iaehe  and  acute  delirium,  with  profuse  diarrho-a  or  great  engtirgenieiit  of  the  lungs." — Tin;  t''>ntiunr<l  IVr.rs ,,/ 
GretU  Bril'iiii,  London,  187;),  p.  54t). 


OF   THE    CO^"TI^•UED    FEVERS. 


481 


v.— AGE  OF  PATIENT,  STATE  OP  NUTRITION,  ETC. 


Ill  addition  to  tlie  anatomical  changes  in  the  various  organs  tlie  post-morfera  records 
frequently  make  note  of  two  points  which  may  be  Lrietlv  referred  to  at  the  present  time — 
one  the  age  of  the  subject,  the  other  the  nutrition  of  the  body. 

The  AGE  is  stated  in  thirty-seven  of  the  fifty  typljoid  cases;  the  minimum,  15  years, 
in  case  30,  the  maximum,  53,  in  case  -17,  and  the  average  24.7  years.  Of  the  sixty- 
throe  malarial  cases  the  age  is  given  in  forty-one;  the  minimum,  16  years,  in  case  364, 
the  maximum,  63  years,  in  73,  and  the  average  25.8  years.  In  thirty-eight  of  the  sixty- 
one  cases  of  true  typho-malarial  fever  the  average  was  24.8  years;  the  minimum,  16  years, 
in  cases  266  and  298,  and  the  maximum,  53,  in  case  96.  The  age  is  given  also  in  one  hun- 
dred and  twenty-six  of  the  two  hundred  and  thirteen  cases  of  the  mixed  series;  the  mini- 
mum, 16  years,  in  299,  348,  359  and  372,  the  maximum,  55,  in  334,  and  the  average  27 
years.  While  these  figures  show  that  the  average  age  of  tlie  victims  of  continued  fever  of 
malarial  origin  was  greater  than  that  of  the  typhoid  subjects,  it  is  evident  that  the  observa- 
tions are  not  sufficiently  numerous  to  offset  the  influence  of  the  intrusion  of  a  few  cases  of 
an  exceptional  character  in  this  regard. 

If  the  cases  constituting  the  clinical  records  of  the  continued  fevers  be  incorporated 
with  those  presented  as  post-mortem  records,  it  will  be  found  that  four  hundred  and  thirty- 
one  cases  have  been  submitted  in  whicli  the  age  of  the  patient  is  stated.  These,  tabulated  on 
the  following  page,  indicate  that  the  especial  victims  of  the  continued  fevers  were  soldiers  from 
eighteen  to  twenty-four  years  of  age ;  but  inasmuch  as  it  may  be  said  that  this  merely  expresses 
the  preponderance  of  men  of  these  ages  in  the  army,  two  columns  have  been  added  showing 
the  relative  frequency  of  fever  among  men  of  certain  ages  as  compared  with  the  ratio  of  their 
numbers  to  men  of  all  ages  in  the  army.*  From  these  it  will  be  seen  that  soldiers  under 
twenty,  and  jiarticularly  soldiers  from  twenty  to  twenty-four  years  of  age,  sufFei'ed  much 
more  from  these  fevers,  in  proportion  to  thoirnumberinthe  ranks, thanmen  of  more  mature  age. 
Men  between  twenty  and  twenty-four  years  of  age  constituted  only  28.03  per  cent,  of  the 
army,  but  they  furnished  38.98  per  cent,  of  the  cases  which  form  the  basis  of  this  calcula- 
tion. On  the  other  hand,  the  number  of  cases  in  men  over  twenty-five  years  was  less  than 
it  would  have  been  had  they  been  affected  in  proportion  to  their  number  in  the  ranks. 

*  It  1!^  impossible  to  obtain  an  accurate  expresj-ion  of  tbo  relative  nninliers  of  nu-ii  of  various  aj^es  in  the  army  during  the  war.  The  ipercentages 
given  in  the  table  have  been  derived  from  data  gathered  from  tlie  second  volume  of  Dr,  J.  II.  Baxter's  t%iti)*lirs,  MuilimJ  ami  Aulfiri'pnli'tjii'al,  f>f  the  Vnu-oul 
Miirsluil  (lenfi-ftrtt  Din-eaii,  Wft/thiiiijtoUf  D.  V.,  ISTo.  Table  XIX,  covering  jiages  4H1— Hj.'j  of  the  vohune  eiteii,  endiraees  the  statistieal  results  of  the  exam- 
ination of  :i:l4,321  recruits,  substitutes,  drafted  and  enrolled  men  of  various  nationalities.  From  these  statistics  were  obtained  the  following  figures, 
which  give  tlie  relative  number  of  men  of  the  ages  stated,  I»ased  on  an  examination  of  211,70")  men  accepted  for  military  dut}-: 


Age. 


I  '  Ilatio  of  ac- 

Xundn-r  of  men   ^'""i*"''' ^''J'*'"*'''!  Nnnila-racceptedj    cepted  men  of 


for  special 
causi 


for  military 
duty. 


stated  ages  per 

IW  of  the  total 

accepted. 


Under  20 

20-24 

25-29 

30-34 

35-39 

40  and  over 

Total 

Med.  Hist.,  Pt.  111—61 


58, 952 

-»,  ia9 

ufi, 711 
45, 777 
50,  4515 
43,  7«r, 


1.5,815 

43,137 

20.38 

19, 305 

59,334 

28.03 

18,721 

37,990 

17.94 

18,8.33 

2fi,944 

12.73 

23,  340 

27, 107 

12.80 

20, 593 

17, 193 

8.12 

34, 


.11 


211,705 


482 


PATHOLOGICAL   ANATOMY    AND    PATHOLOGY 


Table  LI. 

Showing  the  ages  of  four  hundred  and  thirty-one  cases  of  Continued  Fever,  and  comparing  the  frequency 
of  these  fevers  at  certain  ages  with  the  relative  number  of  men  of  those  ages  in  the  ranJcs  of  the 
Army. 


15. 

16. 

17. 

1«. 

19. 

20. 

21. 

22. 

23. 

24. 

25 

20. 


28. 

29. 

30. 

ol. 

32 

33. 

34. 

35. 

31) 

37. 

38 

39- 

40- 

46- 

54- 


■i5. 
•53- 
63. 


Age  ot'iiatieiits. 


Number  of 


Number  t>f  cases  of 
the  ages  bracketed. 


1 

9 

9 

42 

40 

31 

36 

36 

38 

27 

18 

18 

10 

13 

10 

16 

4 

7 

9 

6 

9 

6 


Ratio  of  cases  of 

the  ages  bracketed 

per  100  cases  of 

continued  fever. 


101 


23.  43 


Ratio  of  men  of 
tlie  ages  bracketed 

]>er  100  men  of  all 
ages  in  tlic  Army. 


I 


168 


38.98 


69 


16.01 


42    y 


14 


iJ 


27 


24 


9.75 


6.26 


20.38 


28.03 


17.94+ 


12.  73 


I 


12.  80H- 


8.12+ 


Inasinucli  as  malarial  fever  is  well  known  to  affect  men  of  all  ages,  this  susceptibility 
of  the  younger  soldiers  to  attacks  of  continued  fever  jnust  be  attributed  to  the  influence  of 
the  typhoid  element,  the  more  so  as  statistics  from  civil  and  military  life  are  alike  unanimous 
in  indicating  a  greater  relative  prevalence  of  enteric  fever  in  young  than  in  old  persons/^ 
The  mean  age  of  the  four  hundred  and  tliirtv-one  tabulated  cases  was  25.06  years. 

*  The  ?-arly  writers  on  typlioid  fovcr,  an  di.<tiiict  from  typlnis,  were  ijiclineil  to  rcpanl  the  flfrc  of  tlio  jiatient  as  an  clonient  in  the  formation  of  a 
diagnosis.  Chomkl  and  Lnujs,  in  18:jH,  dechircd  that  they  had  ni-vcr  tihscrvcd  the  diseas*.'  in  [fubjects  umhT  fifteen  nor  over  tliirty  years  of  age ;  hut 
Chomel  hijnself  liad  o<-ia.sion  to  report  at  a  htter  ilate  five  caries  in  which  the  patients  were  over  the  latter  age.  At  first  many  cases  of  tyjilioid  in  jXTSons 
over  forty  years  were  rejjrarded  with  dcuht  as  piissilile  case?  of  typhus  ;  hut  in  progress  uf  time  instances  were  rejiorted  which  could  not  he  .set  aside  in 
this  way,  and  ultimately  hospital  statistics  settled  t)ie  point,  showinj;  that  age  cuuferred  no  immunity  from  enteric  attacks,  MfRCUisoN,  paj^e  4:J9  of  his 
Treatise,  gives  a  tahle  of  tlie  number  of  typhoid  cases  admitted  into  the  London  Fever  hospital  in  each  given  p«'riod  of  life  during  the  twenty-three  years 
1848-7**.  the  total  of  admissions  being  0,911,  from  which  it  appears  that  0^,70  per  cent,  of  the  cases  were  from  fifteen  to  twenty-nino  years  uf  age,  4..H 
per  cent,  over  fnrty-five  years,  1.37  i>er  cent,  over  fifty  years  and  .44  jier  cent,  over  sixty  years  of  age.  LiERKKMKirJTKR  states,  in  liis  article  on  typhoid 
fever  in  Zi'-"m*sfii'H  CyJopedia,  that  of  the  patients  received  into  the  hospital  at  Basle  during  the  perii«l  lStJ;')-7n,  58  i>er  cent,  were  ln-tween  the  ages  of 
twenty -one  and  thirty  yetirs,  7.12  per  cent,  over  forty  years,  2.12  jter  cent,  over  fifty  years  and  0.12  per  cent,  over  sixty  years.  L£ox  C'oiJN — p.  (VS,  De  la 
Fulire  Typhoide  duns  I'linu-'e^  Paris,  1878 — gives  a  table  from  the  Meili^al  Slittixtirs  of  the  Cir'd  Ilonpitals  of  Paj-is  for  tlie  years  18G1-G4,  wliidi  shows  the  sjiecial 
incidence  of  the  diseas<-  un  f»ersons  between  twenty-one  and  tliirty  years  of  age.  lie  says  that  it  is  among  soldiers  of  twenty-two  years  of  age  that  tytihoid 
fever  selects  the  greater  number  of  its  victims. 


OF  THE  CONTINUED  FEVERS.  483 

The  condition  of  the  body. — The  body  was  generally  repre>entei.l  as  greatly  ema- 
ciated, a  result  of  defective  assimilation  and  increased  tissue-waste  during  the  continuance 
of  the  febrile  movement.  ^^Taturally,  however,  there  were  exceptions  in  this  regard.  On 
the  one  hand,  in  rapidly  fatal  cases,  death  occurred  before  the  loss  of  tissue  became  particu- 
larly marked;  on  the  other  hand,  death  arising  from  some  accident  during  convalescence 
might  leave  the  body  in  a  fairly  nourished  condition.  Again,  when  the  fatal  result  was  due 
to  the  sudden  or  early  development  of  some  secondary  lesion,  as  occlusion  of  the  rima  glot- 
tidis,  pneumonic  congestion,  perforation  of  the  intestinal  walls  or  hemorrhage  from  an  eroded 
vessel,  the  subject  was  frequently  said  to  have  been  but  little  emaciated.  These  exceptional 
cases  were  more  common  in  the  malarial  than  in  the  typhoid  series. 

VI.— GENERAL  CONCLUSIONS. 

In  a  large  majority  of  the  cases  it  is  impossible  to  learu  from  the  records  what  rnay 
have  been  the  immediate  cause  of  death  or  the  anatomical  factor  in  determining  the  fatal 
result.  The  patient  was  prostrated  by  the  circulation  of  an  altered  blood;  and  after  death 
the  intestines  were  found  congested  or  ulcerated,  and  the  liver,  spleen,  kidneys,  lungs,  heart 
and  brain  more  or  less  altered  from  the  normal,  but  none  of  them  presented  lesions  which 
of  themselves  sufficed  to  account  for  the  fatal  ending.  Frequently  death  in  these  cases  was 
considered  due  to  asthenia,  failure  of  the  heart's  action  being  manifest  in  the  symptoms;  in 
otliers  coma  was  the  harbinger  of  death.  Among  the  former  an  exhausting  diarrhoea  or 
hemorrhage  was  often  credited  with  the  result;  among  the  latter  were  found  instances  in 
which  the  condition  of  the  brain  failed  to  account  for  the  fatal  issue.  In  all  these  cases 
the  primary  influence  of  the  fever-poison  on  the  blood  must  be  regarded  as  having  been  the 
specially  dangerous  clement.  The  probability  that  the  formation  of  heart-clot  was  the 
immediate  cause  of  death  in  many  such  cases  has  already  been  argued. 

But  there  were  certain  cases  in  which  the  post-mortem  appearances  concurred  with  the 
symptoms  during  the  closing  hours  of  life  in  indicating  that  death  was  due  to  a  particular 
cause.  Tlius,  in  forty-three  cases  the  intestine  was  pertbrated,  in  one  the  walls  of  the  gall- 
bladder were  destroyed,  and  in  sixteen  there  was  peritonitis  apparently  independent  of  per- 
foration. The  lungs  were  more  or  less  congested  in  68.3  per  cent,  of  the  cases,  but  in  a  large 
number  of  these  the  lesion  was  manifestly  insufficient  of  itself  to  account  for  the  fatal  result. 
Nevertheless  in  some,  which  may  readily  be  selected  from  the  records,  it  is  evident  that  the 
congested  or  hepatized  condition  of  these  organs  was  inconsistent  with  the  continuance  of 
life,  and  was  accordingly  the  special  factor  that  determined  the  issue.  In  this  connection 
congestive  conditions  of  the  larynx,  including  the  formation  of  diphtheritic  membranes, 
have  already  been  instanced.  In  other  cases  death  may  be  referred  with  more  or  less  prob- 
ability to  gangrene  of  the  intestines,  of  the  feet  or  of  blistered  and  erysipelatous  surfaces, 
as  also  to  parotid  abcesses  and  purulent  accumulations  in  other  parts  of  the  body,  while 
occasionally  it  was  the  result  of  accident,  as  in  the  instance  of  suflbcation  by  the  intrusion 
of  a  lumbricoid  worm  into  the  air  passages,  case  378,  or,  as  seen  in  the  clinical  records,  by 
the  unwitting  suicide  of  the  delirious  patient,  case  -II. 

In  reviewing  the  symptoms  of  the  continued  fevers  during  the  war  certain  differences 
were  found  between  the  typhoid  fever  of  our  camps  and  the  disease  as  known  to  the  literature 
of  medicine.  Certain  differences  were  also  observed  between  our  typhoid  cases  and  those 
in  which  the  typhoid  was  associated  with  a  malarial  element;  and  these  differences  attained 


484  PATHOLOGICAL    ANATOMY    AND    PATHOLOGY 

their  maximum  when  continued  fevers  of  a  purely  makirial  origin  were  subjected  to  com- 
parison with  those  that  were  regarded  as  unmodified  typhoid.  So,  in  the  examination  just 
conckided  of  the  post-mortem  appearances  of  these  cases,  certain  differences  are  discoverable 
between  our  camp  tvphoid  and  that  of  civil  life,  and  between  the  former  and  the  continued 
malarial  fever  with  which  it  was  so  frequently  associated. 

The  typhoid  of  our  camps  was  distinguished  clinically  from  the  typhoid  of  civil  expe- 
rience bv  si^ns  which  indicated  a  hio-her  descree  of  deterioration  of  the  blood.  In  many 
cases  this  deterioration  was  equivalent  to  a  greater  intensity  of  the  typhoid  fever-poison, 
for  it  lias  already  been  seen  that  a  depraved  condition  of  the  blood  was  a  primary  result  of 
the  action  of  the  poison  and  a  secondary  consequence  of  the  increased  tissue-waste  charac- 
terizing the  febrile  condition.  This  virulence  of  the  typhoid  influence  was  indicated  by 
greater  prostration,  delirium  of  a  lower  type,  the  occurrence  of  hemorrhagic  blotches,  the 
frequency  of  purulent  infiltrations  and  the  increased  fatality  of  the  disease.  Post-mortem 
observations  make  note  of  the  blotches  and  infiltrations;  but  as  the  records  do  not  recognize 
any  special  differences,  other  than  these,  in  the  organs  of  the  body  as  compared  with  their 
appearance  in  ordinary  typhoid,  the  increased  fatality  must  be  referred  to  that  alteration  of 
the  blood  which  was  the  probable  cause  of  the  purpuric  spots  and  purulent  collections. 

Our  typhoid  fever  was  distinguished  clinically  from  fevers  of  malarial  origin  associated 
with  it  by  the  presence  in  the  latter  of  symptoms  indicating  a  more  frequent  or  more  intense 
implication  of  the  stomach  and  upper  part  of  the  intestinal  tract  and  of  the  large  intestine. 
A  greater  gravity  of  the  cerebral  symptoms  and  of  those  referable  to  the  liver,  and  a  greater 
fatality  of  the  disease  also  attended  the  cases  in  which  a  malarial  element  was  associated  with 
tke  operations  of  tke  typkoid  poison.  Correspondingly  tke  post--morte7n  records  disclose  an 
increased  frequency  and  intensity  of  tke  congestive  changes  in  the  stomach  and  duodenum, 
a  more  diffuse  congestion  of  the  ileum  and  a  more  frequent  affection  of  the  large  intestine, 
particularly  of  its  solitary  glands.  A  greater  frequency  and  intensity  of  the  hypersemic  con- 
ditions of  the  liver  and  brain  and  a  somewhat  lessened  frequency  but  greater  intensity  of 
the  morbid  changes  in  the  lungs  and  spleen  are  also  observed.  Tke  malarial  cases  were  in 
fact  ckaracterized  by  tke  intensitv  and  extent  of  tkeir  congestions.  The  greater  fatality  of 
the  typho-malarial  cases  was  largely  due  to  tkese  local  conditions  of  tke  brain,  lungs  and 
intestinal  canal;  but  it  must  also  be  in  part  ascribed  to  tkat  altered  condition  of  tlie  blood 
wkick  constituted  tke  primary  lesion  of  tke  paroxysmal  fevers.  In  association  witk  tke 
similar  abnormal  ckanges  tkat  occurred  in  typkoid  tke  primary  impairment  of  tke  blood  was 
of  necessity  greater.  Tkus  may  be  understood  tke  increased  prevalence  of  kemorrkages, 
suppurations  and  gangrene  in  protracted  cases,  and  tke  more  rapid  course  of  tkose  cases  tkat 
occasionally  suggested  to  our  medical  officers  tke  presence  of  the  tvpkus  poison. 

It  is  believed  tkat  tke  tijphoid  cases  presented  in  tke  previous  sections  of  tkis  ckapter  are 
suck  as  would  kave  been  submitted  under  this  title  by  Dr.  Woodward  had  he  been  spared 
to  conclude  this  work.  Those  which  he  would  kave  presented,  so  {ax  as  can  be  gatkered 
from  kis  remarks  at  tke  International  Medical  Congress  at  Pkiladelpkia,  Pa.,  in  1876,  as 
illustrations  of  typho-malarial  fever  ivith  the  raalarial  element  predominant,  kave  been  kere 
reported  as  continued  fevers  of  malarial  origin;  for  tke  study  prosecuted  in  tke  progress  of 
tkeir  preparation  for  2)ublication  kas  not  only  failed  to  skow  in  tkem  tke  presence  of  a  typkoid 
element,  but  has  assimilated  tkem  to  tke  fevers  due  to  a  purely  malarial  cause  notwitk- 
standing  tkeir  so-called  typkoid  symptoms.     Tkose  tkat  kave  been  described  in  tke  foregoing 


OF  THE  CONTINUED  FEVERS.  .    485 

pages  as  truly  typlio-malarial  in  Dr.  AVoodwaed's  acceptation  of  the  term,  constitute  the  class 
to  wLicli  lie  would  have  applied  the  title  fi/pJio-nudarial  with  tlie  ti/phoid  element  evidently/ 
predominant.  His  scorbutic  class  of  cases  has  formed  no  separate  series  in  the  presentation 
here  given,  for  in  but  few  of  the  cases  were  the  symptoms  of  a  scorbutic  complication  jiromi- 
nently  marked.  Scurvy,  as  will  be  seen  hereafter,  was  one  of  many  causes  which  occasion- 
ally co-operated  to  render  the  typhoid  of  our  camps  different  from  that  of  civil  life,  and  to 
increase  the  gravity  of  our  malarial  and  typho-raalarial  cases.  Being  essentially  a  deteri- 
oration of  the  blood  it  could  not  fail  to  aggravate  diseases  that  owed  not  only  their  primary 
danger  but  many'of  their  serious  secondary  evils  to  a  depraved  condition  of  that  fluid;  but 
unless  under  this  title  be  gatliered  all  the  many  causes  that  tended  to  deteriorate  the  blood 
of  our  soldiers  on  its  formative  a.spect,  to  it  alone  may  not  be  ascribed  the  whole  of  the 
increased  gravity  tliat  characterized  our  continued  fevers. 


VI.— ETIOLOGY  OF  THE  CONTIXUED  FEVERS. 

I.— COMMON  CONTINUED  FEVER. 

The  symptoms  characterizing  this  fever,  as  reported  during  the  first  fourteen  months 
of  the  war,  were  those  which  at  a  later  date  were  generally  accepted  as  indicating  the  prob- 
able presence  of  the  typlmid  poison.  But  a  fever  ushered  in  by  chills  or  malaise,  with 
headache,  dizziness,  ringing  in  the  ears,  epistaxis  and  light  delirium,  and  running  a  variable 
course  of  from  one  to  many  days,  presents  nothing  specific  in  its  aspect.  Even  had  this 
febrile  condition  l»een  associated  with  diarrh(Ba  and  more  or  less  abdominal  tenderness,  a 
diagnosis  of  typlioid  would  hardly  have  been  warranted,  in  view  of  the  great  prevalence  of 
diarrhceal  aflections  among  the  troops.  ' 

Our  soldiers  were  exposed  to  a  variety  of  depressing  influences,  and  especially  to  over- 
heating by  violent  exercise,  to  subsequent  chill,  continued  exposures  in  the  hot  sun,  cold,  damp- 
ness and  foul  air  from  overcrowding  in  closely  shut  tents  and  huts  and  from  decomposing 
substances  on  or  near  their  camping  grounds,  each  of  which  has  been  shown  by  expei'ience 
to  be  capable  of  inducing  a  condition  of  marked  febrile  reaction,  ephemeral  in  character 
under  favorable  hygienic  surroundings,  but  persisting  for  a  longer  period  under  continued 
or  recurring  exposure  to  the  exciting  cause.*  These  fevers,  unaccompanied  by  local  infiam- 
mations,  may  be  conceived  to  have  been  the  result  of  a  temporary  deterioration  of  the  blood, 
whicliin  some  unfavorably  situated  cases  reduced  the  jnitient  to  the  adynamic  condition  so 
generally  associated  with  typhoid  fever.  But  clinically  they  differed  from  enteric  fever, 
and  etiologically  they  have  not  been  proved  to  be  identical."!"     It  is  therefore  a  subject  of 

*  Surgeon-Major  M'illiam  G.  Diirk.  in  an  nrticlo  on  Of  Emlemk-  Continued  Fcrers  of  snMrnpiail  Intitmles, — BWfi.v/*  M'-il.  Jonr.,  Vol.  II,  1880,  p.  7:18, — 
utatos  a.s  the  general  exiiorience  in  tlie  subtroi)ic^  that  cuseri  uf  contiuueil  fever  constantly  occur  wliieli  have  not  only  no  constant  specific  coniplicatiou 
but  no  appreciable  le.sion  of  any  kind. 

f  William  S.  £n(iAR,  Surgeon  3"2d  111.,  in  an  article  giving  lii.s  views  on  tlie  nature  antl  origin  of  C'uiip  T;ii>hoi>l  Ferer, — Chiatgn  Medical  Ream- 
iner,  Vol.  V,  1S*J4,  p.  fl.5, — refers  the  disease  to  non-specific  influeiu-es,  s\u-Il  as  liave  been  indii-ati'd  in  tlie  text,  as  tlie  cause  of  conilnou  continued  fever. 
He  liolds  tliat  the  fever  resulted  from  a  mal-nutrition  and  depravation  of  tlie  blood,  attributing  tlie  defective  nutrition  to  derangeiiieiit  of  the  digestive 
function  and  the  overcharging  of  the  circulation  with  impurities  to  torpor  of  the  excretory  organs,  the  skin,  kidneys  and  liver,  lioth  of  these  abiionnal 
conditions  are  assumed  to  lie  consequences  of  deficient  nerve-force  induced  by  various  influences  op<'ratitig  on  the  nervous  system,  as  escestiive  and  long- 
continued  toil  without  sleep  or  rest,  rendered  more  exhausting  by  depressing  mental  causes,  as  constant  fear  or  anxiety,  the  cheerlessness  and  nioiuitony 
uf  camp  life,  the  deprivation  of  home  joys,  of  the  society  of  friends,  of  accustomed  amusements,  in  short,  of  all  those  things  which  in  the  previotis  lives  of 
the  men  fostered  a  cheerful  and  happy  state  of  mind.  He  allows  that  Ih^-  infiuence  of  such  caiLses  may  not  Ik'  readily  apimrent  in  every  case  of  this  fever, 
but  claims  that  careful  iminiry  will  elicit  in  all  the  antecedent  existence  of  a  disturbance  of  thecerebnil  functions.  He  regards  the  disease  of  Peyer's  glands 
and  other  morbid  states  of  the  alimeutary  canal  as  merely  incidental  and  due  to  the  acrid  and  irritating  secretions  resulting  from  imiiaired  digestion. 


486  ETIOLOGY   OF   THE 

regret  that  they  were  deprived  of  an  appropriate  title  on  the  Monthly  Reports  of  Sick  and 
AVoiinJed.  By  their  separation  from  recognized  febrile  conditions  some  information  might 
have  been  gathered  concerning  their  causation  and  kinship. 

IL— TYPHOID  FEVER. 

There  are  few  papers  on  file  relating  to  the  causation  of  typhoid  fever,  although  many 
incidental  references  were  made  in  general  reports  to  the  hard  service  of  tlie  men,  tlie  inclem- 
ency of  the  weather  and  insanitary  conditions  in  camp  as  connected  witli  the  prevalence  of 
this  fever.  In  the  extracts  which  arc  submitted  below  Fakley  attributes  the  disease  to 
hard  service  and  its  incidental  exposures,  Bache  to  the  unaccustomed  mode  of  life  of  the 
young  soldiers,  AVarrei^  chiefly  to  a  pythogenic  miasm,  Lyman  to  overcrowding  and  bad 
ventilation  and  Jamisox  to  hardships  and  exposures,  although  he  also  suggests  a  transmis- 
sion of  the  disease  from  the  localities  whence  the  men  were  recruited.  Dr.  Saxfoed  B. 
Hrx'r' states  that  the  first  caseof  tvphoid  fever  in  his  regiment  occurred  at  Baltimore,  Md., 
while  the  command  was  en  route  southward  from  K^ew  York.  During  the  illness  of  this 
patient  "two  or  three  of  his  family  in  the  healthiest  part  of  Tioga  county  died  of  typhoid; 
of  course  my  man  brought  the  fever  from  home  with  him.'' 

Surgeon  J.\s.  51.  Farl?:y,  84/7i  X.  F.,  June  30,  1S62. — The  rejiiuient  has  marched  during  the  quarter  345  miles, 
oceniiyiiig  nineteen  days,  heini;  an  average  of  eiirhteen  miles  per  day.  All  the  eamps  ivere  finely  located  except  the 
one  at  Itristol,  which  was  in  a  swamp,  and  during  three  days  of  the  time  we  were  there  it  rained  incessantly.  This 
caused  a  large  numher  of  cases  of  a  low  grade  of  remittent  fever  and  some  of  typhoid. 

Brigade  Surg.  T.  H.  B.vciiE,  Haiferan  Inlet,  X.  C,  Dec.  31,  1861. — The  ground  in  many  places  occupied  by  our 
troops  during  the  tirst  part  of  the  (luarter  was  a  sandy  waste,  a  portion  of  wliich  tlie  water  is  continually  asserting 
its  riglit  to  hold.  A  mile  above  Fort  Hatteras  we  have  Fort  Clark,  where  there  is  a  little  marsh  grass;  a  few  small 
scrub-oaks  were  there  formerly,  but  I  learn  the  rebels  cut  them  down  when  they  occupied  the  phice.  Half  a  mile 
above  Fort  Clark  the  island  l)ecoming  broader,  wo  have  a  tract  of  ground  covered  with  a  scanty  vegetation,  inter- 
sected by  marshes  producing  a  very  coarse  grass  which  yields  a  poor  support  to  some  very  diminutive  cattle.  This 
condition  of  country  continues  for  about  four  miles  up  tlie  coast,  when  .suddenly  we  come  to  a  narrow  part  of  tlie 
island  where  there  is  no  vegetation.  Here  we  find  a  sandy  plain  called  Bald  Beach.  In  barracks  just  below,  but 
bordering  on  Bald  Beach,  the  greater  part  of  the  connuand  is  now  located.  From  this  description  one  can  readily 
understand  why  the  chief  diseases  are  intermittcn-t  and  remittent  fevers.  These  fevers  are  only  to  bo  dreaded  during 
the  spring  and  autumn.  The  typhoid  (enteric)  fever  cases  w-e  should  have  expected  in  regiments  containing  young 
men  who  are  living  a  life  so  diti'ereut  from  that  formerly  passed  by  them.  Many  are  too  thoughtless  to  take  proper 
care  of  their  health,  and  unfortunately,  they  frequently  have  company  officers  over  them  who  are  ignorant  of  the  rules 
to  be  enforced  for  protecting  their  men,  or,  if  told,  do  not  understand  the  importance  of  such  measures.  The  regiment 
would  be  much  less  sickly  if  companj-  olHcers  insisted  upon  personal  cleanliness,  proper  ventilation  of  quarters  and 
thorough  cooking  of  the  government  rations.     The  last  we  have  found  both  ample  and  of  excellent  quality. 

Brigade  Surg.  3.  H.  Warkex,  JVashington,  I).  C.,yor.  26, 1861. — Having  inspected  the  various  cami)s  at  Meridian 
Hill,  Kalorama,  &c.,  near  Washington,  D.  C,  I  have  the  honor  to  report  that  the  52d  Pa.  has  more  cases  of  sickness 
than  any  other  regiment  visited.  The  prevalent  disease  in  this  command  is  typhoid  fever,  of  which  there  are  tliirty- 
tive  or  forty  eases.  The  cause  is  conceived  to  be  the  malarial  location  of  the  camp.  The  soil  is  a  heavy,  cold  clay, 
incapable  of  allowing  the  water  to  filter  through  it ;  and  consequently  the  ground  is  very  cold  and  damp.  Xear  the 
camp  is  a  deep  ravine  containing  mineral  springs  (magnesia,  I  believe).  These,  with  the  vacillating  temperature  of 
the  present  season  and  the  obstruction  of  drains  with  decomposing  waste,  such  as  coffee-grounds,  beans,  bread,  old 
bones  and  slops  from  the  mess-pans,  are  the  principal  agents  which  conduce  to  the  large  amount  of  febrile  disease 
in  this  regiment. 

lleport  on  the  condition  of  the  I'th  X.  ¥.,  hy  3.  H.  Wakuex,  Brigade  Surgeon,  Washington,  Jan.  27,  1862. — This  reg- 
iment is  encamped  upon  the  western  slope  of  Meridian  Hill.  The  ground  is  as  good  for  camping,  owing  to  its  gravelly 
and  porous  nature,  as  any  in  the  vicinity;  but  the  atmosjihero  is  impregnated  witli  a  malarial  odor,  arising  from 
the  decomposition  of  animal  matters  just  lielow  in  an  open  field,  where  a  large  number  of  dead  horses  are  deposited 
upon  the  surface  and  allowed  to  remain  and  decompo.se.  This,  with  rather  poor  policing  of  the  camp,  has  given  rise 
to  typhoid  fever,  from  which,  I  regret  to  say,  we  have  lost  some  ten  or  twelve  men  already. 

Medical  Inspector  Geouge  H.  Lyjiax,  V.  S.  J.,  on  the  sanitarg  condition  of  Fort  Wood,  Xew  York  Harbor,  Feb.  18, 
186.5. — The  comnuind  numbers  1,175:  The  permanent  garrison  448,  recruits,  stragglers  and  deserters  122,  and  convales- 
cents just  discharged  from  \ariuus  hospitals  and  awaiting  transportation  to  the  front  605.     The  barracks  are  unlit 

*C"/<i!o  M</1.  amlSiirg.  Jwmial,  V,jl.  11,  1.SC2,  !>.  2112. 


COXTIXL'ED    FEVERS.  487 

for  use:  their  occupancy  is  calculated  to  send  the  incu  soon  back  to  liosjiital.  The  lloors  vest  on  the  ground;  the  cei!inj;s 
are  low  and  the  light  insullicient.  At  this  time  many  men  are  ol)lij;ed  to  slcpii  on  the  lloor,  and  I  am  told  that  rooms 
which  ouffht  not  to  contain  over  '60  men  (thoujjh  with  bunks  for  80)  often  have  120  occupants.  Forty-five  of  those 
now  in  hospital  are  from  the  convalescents:  and  tlie  cases  are  almost  exclusively  of  a  low  tyj)e — typhoid  fever,  jmeu- 
monia,  erysipelas,  &c.\  of  the  last-mentioned  disease  there  were  six  cases  in  January  and  seven  this  month. 

Siirgeo)!  Jxo.  S.  Jamison,  SGlh  X.  1'.,  Good  Hope,  D.  C,  Dec.  31,  18fil. — Our  present  camp  is  situated  on  the  border 
of  an  open  woodland,  timbered  with  oak  and  chestnut,  upon  a  rise  of  ground  facing  south,  sides  sloping  east  and  west, 
with  a  snuill  sti'eam  of  clear  pure  water  at  the  foot  of  each  declivity.  This  location  is  free  from  nmd,  the  soil  drying 
off  rapidly  after  each  rain-storm.  It  would  become  objectionable,  however,  later  in  the  season, when  the  temperature 
is  siitiicientry  high  to  favor  the  rise  of  malaria  from  the  decaying  vegetable  nujuld  upon  its  surface.  Typhoid  fever 
and  ])neamonia  have  prevailed  to  a  considerable  extent  during  the  months  of  February  and  March,  the  former  having 
caused  fourteen  and  the  latter  five  deaths  in  the  regimental  hospital.  The  whole  number  of  deaths  from  fever  in 
the  regimental  and  general  hospitals  will  not,  jirobably,  exceed  twenty-five.  The  tendency  to  this  fever  in  camp 
at  present  gives  cheering  evidences  of  an  abatement  in  iirevalence  and  severity.  I  can  mention  no  causes  beyond 
those  ordinarily  referred  to  where  many  men  are  crowded  together  and  exposed  to  the  vicissitudes  of  weather  connuou 
to  this  region  of  country.  The  long  and  weary  march  of  sixteen  miles  through  mud  and  rain  to  Camp  Griffin,  Va.i 
the  stay  of  the  regiment  there  for  a  month  exposed  to  constant  storm,  the  sun  rarely  making  its  appearance,  and  the 
march  back  to  this  locality  may  with  propriety  be  referred  to  as  strongly  exciting  causes  of  sickness  amongst  our 
men.  Predisposition  to  this  fever  may  have  been  laid  before  the  men  left  the  vicinity  of  their  homes,  where  the  disease 
in  (luestiou  has  prevailed  to  a  considerable  extent  during  the  fall  and  winter.  Certainly  a  wide  difference  in  climatic 
influence  must  be  felt  by  the  men  who  have  wintered  in  this  climate,  so  different  from  that  of  the  rugged  hills  and 
frozen  winters  of  Western  New  York.  The  troops  are  daily  employed  in  the  ordinary  military  exercises  of  the  field. 
The  habits  of  the  men  are  fairly  good,  bathing  once  or  twice  weekly,  changing  underclothing  weekly,  ventilation 
and  cleanliness  of  tents  observed  and  streets  well  policed. 

A  report  by  Ass't  Surgeon  Milhau,  U.  S.  Army,  contrasts  the  condition  of  tlie  lltli 
and  litli  U.  S.  Infantry,  stationed  at  Perryville,  Md.,  in  the  early  period  of  the  war.  Tlie 
former  regiment  was  healtliy,  the  latter  scourged  with  typhoid  fever.  Dr.  MiLliAU  referred 
the  disease  to  the  bad  quality  of  the  water  used  by  the  men  of  the  14th  and  to  stable 
manure  in  the  vicinity,  although  so  far  as  concerns  the  latter  the  teamsters,  who  were  more 
exposed  to  its  odors,  were  unatlectcd.  From  what  has  been  already  advanced  concerning 
the  ]iri'valence  of  typhoid  fever  among  new  levies,  it  seems  as  if  in  this  instance  the  explana- 
tion must  lie  in  the  character  of  tlic  living  material  constituting  the  two  commands,  although 
both  were  new  and  untried  regiments,  organized  and  recruitt.M.l  during  the  previous  summer 
and  autumn. 

The  quarters  of  the  14t]i  U.  S.  Infantry  were  shortly  afterwards  occupied  by  tlie  10th 
Is.  Y.  Cavalry.  The  regimental  surgeon,  11.  W.  Pkask,  on  inspecting  the  camp  of  the  11th 
Infantry  and  that  assigned  to  his  own  command,  attributed  the  insalubrity  of  the  latter  to 
defective  drainage  and  a  more  recent  turning  up  of  the  soil  for  agricultural  purposes.  Meas- 
ures were  taken  to  remedy  these  objectionable  features,  but  in  a  few  days  diarrhoea  and 
intermittents  became  prevalent,  and  in  three  weeks  many  cases  of  remittent  fever  were 
developed,  two  of  which  assumed  a  typhoid  tyi>o.  At  this  period  the  regiment  was  removed 
to  Havre  do  Grace,  Md.  It  does  not  appear,  however,  that  the  typhoid  symptoms  devel- 
oped in  these  cases  were  due  to  enteric  fever;  for  although  the  special  report  fails  to  follow 
up  the  history  of  the  regiment,  the  ]\Ionthly  Report  of  Sick  and  Wounded  for  the  following 
month,  April,  shows  twenty-eight  cases  of  remittent  fever  and  only  one  reported  as  typhoid, 
all  of  which  ended  favorably. 

Ass't  Surgeon  Woodhull,  U.  S.  Army,  testifies  to  the  absence  of  typhoid  fever  from 
the  ranks  of  the  two  old  regiments,  the  2d  and  10th  U.  S.  Infantry,  with  which  he  served, 
attributing  their  freedom  to  the  more  seasoned  condition  of  the  men  as  compared  with  the 
susceptible  material  of  newly-organized  commands. 

Ass't  Surg.  J.  J.  Milhau,  V.  S.  J.,  on  the  sanitari/  condition  of  troops  stationed  at  J'crrni-iUe,  Md.,  Feb.  10,  1862. 
Eleventh  TJ.  S.  Infantrtj. — Hospital  in  a  one-storj'  stone  house  containing  two  rooms  and  a  garret:  the  rooms  18  X  18 
feet;  only  cue  used  as  a  ward.    An  addition  of  boards  serves  as  a  dispensary  and  kitchen  and  a  further  extension  as 


488  ETIOLOGY    OF   THE 

a  sick  Avard  for  teamsters.  The  Imildinfc,  which  is  heated  by  a  stove,  will  answer  as  long  as  the  mimbcv  of  sick  is 
small.  A  few  of  the  patients  sleep  in  the  garret  on  hunks  and  sacks.  Sick  in  hospital  10,  in  quarters  lli^total  26; 
none  in  general  hospital.     Strength  of  regiment  340. 

Digeases. — There  are  no  serious  cases;  no  typhoid  or  other  fevers. 

The  Tiarrucka  consist  of  four  hoard  huts  each  accommodating  one  company,  and  each  85  X  18  X  Vi  feet  to  plate; 
no  ceiling;  ventilators  in  centre  of  roof;  windows  on  one  side  only;  hunks  double  and  in  two  tiers,  each  with  a  bed- 
sack.  There  is  an  addition  to  eacli  set  of  quarters  for  a  kitchen  and  mess-room.  The  houses  are  a  little  raised  from 
the  ground;  the  soilis  a  pretty  dry  sod.     i'oHce  very  good.     C'io(/i  i'hi/ ample;  men  neat.     Messing  good. 

Il'iitcr  is  obtained  from  a  small  spring. 

.Si'hAs  built  over  the  river  and  well  attended  to. 

Fuiirlienili  U.  S.  Infantry. — IIosj)it((l  in  two  unceiled  board  huts:  one  72  X  14  X  ~i  feet  to  plate,  with  dispensary 
14  X  14  attached ;  the  other  40  X  14,  same  height.  These  huts  are  pretty  well  located,  raised  from  the  ground  and  fur- 
nished with  full  windows  on  each  side  and  two  ventilators  in  the  roof;  they  are  heated  by  stoves.  In  the  large  ward 
are  twenty-six  wooden  bunks,  in  the  smaller  ward  fifteen  iron  bedsteads.  Sick  in  hospital  41,  in  quarters  96;  total  137. 
Strength  of  regiment  850.     Ten  new  cases  were  taken  sick  this  morning. 

Difeasex. — In  hospital :  Typhoid  20,  measles  7,  mumps  4,  diarrhoea  and  convalescents  8,  erysijielas  1  and  injury  1. 
In  (juarters:  Many  cases  of  diarrhtea,  catarrh  and  fever. 

Btirracks. — Board  huts  enclosing  a  quadrangular  sjiace  or  parade  ground,  into  which  the  windows  and  doors 
open ;  there  are  no  openings  on  the  outer  walls.  The  ground  is  an  old  ploughed  field  nearly  level,  the  soil  clay.  The 
huts  are  raised  from  one  to  three  feet,  according  to  the  undulations  of  the  surface;  in  their  front  a  rough  stone  walk 
has  been  laid  and  a  ditch  dug  to  carry  off  the  water.  Each  set  of  quarters  is  80  X  18  X  7i  feet  to  tlio  plate ;  no  ceilings; 
half  windows  on  one  side  only;  two  ventilators  in  the  roof;  heated  by  stoves;  two  tiers  of  double  bunks,  each  with  a- 
bedsack.     Each  company  has  a  kitchen  under  the  same  roof.     Police  good.     Clothing  ample.     Messing  good. 

7r<(/cj'is  drawn  from  a  well  sis  feet  deep;  it  is  cloudy  and  has  a  strong  vegetable  taste. 

Sinks  over  the  river. 

The  sanitary  condition  of  the  regiment  has  not  been  good  for  some  weeks  owing  to  the  prevalence  of  typhoid 
fever.  The  disease  commences  with  severe  vomiting  and  purging  of  a  colorless  lluid,  which  continues  one  or  two 
days,  guatly  prostrating  the  patients;  chills  ensue,  followed  by  continued  fever,  the  tongue  becoming  dry,  with  red 
edges,  and  the  other  symptoms  of  typhoid  soon  show  themselves.  There  have  been  a  number  of  deaths  from  this 
disease  and  from  measles.  I  carefully  inspected  every  part  of  the  barracks,  the  provisions,  etc.,  and  failed  to  find 
any  satisfactory  cause  of  disease  except  in  the  water  used  by  the  regiment,  which  I  consider  bad.  I  understand  that 
the  inhabitants  do  not  generally  use  the  well-water  during  the  winter,  btit  the  river-water,  which  is  said  to  be 
healthier.  There  is  an  extensive  mule-yard  and  stable  adjoining  the  barracks  on  one  side,  though  there  are  neither 
doors  nor  windows  opening  on  that  side.  A  good  deal  of  filth  had  accumulated  in  this  yard,  but  when  the  troops  com- 
menced to  fall  sick  it  was  cleaned  out  and  much  of  its  manure  removed.  There  may  be  something  in  the  soil  which 
so  far  has  escaped  detection;  but  there  are  over  two  thousand  teamsters  camped  in  the  vicinity  and  there  is  little  or 
no  sickness  among  them. 

I  recommend  the  well  to  be  closed  up  and  the  river-water  only  to  be  used.  I  also  reconnnen<l  quinine-whiskey 
to  be  given  to  the  men  to  counteract  what  I  suppose  to  be  a  malarial  influence.  If  the  disease  be  not  checked  in  a 
few  days  the  regiment  should  be  moved. 

Surgeon  R.  W.  Pea.sk,  10(/i  X.  V.  Ciiv.,  Havre  de  Grace,  Md.,  March  31,  1862. — About  the  first  of  March  orders  were 
received  to  move  to  Perryville,  Md.,  and  occupy  the  quarters  of  the  14th  U.  S.  Infantry.  On  the  7th  we  entered  these 
quarters,  and  while  we  found  them  connnodious  and  in  good  condition,  we  learned  that  the  regiment  which  had  just 
left  had  suftered  severely  from  typhoid  fever  and  diseases  of  a  like  character.  The  barracks  are  situated  on  the  eastern 
shore  of  Chesapeake  bay,  an  elevated  and  pleasant  situation.  About  400  yards  distant  were  the  quarters  of  the  11th 
U.  S.  Infantry.  This  regiment,  I  aui  informed,  notwithstanding  its  coutiguity  to  the  lltli,  was  almost  exeuipt  from 
disease.  Dr.  rA(iK,tlie  post  surgeon,  states  that  river-water  was  used  liy  both:  the  camps  were  cciually  well  policed 
and  the  general  management  of  each  equally  good.  The  only  solution  he  was  able  to  give  of  the  difference  in  sanitary 
condition  was  the  fact  that  the  ground  of  the  14th  was  difficult  to  drain;  that  it  had  been  jiloughed  more  recently 
than  that  of  the  11th  and  a  good  sod  had  not  formed  on  it.  With  these  facts  before  me  it  was  my  object  to  render 
the  drainage  as  complete  as  possible,  thoroughly  to  clean  the  barracks  and  to  find  a  new  source  from  which  to  obtain 
our  supjily  of  water.  The  drains  were  opened  and  improved,  and  an  excellent  spring  was  found  convenient  to  the 
quarters,  yet  exempt  from  its  drainage.  The  weather  soon  became  settled,  and  the  mud  which  had  heretofore  been 
very  deep  disappeared  :  everything  apparently  i)romised  well.  But  about  the  10th  diarrluea  began  to  prevail,  and  a 
few  days  later  symptoms  of  malarial  fever  apjieared.  On  the  26th  orders  came  to  luove  across  the  bay  to  Havre  de 
Grace.  On  the  27th  numerous  cases  of  remittent  fever  were  develoiied,  while  acute  diarrhoea  had  become  epidemic. 
It  is  safe  to  say  that  during  the  last  twelve  days  we  have  had  a  larger  number  of  sick  on  our  list  than  for  the  whole 
of  the  previous  month.  Two  of  the  fever  cases  have  assumed  a  tyi>hoid  type.  The  diarrlneal  cases  obstinately  resist 
the  ordinary  treatment,  quinine  being  essential  to  a  cure  in  almost  every  instance.  The  general  characterof  our  men 
is  good.  They  have  been  i-egularly  and  fully  supplied  with  rations  and  their  cooking  has  been  unusually  good.  Otir 
hospital  accommodations  have  been  excellent,  and  the  sick  universally  bear  testimony  to  faithful  care  and  a  full  and 
ready  attention  to  their  wants. 

Jss'i  Surg.  A.  A.  "Woodhull,  U.  S.  A.,  2d  and  lOlh  V.  S.  Inf.,  Sept.  30,  1862. — There  were,  at  least  in  this  command, 
very  few  instances  of  any  form  of  continued  fever,  and  although  a  generally  weakened  state  of  the  system  was  quite 
prevalent,  and  chronic  cases  of  almost  every  disease  fell  into  an  adynamic  and  almost  typhoid  condition,  there  was- 


CO>'TINrED    FEVERS.  489 

wonderfully  little  (certainly  not  one-half  per  cent.)  of  the  true  typhoid  or  enteric  fever  in  the  battalion.  One  reason 
may  he  found  in  the  older  and  more  seasoned  condition  of  the  men  in  tlie  regular  regiments.  It  is  probable  tliere 
were  many  cases  among  the  newly-recruited  forces,  but  I  utterly  repudiate  the  idea  so  often  advanced  that  enteric 
fever  was  the  prevailing  disease.  Of  the  few  cases  I  saw  some  were  remarkably  mild,  almost  escaping  detection,  and 
one  or  two  recovered  in  tents  that  I  believe  never  could  hare  survived  in  a  building.  No  fatal  case  of  enteric  fever 
came  under  my  notice  in  camp. 

The  occupation  of  a  camp  in  which  typhoid  fever  had  prevailed  appears  to  have  deter- 
mined its  occurrence  in  some  instances,  as  in  that  of  the  23d  Mass.,  recorded  by  Surgeon 
George  Derby.  This  regiment  liad  endured  many  hardships  and  exposures  sucli  as  have 
frequently  been  charged  with  the  causation  of  the  disease;  yet  the  command  continued 
healthy  uiitd  a  short  time  after  it  occupied  the  tents  and  camping  ground  formerly  used  by 
a  confederate  regiment  that  had  suflered  severely  from  tyj)hoid  fever.  Within  six  weeks 
after  the  occupation  of  the  infected  camp  one-tliird  of  the  strength  of  nine  hundred  men 
became  affected  with  fever  and  twenty-two  of  the  cases  proved  iatal.  Immediately  after 
this  the  epidemic  subsided,  just  as  in  the  army  as  a  whole  it  began  to  subside  in  1861,  when 
the  susceptible  individuals  who  responded  to  the  first  call  of  the  President  for  troops  had 
undergone  their  attack.  Instances  of  this  character  manifestly  show  that  bad  air,  improper 
food,  exposure  to  wet  and  cold,  great  fatigue,  anxiety  and  other  depressing  and  insalubrious 
causes  do  not  of  themselves  develop  typhoid  fever,  although  tliey  may  render  the  individual 
less  able  to  withstand  the  violence  of  its  attack. 

The  17th  Mass.,  on  duty  at  Xew  Berne,  N.  C,  during  the  quarter  ending  June  30,, 
1862,  was  fully  exposed  to  the  general  causes  of  sickness  that  operated  on  the  armv  as  a 
whole.  Typhoid  fever  was  the  most  prominent  of  the  diseases  affecting  it,  but  even  tliis  did 
not  jiivvail  to  a  great  extent.  Surgeon  Galloupk  considered  the  comparative  immunity 
enjiiycd  l)y  his  regiment  as  the  salutary  result  of  a  careful  observance  of  the  general  princi- 
ples of  hygiene.  This  may  be  allowed;  but  in  connection  with  tin,'  slight  injury  oflccted  by 
typhoid  ;it  this  time,  it  must  be  remcmltered  that  his  regiment  had  already  been  exposed  to 
the  spi'cial  poison  ol  the  ilisease.  The  diminished  susceptil/ilitv  of  the  men  must  therefore 
be  taken  into  account  in  estimating  the  value  o{'  tlie  livgienic  measures. 

Siirnron  Georgk  Dkhiiv,  V.  S.  Vols.,  on  the  Midical  IliKlonj  of  the  2:W  Mu«K.,from  Xomnhei;  l!^(il,  to  June,  18ti2. 

[This  regiuient,  nHnil)eriiig  900  men,  left  Massachusetts  in  November,  IWil,  au<l  occupied  a  salubrious  cauip  at 
Annapolis,  Md.,  until  January  0,  18(!2,  w  hen  the  men  were  closely  stowed  in  transports  for  thirty-two  days.  To  caro 
in  ventilation  and  cleanliness,  including  the  daily  airing  of  bedding  on  deck,  is  attributed  the  good  health  of  the 
command  during  this  period.  On  arriving  at  Koanoke  Island,  February  7,  the  men  were  exposed  to  rainy  weather, 
and  had  to  wade  through  the  swamjis  during  the  engagement  which  took  jilaco  there.  On  JIarch  II  they  embarked 
for  New  Heme,  N.  C,  where,  after  the  battle,  they  occupied  tents  abaniloned  by  rebel  troops,  anwing  whom,  as  was 
afterwards  learned,  fever  had  prevailed.]  I'ntil  our  arrival  at  New  Berne,  March  11,  the  health  of  the  regiment, 
in  spite  of  every  hardship  ami  exposure,  had  been  good  and  but  few  deaths  had  occurred.  We  had,  however,  no 
sooner  settled  in  camp  at  the  Fair  grounds,  just  outside  the  city,  than  typhoid  fever  of  a  severe  type  was  developed. 
In  April  three  hundred  cases  occurred  with  twenty-two  deaths.  It  was  the  same  fever  we  have  in  Massachusetts, 
characterized  by  tenderness  on  pressure  in  the  iliac  region,  diarrhoea,  tympanites  and  rose-spots.  In  a  good  many  of 
the  earliest  cases  the  force  of  the  fever-poison  seemed  to  fall  njion  the  brain,  and  a  low  muttering  deliriuiu,  marked 
nervous  depression  and  subsnltus  were  ol)served;  later  in  April  the  type  was  less  severe  and  fatiil.  Treatment  was 
almost  entirely  expectant :  our  chief  reliance  was  upon  fresh  air,  careful  nursing  and  supporting  the  strength,  treating 
more  actively  symptoms  as  they  appeared.  The  causes  of  this  severe  visitation  seem  to  be  found  in  the  depressing 
insalubrious  conditions  in  which  the  regiment  was  jdaced  on  shipboard  both  before  and  after  the  battle  of  Roanoko 
and  up  to  the  time  of  its  arrival  at  New  Berne :  Bad  air,  improper  food,  exposure  to  wet  and  cold,  with  great  fatigue 
immediately  following  a  long  period  of  inaction.  Some  iutluence  may  also  bo  ascribed  to  the  occupation  for  several 
weeks  of  tents  from  which  many  of  the  enemy's  sick  had  recently  been  removed.  Since  the  subsidence  of  fever  in  tho 
last  of  April  the  health  of  the  regiment  has  been  tolerably  good.  Many  men  were  permanently  disabled  by  the  hard- 
ship and  exposure  which  they  had  endured  and  have  since  been  discharged. 

Siir!/eun  Isaac  F.  Galloupk,  17th  Mass.,  June  30,  1862.— During  the  last  three  months  this  regiment  has  been 
stationed  at  or  near  New  Berne.  N.  C.  The  country  in  the  vicinity  is  low,  level  and  marshy  and  the  soil  universally 
sandy.  The  climate  at  t,.is  season  is  favorable  to  health  and  no  sickness  has  resulted  from  this  cause.  The  food  and 
Mkl>.  Hist.  Pt.  IU— G2 


490  ETIOLOGY    OF    THE 

clotliiiij;  have  been  ample  and  of  fjood  quality.  The  water  is  bad,  but  particular  care  in  filterini;  or  boiliuf;  has 
prevented  any  extensive  illne.ss  from  tliis  eanse.  Tlie  tents  used  by  the  men  are  of  excellent  (iiiality  and  (Sibley) 
pattern,  but  too  few  in  number.  The  crowding  together  of  from  fifteen  to  twenty  men  in  one  tent  has  in  .sonn>  instances 
created  a  tendency  to  typhoid  fever.  The  troops  have  been  almost  constantly  engaj;ed  on  picket  duty,  and  exposure 
to  night-air  in  low,  moist  districts  and  sleeping  on  the  ground  have  been  the  causes  which  have  operated  most  ctl'cctually 
in  producing  sickness.  The  disease  most  prevalent  is  typhoid  fever,  but  even  this  lias  not  existed  to  a  great  extent. 
It  is  rennirkable  that  so  little  sickness  has  been  produced  by  the  causes  which  ordinarily  are  considered  eticctual  in 
inducing  disease.  The  comparative  innnunity  from  sickness  which  we  have  enjoyed  I  attribute  to  the  constant  care 
which  has  been  exercised  in  relation  to  the  sanitary  condition  of  the  men  and  their  ((uarters.  Daily  inspections  have 
been  made  of  the  food,  clothing  and  tents,  and  the  whole  camp,  including  everytliing  that  might  inllucnee  the  health 
of  the  men,  has  received  due  attention:  order,  neatness,  cleauliiu'ss  and  temperance  have  been  enforced  as  military 
duties.  The  good  results  of  this  care  give  me  great  satisfaction ;  for,  while  disease  has  wrought  extensive  destruction 
among  the  troops  in  this  vicinity,  I  have  the  satisfaction  of  reporting  but  three  deaths  from  disease  in  this  regiment 
during  the  quarter.  Our  hospital  accommodations  have  been  all  that  could  be  desired  :  the  best  houses  in  town  have 
been  used  for  hospitals,  with  all  the  contrivances  for  comfort  and  ease  which  our  escaped  enemies  left  behind. 

Surgeon  Isaac  T.  Gam.oupe,  \~th  Mass.,  Canq)  Andrew,  BuUimore,  Md.,  Dec.  31, 18t)l. — The  duties  and  employment 
of  the  troops  have  been  such  as  did  not  interfere  with  their  health  except  iu  one  instance.  Five  hundred  men  of  the 
regiment  went  to  the  Eastern  Shore  of  Virginia  under  (General  Lockwood  in  the  month  of  November,  where  they 
renniined  a'>out  three  weeks.  During  their  absence  one  of  them  died  of  typhoid  fever,  and  soon  after  their  return  to 
Baltimore  twenty-four  were  taken  sick  with  the  san\e  ctunplaint  in  a  severe  form,  which  proved  fatal  in  six  cases. 
In  all  these  cases  the  disease  nmst  have  been  contracted  while  the  men  were  in  Virginia. 

Although  the  disease  was  apparently  propagated  in  many  instances  by  the  infection  of 
a  locality  there  is  no  illustration  on  the  records  of  a  direct  contagion  from  one  individual  to 
another.  Fever  cases  in  the  general  hospitals  were  often  treated  in  the  general  wards,  yet 
no  su?j)icioii  of  direct  contagion  was  roused.  Here,  however,  there  was  usuallv  a  larger 
air-space,  better  ventilation  and  greater  attention  to  cleanliness  tlian  in  tlio  regimental  or 
field  hospitals.  Surgeon  Beck,  3d  Ind.  Cav.,  refers  the  production  of  typhoid  fever  to  faulty 
methods  of  cooking  and  the  fatigues  and  exposures  of  active  scouting  duty  during  the  winter 
months;  but  his  language,  in  speaking  of  tlie  manner  in  which  mild  and  unimportant  attacks 
of  other  forms  of  disease  terminated  after  contact  with  fever  cases,  is  hio-hlv  sucrfestive  of  a 
contagious  quality  of  the  latter.  If  contagion  existed,  the  crowded  regimental  hospitals 
certainly  afforded  every  facility  for  its  activity.  Although  such  an  epidemic  as  affected  the 
23d  Mass.  at  Xew  Berne  must  be  attributed  to  the  operation  of  the  same  influences  on  the 
command  as  a  whole,  it  is  probable  that  in  other  instances  the  disease  was  propagated  and 
its  existence  in  the  command  prolonged  by  contagion  from  one  hospital  inmate  to  another. 
Some  of  the  unwholesome  conditions  existing  in  the  regimental  hospitals  may  be  appreciated 
from  the  statement  of  Surgeon  Colgais,  59th  X.  Y.,  that  his  few  hospital  blankets  were  used 
over  nearlv  three  hundred  men  in  a  period  of  three  months. 

SuriievH  E.  W.  H.  Beck,  3d  Ind.  Car.,  Cnmii  Carter,  Md.,  Dec.  31,  1801. — This  battalion  has  been  in  the  fiehl  about 
five  months.  Jly  observations  are  confined  to  November  and  December.  We  have  about  five  hundred  men  well 
mounted  on  their  own  horses,  encamped  in  pine  woods  near  the  Potomac  river  on  a  hard  clay  soil  holding  water  on 
its  surface.  This  section  of  the  country  is  somewhat  miasmatic,  the  citizens  suffering  every  antuuni  more  or  less 
with  bilious  affections.  These  troojis,  however,  being  from  malarial  districts  iu  Indiana  are  not  climatically  affected 
by  the  transition.  We  have  plenty  of  jirovisions,  but  lack  vegetables — potatoes  especially  are  scarce;  we  only  have 
them  once  a  week  or  fortnight.  Our  men  eat  too  much  grease,  frying  their  hard  bread  in  grease  and  eating  fat  bacon ; 
this  produces  indigestion.  We  get  beef  as  a  general  thing  twice  each  week.  The  men  have  been  very  careless  about 
cleanliness,  many  of  them  of  their  persons  and  nearly  all  of  their  quarters.  They  complain  of  not  getting  straw 
often  enough  to  change.  They  have  neglected  changing  their  underclothing.  The  surgeon  has  laliored  to  correct 
these  evils.  We  have  no  proper  winter-quarters,  but  live  in  tents  with  chimneys  attached.  Green  ]iine  wood  is  the 
only  obtainable  fuel.  We  are  the  only  mounted  troops  this  side  of  Washington  on  the  Maryland  side  of  the  river. 
Our  men  have  been  employed  as  scouts,  pickets,  messengers  and  orderlies,  giving  them  constant  hard  labor;  they  are 
on  guard  every  second  day.  They  go  on  scouting  expeditions  by  scjnads  and  companies  without  tents,  or,  at  most, 
only  one  for  ten  men,  with  bread  and  coflce  only  for  food,  depending  for  shelter,  food  and  forage  upon  good  luck, 
sleeping  when  night  overtakes  them  in  the  woods  or  fields,  making  forced  marches,  taking  prisoners  to  the  city  night 
or  day,  and  all  this  during  the  cold  weather  of  October  and  November.  I'ntil  December  7  only  about  twenty-eight 
men  iu  each  company  had  overcoats.  These  hard  nuirches  ami  exposures,  coajded  with  indigestion  from  the  large 
quantities  of  strong  coffee  and  grease  or  tilt  meat,  brought  nuiuy  to  hospital  or  to  quarters  with  typhoid  fever, 


COXTIXUED    Ff:VER?.  _  491 

broiicbitis  and  catanli.  I.iiw  feveis  prevailed.  Milil  miimpoi taut  attacks  of  other  forms  of  sickness  coming  in 
contact  witli  these  fevers,  in  deliancc  of  our  interference,  gradually  assumed,  in  a  majority  of  instances,  the  for- 
midable symiitoms  of  delirium,  involuntary  discharges,  subsnltus,  ]iickiug  of  bedclothes,  siidamina,  rose-colored  spots 
and  sordes.  The  cases  recinired  tbc  strongest  stimulants,  from  twelve  to  sixteen  onm'es  of  brandy  being  used  per 
diem:  and  witliont  this  they  die.  Dcrangi'ments  of  the  digestion  by  fried  food  and  fats,  fatigue  and  exposure.  I  think 
brouglit  on  these  low  fevers. 

Siirticoii  Joseph  P.  Coiajax,  5iHlt  X.  )'.,  Canqi  SJicnnaii.  I'mi  (ivoil  Unpf.  l>.  C,  Juniiarij.  b^iy. — Our  hospital  aceoni- 
niodatious  are  cimtined  to  two  tents  in  which  we  are  often  comiielled  to  crowd  thirty  patients  with  their  attemlauts. 
We  have  been  allowed  twenty  blankets,  ten  bedticks  and  ten  pillow-cases  for  the  use  of  all  these  persons  for  three 
months.  This  renders  it  necessary  that  these  few  blankets  be  shifted  over  nearly  three  hundred  men  in  that  time. 
The  sup])ly  is  wholly  inadequate  to  provide  covering  for  the  number  of  men  we  are  compelled  to  shelter,  au<l  but  for 
aid  received  from  the  Sanitaiy  Commission  in  the  form  of  (luilts  and  blankets  onr  sick  would  often  have  had  to  suiter 
more  in  hospital  than  in  (quarters  from  want  of  covering. 

From  the  statistics  and  special  reports  relating  to  typhoid  fever  a  siiecilie  cause  must 
be  assumed  to  have  existed  irrespective  of  hard  service,  exposure  to  the  weather,  over- 
crowding, insufficient  ventilation,  defective  police  and  other  insanitary  conditions.  Apjia- 
rently  this  special  poison  was  capable  of  infecting  localities,  which  afterwards  transmitted 
the  disease  to  new-comers.  Probably,  also,  it  infected  the  locality  of  an  aflfected  individual, 
leading  to  direct  or  indirect  contagion  in  the  crowded  and  ill-conditioned  hospital  ward, 
barrack-room,  tent  or  winter-hut  occupied  by  him.  Certainly  insanitary  conditions  of  camps, 
quarters  and  hospitals  developed  the  susceptibilities  of  the  occupants,  thus  facilitating  the 
propagation  of  the  disease  and  increasing  the  gravity  of  its  eflfects.  But  it  is  equally  certain 
that  these  susceptibilities  did  not  survive  the  attack.  Among  the  cases  submitted  there  are 
only  two  in  which  a  second  attack  of  typhoid  fever  is  doubtfully  suggested.*  Local  epi- 
demics occurred  but  once  in  a  regiment  unless  its  ranks,  depleted  by  the  casualties  of  war, 
became  filled  up  by  new  men,  in  which  case  the  recruits  sutTered  while  the  veterans  rnnaiued 
unaflected.  Notwithstanding  the  superlatively  foul  condition  of  the  enclosure  at  Auderson- 
ville,  Ga.,  and  the  presence  of  the  special  poison  of  typlioid  k^yor.  only  sporadic  cases  oceurred 
among  the  prisoners.  This  estalilishment  was  opened  when  the  war  was  well  advanced 
and  the  prisoners,  mostly  veterans,  had  lost  their  suseeptil.iility  to  the  tvplmid  poison.  In 
the  eai'ly  part  of  the  war  prisoners  were  seized  with  typhoid  fever  in  tlie  absence  of  such 
conditions  as  existed  at  Andersonville.  Ass't  Surgeon  DeWitt  C.  Peters,  U.  R.  Army, 
speaks  of  its  presence  in  1861  at  some  depots  in  the  harbors  of  Xew  York  and  JJoston.  It 
appeared  in  spite  of  careful  attention  to  cleanliness,  ventilation  and  other  hygienic  condi- 
tions. During  a  period  of  two  months  there  were  constantly  under  treatment,  exclusive  of 
convalescents,  at  least  seventy-five  of  six  hundred  and  thirty  prisoners.  j\Iost  of  the  cases 
consisted  of  typhoid  fever  in  the  persons  of  young  and  delicate  subjects  who  had  not  attained 
their  full  development. 

But  many  men  had  lost  their  susceptibilitv  prior  to  enlistment,  aii-l  the  proportion  of 
protected  recruits  was  greater  among  city  than  among  country  levies.  According  to  Ass"t 
Surgeon  J.  T.  Calhoun,  U,  S.  Army,  regiments  raised  in  the  country  and  composed  of 
fanners'  boys  suffered  more  from  typhoid  fever  than  city  troops,  although  the  former  were 
superior  to  the  latter  in  physique. 

One  of  the  healthiest  regiments  in  this  division  ami  in  tlie  army  is  the  Fourth  Excelsior  (2d  N.  Y.  Fire  Zouaves), 
composed  almost  entirely  of  New  York  firemen.  Their  losses  from  tyidioid  fever  (if  they  have  lost  any  at  all  from 
that  disease)  must  bo  very  small,  while  in  the  same  lirigade  the  120th  N.  Y.,  comjiosed  of  the  better  class  of  farmers' 
sons  froui  the  river  counties  of  New  York,  althongli  not  having  seen  one-tenth  the  service  or  suffered  one-twentieth 
the  hardships  of  the  regiment  just  referred  to,  have  been  almost  decimated  by  typhoid  fever. t 

The  information  contained  in  the  war  nqiorts  of  our  medical  ntfieers  relative  to  the 


*  See  siqtra,  p.  312.  t  J.  T.  Calhock,  ill  Mtdkul  uitd  SttnjimI  liejtorter.  Vol.  X,  Pbila.,  1863,  p.  il7 


492  ETIOLOGY    OF    THE 

etiology  of  typlioiJ  fever  is  so  meagre  that  to  appreciate  the  causation  of  this  disease  in  our 
camps  it  may  be  well  to  refer  to  the  results  of  general  professional  investigation. 

AYe  speak  of  the  typhoid-fever  'poison,  but  the  facts  establislied  concerning  the  natural 
history  of  the  disease  are  inconsistent  with  the  idea  of  a  non-vitalized  organic  compound  as 
a  causative  agent.  Such  compounds  on  reaching  the  stomach  or  lungs  are  immediately 
absorbed  into  the  blood,  and  if  possessed  of  deleterious  qualities  manifest  their  toxic  effects 
in  a  short  time.  Thus,  prussic  acid  may  be  almost  instantaneously  fatal;  and  although  death 
in  other  instances  may  not  occur  so  promptly,  the  symptoms  caused  by  the  poisonous  presence 
are  speedily  manifested.  But,  as  is  well  known,  the  typhoid-fever  cause  lies  dormant  in  the 
svstem  for  a  period  varying  usuallv  from  one  to  three  weeks.  Even  if  we  call  in  the  unex- 
plained catalytic  action  of  the  chemists,  and  assume  an  organic  poison  developed  from  th.e 
albuminoids  of  the  body  and  capable  of  setting  up  an  alteration  in  the  living  tissues  so  slow 
and  gradual  in  its  progress  that  the  so-called  period  of  incubation  may  be  accounted  for,  we 
are  met  with  the  objection  brought  forward  l;iy  observation  and  experiment  that  such  organic 
compounds  arc  unstable  in  their  constitution,  whereas  the  typhoid-fever  cause  is  known  to 
have  remained  in  full  possession  of  its  virulence  for  months,  perhaps  for  years.  We  must, 
therefore,  assume  a  living  cause  for  the  disease,  an  organism  which,  on  its  admission  into  the 
intestinal  or  pulmonary  tracts,  requires  time  for  its  increase  under  the  favorable  conditions 
of  heat,  moisture  and  suitable  pabulum,  and  for  the  manifestation  of  its  presence  by  detinite 
local  lesions  and  constitutional  disturbances. 

Several  observers,  including  Klein,  Ebeetii,  Klebs,  Koch  and  Letzerich,  have 
announced  the  discovery  of  a  special  form  of  micro-organism  in  tlic  local  lesions  of  typhoid 
fever.  Klein  discovered  microphytes  in  such  numbers  and  so  definitely  arranged  that  he 
believed  their  importance  could  not  be  questioned  for  a  moment.'-'  Nevertheless,  the  appear- 
ances thus  reganled  as  organized  were  shortly  afterwards  shown  to  be  merely  results  of  the 
coagulation  of  albuminoid  matter  by  the  metliods  employed  f  Klebs  announced  the  presence, 
in  the  typhoid  plaques,  of  bacilli  which  occurred  with  a  constancy  that  proved  their  genetic 
nature. J  Moreover,  when  animals  were  inoculated  with  the  supposed  specific  germ  symptoms 
analogous  to  those  of  typhoid  fever,  such  as  a  felirile  rise  in  temperature  and  enlargement  of 
the  spleen  and  patches  of  Peyer,  were  claimed  to  have  been  produced.  But  the  causal  rela- 
tionship of  a  micro-organism  to  the  disease  has  not  been  established.  Septicajmic  results  of 
inoculation  do  not  appear  to  have  been  excluded  in  considering  the  evidence.  In  fact, 
diseased  conditions  produced  by  inoculation  with  bacilli  must  be  viewed  with  caution,  since 
Klein  has  demonstrated  the  insusceptibility  of  the  animalsoperated  on  to  the  typlioid  poison. § 
Ebeetii  did  not  find  his  short  rounded  bacilli  in  every  case  of  typhoid,  Imt  Koch,  bv  tlie  use 
of  better  staininir  methods,  showed  that  thev  are  never  absent  durino-  the  active  staire  of  the 
disease.  They  are  distinguishable  from  the  micro-organisms  of  other  diseases  and  may  be 
artificially  cultivated,  but  the  specific  disease  has  not  been  reproduced  by  them,  as  no  sus- 
ceptible animal  has  been  discovered.  Xevertheless  Kocii  considers  the  assumption  warranted 
that  this  bacillus  stands  in  an  etiological  relation  to  typhoid  fever,  while  he  regards  that 
figured  by  Klebs  as  an  unimportant  invader  of  the  necrosed  tissues, || 

*  Loixil  Government  Ikxird  Heport,  Lou  dun,  ISTO,  p,  9-3.  f  I'roceedimjs  of  tiie  Boijal  SocU'fi/^  June  15,  IsTil. 

"t Archie,  f.  Erpervnent  Pathol,  infj  PhtrmakoUitjie,  Leipzig,  1881,  BO.  XIII.  p.  381  eti'-q. 

+  KLEIX,  p.  83,  op.  cU.f  failed  to  cunvcy  enU-ric  fever  to  auiiuald  by  mixing  their  fo'xl  with  the  fresh  dejecta  of  j^atients  suffering  finm  thf  (HseiLse. 
He  esiH.Timeutcd  ou  Guinea-pig;*,  nilibits,  dogs,  cuts,  white  uiite  and  monkeys,  not  only  whuu  they  were  in  a  hciiUhy  eoiidition  ttut  after  an  iiitcxtiual 
catarrh  had  Im-cii  Bet  up  \>y  ehiteriuni,  aloes  or  castor  oil.  He  used  the  typlioiu  material  in  its  recent  couditiuu  and  also  wheu  more  or  less  decouiiKjaed 
by  keeping  fur  some  time  mixed  with  water. 

;i  Gaffkt,  in  MitUteihingen  a.  d.  k.  Gesundheitaamte,  Bd.  II,  p.  372  tt  seq. 


CONTINUED    FEVERS 


493 


Although  the  typhoid  germ  has  not  been  reeogiiized  its  existence  is  generally  allowed, 
and  many  of  the  conditions  needful  to  its  development  have  been  demonstrated. 

The  passage  of  tlie  germ  directlv  from  an  infected  jierson  to  another  has  been  some- 
times suswested,  but  none  of  the  cases  brought  forward  in  ilhistration  are  without  their  weak 
points.  When  the  instance  has  involved  a  large  number  of  patients  the  influence  of  local 
conditions  affecting  the  whole  of  the  sufferers  has  not  lieen  excluded.'''  When,  on  the  other 
hand,  the  instance  has  involved  only  a  few  persons  in  direct  contact  with  the  infected  indi- 
vidual, an  indirect  contagion  comes  forwarcl  as  a  possibility.f  Liehermelstee  denies  the 
directly  contagious  quality,  asserting  that  the  idea  is  only  a  relic  of  the  past,  when  the  proper 
distinction  between  typhus  and  typhoid  fevers  was  not  made,  and  when  wliatever  was  jiroved 
of  the  one  was  supposed  to  be  true  of  the  other.J 

It  is,  however,  generally  conceded  that  the  spread  of  the  fever  is  in  many  instances 
attributable  to  an  indirect  contagrion  throuo-h  the  medium  of  infected  intestinal  discharges. 
VoN"  GiETL§  and  BuddH  conceived  that  in  all  cases  the  disease  was  thus  propagated.  MuR- 
CHISON  lias  recorded  that  of  1,048  hospital  cases  of  typhoid  fever  under  his  care  only  one 
originated  in  the  wards,  and  yet  the  night-stool  often  remained  for  hours  unemptied;  more- 
over, he  has  known  other  patients  to  sit  over  the  evacuations  of  enteric  fever  patients  without 
becoming  affected  thereby.^  But  althougli  the  discharges  have  thus  been  proved  to  be  harm- 
less when  recent,  it  is  well  known  that  after  a  time,  as  decomposition  progresses,  they  become 
capable  of  propagating  the  disease.  Laundresses,  by  contact  with  soiled  bed  and  bodv  linen, 
are  particularly  exposed  to  attack.  A  want  of  cleanliness  in  the  sick  chamber,  as  when  the 
patient  has  involuntary  passages,  may  give  rise  to  a  suggestion  of  direct  contagioi"i»  the 
materies  morbi  emanating  not  from  the  patient  but  from  alterations  which  have  taken  place 
in  tlie  matter  with  which  the  bedlinen  or  blankets  have  been  contaminated.  The  theorv 
is  that  tlie  spore  or  germ  of  the  disease  when  it  passes  from  the  system  has  to  undergo  a 
stage  of  development  outside  the  body  before  it  is  capable  of  inducing  the  specific  fever; 

*  MriM'iiisox  states  that  tlunn>.'  twi'iity-tlin-i-  ywirs,  1S4S-70,  5,988  cases  of  enti-ric  frvcr  wt-n-  admitted  into  tlie  Lomlnn  Fcvor  Iiospitul,  Imt  uiily 
17  rcsideiitH  in  tlie  hiispitiil  ciditraitfil  tlu'  disease,  uml  must  uf  them  had  no  personal  coinmuiiii-atiitn  with  patients  sick  offiiterir  frvi'v.  ( H"  tli--  17  ra.>es 
9  were  nurses,  only  4  of  whom  were  employed  in  the  f  nterie  fever  wards :  1  was  a  lanndre.-is.  1  a  medical  officer,  and  <i  servants  residinjr  in  a  l)uililing 
dftuehed  from  all  fever  wanls.  Twelve  of  the  17  cases  occurriMl  sultseijuent  to  IStVl,  and.  with  certain  others,  were  referred  to  defeits  of  drainajre.  "My 
experience  in  fact  has  led  me  to  the  conclusion  that  when  enteric  fever  orlKi'iates  in  a  hospital,  there  is  as  a  rule  smnetliin^  radically  defective  in  the 
sanitary  armngements."  See  his  T)-eatite,  jip.  402-0:!.  Sir  W.  .Iesxeh.  however,  in  his  (iulHtniiiim  Lectures  oh  the  Anite  tperijlc  duteant-'a — Mai.  Timrnaml  (i.aelte, 
XXVII,  ISfhJ,  p,  260, — attributes  this  prevalence  among  the  nurses  of  the  London  Fever  hospital  to  a  enncentmtioii  of  the  coutajfious  jjriui-iple  hy 
aggregation  of  the  sick  and  imperfect  ventilation.  For  he  sayi* :  "  I  can  reuiember  only  two  instances  of  the  extension  of  typlioi<l  fever  when  lasea  of 
tiiftt  disease  were  scattered  through  the  wards  of  a  general  hosi)ital ;  and  in  these  casefi.it  was  the  frieiuls  of  the  patient, — the  nmther  in  one  instance,  who 
bad  watched  by  her  son  night  and  day,  who  suffered." 

t  Tlie  following  illustrations  suggestive  t)f  direct  contagion  are  from  the  British  MeiJ.  Jounml.  Vol.  II,  18sii,  pjt.  T.Vl  and  7^V^  :  Sevm"1  a  .).  Sn  \JtKEY 
relates  four  cases  which  originated  in  the  medical  wards  of  St.  Thomas'  hospital  in  the  persons  uf  nurses  employed  in  the  wards.  It  is  customary  at  tliis 
hospital  for  the  sjime  nurses  to  do  duty  alternately  in  tlie  surgical  and  medical  wards,  n-maining  a  m.intli  in  each.  Dr.  Su.xhkkv  emiihasi/.-  t!o-  fact 
that  on  n*^!  occasion  has  a  case  of  typhoid  fever  arisi-n  in  any  of  the  surgical  wards  :  arguing  that  since  the.li-ainage  and  other  arrang'-nient-iarr  tin-  same 
throughout  the  building  thu  cases  origitniting  in  the  medical  wards  must  have  been  due  to  citntagion.  J.is.  McNf.ii.l,  of  the  Ilomerton  Fever  liospital, 
gives  an  account  of  sixteen  cases  which  occurred  in  lt(7G  in  six  houses  on  tlie  sparsely  settled  island  of  Colonsay,  near  the  Argyleshire  coast.  The  distance 
between  the  houses  in  which  the  disease  prevailed,  with  the  exception  of  the  second  and  third,  was  more  than  two  miles ;  between  the  excepted  houses 
there  was  only  a  distance  of  about  one  hundred  yards  of  level  ground.  All  the  affected  families  obtaineil  their  water  from  different  wells,  and  other 
families  using  the  same  wells  were  not  affected.  Each  had  a  sufficient  number  of  cows  to  provide  its  own  milk  sui)ply;  their  othm-  i)rovisions  were 
obtained  from  various  sources.  They  had  no  drainage  in  common  ;  subsoil  water  cuuld  not  permeate  from  the  premises  of  one  family  to  those  of  another, 
and  none  of  the  liouses  were  connected  with  sewers.  Carbolic  acid  was  used  in  the  bed-jians  ami  the  passages  were  emptied  into  a  hole  ihig  some  forty 
or  fifty  yards  from  the  house.  The  disease  was  introduced  by  a  convah'scent  from  tin-  mainland.  It  is  difficult  to  exclude  the  recognition  of  a  direct 
contagion  in  some  of  these  cases.  Thus,  when  the  members  of  the  fiftli  family  were  ill  a  wonuin  caine  a  distance  of  si.x  miles  to  visit  them  ;  she  did  not 
stay  in  the  house  longer  than  ten  minutes,  nor  did  she  i>artake  of  anything  while  there,  but  she  noticed  a  very  disagreeable  odor  from  a  recent  alvine 
discharge,  and  at  the  end  of  twenty-one  days,  during  which  she  was  in  her  usual  he-alth,  she  was  taken  with  typhoid  fever.  In  an  editorial  notice,  page 
748  of  the  same  jourmil,  reference  is  made  to  a  report  to  the  Local  Government  Board  on  the  prevalence  of  enteric  fever  in  the  I'ontardawe  Rural  District 
by  Dr.  Franklin  Pabsons:  A  young  man  affectwl  with  the  fever  came  from  Swansea  to  the  village  of  Mawr  Llangnicko  and  infected  six  persons. 
"Altogether  it  did  not  appear  that  there  was  any  mode  by  which  the  infection  could  have  been  conveyed  from  case  to  case  except  by  direct  transmission." 
A  similar  outbreak  in  the  township  of  Rhyndwyclydach  is  also  mentioned. 

I  J?iViHJw«r>i  Ctfcl"i>ei}ki,  American  Ed.,  Vol.  I,  p.  -Ur. 

^  Franz  X.  von  (Jietl — hie  I'rmchoi  dcx  Euleriifcfteu  Ti/phns  in  MUucheii,  Leipzig,  180">.  pp.  i  and  85. 

[j  WiUJAM  Ilrin>— <M  Inlestin'il  Ft'cer. — The  Lancet,  London,  Isjil,  Vol.  II,  p.  61S. 

l[See  first  edition  of  his  Treatise,  London,  1SG2,  pp.  4rj(>4r)L 


494  ETIOLOGY    OF    THE 

and  while  undergoing  this  change  it  multiplies,  especially  when  in  contact  with  masses  of 
decomposing  animal  matter,  as  in  the  sewer,  privy  or  dung-pit,  so  tliat  an  epidemic  focus  is 
there  established,  whence  the  disease  may  be  propagated  by  exhalation  or  water-carriage  or 
both,  in  accordance  with  local  conditions. 

Although  emanations  from  specifically  infected  matter  have  oftentimes  been  recognized 
as  the  cause  of  local  epidemics,  and  in  sewered  cities  as  the  cause  of  the  endemicity  of  the 
fever,  the  water-supply  must  be  held  responsible  in  manv  instances  for  the  outbreak.  Nor 
is  it  difficult  to  understand  why  this  should  be.  If  the  privy,  cesspool,  sink  or  manui-e  pile 
become  a  hotbed  for  the  prop)agation  of  the  specific  germ,  that  germ  will  percolate  in  the 
usual  line  of  drainage  and  the  subsoil  and  its  water  will  become  infected.  In  localities 
where  the  inhabitants  are  careless  as  to  the  cleanliness  of  their  surroundino;s  even  the  surface 
of  the  area  of  drainage  may  become  infected  with  the  excreta  of  some  primary  case,  as  it  lias 
already  been  contaminated  by  the  accumulated  filth  of  years  of  uncleanly  occupancy.  The 
soil  of  cities  is  generally  extremely  foul;  a  sewerage  system  in  probably  all  instances  was 
introduced  only  after  the  soil  was  honey-combed  with  sinks  and  vaults  or  cavities  filled  with 
filth.  Wells  in  densely  populated  sections  are,  therefore,  specially  liable  to  become  infected. 
In  certain  outbreaks  the  disease  has  been  traced  to  the  waters  of  a  given  well,  persons  living 
in  adjoining  houses  having  been  affected  or  not  according  as  they  used  the  infected  water  or 
obtained  their  supply  from  some  other  source.  Shallow  wells  are  necessarily  more  exposed 
to  infection  than  deep  ones;  but  deepi  wells  and  springs  may  become  infected  not  only  by 
leakage  from  the  overlying  surface  or  subsoil,  but  even  from  their  more  distant  surface  origin, 
as  in. the  case  of  the  Lausen  epidemic,'''  where  intestinal  discharges  contaminated  the  surface 
on  one  side  of  a  mountain  and  caused  enteric  fever  in  those  who  used  the  water  of  the  sjn'ings 
on  its  other  side. 

River-water  polluted  with  infected  sewage  has  also  been  known  to  occasion  the  disease, 
as  in  the  case  of  the  epidemic  at  Plymouth,  Pa.,  in  1885. f 

A  violent  ami  general  outbreak  in  a  community  was  needful  to  establish  an  appreciation  of  the  propagation 
of  typhoid  fever  )>y  the  water  of  running  streams  ;  for  the  eases  that  ordinarily  prevail  in  a  city  having  a  river-water 
supply  more  or  less  contaminated  by  the  sewage  of  the  upper  settlements  are  attributed  to  sewer-gas,  exhalations 
from  s]iecitically  infected  foci  and  the  use  of  specifically  contaminated  well-waters.  Perhaps  each  of  these  factors 
has  its  influence  on  the  prevalence  of  the  disease,  but  so  long  as  the  epidemic  at  Plymouth  is  attributed  to  the  i)ollu- 
tion  of  the  mountain  stream  which  filled  its  reservoirs,  and  the  Lausen  outbreak  to  infected  sewage  in  the  radicles 
of  its  water-supply,  it  will  be  difficult  to  accept  the  doctrine  that  river-water  is  harmless  in  this  respect. 

The  evidence  on  behalf  of  the  wholesomeness  of  a  river-water  that  has  been  tainted  by  sewage  consists  of  a 
demonstration  by  chemical  means  of  the  purity  of  the  suspected  water.  It  has  been  shown  that  after  a  tlo  w  of  a  certan 
number  of  miles  the  water  of  a  riinning  stream  becomes  as  pure  as  it  was  previous  to  the  inflow  from  a  certain  sewerage 
system.  Sedimentation  and  the  fermentative  processes  that  accomplish  the  reduction  of  dead  organic  matter  to  the 
inorganic  conditions  of  annnonia,  nitric  and  carbonic  acids,  do  much  to  iireserve  the  purity  of  our  rivers,  as  deter- 
mined by  chemical  analysis,  but  it  is  a  mistake  to  consider  that  this  purity  is  synonymous  with  wholesomeness. 
Well-waters  that  have  given  excellent  results  on  analysis  have  been  convicted  on  otlier  evidence  of  having  propa- 
gated typhoid.  The  virulent  essence  of  the  disease  cannot  be  detected  by  chemical  means;  and  it  may  be  ])resent 
when  the  natural  processes  of  purification  have  destroyed  the  ordinary  sewage  matters  which  at  an  earlier  period 
were  associated  with  it.  These  processes  as  exerciseil  on  a  water  which  percolates  through  the  soil  into  a  well  are 
more  powerful  in  their  action  than  when  operating  on  the  organic  matter  of  a  running  stream.  This  is  shown  by 
the  fact  that  well-waters  are  on  the  average  so  much  purer  than  surface-waters  that  both  cannot  be  rated  by  the 
same  valuation  of  the  analytical  results.  Organic  impurities  are  found  and  considered  allowable  in  river-waters 
which,  if  present  in  filtered  or  well-waters,  would  be  regarded  as  indicating  a  dangerous  or  unwholesome  (quality. 

*  In  1S72  an  epiih-niic  oceurrwl  wiiich  was  trac(i]  to  the  springs  that  -siipitlicil  ;hu  village  with  water.  These  springs  were  cleriveil  in  part  from  an 
a^jaeent  valley,  the  dniilmgc  of  whieli  found  its  way  hy  an  undergronii.l  channel  to  the  Lausen  siile  of  the  mountain  ridge  and  hrought  with  it  the 
typhoid  infi-ction.  The  connection  between  the  valley  on  the  one  side  of  the  ridge  and  the  springs  on  the  other  was  demonstrated  hy  the  use  of  sjilt. 
The  failure  of  wheat  starch  to  iiass  through  with  the  water  and  sjtlt  showed  that  the  communication  was  not  hy  direct  channels,  hut  in  part  hy  jiercola- 
tion  through  porous  strata.  The  jiarticulars  of  this  epidemic  are  given  hy  Cayley  in  his  Crooniau  Lectures  On  some  pnintn  in  the  I'ntholotjij  and  Treatment  oj 
TijplioUl  Verer,  London,  IS80,  j).  8,  and  are  qui'ted  at  length  hy  Wilson,  p.  12S  of  his  volume  On.  the  Oniliiined  Ferei-n^  New  York,  1881. 

t  Fir»t  Annual  Report  Stale  Board  of  Ueallh  and  Vital  Jitatielies  oj  the  t'oinmonvrealth  of  rennsylcania,  liarrisharg,  Pa.,  1886,  p.  170. 


CO>-TINUED    FEVEKS.  495 

But  the  agencies  which  purify  a  well-water  from  ordinary  sewage  matters  fail  to  destroy  the  typhoid  cause :  and, 
since  these  are  impotent,  it  is  inconsistent  to  assume  that  the  weaker  influences  operating  on  the  water  of  a  running 
stream  would  be  more  etlicient.  Hence  we  may  conclude  that  the  typhoid  cause  liaving  once  entered  a  river-water 
will  retain  its  virulence,  although  organic  matter  of  a  less  stable  nature  associated  with  it  may  be  destroyed.  More- 
over, typhoid  fever  is  so  prevalent  a  disease  that  it  is  impossible  to  consider  the  sewage  of  a  large  city  as  other  than 
an  infected  and  correspondingly  dangerous  sewage. 

As  bearing  on  this  question  it  is  of  interest  to  observe  that  typhoid  fever  is  relatively  less  frequent  in  cities  that 
exercise  care  in  the  exclusion  of  sewage  from  their  water-svipply.  Where  the  drainage  area  furnishing  the  supply  is 
carefully  guarded  from  excremental  taint  typhoid  fever  is  at  a  minimum.  Where  the  water-supply  is  taken  from  a 
river  containing  the  sewage  of  large  cities  typhoid  fever  prevails  extensively  and  constantly.  Its  prevaleivee  may 
be  said  to  be  jjroportioned  to  the  amount  of  sewage  inflow  into  the  water-supply.  Sewerage-works  and  water-works 
are  intimately  related;  the  one  quickly  follows  the  other  in  the  sanitary  history  of  our  growing  cities.  Hitherto  it 
has  been  customary  to  attribute  all  improvement  in  the  health  of  a  connnunity  to  the  sewerage-works;  but  it  may  be 
inquired  if  perhaps  the  greater  part  of  the  benefit  is  not  reallj'  due  to  the  influence  of  a  purer  water-supply, — one  less 
contaminated  by  sewage  than  the  well-  or  river-water  that  was  previously  used.  Certainly  this  appears  to  be  the 
case  so  far  as  typhoid  fever  is  concerned;  for  Baltimore,  Md.,  which  has  no  system  of  sewers,  has  experienced  during 
the  past  twenty  years,  since  the  introduction  of  its  general  water-supply,  as  large  a  decrease  in  the  death-rate  from 
typhoid  fever  as  any  city  which  has  been  sewered  as  well  as  systematically  supplied  with  good  water.  The  health 
reports  of  New  Orleans,  La.,  also  illustrate  the  connection  between  comparative  freedom  from  typhoid  fever  and  a 
water-supply  untainted  by  sewage.  That  city  labors  under  many  unkygienic  disadvantages  on  account  of  the  pecu- 
liarity of  its  site.  There  is  no  sewerage  system ;  but,  fortunately,  there  are  also  no  wells.  Mississippi  river-water  is 
pumped  up,  but  is  used  mainly  for  street  washing  and  as  a  safeguard  against  fire.  The  domestic  water-supply  comes 
from  raised  cypress-wood  cisterns  which,  while  often  foul  from  accumulated  sedimentary  matters  washed  from  the  roof, 
is  never  tainted  with  sewage  or  its  associated  typhoid  germ.  In  view  of  these  considerations  a  river-water  that  lias 
been  once  contaminated  by  sewage  must  be  regarded  as  dangerous  in  this  connection,  no  matter  how  excellent  a, 
character  may  be  given  it  by  chemical  researches.* 

Many  epidemics  liave  been  ascribed,  especially  in  England,  to  an  impure  milk-supply. 
The  well  on  the  dairy  farm  has  become  infected  and  its  water,  used  illegally  as  a  diluting 
adulterant,  has  introduced  the  germ  of  the  disease  into  the  milk.  The  organic  analysis  of 
milk  is  not  required  to  sliow  that  it  contains  all  the  proximate  organic  ])rinciples  needful  to 
tlie  support  of  human  life,  as  this  is  demonstrated  in  every  nursery.  Theoretically  such  a 
liquid,  if  kept  at  an  appropriate  temperature,  furnishes  as  favorable  conditions  for  the  mul- 
tiplication of  the  germ  as  the  human  system  itself.  The  instability  of  milk  is  well  known. 
Professor  Lister  has  demonstrated  that  its  coagulation  is  due  to  the  influence  of  a  bacterium 
(lactis),  and  that  if  it  be  protected  from  invasion  by  this  bacterium  and  exposed  to  other 
germs  ordinary  coagulation  will  not  take  place,  but  instead,  other  changes  will  be  developed 
depending  on  tlie  nature  of  tlie  micro-organisms  which  have  been  introduced.")"  Milk  must, 
therefore,  be  accredited  witli  notable  qualities  as  a  culture  fluid  for  micro-organisms.  In 
some  cases,  in  which  the  infected  water  was  used  only  to  rinse  out  the  milk-pans,  a  multi- 
plication of  the  germs  so  introduced  must  be  assumed  to  account  for  the  disastrous  conse- 
quences which  followed  in  the  line  of  the  milk-supply. 

There  is  a  difference  of  opinion  as  to  whether  the  disease-germ  is  always  derived  from 
a  previous  case.  Some  hold  that  the  disease  may  originate  de  novo.  Murchison  conceives 
that  the  miasm  may  be  generated  in  decomposing  animal  matter  in  the  absence  of  the  dejec- 
tions of  a  typhoid  fever  patient,  that  at  some  particular  stage  of  the  process  a  pythogenic 
fever-cause  is  developed  which,  if  taken  into  the  human  system,  will  produce  enteric  fever  as 
trulv  as  if  it  had  been  propagated  from  a  previous  case.  .He  allows  that  enteric  stools  may  be 
more  prone  than  other  organic  matters  to  the  fermentation  by  which  the  poison  is  elaborated, 
but  denies  the  existence  of  a  specific  germ.  It  is  a  matter  of  common  observation,  however, 
that  places  notoriously  filthy  from  excremental  accumulations,  which  on  this  theory  ought 
to  be  tlie  breeding  places  of  the  fever,  have  continued  exempt  from  it  for  years  until  infected 

*SeeS5lAiiT,  On  Wholesmuc  Water  fir  Cities  and  Tomis.—rhihi.  Meil.  Times, \ol.  XVI,  ISSC,  ii,  UllT. 

f  JiiSKi'H  LlSTEK,  —  On  lactic  jeritlenUition  and  its  bearing  upon pathoUi'jij. — Br<iU}ticaile's  Hetrosprct^  A'ol.  LXXVIF,  1878,  pp.  1-8. 


496  ETIOLOGY    OF    THE 

by  the  discharges  of  an  imported  case.  City  practitioners,  who  have  the  fever  always  with 
them  and  the  sewers  constantly  contaminated  with  the  discharges  from  such  patients,  gen- 
erally regard  the  disease  as  propagated  by  a  succession  of  patients.  But  the  countrv  physi- 
cian, who  does  not  have  it  alwavs  with  him, — who,  on  the  contrary,  has  it  springing  into 
existence  in  his  practice  at  isolated  liouses  without  a  recognizable  connection  with  anv  pre- 
vious case  in  the  locality, — is  often  inclined  to  quote  his  experience  as  throwing  doubt  on  the 
general  application  of  the  accepted  theory  of  indirect  propagation  from  case  to  case,  if  not 
indeed  as  warrantins;  a  belief  in  a  de  novo  orimn. 

Dr.  Cabell  of  the  University  of  Virginia  has  protested  against  the  assumption  of  con- 
tagion, direct  or  indirect,  as  the  only  means  of  propagation  of  typhoid  fever.  He  com- 
municated with  the  members  of  the  Virginia  Medical  Society  and  others,  soliciting  their 
views  on  the  subject  and  a  report  of  the  observations  on  which  they  were  based;  and  in 
reply  to  the  enquiry:  Can  you  recall  any  case  of  typhoid  fever  originating  under  such  cir- 
cumstances as  to  exclude  the  probability  of  the  importation  of  the  disease  from  sonie  other 
locality?  he  received  58  afhrmatives  in  a  total  of  69  responses.*  Dr.  Pinckkey  THOMSO^'■ 
gives  strong  expression  to  a  belief  in  an  origin  independent  of  tlie  contagion  of  a  previous 
case,  and  instances  certain  cases  of  spontaneous  origin  in  sparsely  settled  districts  where 
previous  cases  could  not  have  escaped  detection. f  Faequhaksox  of  Iowa  conceived  the 
disease  in  America  to  be  due  to  exposure  to  emanations  from  the  decay  of  vegetation  during 
the  hot  season,  and  wholly  independent  of  contagion  from  the  intestine  of  a  previous  case 
as  urged  by  Budd,  or  of  fsecal  accumulations  as  claimed  by  Murchisox.J  To  illustrate 
the  character  of  the  testimony  on  which  these  opinions  are  based  the  following  are  quoted 
from  Dr.  Cabell's  paper: 

Dr.  L.  B.  Edwards,  Richmond,  Va.:  A  farmer  who  lived  eight  miles  from  Lynchburg,  near  the  hase  o"  the 
Tobacco  Row  mountains,  had  not  for  months  before  his  attack  been  ■where  there  was  sickness.  For  several  weeks 
prior  to  his  attack  he  had  been  engaged  personally  in  clearing  and  plowing  some  new  ground  on  the  side  of  the 
mountain.     There  was  nothing  in  the  history  of  the  case  that  indicated  an  importation  of  the  disease. 

Dr.  W.  H.  BR.\MBLKTT.Newburn,  Va.:  I  can  recall  a  number  of  cases  occurring  under  sucli  circumstances  as  to 
exclude  the  probability  of  importation.  In  a  thinly  settled  countrj',  as  that  to  which  my  practice  is  most  restricted, 
there  are  many  isolated  neighborhoods  cut  off  by  mountains  and  streams  from  other  portions  of  the  county.  The 
families  comjiosing  these  communities  never  have  a  visitor  from  a  distance;  they  rarely  go  out  of  their  own  neigh- 
borhood and  never  out  of  the  county;  in  fact  they  occupy  a  position  so  cut  off  from  connnunication  with  the  rest  of 
the  world  tliat  the  appearance  of  the  disease  in  their  midst  would  appear  irreconcilable  with  the  modern  theory  of 
its  propagation.  Some  of  these  neighborhoods  I  liave  had  under  observation  for  ten  years,  and  it  is  here  that  typhoid 
fever  often  seems  to  have  its  beginning,  and  can  be  traced  to  none  of  the  ordinary  sources  of  contagion  agreeably  to 
the  modern  theory.  The  same  community  is  never  visited  on  the  year  following  an  outbreak,  and  new  outbreaks 
occur  in  communities  which  have  not  been  invaded  for  ten  years  or  never  before  at  all. 

Dr.  W.  H.  M.\coN,  Hanover  County,  Va.:  Mrs.  E.,  living  in  the  county  of  Kent,  had  typhoid  fever  for  thirty  or 
forty  days,  convalesced,  relapsed  and  died.  She  had  not  been  anywhere  to  contract  the  disease ;  had  not  left  her  farm, 
certainly  not  the  neighborhood.  No  other  case  occurred.  This  case  must  have  originated  there,  if  I  may  use  the  word, 
spontaneously,  and  several  other  cases  similar  to  this  might  be  mentioned. 

Dr.  Bedford  Brown,  Alexandria,  Va.:  1  have  manj-  reasons  to  believe  that  typhoid  fever  may  be  generated 
trithin  the  system  spontaneously.  In  luy  own  experience  cases  have  originated  on  high  isolated  points  where  the 
locality  was  sterile,  the  drainage  most  perfect,  the  water  pure  and  limpid,  gushing  out  from  rocky  mountain  sides. 
In  one  of  these  instances  the  building  was  new,  made  of  wood,  airy  and  comfortable,  sujjported  on  pillars  two  or 
three  feet  high,  underneath  which  the  pure  nM)untain  breezes  had  free  access,  and  the  situation  was  on  a  high  mountain 
point  without  the  vestige  of  a  local  cause  in  the  form  of  privy,  sty,  cesspool,  inclosure,  decaying  animal  or  vegetable 
matter.  Yet  in  this  building  were  two  well-marked  cases  of  malignant  enteric  fever  following  in  rapid  succession. 
Keither  of  these  victims  had  left  the  premises  for  weeks  previously. 

*  On  the  Eti^hitfi/  of  ErUerit:  Fever,  read  bi^fore  the  American  Medical  .\st-ociatiun  in  1877. 

+  In  the  Report  nf  t!ie  State  Buani  of  Health  of  Kentucky  fur  1883  he  says:  ".\s  I  ptiidy  the  literature  of  the  etiology  of  typhoid  fever,  coupled 
with  au  experience  in  the  practice  of  meviicine  for  thirty  years,  I  am  forced  to  the  conclusion  that  typhoid  fever  does  originate  from  other  causes  than 
the  contagion  of  a  previous  case."' 

I  The  Tt/phoid  Fever  of  Amerirn,TeM  at  tlie  meeting  of  the  Iowa  State  Board  of  Health  November  2,  1883. 


COXTIXUEP    FEVERS. 

Dr.  Ai.hax  S.  P.wxf..  Fauiniii-r  C'oimty,  ^';l.:  I  ifuiruil>i'r  iis  far  liack  as  tlie  winter  (if  l.slil  that  a  goiitleman  of 
•wealth,  living  four  miles  west  of  Warienton,  proposed  to  emigrate  Avitli  liis  negroes  durijig  the  eoniing  spring  to 
Mississipjii.  In  the  winter  months  a  strange  malady  broke  out  amongst  the  negroes,  and  by  the  following  spring  he 
had  lost  thirty  liy  death.  This  was  typhoid  fever.  There  was  no  sickness  anywhere  else  of  a  .serious  character  within 
a  hundred  miles  of  this  plantation.  It  was  a  very  dry  winter,  and  the  sjirings  on  the  Jilantation  were  never  of  the 
best.  In  all  other  respects  the  toiiograiihy  was  good.  I'rivies  are  seldom  used  by  these  hardy  mountain  people,  and 
excreraentitious  matter  is  generally  dried  in  the  sun  or  carried  oil' into  water  courses  by  the  rains. 

Several  instances  are  given  in  which  the  disease  was  attribute'l  to  the  decay  of  wood, 
as  in  outbreaks  tliat  soiaetiines  occurred  in  tlie  negro  caLiiis  of  the  shtvelioldei's.  ron- 
cerning  these  Dr.  (1\bell  observes  that : 

There  seems  to  be  little  or  no  room  to  doubt  the  existence  of  a  morbific  inlluence  derived  from  the  old  cabins, 
but  that  the  factor  in  question  is  decaying  timber  is  not,  I  think,  equally  certain.  *  *  *  In  a  few  cases  of  this 
kind,  which  have  fallen  under  m.v  own  observation,  another  and  very  iiotential  factor  was  discovered  in  a  nuiss  of 
sludge,  which  had  been  formed  under  a  very  badly-jointed  lloor  by  the  drippings  of  slops,  and  possibly,  to  some  extent, 
of  the  excreta  of  children.     In  these  cases  there  was  thus  soil-contamination  of  the  worst  sort. 

An  outbreak  of  typhoid  fever,  apparently  independent  of  a  previous  case,  occurred  among 
the  U.  S.  troops  engaged  in  the  Modoc  campaign  in  1S73.  The  command,  consisting  of 
B,  1st  Cav.,  B,  4th  Art'y,  F,  21st  Inf.,  and  E  and  G,  12tli  Inf.,  was  stationed  at  Fort 
Klamatli,  Oregon.  The  following  is  from  the  report  for  Bejitember,  by  Ass't  Surg.  Hexry 
McElderky,  U.  S.  Army: 

Nino  of  the  ten  cases  of  typhoid  fever  reported  as  taken  sick  during  the  month  belong  to  Co.  G,  12th  Infantr.v, 
and  were  received  into  liospital  from  company  quarters.  The  comjiany  at  the  time  were  quartered  in  tents  near  and 
to  the  north  of  the  stockade  in  which  the  Modoc  Indian  prisoners  were  confined.  These  men  were  all  taken  sick 
within  a  few  days  of  each  other.  X'pon  inspecting  the  company  quarters  with  a  view  of  ascertaining  the  cause  of 
the  disease,  it  was  found  that  the  common  tents,  in  which  the  men  were  living,  were  in  almost  every  instance  llooied 
with  boards,  and  that  the  boards  rested  directly  on  the  ground  or  on  poles,  and  that  no  provision  whatever  was  made 
for  ventilation  underneath  the  tloor.  Upon  the  lloor  being  taken  u]>  in  .several  of  the  tents  the  gronud  underneath 
was  foniwl  to  be  damp  and  nuiuldy.  I  recommended  to  the  commanding  ollicer  that  the  company  should  be  renuived 
to  a  new  locality,  the  tents  repitched:  that  if  the  tents  were  lloored  the  boards  should  be  raised  at  least  eiglit  orten 
inches  from  the  ground  and  provision  maile  for  ventilation  undernealli:  that  at  least  twice  a  week  the  tents  should 
be  raised  and  the  ground  exposed  to  the  sun.  These  suggestions  were  favorably  considered  and  acted  upon  by  the 
commanding  ollicer.  with  the  result  of  completely  arresting  the  disease.  One  case  of  fever  was  received  into  hospital 
the  day  after  the  change  was  made.     No  case  has  occurred  since. 

Exception  may  be  taken  to  this  report  in  that  it  fails  to  state  the  grounds  on  which 
the  disease  was  regarded  as  typhoid.  The  clinical  records  of  the  post  do  not  preserve  a  cir- 
cumstantial account  of  any  of  the  cases,  but  from  the  data  furnished  by  the  registers  of  sick 
it  is  evident  that  the  disease,  so  far  as  our  present  knowledge  extends,  could  have  been  no 
other  than  the  typhoid  affection.  Although  no  new  case  occurred  in  Co.  G,  12lh  Inf.,  during 
the  month  of  September,  as  stated  in  MgElderry's  report,  two  cases  appeared  early  in 
October.  The  September  cases  were  taken  sick  on  the  20-24 th;  the  two  subsequent  cases 
on  October  8.  Of  the  twelve  cases  ten  were  returned  to  duty  after  an  avi'rage  stay  of 
two  months  in  hospital,  one  ended  fatally  and  one  was  discharged  for  disability.  The  alimen- 
tary canal  of  the  fatal  case  was  forwarded  to  the  Army  Medical  ^luseum,  where,  on  exam- 
ination, the  stomach  and  upper  part  of  the  small  intestine  were  found  in  normal  condition; 
Beyer's  patches  were  progressively  enlarged  and  some  of  them  slightly  ulcerated — those 
immediately  above  the  ileo-cascal  valve  were  greatly  thickened  and  mammillated  but  not 
ulcerated;  the  colon  was  dotted  with  enlarged  and  ulcerated  sohtary  follicles,  which  were 
most  numerous  in  the  descending  portion.  The  specimen  was  accompanied  by  the  following 
special  report: 

Private  Henry  Everett,  Co.  G,  12th  Inf.,  was  admitted  to  post  hospital,  Fort  Klamath,  Oreg.,  Oct.  8,  1873,  with 

the  ordinary  symptoms  of  typhoid  fever.     The  patient  .seemed  to  be  much  prostrated  and  very  ill.     He  said  he  had 

been  sick  for  several  days.     Five  grains  of  sulphate  of  quinine  every  four  hours,  acetate  of  ammonia  and  beef-essence 

every  two  hours  were  prescribed,  with  milk  and  eggs  three  times  a  day:  the  patient  was  sponged  occasionally  with 

Meu.  Hist.,  Ft.  111—03 


498  ETIOLOGY    OF    THE 

•n-arm  ^vater.  As  he  seemed  to  iinjiiove  iiiitler  this  treatment  it  was  continued  during  the  four  fulloAving  days.  Half 
an  ounce  ot"  whiskey  every  two  huuis  was  added  on  the  12th.  as  the  patient  appealed  weaker.  His  huwels  liad  been 
actiny:  reguhirly  and  never  oftener  tlian  twice  in  the  twenty-four  hours :  but  on  the  evening  of  tliis  day  lie  liad  several 
passages,  one  of  which,  about  daybreak  of  the  13th,  contained  a  considerable  quantity  of  dark-colored  blood.  A 
camphor  and  opium  pill  every  four  hours  was  prescribed,  with  turpentine  emulsion  and  persulpliate  of  iron  every 
two  lionrs  and  a  teaspoonful  of  whiskey  every  half  hour.  He  had  another  abundant  hemorrhage  from  the  bowels 
about  noon  and  a  third  about  4  p.  ni..  tiftei'U  minutes  after  which  he  died.  roKt-morttm  examination  revealed  ulcer- 
ation of  the  xiatches  of  I'eyer  and  erosion  of  a  mesenteric  arterial  branch.  The  sjileen  was  greatly  enlarge<l  and 
much  softened.     The  other  organs  ajipeared  normal. 

Witli  referfice  to  tlie  ease  diselmrgeil  f.n-  disability  tlie  post  ret-i tnls  give  the  following 

iiiforiiiation ; 

Private  Landmesser.  Co.  G,  12th  Inf.,  was  taken  sick  Sept.  21.  1?<73.  with  typhoid  fever,  and  discharged  Aug. 
10.  1874.  for  consumption  following  typhoid  fever. 

It  luav  al.so  be  objecteil  that  a  [>ossible  previous  case  from  wliieli  the  ten  September 
cases  were  derived  is  not  satisfactorilv  excluded.  (J(  course  Dr.  McEldeeey  may  have  over- 
looked it;  but  there  is  no  doubt  that  he  gave  full  consideration  to  all  tho  possibilities  before 
reachino-  his  conclusions  as  to  the  cause  of  the  disease.  Certainlv  his  men  were  and  had 
been  for  months  .so  situated  as  to  allow  a  full  understanding  of  the  conditions  affecting  their 
health.  In  fact  it  seems  impossible  for  the  previous  case  to  have  been  imported  or  his  men 
exposed  to  its  influence  without  his  knowledge. 

An  interesting  case,  reported  bv  Ass't  Surgeon  Hoff,  U.  S.  Army,  will  bo  referred  to 
in  another  connection.'-' 

Similar  experiences  in  Europe  and  in  India  have  also  been  recorded. t  The  argument 
against  the  value  of  such  cases  as  conclusive  of  a  miasmatic  origin,  indei^endent  of  a  specific 
contamination  from  a  pre-existing  case,  is  based  upon  the  persistency  of  the  typhoid-fever 
p-erm.  It  is  known  to  preserve  its  vitality,  and  presumably  to  multiply,  under  favorable 
conditions,  for  many  months;  and  there  is  no  reason  for  supposing  that  it  might  not  thus 
remain  potent  for  an  indefinite  period.  A  certain  covered  ditch  or  drain  which  has  been 
disused  for  years  is  opened,  and  those  who  have  been  exposed  to  its  exhalations  become 
shortly  after  prostrated  by  typhoid  fever  and  may  form  the  nucleus  of  a  series  of  cases  con- 
stituting a  local  outbreak.  A  pile  of  manure,  the  accumulation  of  years  at  a  country  house, 
is  duo-  up  and  carted  away,  and  those  who  have  been  engaged  in  the  operation  subsequently 


*  See  iHfnf.  p.  o'li. 

+  Tin'  BrilM  Med.  JoKr..  in  one  of  its  i.-'sties  for  ls8n.  Vol.  I,  pp.  733  anrt  V-H,  has  two  articles  on  isolated  and  apparently  ppontaneons  cases  of  typhoid 
n-v.r.  R.  liRC.  E  Low,  Medical  Offlcer  of  Uealtli,  Helnisley,  Yorkshire.  sh.>->vs  that  he  has  had  frerinent  opportunities  of  investigating  t\u-  origin  of 
typhoid  cases,  free  from  the  or.linary  sources  of  error  which  surroiuid  similar  inriuirics  in  large  towns  and  populous  centres.  .Sewer  gas,  infection  in  the 
water  or  milk-snpplies.  and  direct  contjigion  were  excluded  from  the  genenitii.n  and  propagation  of  his  eases  hy  the  conditions  under  which  his  patients 
dw-elt.  The  tirst  which  he  relates  requires  an  acknowledgment  of  a  *■  le/c.  origin  or  of  its  connection  with  a  case  which  had  occurre.l  in  the  house 
thirty  years  before.  MincHiso.N  woul.l  have  found  no  ilifficulty  in  assigning'  to  this  case  a  pythogenic  origin,  as  the  privy  was  full  to  the  hvel  of  the 
seat, "the  smell  from  it  offensive,  the  cottage  damj..  dirty  and  overcr..w(Ied.  and  the  general  lial.its  of  the  inmates  iu  ki'eping  with  their  surroundings. 
.\s  the  patient  suffered  from  rc|.eated  attacks  of  diarrh.ea  prior  to  the  ilcvelopnient  of  enteric  fever,  Dr.  Low  suggests  the  possibility  of  the  latter  being 
line  to  the  progressive  elaboration  of  a  siiecirtc  j.oison  from  a  succession  of  attacks  ..f  non-specific  rtiarrhrea  origimiting  in  flith  f.-rmentaticni.  In  the  second 
instance  a  studv  of  the  possible  causes  points  to  one  of  three  theories  of  origin  :  1st.  A  foul  and  overflowing  privy  near  the  house,  but  seldom  used  by 
the  patient ;  2d.  A  momentary  e.xposure  to  a  disgusting  .«lor  from  a  bullock-3  hide  in  an  advance.l  state-  of  decomposition  :  and  3.1.  Ilrinking  a  cup  of 
tea  in  a  house  in  which  a  fever  case  had  been  treatcl  three'yeurs  before.  P.  IIekheet  JIetoalf  mentions  a  characteristic  case  of  enteric  fever  which 
wcurred  on  Norfolk  Island,  in  the  Pacific,  in  January.  ls,«ii.  without  any  ap!.arent  conneition  with  a  i.revioiis  case.  The  island  i.s  four  hundred  miles 
from  the  nearest  inhabited  land.  In  1808  a  febrile  epidemic  of  some  kin.l  prevaile.I,  and  in  the  beginning  of  the  year  1H77  a  man  was  rermled  to  havo 
died  of  enteric  fever.  The  gentleman  who  was  taken  sick  in  Jannary,  Isso,  reached  the  island  four  months  bef.jre  his  attaik.  Stveral  years  before  ho 
left  home  he  lost  a  brother  and  sUter  from  enteric  f,-ver.  but  since  that  time  he  had  not  been  in  contact  with  the  disease.  This  patient  had  used  water  front 
a  well  that  had  the  reputation,  unkuown  to  him,  of  commnnicatiu!;  with  an  open  cesspool.  On  cleaning  out  the  well  its  b.ittom  was  found  to  be  layered 
with  four  feet  of  foul  mud  in  which  were  embeddeil  the  skelet.jn  of  a  dn.k,  a  pig's  jaw,  three  empty  preserve.l  nu'at-cans,  thirty  old  tin  mugs,  etc.;  but 
it  is  conceived  that  the  specific  is.ison  of  typhoid  fever  could  not  have  been  present,  even  supposing  a  previous  case  of  the  fever  to  have  existed,  for  the 
ce.sspool  contained  only  kitchen  wa.-te.  and  the  open  privies  were  far  from  an,l  on  a  lower  level  than  the  well.  Niemt.vee,  in  his  TeH  Book  of  Prmtiml 
iledkiiie,  Vol.  II,  Am.  Trans.,  New  York,  ISO'i,  page  573.  says  that  the  miasmatic  origin  of  ab.l.,minal  typhus  is  rendered  probable  by  ca.ses  wcurring  in 
places  removed  from  travel,  where  no  ca,se  of  this  disease  has  cccnrrerl  for  years  and  where  there  is  not  the  slightest  suspicion  of  a  contagious  origin. 
Surge.jn  General  C.  A.  Goedox,  in  his  report  on  EtUeric  Fei-er  in  reUiliott  to  British  Tror^m  in  the  Mulrns  Connnawl,  Madras,  1S78,  has  shown  that  fevers  with 
enteric  lesions  occur  in  In.lia  which  cannot  reasonably  be  accounted  f..r  either  on  the  assumption  of  a  direit  propagation  or  on  that  of  a  tilth  origin  de 
liore.  Sir  Joseph  Fayeee,  in  his  Croonian  Lectures  On  the  Climate  Mid  Ferers  in  India,  London,  1SS2,  p,  .".'.1,  holds  that  fever  in  India  with  diarrluett,  Pey- 
erian  ulcer..(ion  and  typlo.i !  symptoms  is  not  necessarily  caused  by  a  epeciflc  contagion  derived  from  fiecal  matter  or  from  the  intestines  of  another  person. 


k 


COXTIXUED    FEVERS.  499 

sicken  of  tvidioiJ  fever  and  niav  transmit  tlie  disease  bv  tlieir  nncared-for  discliaro-cs  as 
effectually  as  if  tliey  lifid  received  it  from  the  discharges  of  a  recent  patient.  The  antece- 
dent case  is  assumed  to  have  existed  and  to  have  contaminated  the  drain  or  pile.  In  cer- 
tain epidemics  of  obscure  origin  ^vhich  have  been  thoroughly  investigated,  the  previous  case 
has  not  unfrequently  been  detected.  The  failure  to  discover  it  has  therefore  been  regarded 
rather  as  illustrating  the  difficulties  in  the  way  of  a  thorough  knowledge  of  the  facts  than 
as  demonstrating  the  non-existence  of  the  previous  case.  But  it  is  claimed,  on  the  other 
hand,  that  if  in  many  instances  a  careful  examination  of  all  the  points  bearing  on  the  possi- 
ble origin  of  a  t^vphoid  outbreak  fails  to  discover  a  connection  with  a  previous  case  of  the 
disease,  we  are  warranted,  notwithstanding  the  frequent  superficiality  of  our  modes  of  inves- 
tigation as  compared  with  the  obscurity  of  Nature's  methods  and  the  subtlety  of  the  jioisou 
in  question,  in  assuming  that  in  one  at  least  of  these  many  instances  the  whole  field  has 
been  viewed  and  the  presence  of  the  previous  case  excluded.  If  this  be  ceded  in  one  case 
the  argument  is  at  an  end.  The  truth  will  never  be  known  if  evidence  which  does  not 
agree  with  our  preconceptions  be  excluded.  All  intelligent  testimony  should  be  admitted 
as  tending  to  an  accurate  knowledge  of  the  matter  in  question.  When  an  educated  physi- 
cian, possessing  a  full  knowledge  of  the  facts  and  not  unlikely  a  personal  acquaintance 
ranging  over  years  with  the  house,  its  inmates  and  neighborhood,  has  examined  the  subject 
and  failed  to  trace  a  sjiecific  infection,  it  is  more  reasonable  to  refer  the  origination  of  the 
fever  to  local  fermentative  conditions  than  to  assume  that  the  specific  germ  has  been  in 
existence  there  for  years  without  manifesting  its  presence,  or  that  some  unknown  person, 
necessarily  a  walking  case  of  the  disease,  had  visited  the  premises  and  left  no  other  trace 
of  his  presence  than  the  infection  of  the  privy  or  well.  To  this  latter  supposition,  absurdly 
one-sided  as  it  appears,  we  become  reduced  in  many  instances  of  country-house  typhoid  if 
the  spontaneous  origin  of  the  fever  be  denied. 

In  a  recent  treatise  on  the  continued  fevers  J.  0.  "\Vilso:n'*  denounces  the  theory  of  a 
spontaneous  origin.     He  says: 

If  we  assume  that  a  fever  so  specific  in  its  clinical  and  anatomical  characters  must  be  due  to  a  specific  cause, 
and  that  the  specitic  cause  is  au  organism  of  some  kind,  the  view  that  the  poison  does  not  arise  independently  hut  in 
every  instance  from  a  parent  stock  becomes  a  logical  postulate  from  these  assumptions;  otherwise  we  are  forced  to 
accept  the  theory  of  spontaneous  generation. 

This  author's  enthusiasm  in  behalf  of  a  specific  germ  transmitted  from  case  to  case  leads 
him  too  far.  His  argument  as  stated  is  correct,  but  it  does  not  fipply  to  the  case  in  hand. 
The  view  that  the  poison  arises  in  every  instance  from  a  parent  stock  is  a  logical  |iostulate 
from  the  assumptions,  but  not  that  the  parent  stock  is  in  every  instance  propagated  in  and 
discharged  from  the  human  intestinal  canal.  Dr.  Wilson  does  not  touch  upiun  this  point, 
which  is  nevertheless  the  very  point  at  issue.  Moreover,  spontaneous  generation  on  the  one 
hand,  and  on  the  other  a  transmission  from  case  to  case  through  the  sewers,  which  Dr.  Budd 
fancifully  yet  isractically  regarded  in  this  connection. as  a  continuation  of  the  diseased  intes- 
tines,*)" may  not  be  presented  as  the  horns  of  a  dilemma.  Ague  is  a  specific  disease,  and  if 
we  assume  it  to  be  due  to  a  specific  cause  and  that  the  specific  cause  is  au  organism  of  some 
kind, — all  of  which  may  be  readily  allowed,  as  it  is  considered  jiroved  by  many  observers, 
— the  view*  that  the  poison  does  not  arise  independently,  but  comes  in  every  instance  fi'om 
a  parent  stock  grown  in  the  human  system,  does  not  follow  as  a  logical  postulate  from  the 
assumption,  nor  are  we  forced  to  subscribe  to  the  theory  of  spontaneous  generation, — ibr  the 

*  Wood's  Library  of  Standard  Jledical  AuOiors,  New  York,  1881.  t  Laiieel,  Vol.  II,  1856,  p.  618. 


500  ETIOLOGY    OF    THE 

awue-frerms  live  their  lives  and  ceneration  follows  generation  in  concenial  soils  and 
circumstances. 

The  ajiparentlv  spontaneous  origin  of  tvphoid  fever,  noted  by  many  observers,  indicates 
tliat.  as  in  ague,  we  have  a  miasm  or  germ,  specific  in  character,  propagated  in  and  evolved 
from  certain  matters  in  tlie  soil  under  favorable  conditions  as  to  heat  and  moisture;  yet,  as 
proved  by  other  experiences,  the  disease  thus  originating  de  novo  is  capable  of  being  trans- 
mitted from  case  to  case  by  means  of  decomposing  excreta  containing  its  infection.  In  other 
words,  typhoid  fever  is  a  truly  ruiasmafic-contagious  disease. 

Ague,  including  the  more  pernicious  manifestations  of  its  cause,  is  a  purely  miasmatic 
disease  of  telluric  origin,  although  in  its  literature  there  are  not  wanting  cases  wliich  suggest 
a  contagious  quality.  Dysentery  is  usually  referred  to  miasms  of  telluric  origin,  yet  in 
many  instances,  especially  where  cases  are  aggravated,  as  during  an  epidemic,  contagion 
from  the  excreta  is  allowed;  typhoid  fever  follows  dvsentery  in  this  respect,  its  contagious 
qualities  being  more  frequently  observed.  The  two  serve  to  connect  the  purely  miasmatic 
intermittents  with  the  purely  contagious  disease,  small-pox,  which  the  observations  of  cen- 
turies have  indicated  as  requiring  the  human  system  as  a  nidus  for  its  propagation. 

LiEBEEMEiSTEK  uses  the  term  miasmatic-contagious  in  a  different  sense  to  that  given 
above.*  He  does  not  allow  that  typhoid  fever  is  contagious  as  is  smallqjox,  passing  directly 
from  person  to  person;  but  ibllows  Budd  in  his  theory  that  the  germ  thrown  out  from  an 
infected  person  is  propagated  in  decomposing  organic  matter,  and  thereafter  evolved  to  infect 
the  human  system  and  be  again  thrown  out.  On  the  other  hand  he  considers  it  to  differ 
from  the  purely  miasmatic  class  in  that  it  originates  outside  the  body  only  ^yhen  an  infected 
body  has  furnished  the  germ.  The  poison  is  therefore  miasmatic,  but  with  a  C|ualification. 
As  the  tape-woi-m  cannot  be  transmitted  directly  from  person  to  person,  but  lias  to  joass 
through  another  stage  of  development  before  appearing  again  in  this  form,  he  considers  that 
a  development  outside  the  body  is  needful  to  the  reproduction  of  the  germ  of  typhoid.  The 
fresh  discharges  of  an  enteric-fever  patient  contain  the  germs  in  that  stage  of  their  develop- 
ment in  which  the  living  body  does  not  furnish  the  conditions  necessary  to  their  propagation. 
Tliey  are  therefore  harmless.  But  if  they  remain  until  decomposition  has  begun,  and  espe- 
cially if  in  contact  with  masses  of  decomposing  matter,  a  large  propagation  occurs  and  a 
development  which  empowers  them  to  produce  the  specific  fever  when  introduced  into  the 
liuraan  body.  To  classify  the  typhoid  germ  and  others  resembling  it,  such  as  those  of  dys- 
entery and  cholera,  which  he  regards  as  miasmatic  with  a  qualification  and  contagious  Avitli 
a  qualification,  he  has  suggested  the  term  miasmatic-contagious;  but  it  is  submitted,  with 
dtie  respect  to  the  opinion  of  so  high  an  authority,  that  as  regards  the  term  it  does  not  con- 
vey the  theoretical  ideas  on  which  it  was  framed,  that  is,  the  assumed  peculiarities  of  the 
class  which  it  was  intended  to  define;  and  that  as  regards  the  theoretical  ideas,  they  cannot 
be  sustained  in  view  of  the  occurrence  of  typhoid  fever  under  conditions  which  exclude  the 
possibility  of  a  germ  from  a  previous  case.  On  tlie  other  hand,  in  using  the  term  miasmatic- 
contagious  in  the  sense  of  the  meaning  of  its  components,  as  has  been  done  in  this  discussion 
— miasmatic,  as  originating  without  the  system,  yet  capable  of  producing  a  specific  disease 
when  taken  into  the  system,  and  contagious,  as  capable  of  direct  or  indirect  transmission 
from  person  to  person,  full  expression  is  given  to  theoretical  views^.  which  must  be  allowed 
to  be  in  accordance  with  oliserved  facts. 

*See  his  articles  on  the  infectious  diseases  and  the  etiology  of  typhoid,  in  Vol.  I,  Ziemssen^s  Cyclopedia. 


CO'TINTED    FEVKE:<. 


501 


What  tlie  conditions  may  be  wliicli  are  needi'ul  to  the  propagation  or  evolution  of  the 
typhoid  germ  is  not  definitely  known.  The  di>;ease  appears  in  a  conimuuity  on  the  disap- 
j^earance  of  ague.  The  purely  malarial  fevers  liave  tln'ir  hahitat  in  tlie  wilds  or  in  forming 
settlements,  while  typhoid  fever  appears  in  formed  settlements. '■■  This  has  been  so  well 
recognized  that  ague  has  been  called  a  disease  of  the  country  and  typhoid  fever  one  of  the 
town  or  city.+  But  it  has  been  observed  that  the  latter  fever  has  prevailed  along  mountain 
slopes,  while  ague  has  been  its  cotemporary  in  neighboring  valleys;  and  that  ague,  prevalent 
in  wet  seasons,  has  given  place  to  typhoid  during  long-continued  droughts.  This  suggests 
the  possibility,  nay,  the  probability,  that  moisture  has  to  do  with  the  evolution  of  the  ague- 
poison  and  a  comparative  dryness  with  that  of  the  fever  under  discussion. J  This  comparative 
dryness  is  the  result  of  the  development  of  the  village  into  a  town,  where  the  malarial  gives 
place  to  the  typhoid  germ  evolved  from  the  soil.  Later,  when  sewers  are  built  and  the  town 
evolves  into  a  city,  with  typhoid  fever  endemic,  indirect  contagion  manifests  its  influence  in 
the  propagation  and  continuance  of  the  disease.  Dr.  Cabell  quotes  several  instances  of 
the  supervention  of  endemics  of  typhoid  on  those  of  malarial  fever  when  the  moisture  of  the 
soil  has  given  place  to  dryer  conditions;  of  the  cotemporaneous  existence  of  the  two  fevers 
in  neighboring  localities  having  different  degrees  of  moisture  in  the  subsoil;  of  the  replace- 
ment of  typhoid  by  malarial  fevers  when,  by  unusual  seasonal  or  other  influence-;,  the  moisture 
has  been  again  restored,  and  of  the  coincident  occurrence  of  both  fevers  in  the  locality  and 
apparently  indeed  in  the  individual  at  certain  interniediate  stages  in  the  progress  of  the  soil 
from  moist  to  dry  or  the  reverse.  The  followinL?  are  sj-iven  as  illustrations;  but  many  such 
may  be  gathered  from  recent  literature,  particularly  from  the  Transactions  of  the  American 
Medical  Association  and  of  State  and  local  medical  societies. 

Dr.  R.  S.  r.vYNK,  of  Lyiichliurf;,  Va.,  iccalliiifi  tlio  eliaiigos  produced  in  tho  medical  topoufraiiliy  of  tint  city 
and  its  siirroiuidinf;s  liy  the  conslniction  of  tlio  .James  Hivcr  and  Kanawha  Canal,  which  was  eiimnience<l  in  1831, 
says:  The  low  jirounds  between  the  hills  and  tho  river  hanks  were  watered  hy  siirinjjs  from  the  hills,  and  as  the  river 
hank  was  hii;her  than  the  foot  of  tlie  hill  tho  low  grounds  Were  necessarily  swampy  in  character,  and  until  tho 
grounds  were  drained  liy  the  canal  w*  had  ague  and  fever  along  its  line  every  summer  and  fall.  While  tho  canal 
was  in  progres-s  of  construction  the  laborers  engaged  in  this  work,  as  well  as  those  upon  tho  farms  for  twelve  or 
fotirteen  miles  below  Lynchburg,  suffered  severely  with  congestive  chills.  If  the  patient  did  not  die  during  tho 
third  or  fourth  chill  the  case  generally  became  comjilicatod  with  severe  diarrhiva.  and  the  fever  assumed  a  continued 
type,  frequently  marked  with  tympanites  and  delirium.  After  the  newly  lifted  earth  had  been  exposed  totlie  winter's 
frost  and  a  summer's  sun  the  miasmatic  features  were  greatly  abated,  and  the  fever  now  generally  assumed  very 
distinctly  the  characteristic  features  of  typhoid.  Still,  on  the  same  farms  and  sometimes  in  the  same  families,  you 
would  see  during  this  epidemic  a  well-marked  case  of  chill  and  fever,  but  if  not  arrested  within  five  or  six  days, and 
especially  if  the  patient  took  an  aperient,  however  mild,  a  diarrhtca  would  set  in,  the  intermission  would  bo  loss  and 

*lt  is  Imrdlj'  needful  to  funii.-Ii  illustrations  uf  these  well-known  fm-ts.  In  recent  vean^  ev<>ry  niedical  ni.in  win*  has  K"'ne  West  to  ^ruw"  n['  witti 
the  country  has  exjierieuceil  the  so-ealled  chitnge  in  the  fitiie  <>f  fwerg.  Many  references  to  it  may  l>e  fonml  in  the  Tniiit<nrti"tiii  e/  the  AntfrienH  Mi-tUcal 
A~viociiilio)i,  as,  for  instance  ■  *'In  all  the  .Sonthern  nicilical  journals  of  recent  date  we  find  it  stated  that  thronghont  onr  whole  nuilarial  middle  country, 
anil  indeed,  tlojugh  less  strikingly,  in  onr  Io\v<t  alluvial  districts  also,  typlmid  fevers  are  heconiing  nntre  and  more  fift|nent  in  |daces  atnl  settlenn.'Uts 
an«l  under  circtimstances  where  hitherto  the  ordinary  antunuial  remittents  and  intermittents  prevailed  extensivel.v." — S.  II.  Picksox,  Vol.  \,  18o2,  p. 
In7.  "We  have  heard  no  remark  regarding  our  fevers  oftcner  made  by  idiysicians  in  different  jiarts  of  the  State  than  that  which  refei-s  to  the  evident 
annual  increase  of  continued  or  typhoid  fever  over  the  ordinary  endemic  or  hilions  fever  uf  the  country,  the  former  heing  ilisi>osed  as  it  were  to  displace 
the  latter  as  the  improvement  of  the  agricultunil  districts  advances." — tii-^inrt  nf  a  Cinnmith'e  on  the  Diifiaes  vf  Mhmnvi  titi'l  Imrn,  A'ol.  VIII,  ]SS,"i,  p. 
liiri.  A  similar  change  has  attendeil  the  settlement  and  iinin-oveinent  of  reclaimed  lands  in  other  countries.  Thus,  acconling  to  Lavf.uan, — Traii''  dea 
Mulailiit  el  £piiliiiiua  iles  Aniii'fs,  Paris,  lsT5.  p.  248  :— "  In  the  early  years  of  the  occnniti<in  of  Algeria  hy  the  French  t,V]ihoid  fever  was  as  rare  as  malarial 
fevers  were  common,  and  this  was  one  of  the  principal  facts  which  served  as  a  basis  for  the  tlieury  of  antagonism  ;  but  noire  recently  the  former  disease 
has  become  as  freiinent  an  affection  among  the  troops  in  .\lgeria  as  among  those  serving  in  France  :  In  Isos  the  army  of  the  interior  lust  3.05  men  per 
1,1100  effective  and  the  army  of  Algeria  4.f;;j  i^t  1,(ioO  from  tyithoid  fever.'' 

f  Although  in  growing  cities  malarial  fevers  are  rejilaced  by  typhoid,  a  noted  excei.tiou  to  this  is  found  in  New  Orleans,  where  the  prevalent  fever 
is  of  malarial  tirigin.  In  this  city  there  are  no  sewers  ;  exeremental  filth  is  collecte*!,  removed  and  consigned  to  the  river  under  the  superintendence  of 
the  Board  of  Health,  and  the  water-supply  is  free  from  soil  contamination  by  its  storage  in  raised  wooilcn  tanks.  These  facts  have  been  adilnced  in  expla- 
nation of  the  comparative  rarity  of  typhoid  fever ;  but  since,  according  to  Dr.  Jo.xes,  not  only  the  city  but  the  entire  alluvial  portion  of  Louisiana 
suffers  less  from  this  disease  than  the  more  elevated  parts  (see  the  llejiort  of  the  Iti«ird  vf  H'rillh  r,f  Loiiisi.om,  ISSl,  p.  21'.i)— it  seems  prolmble  that  tho 
water-logged  condition  of  the  soil  is  an  important  factor  in  determining  the  prevalence  of  the  paroxysmal  fevers  and  the  infreiiuency  of  typhoid. 

I  MvBCHlsox  has  shown  that  in  Knglaud  the  seasonal  occurrence  of  typhoid  fever  is  after  hot  and  dry  weather,  from  -Vugust  to  Xuveuiber,  and  that 
years,  such  as  18G",  noted  for  decreased  lirevalence  have  been  unusually  wet  and  cold.     See  his  7'(To((V,  jip.  448-l'.». 


502  ETIOLOGY    OF    THE 

less  marked,  and  ultimately  the  fever  take  a  typhoid  character.  This  peculiarity  was  confined  to  the  population 
residing  on  the  river.  About  two  and  a  half  or  three  miles  from  the  river  tj'phoid  fever  ))roke  out  on  a  plantation 
with  a  largo  family  of  negroes,  and  many  died.  There  was  no  malarious  complication  here.  The  only  chill  I  saw 
was  produced  by  myself  in  sponging  a  patient  with  cold  water  with  a  view  of  reducing  the  higli  temperature.  A 
chill  came  on  by  the  time  I  had  sponged  the  face,  neck  and  cue  arm,  and  the  patient  died  in  less  than  two  days. 

Dr.  K.  T.  Lemmox,  of  Campbell  County,  Va.:T-I  have  had  frequent  occasion  to  mark  an  apparent  antagonism 
between  typhoid  and  malarial  fevers.  In  tlie  year  1845  this  section  of  the  State  was  fearfully  scourged  by  a  typhoid 
epidemic.  The  backbone  or  ridges  suffered  more  severely,  while  the  malarial  region  on  the  banks  of  the  Staunton 
River  aud  some  large  and  old  mill-ponds  escaped  entirely,  the  usual  amount  of  ague  prevailing  there.  The  line  of 
demarcation  was  veiy  apparent.  Subseijuently  I  have  seen  cases  of  typhoid  witliin  the  malarial  region,  but  no  cases 
of  intermittent  at  the  same  time. 

Dr.  S.  Pi'TXAM,  of  Montpelier,  A'a.: — During  a  somewhat  extensive  country  practice  for  thirty  years  and  more, 
typhoid  fever  has  more  generally  occurred  as  an  epidenuc  from  August  to  Noveudier,  particularly  in  dry  seasons,  after 
a  succession  of  yt'Uow,  siiiuky  (Iki/s,  u-ithoul  sim-m,  ivinds  or  clcctiicid  displdi/,  the  beds  of  streams  and  ponds  having 
become  dry  or  half  dry  and  stenchy.and  vegetation  ])arched  or  shriveled.  Under  these  circumstances,  constituting, 
as  I  conceive,  an  epidemic  influence,  typhoid  fever  has  often  soon  ai)peared,  more  fre(iuently  iu  families  residing  on 
the  banks  of  streams  or  ponds,  but  often  also  in  the  farm-houses  scattered  over  the  hills  here  aud  there,  without  any 
possibility  usually  of  tracing  the  importation  of  the  disease  or  its  spread  from  house  to  house  by  contagion.  Under 
these  circumstances  in  the  fall  of  18(55  I  saw  thirty-seven  cases  and  made  notes  of  them. 

The  following  from  a  paper  by  J.  H.  Glaiborxe,  of  Petersburg,  Va.,*  is  also  of  interest 
in  this  connection: 

Some  further  light  is  probably  thrown  upon  the  nature  of  the  disease  in  this  immediate  locality  from  the  fol- 
lowing facts:  During  the  past  year  (1879)  there  was  perhajis  a  smaller  rainfall  jnst  in  this  section  of  the  country  than 
for  any  one  year  in  the  memory  of  the  oldest  inhabitant.  It  is  doubted  whether  the  ground  was  ever  thoroughly 
wet  from  April,  1879,  to  January,  1880.  A  gentleman  who  had  been  observing  the  opening  of  a  number  of  graves 
in  the  month  of  December  informed  me  that  he  had  never  seen  the  earth  so  dry — even  in  any  summer  nu>nth.  There 
was,  therefore,  great  sluggishness  in  the  streams  and  runs  of  the  vicinity-— even  where  they  were  not  totally  dried 
up.  For  similar  reasons  the  sewers  and  gutters  of  the  city  couhl  not  be  lluslied,  viz:  on  account  of  the  scarcity  of 
water  and  the  necessity  of  economizing  its  use.  There  was  on  this  account  imperfect  drainage  both  iu  the  city  and 
the  surrounding  country,  and  a  great  accumulation  of  garbage  and  other  noxious  stuft'  which  is  usually  swept  oft'  by 
our  rapidly  flowing  streams  when  flooded  by  storm-water.  Though  situate  just  at  the  head  of  tide-water,  the  land 
rises  in  the  city  and  vicinity  from  50  to  300  feet  above  the  sea :  and  }>er  consequence  the  streams — severrl  of  which  pass 
through  aud  around  the  city — have  quite  a  fall  and  of  course  a  rapid  current.  This  gives  us  excellent  natural 
drainage,  aud  iu  heavy  rains  we  usually  get  a  good  washing  out.  During  the  protracted  drouth  of  the  last  year  these 
natural  advantages  availed  us  nothing.  But  these  accumulations  from  lack  of  drainage  were  not  of  a  rtgetahle  nature. 
On  account  of  the  want  of  nmisture  the  ordinary  luxuriant  vegetation  of  our  aluvial  soil  was  lacking,  and  there  was 
very  little  ri'ijitahle  mould  or  decomposition.  Tlie  noisome  products  which  had  been  left  to  seethe  aud  ferment  by  the 
dried  aud  drying  streams  were  rather  of  an  animal  orii/in.  The  ordure  of  more  than  twenty  thousand  people,  the 
refuse  and  offal  of  half  a  dozen  abattoirs,  the  garbage  from  the  kitchen,  cookshops  and  fish-stands — all  contrib- 
uted to  tlie  savory  mass  left  to  ferment  in  our  midst  and  about  us.  Now,  coincident  with  this  condition  of  things, 
shall  I  say  as  a  seijueuce  there  appeared  tliis  new  form  of  fever,  partaking  more  of  the  nature  of  typhoid  fever  than 
of  malarious  fever  and  yet  not  essentially  either.  Iu  addition  to  these  facts  it  is  notalile  that  tl'-ere  was  almost  a 
total  absence  of  the  usual  climatic  remittent  and  intermittent  fevers.  Indeed,  so  far  as  my  own  practice  is  concerned, 
I  can  say  that  not  one  uncomplicated  ease  of  simple  intermittent  fever  was  brought  to  my  notice  during  the  sunuuer 
or  antumn  of  1879.  In  its  place  came  this  new  evil — typlio-malarial  fever  I  suppose  it  must  be  called — originating 
perbajis  iu  the  infection  begotten  of  undrained  ditches,  sewers  aud  streams,  and  having  implanted  upon  its  nature  the 
habit  of  jieriodicity  whicli  our  malarial  fevers  have  been  establishing  in  the  systems  of  our  people  for  so  uumy  years. 

Another  circumstance  favoring  the  supposition  that  a  comparative  dryness  of  soil  is 
essential  to  the  develoi)ment  or  propagation  of  the  typhoid  cause  is  Ibund  in  the  connection 
between  the  prevalence  of  the  disease  and  the  level  of  the  subsoil  water.  Buhl  and  Pet- 
TE>'KOFER  Lave  shown  that  in  ]\[unicli  typhoid  increases  as  the  water-level  falls  and  decreases 
as  it  rises.  Viechow  has  demonstrated  similar  facts  in  Berlin.  In  this  country  H.  B. 
Baker  of  Micliigan  noted  the  condition  of  the  water-level  in  connection  witb  reports  of 
tvplioid  received  from  his  correspondents  in  various  pai-ts  of  the  State  during  the  years 
1873-83.  His  investigations  appear  to  demonstrate  that  a  fall  in  the  subsoil  water-level, 
beginning  usually  in  June  and  continuing  until  October,  corresponds  with  a  somewhat  later 

*  Tyi^ho-Yn-ihvi'il  K-r^'-;  Pke„>'irks  on  an  Eu'teniic  Fef'.r,  ISTQ,  in  thf  City  of  PeUrsbitnj  and  vivin-ojr. —  Vinjinia  Mrtliiitl  Montliltt,  Vul.  VII,  p.  S9  t-t  ei'<i. 


CO^'TIX^ED    FEVER?. 


503 


Lut  similarly  progressive  increase  in  the  prevalence  of  typlioiJ,  amj  that  the  subsequent  rise 
of  the  Avater-level  is  followed  l.y  a  ditninished  prevalence  of  the  fever.'*' 

The  Municli  observers  suggested  in  explanation  that  tlie  matter  which,  by  its  fermen- 
tation, gives  origin  to  the  causes  of  typhoid,  lies  deuj^  in  the  earth  and  undergoes  fermenta- 
tion onlv  when  freed  from  excess  of  moisture  by  the  fall  of  the  subsoil  Avater-leveh  Lieb- 
ERMEISTER  regards  the  increased  prevalence  associated  "with  low  water  in  the  wells  as  due 
to  a  concentration  of  the  infective  matter  resulting  from  the  increased  area  of  drainage  and 
the  diminished  quantity  of  diluting  water. t  Baiter  holds  in  a  similar  manner  that  the 
S2:>ecific  poison  of  tvphoid  fever  from  neighboring  privies  and  infected  soil  is  more  likely  to 
enter  the  wells  when  the  water  is  low.  He,  however,  announces  that  in  Michigan  the  law 
of  correspondence,  as  formulated  by  Buhl  and  Pettenkofer,  does  nut  hold  good  during  the 
Avinter:  ** Typhoid  fever  follows  hnv  water  in  summer  and  higli  water  at  that  season  of  the 
year  when  the  ground  is  usually  thoroughly  frozen. '"| 

The  proposition  that  water  percolating  through  a  soil  contaminated  with  the  specific 
germ  or  cause  of  typhoid  fever  may  carry  the  infective  principle  into  wells  and  springs 
appears  to  be  definitely  established.  The  Lausen  epidemic  has  shown  that  filtration  through 
the  soil  is  incompetent  to  remove  the  cause  of  typhoid  fever  from  water. §  Again,  the 
proposition  that  a  well  or  spring  infected  in  this  manner  is  more  dangerous  when  it  contains 
little  than  when  it  contains  much  water,  is  highly  probable.  But  neither  of  these  prop- 
ositions excludes  the  possibility  of  the  fever  originating  independently  of  germs  that  have 
had  a  previous  habitat  in  the  human  system:   nor  do  they  demonstrate  that  the  causes  of 


*  Tiiphoi.J  F"rrr  an-r  L.nr  Wat.r  in  Wrlh. 
llrulth  .l.v.,.„,„f;,„(.  V,,l.  XII. 

fS.'t'  Anu-ricaii  Traiisliitinn  Z'umxf^fu'K  C>/'h>j>.,  Vol.  I,  ji.  71. 
ITho  Year  18.*2  fiiriiWi.-.l  I>r.  IVvkkr  with  his  m..>i  nntahh' 
hi^rli-^;iinm(l  wntcr  ruri-i-si>i>ii<iiiii;  with  ii  cniisith'raMi'   liiTvaliiuf 


('  Autitial  It'port  S/<it''  Bo.trii  >■/  Jhnlih  ./  Mi.hi.j.u,   f..r  1SS4.  or  U-p-rl-^  nu-l  P-.j-rs  of  the  Aoiiriciii  Pi'hH-' 


illustmtinn  nf 
.f  f.-vrr  ill  tlif 


:>rM.nAM    sh..,ri,i.l  fh>-   rihiti-m    }..fir,n\    On-   h'l'lht   of  (]>'•  i=..;..>-.n7  vnki 

hnl  ut,<nii>'}u:r.,lr„<o  i<f  tili'hi'i.l    frr.'r  /)(  'tf,r  Shitv  ,>/ 

Mirhi./.Di  ibning  (in-  ifur  ISS'J. 


uiiitiT  scuMiii.  It  is  liMtii-iMl.li',  liitwi'VtT,  that  iti  Iiis  ilijt)_'r:im  for  the  yt-ar  iiicii- 
tiuiu'd  the  iiicr<»a.si'il  niuvcini'iit  of  tin?  fvwr  fnllnwfd  tin.-  luwrriiij;  of  tlio  Buh.soil 
Wiitcr-lovfl  t-o  slowly  tliat,  altlimiuli  tho  hjwcst  Ii^vel  was  noted  in  July,  thi^  inaxi- 
inuni  of  i)rL'vaU'nce  was  not  attainnl  until  Ot-tolnT.  Tho  liijrh  rate  of  iirfvak'nce  ia 
January  may  not  thi.'rrf,.rt!  W-  coniparcil  with  tho  hi^rh-wati-r  h'vrl  of  the  winic 
month,  but  with  the  Icvi-I  of  on<-  of  the  latt-r  months  of  1S81.  ^Vhat  this  may  have 
been  is  not  known  ;  for  since  tla-  wells  examined  wi-re  not  tlie  same  wt'Ils  in  l>oth 
years,  *'uo  coimiarison,"  as  Pr.  Bakkr  jiojnts  out,  "ran  he  made  of  one  year  with 
the  otlier  as  to  tlie  exact  height  of  tlie  water  during-  thi-  yi-ar  as  a  whide  or  of  one 
month  with  the  corresiiomlinj^  niontli  in  another  year."'  The  liijrli-wator  level  in 
the  wells  oI.>.-rveil  iu  1881  was  IGO  inchi'S  below  tlie  Burfa.-.- ;  the  low  h-vel  2.JG 
inches.  The  highest  level  in  1882  was  10-1  inches,  the  lowest  ISoinehfs.  IJut  as  the 
frequency  of  tyidioid  iu  hotli  years  was  detennined  in  tlie  same  manner,  the  rates 
j)revailinir  in  the  spring  of  18S2  are  susceptible  of  conijiarison  with  tht)se  of  the  jir*'- 
ceding  winter ;  and  tliese  show  a  gradual  dcrrea-se  fmni  37  jxt  cent,  of  the  rein>rts 
furnished  in  (irtol-er,  1S81,  to  32  in  N'ovenilier,  25  in  I)ecemh.-r,  21  in  January  (tf  the 
following  year,  10  in  February,  12  in  Slarch,  S  in  A]'ril  and  7,  the  minimnin,  in  May. 
Ah  the  general  tendency  of  Dr.  Bakkr's  r<'si-arches  favors  the  e^taldishment  of  a 
relationship  between  high  water  and  diminisbed  prevalence,  it  seems  likely  tliat 
this  gradual  decline  iu  the  fever-rate  was  jirecedi-d  liy  a  correlated  movement  of  tiie 
level,  even  although  high  water  was  in  this  instance  assoiiated  with  a  high  jireva- 
lence  of  the  fever.  It  may  also  be  pointed  out  that  if  Dr.  Bakeh  be  warrant-'d  in 
inferring  a  connection  between  high  water  and  iinreas*^!  prevalence  in  January  and 
February,  18S2,  the  connection  between  h>w  water  and  diminislied  prevalence  iu 
July  would  be  equally  authorized  ;  but  this  last  is  oi)pof-ed  to  the  general  tenor  of 
the  oh-.ervatiniis.  There  appears,  however,  in  some  of  his  diagrams  a  slight  want 
of  that  cirrespoudeuee  Ix'tween  the  water-level  and  the  itrevalence  of  tyjilioid  that 
iri  kn(»wn  to  exist  during  the  summer  and  autumn.  When  the  ground  is  fritzen  the 
privies  and  other  sources  of  tyi)boid  contamination  are  alH>  frozen  ;  the  wator-level 
is  low  in  the  absence  of  percolation  from  the  surface,  and  typhoid  fever  is  at  a  mini- 
mum. ^\^len,  on  the  other  baud,  in  the  cold  months  the  ground  is  Uot  bound  up 
by  frost  and  perc<.dation  from  the  surface  is  unimpe<ied,  the  water-level  may  ri::e,  and 
this  rise  be  followed  by  an  increase  of  typhoid  rather  than  a  decrease. 
§  See  fjj'jim,  note  *,  page  404. 


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7 

504  ETIOLOGY    OF    THE 

typhoid  lie  so  deep  in  tlie  ground  as  to  be  incapable  of  reacliiiiy  the  pysteni  except  I'V  tlie 
water-^iupplv.  The  onlv  deduction  aUowalile  from  many  of  the  experiences  on  whicli  they 
arc  based  is  tliat  a  certain  drvness  of  sorae  layer  of  the  subsoil  overlying  the  water-level  is 
needful  to  the  development  of  the  cause.  Whether  this  layer  be  deep  or  superhcial  has  not 
been  demonstrated,  but  so  far  as  the  evidence  goes  it  is  apparently  rather  superficial  than 
deep.  A  certain  amount  of  moisture  is  necessary  to  the  production  of  malaria.  Typhoid 
follows  malarial  diseases  so  pmmptlv  in  some  instances,  that  the  symptoms  of  both  diseases 
mav  be  developed  coincidontallv  in  the  same  person.  This  absence  of  interval  indicates 
that  the  superficial  layers  of  the  soil,  or  those  incompetent  to  evolve  malaria  on  account  of 
their  dryness,  are  the  site  whence  the  typhoid  germ  is  evolved. 

Ltebekmeister  takes  occasion  to  remind  us  that  in  discussing  tlie  iniluence  ot  low 
water  in  wells  the  influence  of  season  must  not  be  forgotten.  The  summer  heats  certainly 
lower  the  subsoil  water-level,  and  are  known  to  be  favorable  to  fermentative  processes. 
Both  of  these  effects  may  be  assumed  not  only  to  increase  the  virulence  of  a  water-supply 
derived  from  an  infected  area  of  drainage,  but  to  favor  the  development  and  evolution  of 
the  typhoid  miasm  from  a  suitablv  dry  and  otherwise  congenial  soil.  But  as  all  works  of 
imi"irovement,  euaineerina',  acrieultural  or  civic,  which  lower  the  level  of  the  subsoil  water, 
promote  the  disappearance  of  malarial  fevers  and  the  sulisequent  appearance  of  typhoid 
cases,  the  proper  condition  of  the  soil  as  to  moisture  seems,  under  ordinary  ranges  of  temper- 
ature, to  be  the  determining  influence  in  the  evolution  of  the  typhoid  cause.  The  lowering 
of  the  water-level  in  wells  is  a  coincidence,  but  not  an  essential  of  the  prevalence  of  typhoid 
fever,  although  it  mav  aiil  in  the  propagation  of  the  disease  bv  concentrating  a  percolated 
infection  or  miasm  in  the  driakino--water. 

Besides  a  certain  drvness  of  soil  and  a  temperature  suitable  for  fermentative  processes, 
nutritive  material  of  an  organic  nature  seems  to  be  requisite  for  the  development  of  the 
miasm  or  germ.  Formerlv  animal  matter  was  considered  essential — an  opinion  originating 
no  duulit  in  the  general  acceptance  of  Budds  theory  of  propagation  from  intestine  to  intestine, 
or  of  MrECHISO^■'s  pythogenesis, — but  the  evidence  certainly  favors  the  belief  that  vegetable 
matter  affords  a  congenial  soil  for  the  increase  of  the  typhoid  cause;  and  sorae  of  the 
instances  seem  to  indicate  that  to  be  effective  the  quality  of  this  need  not  be  such  as  to 
constitute  filthy  surroundings  in  the  ordinary  acceptation  of  this  phrase. 

From  the  considerations  involved  in  the  above  inquiry  it  seems  probable  that  tvphoid 
fever  is  a  miasmatic  disease  arising-  from  the  concurrence  of  certain  conditions  of  the  soil, 
and  projiagated  as  well  by  indirect  and  perhaps  direct  contagion  as  by  purely  telluric  exhala- 
tions and  percolations,  contaminating  air  and  water  with  tlie  specific  poison  or  germ.  If 
we  assume  the  disease  to  be  miasmatic-contagious  in  this  view  of  the  meaning  of  the  com- 
pound term,  the  probable  origin  and  mode  of  propagation  of  an  outbreak  in  civil  life  may  in 
many  instances  be  determined.  In  country  districts  the  normal  environment  of  the  sufferers 
is  well  known,  and  the  unusual,  among  which  are  the  typhogenic,  conditions  may  be  studied 
with  proportionate  facility.  In  large  cities,  where  the  environment  is  complicated,  the 
origin  of  local  epidemics  is  necessarily  involved  in  corresponding  obscuritv.  In  an  army 
the  ditHculties  attending  an  investigation  into  the  causatiun  and  transmission  of  tvphoid 
fever  are  increased  by  the  possible  existence  of  unknown  and  unsuspected  factors.  To  these 
difficulties  may  be  attributed  the  absence  of  special  reports  on  its  causation  in  our  camps. 

Xot withstanding  the  great  prevalence  of  typhoid  fever  reported  by  our  medical  officers 


COXTI>'UED    FEVERS. 


505 


during  tlie  first  year  of  the  war  the  epiJemic  was  never  general.  It  consisted  of  a  series  of 
local  or  regimental  outbreaks.  One  regiment  sufFereJ  while  that  encamped  in  an  adjacent 
field  was  unafFected,  although  the  shelter,  duties,  diet,  water  and  soil  were  to  all  appearances 
of  the  same  character  in  both  instances.  One  regiment  suffered  severely — a  second  was 
affected  to  a  less  extent — and  in  both  the  rapid  sequence  of  the  cases  indicated  a  local 
epidemic;  but  in  a  third  command  the  cases  were  scattered  over  a  longer  period  and  a 
typhoid  epidemic  was  not  recognized.  Tiie  surroundings  of  each  regiment  were  subject  to 
constant  change, — by  the  general  movements  of  the  army,  by  the  special  movements  of  indi- 
vidual detachments  in  compliance  with  orders  assigning  them  to  various  duties  within  the 
lines  of  the  arrnv,  and  by  transfer  to  distant  military  commands.  A  close  study  of  the 
medical  history  of  each  regiment  is  essential  to  a  knowledge  of  the  typhoid  epidemics  of  the 
war;  but  the  materials  for  this  have  not  been  furnished. 

ISTevertheless,  from  what  has  been  already  submitted,  the  appearance  of  the  disease  in 
a  regiment  or  other  unit  of  military  organization  may  be  granted  as  having  been  due  in  some 
cases  to  impiortation  from  the  localities  in  which  the  command  was  recruited;  in  others  to 
camping  on  ground  infected  by  its  former  occupants;  in  others  again,  to  miasmatic  influences 
affectinof  the  air  or  water,  encountered  amid  the  chantreful  conditions  of  field  service  and  due 
to  a  dryness  of  soil  inconsistent  with  the  development  of  unmodified  malarial  fevers.  Gen- 
erally this  condition  of  the  soil  as  to  moisture  depended  on  its  porosity  and  on  ordinary 
meteorological  infiuenccs;  sometimes,  however,  it  was  produced  artificially,  as  wlien  tlie 
subsoil  water-level  was  lowered  by  the  work  of  military  engineers;  even  the  means  adopted 
by  the  men  to  make  themselves  comfortable  in  field-quarters  were  frequently  the  cause 
of  small  local  outbreaks,  which  assumed  the  proportions  of  an  epidemic  when  multiplied 
by  a  multiplication  of  the  causes.  In  view  of  the  miasmatic  origin  of  typhoid,  the  huts 
constructed  by  the  troops  in  the  early  part  of  the  war  alKjnk'd  all  the  elements  needful  to 
its  production.  The  shelter-canvas  was  jiitched  over  low  walls  built  of  logs;  the  ground 
around  the  walls  was  trenched  to  keep  the  fioor  dry,  and  the  earth  removed  from  the  trenches 
was  banked  up  on  the  exterior  of  the  logs  to  close  up  the  crevices.  Organic  additions  were 
made  to  the  soil  fornung  the  floor  of  the  hut  by  crundjs  and  scraps  incidental  to  the  messing 
of  several  men  in  this  confined  space.  Heat  only  was  required  for  the  fermentation  of  the 
soil,  and  this  was  afforded  by  the  fire  built  for  interior  warmth.  The  external  cold  prevented 
emanations  from  the  camp-site  as  a  whole,  but  each  tent  or  hut  became  a  hotbed  for  the 
development  of  the  typhoid  miasm — in  small  quantities,  no  doubt — but  in  a  liigli  state  of 
concentration;  for  the  energies  of  the  occupants  were  devoted  rather  to  exeludiu"-  the  cold 
than  to  ventilating  their  quarters.'^'  Many  medical  officers  were  active  in  their  endeavors 
to  suppress  fever  in  their  commands  by  destroying  these  hotbeds  or  by  dilutincf  and  dissi- 
pating their  emanations. 

Probably  in  no  instance  that  occurred  during  the  war  could  a  miasmatic  orifin  of  the 


*  >[.  L£"N  CciLiN— in  Ln  Fi'ire  liij:lim<le  :Imis  V  Annie,  Paris,  18TS,  rp.  lOOauil  102 — roiL^iilers  tlie  siiontaiifoiis  origin  of  typhoid  established  hy  instances 
occurring  in  French  garrisons  in  time  of  |M-ace.  His  artrnnient  is  this  :  "AVlicn  a  nnniher  of  persuiis  coming  from  a  perfectly  salnlirious  localitv  j.  e. 
not  carrying  any  germs  of  typhoid  fever  with  them,  are  subjected  to  crowding  within  entirely  new  premises,  but  are  protected  at  the  same  time  from  the 
adniissi.iTi  of  any  external  influenie  of  a  jintrid  nature,— typhoid  fever,  slmuld  it  make  its  apiH'arancc  among  them,  must  be  held  to  have  originated 
spontaneously."  He  specifies,  as  a  case  in  point,  an  I'pidemic  tliat  occurred  in  the  ild  battalion  of  Chassi^nrs.  This  corps  was  sent  from  Limoges  to  Bellao 
(Haute  Vieniie)  in  February,  ISTll.  Its  new  station  was  a  healthy  little  city  which  had  never  before  lieen  garrisoneil.  As  none  of  the  barracks  in  pri-p- 
aration  for  the  troops  were  finished,  ir.O  men  were  quartered  in  three  confineil  rooms,  caclt  of  which  had  but  two  windows  ami  no  ventilatino-  shaft. 
The  air-sjiace  per  man  hardly  anuiuntetl  to l:JO cubic  feet.  Bad  weather  cuntineil  the  nn-n  to  their  t^narters  even  during  the  da v,  and  cause.1  them  to  stulT 
up  carefully  all  apertures  that  would  have  given  entrance  to  air.  From  February  21  to  JIareh  2."i  typhoid  fever  attaekeil  18  men,  one  of  whom  died.  Tho 
water-snpply,  although  impure,  was  unconnected  Willi  the  outbreak,  for  the  liuli-c.rnnnissioned  oHici'rsand  othcn-s  belonging  to  tie-  command,  who  hail 
better  quarters,  were  unaffected.  31.  Dr  C.vzal.  who  rep.irted  tlo'  outbreak,  referred  it  to  infection  of  the  air  by  organic  emanations  from  the  humaa 
boily — le  niUii*mehi(iiialn — and  31.  Colin  concurs  in  this  exjilanatiou. 

Meij.  Hist.,  Ft.  Ill— Gt 


506  ETIOLOGY    OF    THE 

fever  Le  uemonstrated.  Instances  in  wliich  no  other  origin  could  be  indicated  may  not  liave 
been  uncommon,  but  tlie  many  and  varying  exposures  to  which  the  individual  or  the  com- 
mand might  have  been  subjected,  unknown  to  the  regimental  medical  officers,  invalidate  all 
conclusions  reached  bv  the  method  of  exclusion.  Xevertheless  the  strikiniT  illustration 
furnished  by  the  exj^erience  of  Ass't  Surgeon  McElderky,  in  the  Modoc  campaign,  shows 
that  typhoid  of  a  purely  miasmatic  origin  may  have  been  frequently  present  during  the  war, 
since  the  conditions  that  developed  the  disease  in  Company  G,  12th  U.  S.  Infantry,  in  Oregon, 
were  of  common  occurrence  among  our  volunteer  troops. 

Bv  recognizing  as  one  cause  of  enteric  fever  a  telluric  germ  capable  of  naturalization 
in  the  human  system  and  of  indirect,  and  perhaps  direct,  transmission  from  2:)erson  to  person, 
the  existence  of  the  specific  disease  may  be  acknowledged  in  cases  where,  on  other  theories, 
a  malarial  fever  only  coidd  be  allowed  as  present.  The  prompt  acceptance  of  the  term  typho- 
malarial  by  a  majority  of  the  profession  in  this  country,  where,  in  our  growing  settlements, 
the  condition  of  the  subsoil  as  to  moisture  is  such  that  malarial  and  typhoid  conditions  alter- 
nate, shows  the  tendency  to  avoid  a  diagnosis  of  typhoid  when  the  previous  case  is  wanting 
to  account  for  the  specific  poison.  Were  these  cases  acknowledged  as  typhoid,  and  their 
infectious  qualities  allowed,  disinfection  of  the  intestinal  excreta  would  be  in  order,  with  a 
consequent  diminution  of  the  prevalence  of  the  disease.  So  long  as  they  are  I'egarded  as 
malarial,  because  the  connection  with  a  previous  case  cannot  be  established,  quinine  will  be 
administered  as  the  one  thing  needful,  the  chambers,  sinks,  privies  and  sewers  will  become 
charged  with  the  specific  germ  emanating  from  the  obscure  febrile  case,  and  a  local  epidemic 
of  a  dangerous  but  preventable  disease  may  be  the  consequence. 

When  the  disease  originated  in  miasmatic  influences  a  violent  but  short-lived  outbreak 
resulted;  for  although  the  whole  of  the  men  susceptible  to  the  miasm  may  not  have  been 
directly  affected  by  it,  the  large  number  of  primary  cases  quickly  established  a  focus  of  infec- 
tion which  threw  its  baleful  influence  over  all  the  command,  and  perhaps  beyond  it,  into 
neighboring  camps,  if  j.irompt  and  effective  measures  were  not  taken  to  stamp  out  the  disease. 
A  similar  rapidit^v  characterized  the  outbreaks  resulting  from  the  occupation  of  localities 
infected  by  their  previous  occupants. 

When  the  disease  originated  by  direct  or  indirect  contagion,  affecting  in  the  first  instance 
one  or  at  most  few  individuals,  its  progress  was  less  rapid.  Transmission  from  man  to  man 
through  the  medium  of  the  sinks,  close  communication  in  quarters,  infected  blankets,  etc., 
necessarily  separated  one  case  from  its  progeny  by  at  least  the  period  of  inculjation.  The 
prompt  removal  of  the  cases  from  quarters  to  hospital,  although  prirnarilv  in  the  interest  of 
the  sick  man,  was  jiractically  an  imperfect  isolation  which  tended  to  confine  the  sphere  of 
infection  within  limits  under  the  special  surveillance  of  the  medical  officers. 

The  water-supply,  although  frequently  detected  in  transmitting  the  spiecific  germ  of 
typhoid  in  civil  life,  was  seldom  arraigned  by  our  military  surgeons  except  in  the  aljsence 
of  other  and  more  evident  insanitarv  influences.  In  large  and  crowded  camps  it  was  imjios- 
sible  to  preserve  the  streams  from  faecal  contamination.  Every  rainfall  washed  more  or  less 
of  the  filth  of  the  camps  into  their  current.  Wells,  also,  were  liable  to  become  dangerous 
from  typhogenic  miasm  or  infection  from  a  previous  case.  It  may  be  assumed,  therefore, 
that  the  water-supply  was  not  unfrecjuently  the  veliicle  of  transmission  and  even  of  primary 
invasion. 

The  diet  was  sometimes  included  amon^  the  insanitarv  agencies  tending  to  the  devel- 


i 


CONTINUED    FEVERS.  507 

opment  of  the  fever,  and  at  least  two  medical  officers  regarded  it  as  t\\e  primu/n  mobile  of  the 
disease.'''  But  men  became  affected  whether  tliey  were  well  or  jioorly  fed,  and  of  regiments 
on  the  same  rations  some  were  attacked  while  others  escaped.  The  diet  was  apparently 
unconnected  with  the  causation  except  in  so  far  as  a  state  of  mal-nutrition  may  have  increased 
the  susceptibility  of  the  individual  to  this  as  to  other  diseases  by  diminishing  the  resistance 
of  his  system  to  morbific  influences. 

Hardships,  fatigues  and  exposure  to  the  vicissitudes  of  the  weather  were  often  men- 
tioned among  the  causative  agencies,  but  their  action  was  evidently  of  the  indirect  and  gen- 
eral character  attributed  to  an  insufficient  dietary. 

Overcrowding  was  certainly  unconnected- with  the  causation  of  the  disease.  Of  com- 
mands on  similar  areas  some  were  scourged  wdiile  others  escaped  visitation.  The  disease 
prevailed  among  troops  stationed  in  barracks  which  gave  a  larger  air-space  per  man  to  their 
occupants  than  was  furnished  by  buildings  of  similar  construction  to  troops  who  remaineil 
unaffected.  ISTevertheless,  overcrowding  was  as  certainly  a  chief  factor  in  the  propagatioii 
of  the  disease.  Its  importance  in  this  respect  cannot  well  be  overestimated:  It  afforded 
facilities  for  every  mode  of  transmission  from  man  to  man, — by  the  latrines,  the  wells,  the 
infection  of  beds,  bed-clothing,  wearing  apparel  and  other  articles,  and  by  direct  contagion, 
if  this  last  mode  be  allowed.  Moreover,  it  increased  the  virulence  of  the  disease  and  added 
proportionately  to  its  fatality, — effects  which  were  experienced  also  by  the  victims  of  other 
acute  diseases,  the  most  common  of  which  were  remittent  and  continued  malarial  fevers  and 
pneumonia.  Xon-specific  ochletic  emanations  by  aggravating  the  disorder  of  the  blood  in 
tvphoid  intensified  the  cerebral  symptoms  and  gave  rise  to  cutaneous  macidations  by  wliich 
the  fever  became  confounded  with  typhus,")-  an  error  sustained  for  tlie  time  being  by  the 
actively  contagious  qualities  which  the  disease  apparently  manifested. 

But,  aside  from  the  essential  miasm  or  infection,  the  principal  element  in  determining 
the  occurrence  of  a  regimental  epidemic  was  without  doubt  the  presence  of  a  susce])tibility 
to  the  disease  on  the  jiart  of  the  mendjers  of  tlie  command.  This  is  demonstrated  by  the 
accessions  of  fever  which  were  associated  with  the  advent  of  new  and  so-called  unseasoned 
men  and  the  decrease  of  the  disease  as  these  men  became  converted  into  veteran  soldiers; 
by  the  freedoui  of  the  old  regiments  of  the  regular  array  from  typhoid,  as  compared  with 
its  prevalence  in  new  regiments,  whether  regulars  or  volunteers;  and  by  observations  show- 
ing tliat  troops  recruited  in  cities  where  typhoid  is  endemic  were  less  suscejitible  tlian  those 
raised  in  country  districts  where  the  disease  is  relatively  less  frequent.  As  a  matter  of 
fact,  the  extent  of  the  epidemic,  other  things  being  equal,  depended,  as  in  the  eruptive 
fevers,  on  the  number  of  susceptible  individuals  in  the  command. 

This  inherent  susceptibilitv,  so  far  as  is  known,  can  be  exhausted  only  by  an  attack  of 
the  disease.  A  gradual  exposure  of  the  system  to  the  causative  agencies  of  typhoid  is 
assumed  by  many  to  give  a  certain  amount  of  protection,  or  to  inure  the  individual  to  the 
morbific  presence;  but  there  is  no  valid  ground  for  assuming  that  anything  more  is  proved 
than  that  the  susceptibility  of  the  individual  was  not  originally  of  a  high  order,  or  that  it 
had  already  been  exhausted  by  an  attack  of  the  disease. 

That  which  is  true  of  the  individual  may  be  predicated  in  a  general  way  of  the  assem- 
blage of  individuals:  Regiments  have  a  susceptibility  which  is  destroyed  only  by  a  thorough 

*  Sec  note  t,  page  4^5,  aud  rt-purt  of  Surgeon  Beck,  page  4W,  supra.  f  See  mpni,  page  325. 


508  ETIOLOGY   OF   THE 

exposure  to  tlie  typlioi'l  genu;  but  it  Joes  not  follow  that  every  regiment  must  undergo 
an  epidemic  visitation. 

Altliougli  medical  officers  can  do  much  to  prevent  the  occurrence  of  first  cases,  it  is 
impossible  for  them  to  be  always  or  even  often  successful.  The  known  channels  of  attack 
during  active  service  are  too  numerous  to  be  efieetively  guarded;  and,  moreover,  until  the 
conditions  of  miasmatic  evolution  are  ascertained  with  precision  no  exercise  of  care  or  caution 
can  guarantee  protection  against  its  occasional  manifestations,  although,  with  the  co-opera- 
tion of  commanding  officers,  the  attack  may  be  prevented  from  assuming  the  proportions  of 
an  epidemic.  This  may  not  be  possible  where  a  general  miasm  prevails,  as  when  the  soil, 
barracks  or  other  quarters  have  been  liighlv  infected  bv  previous  cases,  or  when  tlie  morljific 
cause  has  operated  through  the  water-supplv.  In  such  instances  the  immediate  aljandon- 
ment  of  the  infected  locality  and  the  separation  of  the  sick  from  the  well  are  imperatively 
required  to  check  the  j^rogress  of  the  epidemic. 

"\^  hen,  however,  the  primary  cases  are  few  in  number  and  depend  on  importation  or 
individual  exposure  in  infected  localities,  an  epidemic  may  be  avoided,  irrespective  of  sus- 
ceptibility, by  measures  of  general  sanitation  in  camp  and  the  prompt  removal  of  the  patients 
to  a  hospital  where  ample  space,  strict  attention  to  cleanliness  and  the  disinfection  of  stools 
and  contaminated  bed-  and  body-clothing  will  limit  the  spread  of  the  disease.  General 
sanitary  measures  not  only  destroy  epidemicity  but  exercise  a  powerful  influence  in  mod- 
erating the  intensity  of  tlie  typhoid  phenomena  in  individual  cases;  thev  may  even  prevent 
the  primary  development  of  the  fever  by  removing  such  local  sources  of  typhoid  miasm  as 
may  have  existed  in  certain  tents,  huts  or  barracks. 

The  direct  miasmatic  derivation  of  typhoid  prepares  us  for  the  occurrence  of  the  disease 
in  susceptible  regiments,  notwithstanding  all  care  in  the  hygienic  government  of  their  camp  ; 
but  this  is  no  reason  why  such  care  should  not  be  exercised.  Proper  construction  and  ven- 
tilation of  the  huts,  ample  space,  purity  of  soil  and  care  that  neither  the  water  nor  the  air 
of  the  camp  be  contaminated  by  its  refuse,  will  often  prevent  the  introduction  and  alwavs 
limit  the  spread  of  typhoid  fever  as  a  camp  disease. 

III.— CONTINUED  MALARIAL  FEVER. 

It  is  unnecessary  to  do  more  than  mention  the  continued  malarial  fevers  in  this  place; 
their  miasmatic  cause,  a  specific  malaria,  has  already  been  discussed,  together  with  their 
complication  by  adynamic  or  typhoid  symptoms  resulting  from  disorganization  of  the  blood 
by  typhogenic  influences. 

IV.— TYPHO-MALARIAL  FEVER. 

Xor,  after  what  has  been  said  on  the  suljject  of  typhoid,  is  it  needful  to  dwell  at  length 
on  the  causation  of  the  true  typho-malarial  fevers, — an  exposure  to  the  co-existing  miasms 
of  t}'phoid  fever  and  malarial  disease,  as  when  the  pregnant  soil  is  in  transition  between  the 
comj^aratively  moist  state  essential  to  the  production  of  the  latter  and  the  comparatively  dry 
state  apparentlv  as  essential  to  the  former,  or  the  exposure  to  the  typhoid  cause  of  an  indi- 
vidual already  under  the  influence  of  the  malarial  miasm.  But  a  few  remarks  on  typho- 
malarial  fever,  as  presented  to  the  profession  by  medical  writers  and  teachers  since  the  close 
of  the  war,  mav  not  be  out  of  place  in  this  history.  In  truth,  the  literature  that  has  crys- 
talized  around  this  term  maybe  regarded  as  a  medical  }>roduct  of  the  war  of  tlie  rebellion. 


CONTI^-UKD    FEVKES.  509 

At  the  close  of  tlieir  service  tlie  medical  officers  of  our  volunteer  armies  returneJ  to  the 
duties  of  civil  lite  carrying  witli  tliem  an  enlarged  experience  of  fevers,  together  with  the  use 
of  the  term  typho-malarial.  The  effuit  made  in  this  volume  io  estimate  the  current  value 
of  this  tei'm  during  the  period  of  the  war  has  shown  that  clinicallv  it  was  involved  in  uncer- 
tainties and  obscurities  which  were  increased  and  intensified  by  the  ambiguity  of  its  jxitlio- 
logical  meaning.  Clinically  it  embraced,  or  was  at  liberty  to  embrace,  all  the  continued 
fevers  of  our  camps  excepting  such  as  were  examples  of  what  may  be  called  text-ljook  tvphoid. 
for  all  deviations  from  a  typical  course  might  be  regarded  as  modifications  by  the  ever-present 
malaria.  It  embraced  also  all  febrile  manifestations  resulting  from  tlie  malarial  miasm  when 
upon  these  supervened  the  low  or  typhoid  condition  dependent  on  the  retention  in  the  blood 
of  the  products  of  tissue-waste.  The  aggregation  of  many  of  these  purely  malarial  cases 
under  the  typho-malarial  heading  gave  to  the  so-called  fever  a  rate  of  fatality  inconsistent 
with  the  presence  of  a  specific  typhoid  element.  This  satisfied  those  who  reported  their 
adynamic  remittents  under  the  new  heading  that  thev  were  correct,  or  at  least  by  no  means 
alone  in  their  method  of  classification,  and  obliged  those  who  claimed  the  presence  of  a 
specific  typhoid  in  all  the  reported  typho-malarial  cases  to  fall  back  ujxmi  a  iavorable  infiu- 
ence  exerted  on  the  typhoid  element  by  the  co-existence  of  the  malarial  poison.  In  fact, 
as  the  name  scarlatina  indicates  to  the  popular  ear  a  much  less  dreaded  enemy  than  scarlet 
fever,  so  to  many  who  examined  the  reported  figures  without  considering  the  facts  repre- 
sented by  them,  the  term  typho-malarial  became  a  euphonious  appellation  in  which  the 
gravitv  of  tvphoid  was  comparatively  dissipated. 

In  the  absence  of  instructions  concerning  the  pathological  conditions  characteristic  of 
typho-malarial  fever,  cases  presenting  typhoid  impaction  or  ulceration  of  the  patches  of 
Peyer  and  solitary  glands,  as  well  as  those  free  fronr  such  lesions,  were  necessarily  included 
under  the  title.  Tliis  period  of  uncertainty  as  to  the  pathological  value  of  the  ambiguous 
term  lasted  for  more  than  a  vear.  Indeed,  it  mav  be  said  that  no  guide  or  guard  for  its  use 
Avas  at  any  time  announced  to  the  medical  officers  of  the  army;  for  although  Dr.  Wood- 
ward published  his  view  of  the  meaning  intended  to  be  attached  to  it  fourteen  months  after 
its  introduction,  the  publication  was  incidental  and  evidently  not  specially  intended  to  invite 
attention  to  probable  errors  of  diagnosis.  It  may  be  assumed,  however,  that  this  incidental 
reference,  or  the  volume  on  Camp  Diseases,  issued  shortly  afterwards,  succeeded  in  reaching 
some  of  the  reporters  on  account  of  the  increased  fatality-rate  of  the  fever  subsequent  to  the 
date  of  these  publications.*  Nevertheless,  it  may  be  considered  a  fact  that  the  majority  of 
our  medical  men  left  the  service  for  civil  duties  with  as  much  uncertainty  concerning  typho- 
malarial  fever,  clinically  and  pathologically,  as  when  the  term  was  first  introduced. 

Soon  afterwards  the  profession  in  civil  life  appreciated  the  labor-saving  value  of  the 
title,  and  typho-malarial  fever  became  common  in  the  health  I'cports  of  cities  and  towns  and 
in  the  private  practice  of  physicians  where  formerly  only  common  continued,  typhoid  and 
malarial  fevers  were  known.  We  may  assume  that  the  errors  of  diagnosis,  and  doubt  as  to 
pathology,  which  vitiated  the  army  statistics  were  propagated  with  the  term  and  operated  to 
create  confusion  of  ideas  among  the  profession  in  civil  life.  The  lack  of  clinical  records 
illustrative  of  the  typho-malarial  fever  of  the  warf  may  be  attributed  only  to  the  generally 

*  Sec  Talde  XLII,  p.  11*4,  mpni.  I)uriMg  tin*  fmirti-i-ii  months  menti'incd  in  thr  text  27.ti!Ht  ouws  werr  n-jxirtcil  anion;:  the  whito  troop,si.  with  l.-">.'  5 
(loatlis,  ffjualling  5. 71)  i>er  ct-ut.  of  fatality;  during  tlte  reiuaiaUer  uf  the  ja-riod  cuveri-il  liy  tlie  ^tatistios  of  the  war  :i2,472  cases  were  rejiorted  with  2,47i 
deaths,  or  11.01  per  cent. 

f  See  jiage  212,  wjim. 


510  ettoloctY  of  thk 

felt  uncertaiiitv  as  to  what  voallv  constituted  the  fever  in  question.  A  similai'  deartli  of 
cases  iu  the  medical  journals  after  the  war  may  be  explained  in  like  manner.  Pr.  AVooD- 
AVAED  held  the  whole  matter  in  hand,  and  to  him  tlie  profession  looked  for  enlightenment. 
This  was  given  in  a  paper  read  in  the  section  of  medicine  of  the  International  Medical  Con- 
gress held  at  Philadel[ihia  in  1876.  This  achieved  a  wide  circulation,  and,  as  might  have 
been  expected,  did  much  to  clear  away  the  mists  of  the  typho-malarial  atmosphere.  But 
inasmuch  as  this  author  failed  to  appreciate  the  influence  of  a  continued  malarial  fever  in 
the  evolution  of  typhoid  symptoms,  he  was  obliged  to  recognize  a  specific  typhoid  element 
wdiero  there  was  no  ^^ost-mortem  evidence  of  its  presence. ""^  The  group  of  febrile  cases  wdiich 
in  this  volume  has,  for  reasons  assigned,  been  set  down  as  continued  malarial,  was  regarded 
by  him  as  typjho-rnalarial,  and  constituted  his  iirst  group  of  typho-malarial  cases, — fevers  in 
which  the  malarial  element,  without  being  the  only  pathological  condition  present,  is  the 
predominant  one.  This  complication  of  the  tvpho-malarial  series  with  cases  which  presented 
neither  clinical  nor  anatomical  evidence  of  the  presence  of  a  specific  typhoid  fever  has  per- 
mitted a  continuance,  even  to  the  present  time,  of  much  of  the  obscurity  in  wdiich  typho- 
malari-al  fever  had  been  enveloped. 

Before  the  introduction  of  the  term  the  association  of  typhoid  symptoms  witli  malarial 
fever  and  of  malarial  symptoms  with  typhoid  fever  was  well  recognized. 

Dr.  W.L.Felper,  of  Sumter  District,  S.Cdesoribedt  a  form  of  fever  which,  originally  intermit  tent  or  remittent, 
lapsed  into  typhoid,  this  latter  becoming  complicated  with  s\Yelling  and  suppuration  of  the  parotid  glands. 

In  the  report  of  a  committee  on  the  diseases  of  Missouri  and  Iowa  J  we  find: 

The  term  typhoid  is  also  sometimes  applied  to  designate  the  terminal  stage  of  an  autumnal  endemic  fever  of  a 
periodic  type,  in  which  the  distinct  paroxysmal  type  becomes  ultimately  absorbed  or  lost  in  the  continued  febrile 
movements  established  by  the  supervention  of  acute  or  subacute  iutlammatory  lesions,  with  nervous  lesions  terminating 
the  pathological  role. 

Dr.  S.  H.  Dickson,^  Charleston,  S.  C,  considers  it  a  matter  of  familiar  remark  that  in  long  protracted  oases  of 
the  ordinary  remittent  of  malarious  regions  there  is  a  diminution  or  shading  down  of  the  palpable  contrasts  and  alter- 
nations of  the  periods  of  febrile  exacerbation  and  remission  ;  a  tendency  in  the  former  to  contiuuousness,  the  latter 
exhibiting  less  alleviation  of  symptoms,  and  the  whole  appearance  approaching  that  met  with  in  continued  fever, 
simple,  nervous  or  typhoid.     In  common  professional  parlance  such  cases  "  take  on  the  typhoid  character." 

Typhoid  fever,  says  Elisha  Bartlett,||  like  all  other  continued  affections,  is  sometimes  more  or  less  mixed  up 
with  and  influenced  by  the  pathological  element  of  periodicity.  This  will  happen  most  frequently  and  will  be  most 
strongly  marked  in  malarious  regions  and  during  the  prevalence  of  rennttent  and  intermittent  fever.  He  cites  Dr. 
VVoOTEX,  of  Lowndesboro',  Ala.,  as  follows:  "I  may  remark  that  I  have  often  seen  tjplioid  fever  complicated  with 
regular  remittence — that  is,  typhoid  fever  and  remittent  fever  existing  together;  and  I  have  cured  the  paroxysmal 
exacerbations  whilst  the  disease  essential  to  typhoid  fever  contiuued  ;  and  I  have  frequently  found  it  necessary  to  do 
this  before  the  more  formidable  disease  could  be  influenced  by  remedies.  I  have  seen  such  cases  iu  the  practice  of 
physicians  who  supposed  them  to  be  remittent  or  bilious  fevers,  in  which  the  bowels  had  become  diseased  as  a  con- 
sequence of  the  fever.  I  think  this  is  a  very  common  error.  The  malarial  influence  frequently  so  predominates  in  the 
symptoms  of  inflammatory  disease  in  our  latitude  as  to  obscure  the  real  disease  for  many  days ;  and  in  such  cases  it 
is  easy  to  look  upon  such  influence  as  the  cause  of  the  structural  lesion,  whilst  iu  fact  the  latter  has  acted  as  tlio 
exciting  cause  to  the  manifestations  of  the  former." 

It  is  interesting  to  observe,  as  part  of  the  history  of  this  typho-malarial  epoch  of  tlie 
literature  of  the  continued  fevers,  that  in  the  early  part  of  the  war,  before  the  term  became 
an  official  designation.  Dr.  Jas.  J.  Levick  of  the  Pennsylvania  hospital  described,  in  one  of 
his  clinical  lectures,  a  series  of  cases  identical  with  those  afterward  correctly  regarded  as 
typ]io-malarial.1[  These  he  called  viiasmatic  typhoid  fever,  and  to  them  he  invited  special 
attention,  as  he  believed  that  this  mixed  fever  was  of  frerjuent  occurrence  at  that  time  among 

«  S<-e  Jiagf  402,  supra.  t  Trans.  Ainer.  3Ieil.  Atmdalimi,  Vol.  V,  1852,  )p.  301.  J  Idehi,  Vol.  VIII,  1.S55,  ]).  100. 

i,  Ihm,  Vol.  V,  1S.J2.  r-  111.  i;  Tne  lli^.rij,  I.li„j„os!s  n,id  Tnalnuilt  af  the  Ffren  of  the  UmM  Sinles,  Plllla.,  ISIT,  |..  12T. 

^  jn^uinalic  T^j>l,i,i'l  F€nr,—Me4.  rm.l  Siinj.  Itf}mbr,  PLila.,  Jmiij  21,  18il2,  also  A,„frmin  J.jiir.  Mr:!.  .SV;..«««,  W,].  .XI.VII,  IsDl,  [..  4n4  .•(  sf.y. 


CONTI^'UED    FEVEKS.  511 

our  troops  in  tlie  field.  He  considered  that  the  two  complaints  coexisted  in  their  essential 
natures  and  ran  their  course  together  without  losing  their  individual  characteristics.  His 
description  of  typho-malarial  fever  agrees  very  closely  witli  that  afterwards  given  by  I)i-. 
"Woodward  in  his  volume  on  the  Canip  Diseases  of  the  U.  S.  Army. 

After  the  introduction  of  the  term  its  restriction  to  c-ases  in  which  the  poisons  of  both 
malarial  and  typhoid  fevers  were  present  was  insisted  on  by  many  obj;ervers. 

Dr.  Austin  Flixt  says*  typlio-malarial  fever  is  cau.sed  by  the  combined  action  of  malaria  and  tlio  .si)ci'i:Ll  cause 
of  typhoid  fever.  Practitioners  in  malarious  situations  have  been  accuston>e(l  to  say  that  remittent  beCT)mes  con- 
verted into  typhoid  fever.  This  mode  of  expression  is  not  accurate:  there  isnot  a  metamorphosis  of  tlie  one  disease 
into  the  other,  but  a  combination  of  both  diseases,  the  phenomena  of  the  one  or  the  other  disease  predominating  in 
different  cases. 

Dr.  Aloxzo  Ci-ARKf  has  accepted  the  term  typho-nialarial  as  indicating  the  result  in  the  human  system  of  the 
conjoint  operation  of  the  poisons  of  malarial  and  typhoid  or  typhus  fevers.  He  gives  as  an  example  a  case  of  tyi>liU8 
in  which  intermitting  coma  was  removed  by  the  use  of  quinine.  ".Symptoms  as  severe  as  this  do  not  commonly 
appear  in  typho-malarial  fever,  but  accessions  of  fever  are  very  apt  to  correspond  with  the  accessions  in  the  intermit- 
tent and  remittent  fevers — that  is,  the  highest  temperature  is  more  apt  to  be  present  in  the  morning  than  in  the 
evening."' 

In  a  recent  medical  journal  we  find: 

I  have  met  with  many  cases  this  season  which  connncnced  with  a  chill  every  afternoon,  foUoweil  by  a  temper- 
ature of  104°  and  105°  in  the  evening.  Tlie  next  morning  it  would  be  normal.  Ami  with  all  the  anti-malarial  reme- 
dies used  the  chills  would  continue  for  ten  days  or  more,  when  they  would  gradually  cease  ajid  the  fever  become 
continuous,  with  all  the  syinjitoms  of  typhoid  fever,  even  the  rose-colored  spots,  bronchial  trouble,  tympanites  and 
diarrhoea.  Some  cases  would  start  as  remittents  and  end  with  all  the  ty)>hoid  symiitoms.  To  call  such  cases  per- 
nicious intermittents  or  remittents  is  nonsense.  When  a  case  of  intermittent  orremillent  fever  does  not  yield  to 
full  doses  of  quiuia,  repeated  for  three  or  four  days,  you  generally  have  the  typhoid  eombination.t 

Similar  ideas  are  found  in  recent  English  literatuiv: 

There  seems  no  doubt  that  there  occur  epidemics  of  fevers  partaking  of  the  nature  of  ty))hoid  and  of  truly 
malarial  intermittent  or  remittent  fevers.  This  typho-malarial  fever  seems  chielly  to  originate  .■ind  spread  in  regions 
where  the  poisons  of  both  types  of  fever  coexist — as  in  swampy  regions  in  which  the  soil  and  water  are  largely  impreg- 
nated with  decomposing  organic  matter  of  both  vegetable  and  aninnil  origin.  In  ill-drained  marshy  regions  in 
proximity  to  human  habitations  much  animal  refuse  matter  tends  to  accumulate  and  undergo  decomposition  simulta- 
neously with  the  vegetable  matter  of  the  swamp.  We  find  that  in  such  regions  ague  and  typhoid  are,  ordinarily, 
both  prevalent. § 

But  various  other  viev\'s  have  been  expressed,  Irom  a  weak  denial  of  the  existence  of  a 
typlio-malarial  fever  to  the  recognition  of  a  typho-inalarial  miasm,  both  as  a  hybrid  from 
typhoid  and  malarial  factors  and  as  sui  generis  or  of  telluric  evolution  independent  of  typhoid 
or  malarial  causes. 

Roberts  r!.\RTHOLOW  ||  doubts  the  existence  of  a  typhoid  fever  modified  in  its  progress  by  a  malarial  fever.  ITe 
attributes  the  frequency  of  the  typho-malarial  diagnosis  by  the  profession  to  errors  arising  f.om  a  want  of  ap])recia- 
tion  of  the  remissions  in  the  stages  of  accession  and  subsidence  of  ordinary  typhoid  and  frfim  a  want  of  lecognition 
of  the  antipyretic  influence  of  large  doses  of  quinine  in  this  disease.  lie  believes  that  then-  exists  such  an  antag- 
onism between  the  two  that  in  the  presence  of  the  typhoid  poison  the  malarial  poison  ceases  to  be  active.  He  had 
lield  that  the  thermal  line  of  typhoid  might  receive  an  impression  from  a  coexiNting  uuilarial  comiilii'atioii.  but  in 
the  light  of  a  wider  experience  he  concludes  that  the  modification  in  the  lherm:il  line,  sniiiiosed  to  be  due  to  malarial 
complication,  has  for  the  most  part  no  real  existence.  In  chronic  malarial  jioisoning  the  malarial  intlMcncc  is  insulli- 
cient  to  modify  the  typhoid  process  to  any  appreciable  extent;  but  where  the  malarial  infection  is  active  its  mani- 
festations cease  during  the  typhoid  progress,  to  become  again  prominent  as  an  intermittent  during  the  progress  of 
convalescence. 

J.  S.  CAri.KlxS,irof  Thornville,  Mich.,  argues  that  typho-malarial  fever  is  a  distinct  disease,  jiropagated  by  its 
own  special  cause,  and  that  this  special  cause  is  a  hylirid  or  fertile  cross  between  marsh  miasm  and  the  typhoid-fever 
l>oison.  lie  infers  that  .these  morliilic  agencies  are  nearly  related  saiirophytes,  proliably  varieties  of  one  si)ecies,  or 
at  the  farthest  species  conforming  closely  to  a  common  ty]ie.  because  the  progeny  of  parents  more  remotely  connected 
is  incapable  of  propagating  the  cross,  which  perishes  with  the  first  generation.  Cases  last  usualh-  abotit  four  weeks. 
At  firSt,  in  some  instances,  a  redness  of  the  tip  and  edges  of  the  tongue  nuiy  l)e  suggestive  of  the  future  progress  of 


*  Principles  ami  Practice  n/  3IetUci}ie,  New  Yurk,  1S73,  p.  937.  ^  Medical  HeCQnl,  Vol.  XIII,  New  York,  1878,  p.  304. 

t  Dr.  W.  i:  Smith,  ,Vc.(.  and  Swj.  Ilcp„rtir,  rbilii.lvlpliia.  Pa.,  1SS2,  Vnl.  XLVI,  ]..  If-. 

g  Surgeon  E.  G.  Rcs^eli.,  Bengal  Med.  Service, — Malaria,  its  f'anse  aad  Ff'-ct,  Calcutta,  18S0,  p.  92. 

II  Seo  his  pajier  Oa  Tijphj-malarial  Fecer,  Medical  .Yens,  Vol.  XI.V,  I'liila.,  1S^4,  p.  2M.  ^  helrait  Lawet,  Vol.  I,  lf-7S,  p.  403. 


512  ETIOLOGY    OF    THK 

the  disease:  in  others  the  tongue  is  pale  and  coated  with  a  hilions-lookins  fur.  Tlie  intermissions  may  he  so  distinct 
that  tlie  case  is  lo^arded  as  an  ordinaiy  agne;  hut  the  febrile  action  becomes  continuous,  and  in  the  second  week 
enteric  synijitoms  are  developed,  lie  gives  notes  of  one  case  and  briedy  refers  to  five  others.  In  the  case  noted  there 
were  recurring  chills  with  nausea  and  vonuting,  fever  and  luofuse  sweats.  In  the  second  week  the  patient  seemed 
much  improved  and  was  able  to  he  up  and  walk  about,  hitt  his  appetite  did  not  return,  Ids  tongue  continued  smooth 
and  red  and  he  perspired  profusely  at  night.  In  the  third  week  a  relapse  occurred  with  nausea,  vonuting  and  chills 
as  at  first.  Diarrhiea  followed  the  adnnnistration  of  castor  oil.  Improvement  was  gradual;  even  at  the  end  of  the 
fifth  week  tlie  evening  temperature  was  100°  Fahr.  and  perspirations  occurred  nightly.  No  cerebral  symptoms  were 
present:  no  rose-colored  spots  are  mentioned  as  having  been  seen. 

M'.  C.  Jarxagin',*  Macon,  Miss.,  takes  a  chemical  view  of  this  subject.  lie  considers  that  the  specific  poison 
■which  prodifces  typho-iualarial  fever  is  distinct  in  its  individuality,  and  argues  that  since  we  are  ignorant  of  the 
nature  of  the  typhoid  or  malarial  poison  there  is  nothing  left  for  us  but  to  api>roximate  the  truth  "by  reasoning 
from  the  visiljle  and  tangible  effects  through  the  conditions  requisite  for  the  development  of  those  poisons  to  their 
nature.*'  He  is  thus  led  to  believe  them  gaseous;  but  as  he  knows  of  nothing  in  nature  that  has  not  a  chemical 
existence  and  is  not  controlled  by  definite  chemical  laws,  the  separate  and  distinct  septic  poison  which,  under  favor- 
able anti-hygienic  conditions  gives  rise  to  typho-malarial  fever,  must  naturally  be  the  product  of  the  chemical  com- 
l)iuation  of  the  gaseous  poisons  of  typhoid  and  malarial  fevers. 

J.H.  CARSTENS.t  Detroit,  ilich.,  holds  that  this  fever  is  siii  generis  and  to  bo  distinguished  from  ty]ihoid,  inter- 
mittent and  renuttent  fevers.  After  a  few  days  of  malaise  there  is  a  chill  followed  by  high  fever,  the  temperature 
renuiiuing  thereafter  at  103°  to  105°  Fahr.,  and  the  evening  observations  being  sometimes  a  little  higher  than  those 
taken  in  the  morning.  The  sudden  development  of  the  febrile  condition  excludes  typhoid  fever;  continuance  of  the 
high  temperature  excludes  remittent  fever.  Among  other  diagnostic  signs  are  mentioned  the  pulse,  which  is  rai)id, 
120  to  140,  small  and  qtiiek  ;  delirium  present  from  the  very  first  night,  and  the  occasional  appearance  of  purpuric 
spots;  rose-colored  spots  do  not  appear.  The  anatomical  changes  are  said  to  be  almost  pathognomonic,  consisting 
of  enlargement  of  the  solitary  follicles  of  the  small  intestine  with  deposit  of  pigment  in  them  and  sometimes  ulcera- 
tion of  their  apices,  Peyer's  patches  being  unaltered  or  merely  congested. 

All  association  or  combination  of  the  malarial  miasm  with  a  septic  poison,  not  that  of 
typhoiil,  i.s  Invoked  by  some  writers  to  account  for  the  existence  of  typho-malarial  fever. 

Hexry  ^VoRTHIXGTO^■,{  Los  Angeles,  Cal.,  says  that  the  morbific  principle  is  not  identical  with  the  typhoid 
material  of  the  pythogeuic  disease,  but  rests  upon  a  double  animal  and  vegetable  basis,  a  combination  of  septic  and 
malarial  elements.  He  gives  the  following  account  of  the  symptoms.  The  patients  suffered  from  the  remittent  tyi)e 
of  fever  in  the  beginning,  which  gradually  became  continued.  A  characteristic  group  of  symptoms  was  present 
such  as  dry  tongue,  cough  with  expectoration,  usually  vomiting,  inconsiderable  iliac  tenderness  and  tympany;  in 
one  case  diarrhiea,  in  one  constipation  and  in  a  third  slight  hemorrhage  from  the  howels.  They  sank  into  an 
apathetic  condition  with  delirious  muttering  and  in  one  case  extreme  jactitation,  involuntary  evacuations  and  the 
hippocratic  expression.  He  gives  as  follows  the  results  of  ^'os'-iHorftm  examination  in  three  cases:  First  case.  Brain 
aniemic;  lungs  congested  and  spleuified  posteriorly:  heart  soft  and  flabby;  mucous  membrane  of  stomach  red  and 
softened;  spleen  enlarged  and  easily  torn;  liver  enlarged  and  brown;  kidneys  congested;  mucous  membrane  of  intes- 
tines intensely  pigmented  throughout,  near  ileo-ciecal  valve  several  small  ulcers  with  inverted  edges ;  Peyer's  patches 
and  mesenteric  glands  unchanged;  bladder  softened  and  containing  fetid  urine.  Second  case.  Brain  normal;  lungs 
hypera'micby  hypostasis;  heart  pale  and  easily  torn,  mucous  membrane  of  stomach  reddened;  spleen  soft  and  enlarged; 
liver  hypertrophied  and  brown;  kidneys  enlarged  and  hyperainic;  mucous  membrane  of  intestines  engorged  and 
stained  with  jiigmentary  matter,  mesenteric  glands  slightly  swollen ;  Peyer's  patches  unchanged ;  bladder  softened  and 
very  pale.  Third  case.  Brain  healthy ;  lungs  congested,  consolidated  and  pigmented;  heart  flaccid  and  jiale;  stomach 
healthy:  spleen  enlarged,  its  trabeculie  easily  broken  down  :  liver  congested'  kidneys  enlarged  and  the  seat  of  small 
infarctions;  mucous  membrane  of  intestines  swollen  and  red;  mesenteric  glands  swollen;  ISriiuner's  glands  enlarged 
and  congested;  bladder  normal. 

L.  A.  SxiDKR,?  Sacramento,  Cal.,  in  a  paper  on  an  epidemic  in  that  city,  announces  that  the  disease  is  developed 
from  the  combined  intluence  of  a  malarial  and  septic  poison  arising  from  sewer  gas  and  wholly  independent  of  a 
specific  typhoid  germ  or  other  morbific  agent  derived  from  a  diseased  organization;  but  he  gives  none  of  the  experi- 
ences or  arguments  on  which  his  belief  is  formed. 

A.  L.  LooMls||  has  systematized  tlils  idea  of  a  septic  ]")oison,  and  suppressing  the  term 
iypho-malarial,  has  aggregated  the  cases  supposed  by  him  to  be  due  to  the  septic  and 
malarial  combination  under  the  heading  of  Continued  JIalarial  Fever.  Here  he  })laces 
those  malarial  fevers  of  continued  type  that  have  no  claim  to  typho-malarial  characteristics 
except  tJiat  clinically  they  present  the  ty]ihold  signs  attending  a  non-specific  deterioration 
of  the  bloo'l.      These  are  his  cases  in  whicli  the  malarial  clemfut  predominates.      Here  also 

•SV.  Lninx  Courier  nf  M.':lirli,e  an.l  Cullil^ral  i^-iniref.  Vol,  111,  l.->n.  j,.  ?.:',:,.  f  I'-ln.il  rlmir.  Vi.l.  I,  1SS2,  |i.  7. 

J.V.-//-  Io;J-  Mfi:,„l  r!.;.,r,l.  V,,l.  XIV,  IsTs,  ,,.  s:!.  >  ;',„.;rii  .Vi.(.  u„d  Simj.  Jr.iir.,  V..I.  .XXIII,  lt<SlJ-'Sl,  lip.  248  el  te,j. 

i,.l  Tert-l'...„k'it  l'r.i.li,,il  Mt'li.  i,,,-,  N,-w  Yurk,  l.ss4,  fy.  82i;  f  ( »«;. 


CONTINUED    FEVERS.  513 

* 

lio  places  the  true  typlio-malarial  cases,  tliey  constituting  liis  septic  group  of  tlie  continued 
malarial  fevers.  Having  associated  these  essentially  different  sets  of  cases,  he  apparently 
assumes  that  what  has  been  proved  of  one  set  is  applicable  to  the  other,  arguing  that  because 
in  the  one  the  glands  of  Pever  are  not  ulcerated  and  no  suspicion  of  contagion,  direct  or  indi- 
rect, is  apparent,  there  can  be  no  typhoid  in  the  othei';  ami  that  since  there  is  no  typhoid 
ill  these,  the  ulcerations  that  look  so  like  those  of  tvphoid  must  be  du(!  to  some  other  septic 
cause.  Dr.  LooMis,  indeed,  points  out  that  thei'e  is  little  to  distinguish  these  intestinal 
changes  from  those  that  are  developed  in  typhoid  fever  except  the  tendency  to  the  deposit 
of  black  j)igment  in  the  enlarged  follicles;  but  he  considers  that  this  pigment  is  enough  in 
itself  to  show  that  the  disease  depends  on  an  essentially  different  exciting  cause.  It  has 
already  been  shown  in  this  discussion*  that  the  presence  of  the  pigment  is  susceptible  of 
satisfactory  explanation  without  calling  in  the  aid  of  peculiar  and  unknown  poisons. 

M.  Lpion  Colin  has  expressed  the  opinion  that  a  real  affiliation  exists  between  typhoid 
and  remittent  fevers.^ 

Does  the  iialiiflal  typhoid  fevei-  of  camps  and  marshy  countiifs,  arisiiis  outsido  of  cities,  and,  lioiice,  outside 
the  piincipal  t,v2'hogcnic  foci,  depend  on  a  coincidence  of  two  nioil)id  inllllencc^s?  We  nii;;ht  liave  aito])tod  tliis 
opinion  if  we  had  not  extended  our  observations  over  a  greater  period  than  a  year;  but  during  the  tllr^^e  sunmuMS 
lliat  we  liave  observed  tlui  disease  of  the  Konian  C'anipagna  wo  liave  always  seen  tlie  typlioid  fever  break  out  iu  the 
monthof  July,  together  with  remittent  fever  of  i>alu(hil  origin,  presenting  from  the  tlrst  its  niaxiuniui  gravity,  showing 
neither  increase  nor  decrease,  and  attacking  in  preference  those  in  whom  the  plienomenaof  remittent  fever  were  nu)st 
cliaracteristic.  If  suidi  associations  periodically  reappear  at  a  tinu)  when  telluric  inlluences  i)redominate,  it  follows 
that  something  more  is  required  than  coincidence  of  two  different  affections,  and  that  there  exists  l)etwoou  thorn  » 
real  affiliation. t 

Although  Well  versed  in  the  characteristics  of  these  fevers  he  found  it  impossible  to 
distinguish  during  life  between  a  so-called  adynamic  remittent  and  a  tyjihoid  fever  compli- 
cated li\'  an  antec(,'dent  malarial  influence.  Often,  when  he  believeil  the  maladv  to  bt;  exclu- 
sively malarial,  the  typical  typhoid  fever  lesions  w<,'r(!  iound  on  post-iiiorteiii  examination, 
and  111  other  cases  in  which  from  the  clinical  appearances  \iv.  regarded  typhoid  fever  as  cer- 
tainly present,  i>nly  the  lesions  of  pernicious  fever  were  discovered  after  death.  He  was 
therefore  led  to  suggest  an  iiitiiuate  relationship  between  the  two  fevers.  ]le  C(jnsidered 
the  typhoid  fever  in  these  instances  due  to  the  development  of  a  iiredisposition  in  the  human 
system,  under  the  influence  of  a  prolonged  febrile  movement,  gastric  troubles  and  altered 
secreti(.iiis.  In  fixct,  he  assumed  that  the  malarial  fever  jirepares  the  system  for  invasion  by 
the  telluric  miasms  which  are  the  cause  of  typhoid  fever,  the  tormer  being  thus  a  determining 
agent  in  the  production  of  the  latter.  But  he  goes  further.  He  believes  that  malarial  fever 
can  induce  true  tyjdioid  by  auto-infection,  and  in  this  way  he  exi'lains  the  succession  of 
typhoid  to  remittents  not  only  in  individuals  but  in  districts.  When  a  malarious  section 
has  been  improved  by  drainage  and  made  suitable  for  agriculture,  immigration  tills  it  with 
a  class  of  people  hitherto  preserved  from  malarial  and  typhoid  ail'ections.  Their  predispo- 
sition to  these  diseases  is  strong  an<l  there  is  required  only  the  malarial  cause  of  a  remittent 
fever  to  develop  in  them  a  true  typhoid  fever.  Indeed  his  theory  finds  expression  in  the 
phrase  popular  in  some  parts  of  this  country — "the  fever  turned  into  typhoid."  There  is, 
however,  such  essential  differences  between  the  natural  history  of  the  t}'[ihoid  and  the  mala- 
rial ])oisons,  differences  which  led  Boudin  to  adopt  the  doctrine  of  a  veritable  antagonism 
between  the  diseases  caused  by  them,  that  it  is  impossible  to  admit  the  development  of  the 
one  from  the  other.     On  Colin's  hypothesis  typlioid  fever  should  be  more  common  where 

"Stipra,  iiagc  455.  fSee  bis  Traili-  det  Fiivret  IiUermiiteiiier,  I'nris,  1870,  pp.  276  H  mj. 

f  Set-  Iai  FitiTt!  Typho'iilf  ihiun  rAi'mre,  Paris,  1878,  p.  155. 

Med.  Hist.,  Pt.  111—65 


514  ETIOLOGY    OF   THE 

remittentrf  prevail;  l:>ut  it  is  well  known,  on  tlie  contrary,  to  incrou.<e  with  their  diminution. 
Typhoid  ■si/niptoms  are  frequently  associated  with  persisting  remittents  and  continued  mala- 
rial fevers,  hut  these  are  unconnected  with  the  anatoniicai  lesion  which  indicates  the  pres- 
ence of  a  true  typhoid  fever.  From  the  invariahle  presence  of  this  lesion  in  tyi)hoid  fever 
is  inferred  the  action  of  a  specific  cause. — an  inl'erence  sustained  by  our  knowledge  of  its 
inci;bation  in  the  system  and  its  infectious  qualities,  and  this  is  inconsistent  with  the  idea 
of  the  development  of  the  disease  from  a  cause  which  ordinarily  evolves  a  malady  closely 
associated  with  the  simple  intermittents. 

Another  French  writer,  Corre,*  defines  typho-malai'ial  fevers  as  engendered  under  the 
combined  influence  of  malarial  and  typhous  conditions  and  presenting  p)henomena  suggestive 
of  the  presence  of  both  diseases.     He  divides  them  into  three  classes: 

1.  Typho-iiialarial  l)y  association,  each  of  the  two  elements  l)eiug  present  and  i)ioducing  its  eiFects. 

2.  True  typho-nialaiial  fevers  resulting  from  the  operation  of  a  single  agent. — Ijipho-malaria  of  external  origin. 

3.  Typho-nialarial  fevers  by  transformation,  in  which  in  a  malarial  fever  the  typhoid  couditiou  is  developed 
under  the  influence  of  an  infection  engendered  in  the  system  of  the  patient. 

His  first  class  comprises  the  true  typho-malarial  cases  of  the  civil  war;  his  third  class 
the  advnamic  malarial  cases.  Our  records  give  no  evidence  of  the  existence  of  cases  such 
as  are  comprehended  in  his  second  class. 

Tlie  medical  journals  do  not  contain  many  cases  illustrative  of  typho-malarial  fever. 
Nevertheless  a  few  notes  may  he  submitted  to  show  the  character  of  the  cases  reported 
under  this  heading.  Some  of  these  no  doubt  were  trulv  cases  of  the  associated  diseases; 
others  were  remitting  or  continued  malarial  fever  or  other  continued  fever,  not  even  excluding 
specific  typhoid  with  or  without  typhoid  symptoms.  In  fact,  the  same  aggregation  of  cases 
of  doubtful  character  that  constituted  the  typho-malarial  fevers  of  the  war  appear  to  have 
constituted  tlie  typho-malarial  cases  that  have  been  reported  since  the  war. 

J.  p.  CnKSNEY,t  New  Market,  Platte  County,  Mo.,  refers  to  the  ambiguity  of  the  term  typho-malarial,  and  states 
that  in  his  i>art  of  the  country  its  use  is  restricted  to  cases  ])resenting  "one  or  more  symptoms  common  to  eacli  of  the 
two  fevers.''  I'liis  mixed  form  as  well  as  uncomidicated  tyj)lioid  is  rare  in  his  section.  He  gives  a  case  to  illustrate 
the  Platte  county  use  of  tlie  term.  A  man  who  had  tieeu  living  for  some  months  in  a  highly  nuilarious  locality  was 
seized  July  1(1,  18(59,  with  intermittent  fever  which  was  readily  controlled.  After  this  he  was  somewhat  indisposed 
but  able  to  attend  to  business  until  towards  the  end  of  the  month,  when  he  took  to  bed  August  2.  Dr.  Cuksnev 
noted  his  condition  as  fidlows:  "  l>orsal  decubitus,  stiijior,  cutaneous  surface  presenting  a  sallow  shriveled  appear- 
ance, night  sweats,  great  tenderness  in  the  ileo-colic  junction,  diarrluea,  tongue  dry,  red  auA  pecuUurlj/  ci/litxlricnl  in 
form,  cold  extremities,  dilated  pupils  and  pulse  12(1  to  the  minute."  On  the  4th  the  jiatlent  was  im))roving,  but  having 
been  left  unattended  he  went  out  to  stool,  and  becoming  bewildi^red  anuuig  the  tall  grass  and  corn,  wandered  from 
midnight  till  day  before  he  was  found.     He  was  ecnupletely  exhausted,  and  died  on  the  6th. 

Mr.  C,  a  farmer;  aged  i'J:  married:  came  under  the  care  of  J.  H.  V.vx  E.max,*  of  Toganoxie,  Kans.,  (Jet. 
23,  1872.  Three  weeks  ])rior  to  this  date  he  had  been  taken  with  chills  and  fever,  the  latter  soon  becoming  subcon- 
tmuous.  Some  medicine  administered  by  his  family  physician  set  up  violent  catharsis  accompanied  with  delirium, 
but  the  diarrluea  was  speedily  controlled.  Delirium  and  sleeplessness  had  continued  for  six  days,  when  V.vN  E.man 
was  called  in.  The  patient's  tongne  was  brown  in  the  centre  and  red  at  the  tip  and  edges:  his  e.ves  congested  and  the 
pupils  somewhat  contracted  and  sluggish:  resi)iratory  and  percussion  sounds  nornuil;  pulse  118  and  rather  feeble; 
bowels  unmoved  for  twenty-four  hours,  tymj)anitic,  tender  ami  gurgling  on  pressure  in  the  right  iliac  region  ;  every 
few  minutes  the  patient  tried  to  get  out  of  bed  and  out  of  the  house,  and  when  in  a,  (juieter  mood  worked  his  hands 
and  fingers,  i)ickiug  constantly  at  the  clothing.  To  iironiote  sleep  and  restrain  delirium  a  solution  of  ten  grains  of 
chloral  and  live  of  bromide  of  potassium  was  given  occasionally:  (jninine  in  three-grain  doses  every  two  hours  was 
also  prescribed,  with  milk  and  beef-essence  as  nutriment.  The  tongue  became  very  dry  on  the  2C>th:  the  quinine 
was  reduceil  to  two  grains  every  four  hours  with  small  doses  of  turpentine  emulsion.  Next  day  his  passages  were 
involuntary,  and  during  the  following  night  he  had  an  attack  of  violent  delirium ;  but  on  the  30th  the  tc  iigue  began 
to  clean,  and  on  November  1  consciousness  was  restored.  After  this  improvement  was  slow  but  uninterrupted.  On 
December  10  the  patient  was  considered  well. 

The  experience  of  H.  K.  PusEY,iS  of  Garnettsx  illc.  Ky..  leads  him  to  doubt  the  accuracy  of  the  view  that  the 

*  A.  ("ORRF- — Trail''  ties  Ji':rr<'iihiIieusP8  e.t  tiiphiqi't'ii  lUii  i-xuj!^  I  IhiikU,  \'.\v\-.  lh;*;l,  p.  255. 

iPacifir.  Mi.l.  ,„„(  .s,,,-,,.  ./,„„•..  .v.  .S.,  Vol.  lit,  |i.  3111.  t Leaienwnrlh  Me'lknl  Uiml.I,  Vol.  VI,  lK7i-73,  p.  85. 

§  Louisville  M'-ii.  Xeii-f,  1878,  p,  I'H. 


CONTINUED   FEVERS.  515 

tyiilui-iiuilaiiiil  f'evi-r  wliicli  ]>revails  ir  that  section  of  tlic  countiy  is  tyiilioid  fever  nioditied  liy  a  co-exist iiij;  acute 
iiialaiial  alta<'k.  Fiiidiiij;  tliat  in  many  instances  tlie  disease  is  cut  sliort  liy  quinine,  he  considers  liiniselt  Justified 
in  rcftaidinf;  it  as  lieiiif;  essentially  nialaiial  and  having  no  N|ieeific  typhoid  elenu-nt.  He  Niifjircsts  the  name  of  con- 
tinued malarial  fever  as  mine  aiipiopriate  and  suj;gestive  of  correct  ]iriiH'iides  of  treatment. 

R.  ]!.  MaTry,*  Mem]diis,  Tenn.,  in  descriliini;  what  he  calls  malarial  continued  fever,  says:  "Cases  of  this 
kind  are  liy  others  referred  to  as  '  nejilected  remittents.'  and  as  •  riMuittents  with  adynamic  tendencies";  ami  for  several 
years  jiast,  as  far  as  I  can  learn,  this  is  the  form  of  fever  denominated  in  the  mortality  reports  of  this  city  'tyjilio- 
malarial.'  *  *  *  This  term  has  liecn  applied  gi'iierally  hy  our  jdiysicians  to  all  the  casi^s  of  continued  fever 
heeanse  they  were  recogni/ed  as  not  lieing  tyjihoid  and  were  init  looked  u]ion  as  vemittents."  His  description  of  the 
disease  is  as  follows:  Its  invasion,  instead  of  heinj;  abrujit,  as  is  the  case  with  remittent,  is  sometimes  marked  liy 
]irodromes.  In  many  cases  the  patient  has  been  ailing  for  a  week  befoic  ftoing  to  lied;  in  others  he  has  had  a 
repetition  of  chills  for  two  or  more  weeks  at  irregular  intervals,  when  finally  the  fever  which  follows  the  chill  assumes 
a  continued  form  and  goes  on  rising  gradually  until  the  sixth  or  seventh  day,  when  the  temperature  reaches  lO'Si" 
or  104°.  This  fever  presents  a  staditiin  of  increase  of  about  one  week,  a  stadium  of  height  of  five  or  six  days  and  a 
stadium  of  decrease  which  terminates  completely  on  the  twenty-first  day.  Its  thermonietric  rang<^  is  decidedly  lower 
than  that  of  typhoid;  it  seldom  goes  above  1031°.  Vomiting  of  bile  is  a  conuuon  symptom  during  the  first  days  of 
the  attack;  bronchial  catarrh  is  generally  present;  constipation  and  a  concave  abiloiuen  arc  nuirked  features; 
appreciable  splenic  ten<leruess  or  enlargement  has  been  so  rare  in  his  observation  that  from  memory  he  can  recall 
but  two  cases  in  fifteen  years.  All  the  essential  features  of  typhoid  or  enteric  fever  are  ab.sent  :  There  is  no  diarrhcpa, 
no  ileo-ca'cal  tenderness  or  gargling,  no  meteorism,  lu)  eruption  of  rose-colored  spots,  and  as  a  rule  there  is  an  entire 
absence  of  abdominal  symptoms;  but  in  some  cachectic  instances  in  which  the  jiatient  was  iinfav<irably  situated  for 
treatment  or  had  no  treatment  he  has  seen  diarrlnea,  dry,  red  and  shining  tongue,  sordes  and  low  delirium,  with 
picking  at  the  bedclothes  and  a  condition  closely  resembling  tyjihoid. 

Snrgeon  C.  B.  Whitk,!  U.  S.  Army,  consiilers  the  disease  a  compound  fever,  ty|ihoid  in  form  ami  nuilarial  in 
character.  He  refers  to  an  epidemic  in  the  Sciot'i  Valley  beginning  by  distinct  chills,  with  rii]iealed  perfect  inter- 
missions. Although  in  some  cases  the  chills  were  broken  by  (luininc  a  low  form  of  continued  fever  earner  on  after 
an  interval  of  three  to  seven  days,  accom]ianied  by  moderate  delirium,  loss  of  relish  for  food,  little  thirst  but  much 
heat  of  skin  and  derangement  of  the  digestive  organs;  diarrlnea  was  not  constantly  ]iri'sent.  •  *  »  "During  the 
past  year  I  have  noticed  ulcerated  jiatidu's  as  more  usual  and  more  frci|U«'nt  in  the  colon;  ]ierhaps  very  few  spots  in 
the  small  intestine,  and  in  the  large  inti'stino  large  ami  freinu'ut  ulceration.  I  should  not  give  this  so  iinporlant  a 
notice,  but  on  consultatiiin  with  I'rofessor  IjOVIN(!  of  Columbus,  a  careful  and  conscicnl  ions  observer  of  large  experi- 
ence, he  states  that  he  believes  nh'crations  of  the  large  intestine  to  be  a  distinguishing  mark  of  the  disease,  and 
exhibited  spccinu'us  illustrating  this  pathological  view." 

.1.  M.  Da  Cdsta  shows  that  he  does  not  regard  tlui  presence  of  enteric  fi'vcr  as  an  essential  of  the  fever  which  ho 
designates  by  llie  term  ly pho-mahirial.i     On  tlu'  contrary,  it  may  be  inferred  from  liis  remarks  that  if  the  abdominal 

lesion  of  lyplmiil  had  been  indicaled  liy  the  symptoms,  hisdiagnosis  would  lia\  e  I n  ty)ihoi<l  and  not  typho-nuilarial 

fevei.  The  patient  was  a  girl  about  I'ighteen  years  of  age.  "A  week  prior  to  her  admission  to  the  war<ls  she  was 
sci/.ed  with  fever,  headache  and  jiain  in  the  back,  stomach  and  left  side.  Her  face  to<i  was  llushe<l.  Thi^  thermometer 
niaiked  102i°  on  the  evening  of  her  admission.  Her  tongU(i  was  coated  and  dry.  The  pain  in  her  neck  and  the  back 
of  her  head  grew  more  intense.  She  als<i  complained  <if  cough  and  of  |iain  in  her  left  chest.  Tliele  w;is  no  stiffness  of 
the  neck  and  none  of  the  symptoms  of  cerebro-s|)inal  nu'iiingitis.  J'hi'ie  was  a  slight  amount  of  minsea  and  gastric 
uni'asiiu>ss.  As  regards  my  diagnosis  of  the  case,  tin!  intestinal  jiains,  tlu^  fever  a|iparenlly  without  cause,  lln'  lieail- 
ache  and  th<'  age  of  the  patient  all  iiointcd  towaids  typhoid  fever.  On  the  si'cond  day  alter  admission,  however,  I 
decided  positively  that  it  was  not  a  ca.se  of  tyjihoid  fever,  and  this  conclusion  has  bei'U  verified  by  the  results.  The 
symjitoms  which  led  me  to  exclude  the  thought  of  typhoid  lever  was  the  extraor<lin:iry  temjierafure  record, — show- 
ing such  marked  remissions  and  exacerbations.  In  the  corresj)onding  stage  of  tyjihoid  fever  smh  a  state  of  affairs 
would  be  almost  if  not  entirely  unknown.  On  the  evening  of  the  secoml  day  of  admission  the  tenijierature  was  103°, 
on  the  third  morning  it  was  9Sl°,  in  the  evening  it  again  rose  to  103°.  For  several  days  following  this  tin>e  there  was 
a  daily  variation  of  from  3°  to  4°  between  morning  ami  evening  tenijierature.  On  tlni  iUh  of  the  month  the  morning 
temjieraturc  was  0!(°  and  the  evening  temperature  101°.  On  the  llth  the  temperature  w;is  about  normal,  with  lint  very 
little  dilference  between  morning  and  evening  charts.  On  the  IJth,  yesterday,  1  ordered  the  (|uinine  to  lie  stojiped, 
as  quiiiiiiiniii  was  rapidly  making  its  ajijiearance.  The  patient  had  been  taking  a  daily  dose  of  sixteen  grains  of  the 
drug.  Our  treatment  by  ijuinia  had  Jiroved  two  things  to  our  entire  satisfaction — lirst,  that  our  view  of  the  nature 
of  the  case  was  the  only  correct  one.  and,  second,  that  the  minute  you  discontinui'  the  antijieriodic  in  a  ease  <if 
malarial  infection  the  tenijierature  may  run  right  uji  again,  althimgh  yon  may  have  succeeded  in  rciliuing  it  almost 
to  the  normal  state.  (On  the  evening  of  the  12th  the  temjierature  rose  again  to  101°.)  Ihis  morning  the  jiatient's 
pulse  is  74,  her  respiration  26  and  her  tenijierature  90i°;  her  face  is  somewhat  linshed.  She  is  again  uinler  the 
influence  of  (juinia,  having  taken  eight  grains  this  morning.  There  is  no  enteric  tenderness  and  no  erujition.  The 
spleen  is  somewhat  enlarged,  extending,  as  it  does,  nearly  an  inch  below  the  ribs.     The  area  of  liver  duluess  is  but 


"  Aw.ficm  Juiini.il  M,  .li'nl  Sinires,  S.  S.,  \n\.  I.XX.KI,  1881,  p.  4nl.  \  Mrili<<fl  Hr,„r,l,  Nr«   V..rk,  \o\.  .\V,  ISTrt,  p.  207. 

I  111  a  cliiiinil  li-ctuii'  Oil  Tijiilin-miilwinl  Finr,  ill  tlic  PhUnililpliM  Mnlirnl  Thiira,  1«77-'TS.  p.  4:14.  Ilr.  \i\  C'osT.v,  ill  II  ri'iellt  letter  to  the  writer, 
exprt-y^es  h\ii  iipinioii — "Tliiit  reiiiilteiit  fever  iint  iliit'ri'uneiitly  riiiis  into  si  {•nntimieii  fever  i>f  )n\v  type  tn  wliieli  the  term  nmlario-typhiiitl  fever  might 
lie  applied.  It  is  nut,  however,  tlie  sjHx-ifie  enteric  fever  with  its  eliararteristii-  lesions  ;  aiirl  what  is  called  typUu-nialarial  fever  is,  1  helit've,  generally 
from  the  onset  typhoid  fever,  it»  features  slightly  blurred  hy  occurrini;  in  malarial  subjects." 


516  ETIOU)UY    OK   THE 

slightly  iutreased  below  the  margin  of  the  ribs.     There  is  a  left  basic,  systolic  blooil-miirniiir  to  be  distinguished 
over  the  heart." 

Wm.  H.  Veatc'H,*  of  Pawnee,  Sangamon  County,  111.,  arranges  the  cases  of  the  typho-malarial  e]>idenuc  of  1864 
in  his  county  into  three  classes.  The  first  cases  that  came  under  his  observation  began  as  connuon  remittents,  but 
after  three  to  seven  days  a  typhoid  character  was  assumed;  death  occurred  or  convalescence  was  established  by 
the  end  of  the  second  week.  In  others  the  remittent  attack  continued  for  eight  or  nine  days  without  the  appearance 
of  typhoid  symptoms,  when,  suddenly,  a  recurrence  of  chills  would  take  place  with  an  aggravation  of  the  febrile 
condition,  petechia-,  delirium,  heavy  i)erspirations,  diarrluea,  collapse  and  death  about  the  tifteeuth  day,  if  at  this 
time  a  favorable  elumge  failed  to  make  its  appearance.  In  the  third  class  the  onset  was  gradual, — general  indispo- 
sition, lasting  from  seven  to  fifteen  days,  was  followed  by  chills,  a  febrile  couilitiiiu,  diarrhiea,  with  a  brown-coated 
tongue,  red  at  the  tip  and  edges,  and  congestion,  perhaps  even  ulceration  of  the  fauces;  wild  delirium  supervened, 
followed  by  conui  and  speedy  death,  or,  if  stu])or  did  not  couie  on,  the  patient  passed  tliiough  a  course  of  tyi)hoid 
fever  lasting  from  fifteen  to  forty-two  days.  In  this  class  the  typhoid  symptoms  appeared  at  various  periods  of  the 
fever  from  the  sixtli  to  the  twenty-sixth  day,  but  in  some  cases  it  was  not  observed. 

According  to  Dr.  Ci,.viH()iiN'E  the  cases  in  the  epidemic  at  Petersburg,  Xa...  in  1879, t  were  always  distinctlx 
intermittent  or  remittent  in  their  ince))tiou;  but  (juiuine  did  not  exercise  its  ordinary  antiperiodic  effect.  In  three 
cases  there  was  a  cleaner  tongue,  less  thirst,  nausea,  anoiexia,  debilitj-  and  fever,  fewer  lu-rvous  symi)touis  and  less 
delirium  than  in  the  typho-malarial  fevers  of  the  war;  they  lasted  six,  eight  and  ten  weeks.  The  tongue  became 
red  and  dry  about  the  third  week,  but  only  in  grave  cases;  diarrluea  was  the  exception,  not  the  rule,  and  the 
rose-colored  spots  of  undoubted  typhoid  were  not  present.  But  on  the  typhoid  side  there  was  in  all  cases  some 
bleeding  from  the  nose,  soiuetimes  only  a  few  drops,  sometimes  more;  and  in  most  of  the  cases  dulness  of  hearing, 
tinnitus  aurium,  the  russet  flush  on  the  cheeks  and  abdominal  tympanism ;  moreover,  the  disease  occurred  exclusively 
among  young  people  and  manifested  a  certain  limited  or  quasi  infectiousness.  It  was  characterized  by  a  high  tem- 
perature, seldom  less  than  105°  or  106°  at  1  or  2  i'.  M.;  the  frecjuency  of  the  pulse  increased  with  the  felu'ile  exacerba- 
tion, but  not  in  the  sauie  proportion,  seldom  rising  above  100  or  110  i)er  minute.  Fatal  ca.ses  usually  terminated 
during  the  third  week  with  wild  delirium,  acute  niaiiia,  insomnia  and  convulsions,  yet  with  recurring  consciousness 
and  without  itaralysis,  showing  tlie  absence  of  organic  lesions  of  the  brain.     l>io  jioxt-mortcm  observations  were  made. 

D.  W.  Hand,  St.  Paul,  Minn.,  gives  a  general  description  of  typho-malarial  fever  as  it  is  occasionally  seen 
in  St.  Paul  during  the  autumn  along  with  ordinary  remittent  fevers,  and  as  it  occurred  epidemically  in  the  autumn 
of  1870.}  It  was  distinguished  from  typhoid  liy  its  uuirked  remittent  form,  the  mildness  or  absence  of  delirium, 
the  nu)i8t  white  condition  of  the  tongue,  the  sliglit  amount  of  intestinal  irritation  and  tyiupauites  and  the  early 
period  at  which  convalescence  fre(|uently  began;  nevertheless  the  symptoms  at  first  were  uuich  like  those  of  typhoid. 
The  chill  was  often  unobserved  and  the  attention  first  arrested  by  sudden  loss  of  appetite  and  strength,  violent 
head-pain  and  decidetl  fever  in  the  afternoon  and  evening.  In  some  cases  a  bilious  diarrlio'a  was  developed  ;  in  others 
constipation,  which' did  not  yield  readily  to  cathartics.  The  tongue,  which  was  pale  and  round,  usually  remained 
coated  with  white  fur  throughout  the  disease.  The  stomach  was  generallj'  irritable,  and  in  many  cases  there  was 
distressing  vomiting.  The  pulse  was  froiu  90  to  120  and  not  usually  very  feeble.  In  all  cases  the  temperature  was 
largely  increased,  varying  from  102°  to  10.")i°  Fahr.;  indeed,  most  cases  showed  a  temperature  of  104°  to  105°  every 
evening  for  a  week  or  ten  days;  the  morning  temperature  was  usually  1°  to  li°  lower  than  that  of  the  evening. 
During  the  first  three  or  four  days  the  throat  was  sore,  sometimes  showing  a  diphtheritic  exudation:  and  in  a  few 
cases  a  rash  like  that  of  nu-asles  appi-ared  during  the  first  week.  Epistaxis  sometimes  occurred  and  the  hearing 
became  impaired.  Duriug  the  second  week  a  brouchitic  cough  was  invariably  developed.  There  was  generally  some 
abdominal  tenderness,  but  tympauites  was  rarely  marked  and  diarrlnea,  if  present,  was  usually  easily  controlled. 
Sordes  seldom  appeared  and  the  tongue  rarely  became  dry  or  rough.  After  the  early  headache  passed  off  the  mind 
usually  remained  clear,  although  the  patient  was  fre(iuently  rather  dull  and  the  countenance  heavy;  delirium,  if 
present,  was  mild.  Rose-colored  spots  were  seen  in  very  few  cases,  although  carefully  looked  for;  sudamina  were 
common.  Convalescence  often  began  in  the  first  or  second  week,  although  the  fever  lasted  three  weeks.  Profuse 
night-sweats  were  common  duriug  convalescence.  Dr.  H,vxi>  saw  at  least  one  hundred  cases  duriug  the  epidemic 
and  only  three  of  these  died.  The  disease  was  widespread,  but  the  reports  of  the  city  health  officer  showed  only 
five  deaths  attributed  to  it;  perhaj)S,  however,  many  of  those  reported  due  to  typhoid  sliould  have  been  placed  to 
the  account  of  the  typho-malarial  epidemic,     'i^o  jiont-morttin  examinations  were  nuide. 

J.  A.  Porter,^  Jackson,  Mich.,  states  that  an  endemic  fever  prevailed  in  the  counties  of  Jackson  and  Lenawee 
in  the  summer  and  autumn  of  1873,  and  that  while  the  disease  was  regarded  ditteiently  by  various  practitioners,  some 
terming  it  cerebro-spinal  meningitis,  some  remittent  fever  and  some  tyjihuid  fever,  he  with  others  called  it  typho- 
malarial  fever.  He  gives  two  ca.ses  to  illustrate  his  general  dBscrii)tion.  The  attack  began  in  various  ways.  Some- 
times the  patient  was  seized  with  a  severe  j)ain  in  the  left  shoulder,  extending  up  the  back  of  the  neck,  or  in  the  arm 
or  leg,  with  hypera'sthesia  and  febrile  action;  in  others  the  febrile  attack  was  preceded  by  a  period  of  general  indis- 
position, (ienerally  there  was  an  initial  chill.  Occipital  or  frontal  headache  was  rajiidly  followed  by  delirium,  with 
subsultus  tendinuni,  some  deafness  and  defective  vision.  Epistaxis  was  an  early  .symptom  and  seemed  to  be  a  measure 
in  some  degree  of  the  severity  of  the  attack,  it  being  more  fre(iueut  in  the  severe  eases.     The  tongue  for  the  first  three 


*  Chicago  Medical  Examiner,  Vol.  VII,  18fi6,  p.  680.  t  See  page  5fl2,  mpra, 

I  Xorthweatem  Medical  ami  intvincal  Juiir.,  1S7U-71,  Vol,  I,  p.  367.  ^  Detroit  Hevunc  of  Mtdicine  and  Vhannary,  Vul.  IX,  1874,  p.  387, 


CONTINUED    FEVERS.  517 

weeks  was  moist,  deep  scarlet  in  color,  with  elevated  pajiilla'  a1)0ut  the  tip  and  sides  and  sliffhtly  furred  at  the  liase. 
The  Btiiniacli  was  sometimes  irritable.  The  abdomen  was  tympanitic;  the  bowels  irregular,  diarrho'a  and  constipa- 
tion alternaTing,  and  susceptible  to  the  action  of  purgatives;  the  discharges  fetid,  at  first  dark-brown  or  black  in 
color  and  afterwards  of  a  light  yellow.  Mucous  rales  were  generally  heard  in  the  lungs.  The  fever  was  distinctly 
and  regularly  remittent  in  character,  and  the  skin  at  times  bathed  with  i)ers]iiration  without  any  diminution  of  the 
bodily  temperature,  and  at  other  times  dry  and  harsh  without  any  marked  increase  of  surface  heat.  Moreover, 
about  the  eighth  or  ninth  day  from  the  initial  chill  or  jiain  a  remission  occurred  of  so  marked  a  cliaracter  that  it 
appeared  as  if  the  fever  had  subsided;  but  in  about  tliirty-six  hours  the  fever  recurred  and  pursued  a  uniform 
course,  so  that  one  day  was  an  exact  representation  of  another  day.  but  for  the  increasing  i)rostration  and  coma 
tending  to  deatli.  If  not  fatal  a  slow  convalescence  similar  to  that  from  typhoid  led  to  recovery.  Petechial  spots, 
appearing  generally  as  early  as  the  tenth  day,  were  fonnd  in  most  of  the  cases,  usually  on  the  abdomen  and  anus; 
in  some  they  were  numerous,  in  others  not  more  than  five  or  six. 

T.  K.  PowKi.i.,*  Dyersburg,  Tenn.,  under  the  title  of  typho-malarial  lever,  describes  an  epidemic  that  prevailed 
in  Haywood  County  in  the  autumn  of  18><1.  By  soiue  it  was  called  ty'p'mid,  by  otiieis  typho-nuilarial  and  by  others 
again  continued  malarial  fever.  The  prevailing  diseases  of  the  ccninty  are  of  a  nuilarial  character,  but  Dr.  I'owki.l 
does  not  remember  to  have  seen  a  case  of  intermittent  fever  during  the  height  of  the  eiiidemic  in  question.  In  con- 
nection with  its  causation  he  refers  to  the  extremely  hot  and  dry  weather  of  the  preceding  sunnner.  In  a  certain 
proportion  of  the  cases  hemorrhage  from  the  bowels  was  present,  not  in  the  beginning  or  congestive  stage  as  in  inter- 
mittent or  remittent  fever,  but  at  the  height  of  the  disease.  Some  cases  were  cluiracterized  by  a  pointed  tongue 
with  red  tip  and  edges,  rose-colored  spots,  tympanites,  tenderness  in  the  right  ilia(^  region,  diarrhiea  and  low  delirium. 
Few  cases  were  fatal.  No  post-morttm  examinations  were  made.  Dr.  i'oWKl.l.  regarded  it  as  a  mild  form  of  typhoid, 
influenced  to  a  great  extent  by  the  nuilarial  jioisoii,  as  shown  by  markeil  morning  lemissions  or  even  intermissions  in 
the  early  days  of  the  fever. 

Jeff.  D.  Wii,Li.\.MS,t  Philadelphia,  Miss.,  Ins  published  acase  to  illustrate  his  general  description  of  the  disease 
and  his  statement  that  it  seems  to  be  only  a  milder  form  of  tyjihoid. 

Dr.  DavyJ  submitted  to  the  Cincinnati  Medical  Society  two  illustrations  of  fever  without  rose-spots,  which, 
for  want  of  a  better  name,  he  was  in  the  habit  of  calling  ty))ho-nuilarial  fever.  "A  boy,  aged  ton  years,  had  staid 
at  home  from  school  on  Thursday,  but  was  first  seen  by  the  do<-tor  on  Saturday.  His  temperature  was  1()H°,  his 
pulse  about  110  per  minute,  bowels  slightly  ccuistipated  and  tongue  white.  He  had  considerable  thirst  and  loss 
of  appetite,  but  he  refused  to  go  to  bed.  Tlic  case  had  appiari'd  altogether  similar  to  a  slight  attack  of  malarial 
fever,  and  the  speaker  thought  a  mercurial  jpurge  and  liberal  doses  of  <|uiuia  would  bring  about  convalescence  in 
a  day  or  two.  The  day  followiug.  however,  the  patient  was  not  imi)roved,  still  hiiving  a  temperature  of  10L'..")°. 
The  next  day  he  went  to  bed  coui|ilaiuing  of  a  severe  jiaiu  in  the  frontal  regicui,  while  his  tongue  beeanii'  heavily 
loadeit  and  his  jpulsc^  Ix'at  I'JO  jier  miuute.  Me  went  on  growing  worsts  for  a  fi'w  days.  Tlie  day  was  jpassed  in 
mild,  the  night  in  wilil  di'liriuui.  with  .jactitations,  subsultiis  tendinum  aud  jiiikiug  at  the  bedi'lothes  vitv  well 
marked.  About  this  tiuu^  slight  iliarrhd'a  set  in,  a<'<'oui]>anied  l)y  some  abilominal  |iain.  Then'  was  no  gurgling  of 
the  right  iliac  region  and  no  rose-colored  spots  or  sudamimi  at  any  tiuu!  to  be  seen.  The  delirfum  subsiiled  in  about 
a  week  and  he  made  a  gradual  but  complete  recovery.  The  other  case  was  that  of  a  girl  of  fourteen  on  the  verge  of 
the  first  eatanuuiial  period.  She  hail  been  indisposed  for  several  days  but  refused  to  go  to  bed.  Her  temjierature 
was  imt  above  103°,  her  pulse  about  100  jier  minute.  On  the  second  day  following  she  went  to  lied  complaining  of  a 
slight  headache  only.  From  this  tinu!  her  condition  became  gradually  aggravated,  mental  hebetude  and  slight 
delirium  also  appearing.  About  the  beginning  of  the  attack  she  had  had  a  sjiell  of  nose-bleeding,  but  it  ilid  not  recur. 
About  the  fifteenth  day.  w  hen  she  was  a]iparently  convalescing,  slii^  dischargecl  from  the  bowels  about  a  pint  an<l  a 
half  of  dark  blood  in  three  stools.  For  aliout  a  week  previous  to  these  bloody  discharges  she  IukI  ])ain  in  the  abdomen 
and  diarrho'a,  but  this  was  readily  controlled  by  an  ojiiate.  The  appetite  was  almost  though  not  entirely  lost.  The 
tongue  once  became  clean  and  then  recoated.  Temiierature  remained  about  102..")°  most  of  the  time,  falling  to  100° 
when  convalescence  was  established;  for  a  few  days  towards  the  end  <d'  the  attack  it  was  intermittent,  showing  a 
dift'erence  at  one  time  of  2.5°."- 

W.  Hli.i.lAKi>i5  gives  a  chart  of  the  temperature  curve  of  typho-nuilarial  fever,  reproduced  on  the  next  jiage.  He 
does  not  express  his  views  on  the  etiology  or  pathology  of  the  disease.  "  Its  syniiitoms,''  he  says,  "are  ([uite  familiar 
t6  those  jihysicians  who  have  resided  in  the  nuilarious  regions  of  the  south  and  southwest.  Above  all  the  rest  of  the 
essential  fevers  incident  to  this  climate  tyiiho-uuilarial  fever  stands  jire-emineut  as  to  duration.  While  in  a  few  mild 
cases  the  mercury  will  recede  to  it8.5°  Fahr.  after  ranging  above  that  point  for  lilteen  days,  yet  in  a  largi'  majority 
of  cases  the  preternatural  heat  will  extend  over  a  period  of  at  least  thirty  days;  in  some  instances  the  iiathological 
heat  will  last  forty,  fifty,  even  sixty  days.  Early  in  the  career  of  this  pyrexia  the  thernuil  w  aves  are  generally  high; 
for  the  first  two  or  three  days  the  lowest  markings  will  be  103°  Fahr.,  the  highest  104°,  10,5°  or  even  10t).r>°  Fahr,  The 
thermal  wave  during  this  period  is  to  all  appearances  the  same  as  that  of  remittent  fever.  Gradually,  however,  these 
high  altitudes  subside  into  a  gentle  undulating  thermal  wave  only  a  few  degrees  in  n\ild  cases  above  the  health-line. 
Finally,  when  the  mercury  sinks  to  the  health-line,  it  will  suddenly  rise  a  few  degrees  above,  then  fall  to  rise  again, 
displaying  the  thermometry  of  intermittent  fever." 


*  Trims.  Med.  Hoc.  Teimessee,  1882,  p.  M.  ^  f  Vinjhiia  Medinil  Mimlhhj,  Vol.  Ill,  1876-77,  p.  8!J9, 

X  Report  in  CtnnuHuH  Lintiy't  aiid  Clinii',  ISSO,  ]>.  ,'j5(). 

g  Oit  Ihf  MfiJi'iil  TlnTrtiometrti  nf  Certniu  Iilxt'usfK  ,».« tlifij prfvitil  in  Oif  S^tntii  ami  SuHthireft. — Sew  Orleans  Medical  and  t^urgieal  Joiintal,  1877-78,  p,  32, 


518 


KTIOLOGY    OF   TTIK 


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Two  temperature  cliarts  of  typlio-inalarial  fever,  drawn  by  Surgeon  F.  1j.  Towx.  V.  8. 
Aiiiiy,  Fort  8ill,  IiKJian  Territory,  are  on  file  in  this  offiee.  The  cases  occurred  in  1S77. 
Many  remittents  were  treated  at  tfie  post  during  the  summer  and  fall  of  that  year,  but  only 
in  these  two  cases  were  typlioid  or  adynamic  symptoms  deyeloped. 

Case  1. — Private  Geo.  W.  Barnes,  Co.  A,  4th  U.  S.  Cav.,  was  admitted  to  hospital  Septonil)er  13,  presenting 
Bymptoms  similar  to  those  of  a  tertian  intermittent  but  with  unusual  depression.  The  exacerbations  did  not  yield 
to  antipeiiodics,  and  after  a  few  days  the  case  assumed  the  character  of  a  remittent  with  diarrhtt'a,  the  abdominal 
symptoms  becoming  gradually  more  prominent.  Prostration  was  progressive  and  the  fever  slowly  assumed  the  con- 
tinued form,  wliich  was  fully  developed  on  the  18th  day  after  admission.     I'p  to  this  time  no  record  of  temperature 


was  made,  as  the  case  had  not  differed  materially  from  other  severe  remittents.  Tliere  now  appeared  low  dtlirium 
with  increasing  stupor,  prostration  and  involuntary  discharges,  wliich  were  associated  on  the  2;:!d  day  with  a  rapid 
and  abnormal  lowering  of  the  temperature.  The  gravity  of  the  symjitoms  ajjpeared  to  indicate  a  speedy  an<l  unfavor- 
able termination.  On  four  consecutive  mornings  the  temperature  registered  was  one  or  two  degrees  lielow  the  normal. 
On  the  27th  day  it  rose  from  95.0°  to  103.4°,  after  which  it  did  not  again  fall  below  the  normal.  8oon  after  this  the 
patient  began  to  mend,  although  convalescence  was  not  established  until  the  37tli  day.  Some  degree  of  mental 
aberration  persisted  until  the  patient  l)egan  to  sit  up,  and  even  until  he  was  able  to  walk  into  the  dining-room  at 
meal  times.     He  was  returned  to  duty  December  10. 

Case  2. — Private  Charles  Krull.  Co.  }?,  16th  U.  S.  Inf.,  was  admitted  to  hospital  Octolier  12.  This  case  was  of 
equal  severity,  although  the  abdominal  symptoms  were  not  prominent  and  there  was  no  diarrho'a  until  the  close  of 
the  attack.  The  progress  of  the  fever  was  characterized  by  a  prolonged  period  of  abnormally  low  temperaturi'.  On 
admission  the  case  presented  the  appearance  of  a  severe  remittent  with  r:i)>idly  increasing  prostration.  Hy  the  7lli 
day  the  typlioid  condition  was  unmistakably  manifested,  and  a  record  of  daily  temperature  was  comiiieneed.  Cere- 
bral symiitoms  appeared  and  the  bodily  heat  fell  to  below  the  normal  and  eoiitiniied  below  this  point  from  the  9tli 
to  the  22il  day  of  the  disease.  During  the  continuance  of  this  vital  depression  the  skin  was  cool  to  the  touch,  and 
the  patient  lay  in  a  condition  of  ))artial  stupor,  moaning  at  intervals  ;is  he  breathed  and  liaving  involuntary  jiassages; 
the  pulse  was  slow  aud  weak — .jO  per  minute  on  the  11th  day:   by  gent  le  shaking  and  iiiiestiouing  ho  could  usually  be 


CONTINUED    FEVERP. 


519 


partially  aroused,  but  liis  atteinpts  at  articulation  were  incoherent,  if,  iiuleed,  they  did  not  fail  altogether  on  account 
of  the  parched  conilition  of  the  mouth,  tonjtue  and  fauces.  After  the  temperature  rose,  on  the  23d  day,  an  ameliora- 
tion of  the  symptoms  was  pcrceptihle.  From  this  time  until  about  the  28th  or  29th  day  the  patient  would  at  intervals 
cry  out  as  if  alarmed,  and  continue  tliis  as  loud  and  as  long.as  his  exhausted  condition  would  i)t>rniit.     Subseciuently 


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the  case  progressed  slowly  to  convalescence,  with  occasional  recurrences  of  moderately  increased  tenipeiatnre  and 
accelerated  pulse,  due  probably  to  intestinal  lesions,  as  some  diarrlnea  occurred  during  this  stage,  lie  was  not  finally 
returned  to  duty  until  March  4,  1878,  and  even  then  he  was  somewhat  ana'inic.  I?y  Ajiril  20,  however,  he  had  in  a 
great  measure  recovered  his  usual  weight  and  strength.     The  temperature  observations  were  nuide  in  tlie  axilla. 

These  two  cases  show  the  coincideiu'e  of  tlie  ty}>hoid  condition  aiul  an  abnonually  low 
temperature.     Two  other  cases,  filed  in  this  office  since  the  war,  associate  these  low  temper- 
atures with  the  weakness  of  convalescence;   they  were  reported  from  Fort  Duncan,  Texas 
by  Ass't  Surgeon  E.  T.  Comkgys,  U.  S.  Army. 

Case  1. — Private  Claudius  Mausoz,  Co.  K,  8th  Cav.,  a  young  French  recruit ;  robust  and  hi'althy;  was  admitted 
June  7,  187(!,  complaining  of  dianhiea.  The  ease  remained  under  observation  until  the  (evening  of  the  7lh  day,  when 
treatment  by  baths,  (luinine  and  stimulants  was  adojited.  The  record  has  few  entries  except  as  ri'gards  treatnu'nt. 
On  the  VMh  day  the  patient  was  restlc^ss  and  had  a  steady  and  dull  jiain  over  the  liver.  On  the  28tli  day  jirofuse  noc- 
turnal persjiirations  were  noted.  He  was  able  to  sit  up  in  bed  on  th<^  iidth  day,  and  two  days  later  he  began  to  sit  up 
in  a  chair.  He  is  said  to  have  recovered  his  stiength  slowly  and  to  have  been  returned  to  duty  August  28.  In  com- 
paring the  course  of  treatment  with  tlu^  chart  it  is  found  that  a  distinct  imiiression  was  made  in  the  eurvi'  of  tempera- 
ture by  the  administration  of  large  iloses  of  (|uinine.  On  the  evenings  of  the  7th,  8th  and  Itth  days  ten  grains  were 
given;  this  dose  was  doubled  on  the  lOth  and  llth  days;  thirty  grains  were  given  on  the  12fli,  lUth  and  lUh  days, 
after  which  small  doses  were  occasioiuifly  ii.sed  until  the  18th,  lUth  and  2()th  days,  when  large  doses  were  again  admin- 
istered. Two  days  after  the  temjierature  fell  below  the  normal  the  patient  was  able  to  sit  up  in  bed.  When  the 
temi)eratnre  again  reached  the  normal  line,  at  the  en<l  of  the  thermonu'tric  record,  he  was  on  full  diet  and  able  to  walk 
about.     The  temperature  charts  of  this  case  and  of  that  which  follows  are  submitted  on  the  next  page. 

C.\.SE  2. — Private  I-dward  K.  St.ittord.  Co.  K,  8tli  t'av.,  a  young,  healthy  but  rather  dcliiate-looking  recruit, 
reported  ,Iune  8,  1876,  as  alleeted  with  headache,  weakness  and  dizzini^ss.  The  case  remained  under  ob.servation 
until  the  evening  of  the  6th  day,  when  quinine,  the  sponge-liath  and  stimulants  were  ordered.  F.pistaxis  is  the 
only  symptom  mentioned:  it  occurred  on  the  9th,  10th  and  27th  days.  On  the  last-mentioned  day  the  temperature 
fell  below  the  normal;  two  days  later  the  patient  was  able  to  sit  up  in  bed;  four  days  after  this  he  was  walking 
about  the  ward,  and  in  three  more  days  he  was  permitted  to  go  out.  During  this  period  of  iniprovement  the  tem- 
perature was  generally  considerably  below  the  normal. 

Post-mortem  records  have  been  rarely  published,  fn  the  few  cases  in  wliidi  the  ana- 
tomical conditions  are  mentioned  typhoid  fever  appears  to  have  been  nbsent.  Carstp^ns 
of  Detroit,  speaks  of  enlargement,  pigmentation  and  ulceration  of  the  solitary  follicles, 
Peyer's  patches  being  unaltered  or  merely  congested;  but  there  is  nothing  in  his  article  to 
show  that  his  statements  were  founded  on  original  researches.*  C.  Vi.  White,  U.  S.  Arm\\ 
announced  as  his  personal  experience  and  that  of  Dr.  Loving  of  Columbus,  Ohio,  the  exist- 
ence of  ulcerated  patches  in  the  colon  rather  than  in  the  small  infestine.f  WuirrHiNOTOK 
of  Los  Angeles,  Cal.,  reported  three  cases  in  which,  with  congestion,  pigmentation  and 
ulceration  of  the  intestinal  ntucous  membrane  there  was  no  affection  of  the  glands  of  Peyer.| 

The  term  typho-malarial  has  also  been  given  of  late  years  to  the  fevers  of  the  Rocky 


*  Supra,  V.  512. 


■)■  Supra^  p.  515. 


X  Supra,  p.  512. 


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CONTINUED    FEVERS. 


621 


Mountain  region, — the  mountain  fever  of  tlie  froutiersuien.*  At  first  these  fevers  were 
supposed  to  be  something  new,  dependent  on  'the  rarefaction  of  the  air  or  some  obscure 
atmosplieric  causes  ;-j-  1)V  some,  however,  tliey  were  regarded  as  malariahj  Baetholow, 
wliile  serving  witli  the  ex])edition  to  Utah,  saw  two  forms  of  fever:  Malarial  fevers  first 
affected  the  troops,  and  two  months  later  typhoid  became  associated  with  remittent  fever  not 
only  in  the  camp  but  in  the  individual;  rose-colored  spots  were  present  in  some  of  the  cases, 
and  all  tliose  that  were  fatal  showed  the  intestinal  ulcerations  of  enteric  fever.  Probably 
the  aggregation  of  troops  constituting  tlie  army  of  Utah  had  an  influence  in  determining 
the  occuri'ence  of  tvplioid  in  Bartholow's  oxperien<'e.  Certainly  this  disease  became  less 
frequent  in  the  service  of  officers  who  wei'o  on  duty  in  that  part  of  tlie  country  at  later  dates 
and  with  smaller  conmiands.  Moreover,  when  typhoid  fever  was  recognized  it  was  so 
reported  and  its  cases  ceased  to  form  a  constituent  part  of  the  totality  of  the  records  of  moun- 
tain fever.  The  former  was  rare,  the  latter  common.  At  Fort  Bridger,  Wyoming  Territory, 
for  instance,  in  a  Inean  strength  of  153  men  there  were  recorded  during  the  eight  years, 
1866-73,  fifty-nine  cases  of  mountain  fever  expressed  as  malarial  remittent  and  but  one 
case  of  typhoid  fever.  Among  medical  men  tlie  name  mountain  fever  came,  therefore,  to  bo 
synonymous  with  remittent  or  continued  malarial  fever. 

A  species  of  remittent  fever,  called  l>y  the  eitizeiis  moiiiitiiiii  ffrir,  is  the  previiiliiif;  <liKeiis<'.  It  is  easily  con- 
trolled by  (luiniiie.J 

F.  Rice  WacGOXKHJI  S'v<'**  *l"'  rc<'ord  of  three  eases  Illustrative  of  this  disease.  Fnini  a  eoiisideralioii  of  the 
surroiindiujis  of  Fort  Lyon,  at  which  his  cases  oci'iirred,  and  from  th<^  ])rcval<'iice  of  si^vei-e  iiileiiiiit tents  aii<l  remit- 
tents ill  the  same  garrison  at  tlie  same  time,  he  lielieved  (his  eontiiiucd  fever  to  he  of  malarial  orit;iii.  and  llie  clfieacy 
of  lari;e  tloses,  sixty  to  Ncvcnty-livc  grains  of  (piinine  daily,  gave  therajieutii^  sn)i)iort  to  this  view.  The  alisiMiee  of 
enteric  symptoms  ajiiiearcd  to  iu<licate  that  tlic  fever  was  not  dn(^  to  th<!  tyi>hoid  jioison. 

Ass't  Surgeon  J.  11.  P.vtzki,  U.  S.  Army,  rejiorts  from  Fort  Steele,  Wyoming  Territory ,1]  that :  A  ri'mittent  fever, 
occasionally  very  severe,  is  met  with,  by  thi^  monnlaincers  called  mountain  lever  and  nincli  iheadcd  by  them.  The 
most  prominent  symptoms  arc  headache,  si'vere  aching  through  the  whole  body,  insomnia,  furred  tongue,  fie<inent, 
full  ]>ulse,  constipation.  (Inlls  ari^  frei|Uent.  The  eliicac^y  of  large  do.ses  of  i|iiinine]ii'oves  the  malarial  origin.  The 
mountaineers  treat  il  w  itii  (  hiir  panacea,  sage  tea,  and,  as  they  assert,  cjuite  successfully.  Men  cutting  timber  along 
till'  streams,  mostly  DaiU'S  and  Swedes,  sulfer  most  from  this  fever. 

.Surgeon  Chahi.ks  K.  lil!KK.xi.K.\F,  F.  ,S.  Army,  in  a  letter  from  Fort  licnton,  Montana,*"  says:  Th<^  subject  of 
mountain  fever  is  one  in  wliicli  I  have  taken  a  great  interest,  having  met  the  disease  dining  my  tonr  of  duly  on  the 
iratt  »[i\<:  of  the  Rocky  Mountains  in  Idaho,  in  l><(>;t-7S,  and  again  during  my  i>icsent  tour  on  the  vant  side  of  Hie  same 
range.  I  was  much  struck  with  the  similarity  of  its  features  in  both  localities,  but  more  particularly  with  its  close 
resemblance  to  the  malarial  fevers  1  had  treated  ill  the  South  during  the  intervening  four  years  lS7:{-77.  Recently 
1  have  treated,  among  the  citizens  in  and  about  Helena,  a  great  many  ca.ses  recognized  by  the  local  physicians  as 
numntaiu  fever,  which  I  regarded  as  pure  malarial  fever,  and  successfully  treated  accordingly;  I  kept  careful  notes 
of  all  my  cases  in  civil  and  military  jiraetice  and  am  thoroughly  satisfied  that  the  dissease  is  malarial  remittent. 
The  name  of  moniitaiu  fever  is  simply  a  local  one,  the  u.se  of  which  should  be  discouraged  in  the  profession  as  causing 
<'onfiision  and  misleading  new  comers  to  the  country.  The  disease  runs  a  course  luecisely  similar  to  tliose  of  oiir 
Soutliern  and  Western  reniittcnts,  assuming  a  typhoid  type  in  severe  and  long-continued  cases  and  yielding  reaiUly 
to  vigorous  doses  of  quinine.  I  think  your  term  tyiiho-malarial  is  admiralily  descriptive  of  its  later  stages  so  far  as 
.iipiiptniHS  go;  as  to  the  pathological  significance  of  the  term  I  cannot  .say,  never  having  made  a, poni-mortem  examina- 
lioii  nor  in  fact  had  a  fatal  case. 

But  in  the  meantime  the  term  typlio-malarial,  im[)orted  into  these  regions  and  applied 
without  a  reference  to  patliological  restrictions,  became  to  many  practitioners  a  generic  title 


*  It  limy  Ix'  iiirittiuucd  that  the  Momita'm  Ferer  cU'srribt'il  by  .Vi.fred  Wisf — Brituih  Mediml  JoHmtit,  Vol.  II,  18S0,  p.  80.t — is  not  the  mountain  fnver 
of  .\nioricaii  writers,  but  u  low  febrile  or  ratlicr  irritablr  romiitioii  due  to  siulclen  exposure  to  iliiiiiiiisheil  iitinos|iherie  pretirJiire  ami  correspoiuUug  rare- 
faetion  of  the  air.  The  attacli  lasted  about  a  week,  the  temperarun;  varying  from  'M°  to  lOlo  i'alir.;  hut  its  ehiet  feature  was  eardiac  irritability, — the 
pulse  jnid  respiration  on  the  slightest  inovenielit  were  iuereased  out  of  all  proportion  to  the  exereise  taken. 

t  Dr.  Ewixo,  in  the  SI.  Lmm  Maiinil  uiid  Simjkud  Joanud,  Vol.  XIII,  ISof,,  pp.  HI'J-Hll. 

J  .1.  K.  Oatmax,— .1/.<ioi/a/a  uiid  Muluriuim  Firinin.nhi'-td  hij  llie  mine  e.iOKC,— .Verrtin»(  Medical  nnd  Siii-jirid  Jonnnd,  Vol.  VIII,  IS.'il,  pp.  105-ins,  aud 
B.«/o«  Mtdiail  ami  Nimjkal  JumMil,  Vol.  XI.IV,  pp.  fin-.512. 

g  Letter  of  Joliv  II.  FmrRofK,  .\sst  Snig.  lltli  Uhio  C'av.,  Fort  Ilalleck,  Idaho.— 7;o,s(uii  M,d.  and  Himj.  Jour.,  Vol.  Oil,  ISfi-'i-M,  p.  527. 

I  American  Juiir.  Med.  fy:kttce.i.  Vol.  L,  1SI>."',  p.  50.  ^  Report  on  the  Uyijiene  of  l}ie  U.  ^'.  Aritii/,  1875,  p.  385. 

**  Dated  July  7,  ls78,  to  Surgeon  J.  .1.  Woodward,  U.  S.  .\rmy. 
Mki>.  Hist.,  Ft.  Ill— (16 


522  EtTOLOGY    OF   THR 

equivfileut  to  mountain  fevoi',  in  wliirli  tlie  linos  of  separation  into  typlioid,  tvphoid  witli 
malarial  cotnplications  and  malarial  t'<>ver.-<  \vitlL  ty|ilioiJ  si/mptoin^i  were  more  or  less  oblit- 
erated.     Vt'V  instance: 

SiUf^i'oii  1'.  1..  Town.  V.  S.  Army,*  states  tliat  remittent  luul  typho-inalarial,  and  probably  enteric  fevers,  are 
not  int'requt'ut  in  the  spring  and  fall,  especially  ;iiiiiing  miners  and  hunters,  or  persons  who  are  generally  without 
shelter;  these,  in  the  parlance  of  the  country,  are  called  monntain  fevers  iudiscrimiuatoly. 

Ass't  Surgeon  (tF.o.  P.  Jaquettk..  1".  S.  Army,  rejiorted  from  Fort  Bowie,  Idaho,  the  occurrence  of  an  occasional 
case  of  fever,  either  remittent  or  intermittent,  commonly  called  in  this  country  mountain  or  typho-malarial  fever. 

One  of  the  most  recent  })apers  on  monntain  fever,^  or  as  the  writer  calls  it,  typho- 
laalarial  fever,  gives  a  historv  <if  five  casus  aggregated  under  this  generic  title.  One  case 
proved  fatal,  and.  on  ]>ost-m(irt<'iii  examination  the  lesions  of  typhoid  fever  were  discovered. 
This  case  is  of  particular  interest  as  showing  tlie  development  of  that  fever  in  one  of  five 
luindred  men,  all  of  whom  had  been  on  scouting  duty  in  an  unsettled  country  for  four  months 
before  the  disease  made  its  appearance  in  his  person, — in  fact,  the  spontaneous  or  miasmatic 
origin  of  typhoid  does  not  require  a  stronger  illustration  to  establish  its  existence.  But  it 
is  not  on  this  account  that  Dr.  HoFF,  the  writer  of  the  article  in  question,  describes  the  case: 
He  makes  use  of  its  typhoid  lesions  to  infertile  existence  of  similar  lesions  in  all  the  cases 
that  have  been  described  and  treated  as  mountain  fever. 

The  five  cases  were  turned  over  to  Dr.  Hoff  at  Fort  Fetterraan,  Wyo.  Ty.,  by  Acting  Ass't  Surgeon  A.  .7.  Gray, 
U.  S.  Army,  chief  medical  officer  of  the  expeditionary  column.  This  command,  consisting  of  about  five  hundred  men, 
took  the  field  May  24,  1878.  It  was  well  ciiuipjied,  having  ample  and  suitable  clothing,  tentage  aiul  rations:  and, 
moreover,  its  morale  was  excellent.  Its  first  permanent  ciinip  was  on  the  Clear  Fork  of  Powder  Kiver,  three  miles 
from  the  eastern  base  of  the  Big  Horn  Jlouutaius.  The  only  feature  of  this  camp  to  which  excejition  might  be  taken 
was  the  water-supply,  which,  although  at  first  soft,  clear  and  pleasant  to  the  taste,  ha<l,  later  in  the  season,  a  sus- 
picion of  vegetable  infusiiiu.  From  this  camp  the  command  moved  .Tuly  !.">  to  a  similarly  good  site  on  Rock  Creek,  a 
few  miles  to  the  northward.  The  duties  of  the  men  were  light:  the  teiui)erature  equable  and  never  oppressive.  The 
only  sickness  recorded  consisted  of  a  few  cases  of  intermittent  fever,  in  all  of  which  there  was  a  history  of  previous 
malarial  toxseniia.  On  Sejitember  .T  the  troops  broke  camp  to  cross  the  mountains  to  Camp  Brown  (now  Fort  \Vashaki) 
which  was  reached  on  the  14th.  During  this  march  they  encountered  a  rain- and  snow-storm  which  covered  the  country 
to  a  depth  of  twelve  or  more  inches  and  flooded  the  streams  with  tnrbid  water.  The  water-supply  during  this  time 
was  obtained  from  the  melting  snow.  The  health  of  the  men  continued  good  until  the  12th,  when  a  strong  young 
soldier  of  good  habits,  who  afterwards  becanu'  one  of  Dr.  Hoff's  five  cases,  was  seized  with  intermittent  fever,  which 
yielded  to  large  doses  of  (]uiiiine.  He  resumed  duty  on  the  Itith.  On  the  19th  the  command  left  Camp  Brown,  but 
meanwhile  three  men  had  been  taken  sick  with  symiitoms  of  paroxysmal  fever  and  were  left  under  treatment  at  that 
post.  On  arriving  at  Fort  Fetterman  on  the  28t1i  five  jiatients  were  turned  over  to  Dr.  Hoff,  two  as  ca.ses  of  iiuotidian, 
two  as  tertian  and  one  as  remittent  fever.  ■•That  these  cases."  Dr.  GK.iY  says,  "  were  malarial  there  is  in  my  opinion 
no  room  for  doubt,  but  whence  came  the  toxic  germs?  Heasoning  by  exclusion  I  am  compelled  to  attribute  their 
source  to  the  water  formed  by  the  melting  snow."  But  although  presenting  these  characteristics  at  their  inception 
and  during  the  early  period  of  the  attack,  when  transferred  for  treatment  at  Fort  Fetterman  the  febrile  action  was 
of  a  continued  or  subcontinued  type. 

In  case  I  the  morning  temperature  was  about  the  normal,  but  a  diurnal  elevation  averaging  two  degrees  of 
Fahrenheit's  scale  was  manifest  for  ten  days  after  the  i)atient's  arrival  at  Fetterman.  From  the  historj' and  temper- 
ature chart,  constructed  after  his  admission  into  liospital,  this  man  was  apjiarently  recovering  from  an  attack  of 
malarial  fevi-r  which  had  been  in  ]>art  controlled  by  iiuinine. 

In  case  II  the  temperature  oscillated  from  102°  to  10.">°  Fahr.  for  six  days  after  admission  into  hospital,  when 
fifteen  grains  of  (|uinine,  administered  on  the  morning  of  October  4  and  rejieated  on  the  evening  of  that  day,  sent 
the  temperature  down  to  97.4°  on  the  following  morning.  Similar  doses  thereafter  ])revented  the  recurrence  of  the 
former  high  temjieratures.  Quinine  was  continued  until  the  22d,  at  which  date  convalescence  was  progressing  rapidly. 
The  temperature  charts  of  these  two  ca.ses  are  given  on  the  opposite  page. 

In  case  III  the  subcontinued  fever  persisted  for  a  long  time.  A  careful  study  of  this  case  shows  that  thirty 
grains  of  quinine  daily,  usually  given  in  morning  and  evening  doses  of  fifteen  grains  each,  exercised  a  l)eneficial 
influence.  Occasionally,  when  a  day  was  permitted  to  pas.s  without  the  exhibition  of  the  specific,  the  teniperatiiie 
innnediatelj-  ran  up  to  101°  Fahr.  During  a  considerable  jxntion  of  the  time  the  daily  dose  amounted  only  to  ten 
grains:  but  when,  on  Xovember  14,  more  than  six  weeks  after  admission,  large  doses  were  administered,  the  disease 
was  immediately  controlled  and  convalescence  established.     The  accompanying  cliart,  constructed  from  Dr.  Hofk\s 


*  Report  on  the  lIiHjvne.  of  Hie  f.  .S.  .Irmii,  187."i,  |i,  4:'.4. 

t  T;tj<li"-ti4nl'iri'd  Fer<rr,  Ih'-  «..-.■,(//- -i  Munidiiiti  F*!f':r  I'f  the  Uorki/  ^folfntaiti  Uc<ji>ni. — H_v  J.  Van  K.  Hoff,  -If-Vi  .Sin;/.  U.  S.  A.,  Amerknn  Jour.  Meil.  -SfiVno 
-V.  S.,  V..1    LXXIX,  IS.SIJ,  p.  .'is  <(■««.;. 


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ETIOLOGY    OF   THE 


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M 

i(>coiil,  illustrates  the  effect  of  four  doses  given 
between  the  14th  and  19tli.  After  this  tlie  ease 
was  completed  witli  hardly  a  syniptoiii  worthy  of 
remark.  The  periods  of  administration  and  tlie 
(piantity,  in  {grains,  of  the  (|uiniue  which  pro- 
duced the  defervescence  are  indicated  on  the  face 
of  the  chart. 

In  ease  IV,  also,  the  febrile  action  was 
markedly  under  the  control  of  the  quinine  ad- 
ministered. 

Case  V  was  the  only  one  in  which  there 
was  a  distinct  approximation  to  the  status  typhn- 
»»».  The  patient  was  much  emaciated,  and  delir- 
ious on  admission  on  the  20th  day  of  the  attack, 
the  tongue  slightly  coated  in  the  centre,  clean 
and  pink  at  the  tip  and  edges.  During  lucid 
intervals  he  comjdained  much  of  headache;  his 
Tenip.mturo CUart of  Dr.  Huff's :!.l(;!i«>.  al)domen  was  tender  but   the  bowels  were  not 

relaxed.     While  improving  somewhat  in  his  general  condition  he  was  seized  with  symptoms  of  peritonitis  and  died 
November  11,  the  o2d  day  of  the  disease,  from  perforation  in  the  site  of  an  ulcerated  patch  of  the  intestinal  glands. 

In  all  these  cases  excepting  the  first,  the  convalescent  case,  there  were  chills,  fever  and 
perspirations  recurring-  with  greater  or  less  regularity,  and  these  were  of  such  a  character 
that  they  could  not  be  regarded  as  recrudescences  or  relapses  of  typhoid.  In  no  case  was 
the  ultimate  defervescence  effected  by  the  oscillations  of  decline  considered  characteristic  of 
typhoid  fever.  There  was  much  headache  in  all,  with  some  delirium  in  two  of  the  cases; 
diarrhoea  in  none, — on  the  contrary,  the  patients  were  all  more  or  less  constipated;  nor  did 
raeteorism  exist  in  anv  of  the  cases,  although  there  was  some  abdominal  tenderness;  the 
tongue  was  thick,  flaliby,  coated  at  the  base  but  clean  at  the  tip  and  edges;  the  breath  was 
offensive.  In  one  case  the  patient  said  lie  had  noticed  some  red  pimples  on  his  chest  and 
abdomen  about  the  sixth  dav  of  his  sickness,  and  in  this  case  Dr.  Hoff  observed,  about  the 
thirty-sixth  day,  on  the  chest  and  abdomen  a  papular  eruption  wiiich  remained  for  many 
days,  the  papules  meanwhile  increasing  in  number;  they  were  of  a  bright-red  color,  [tain- 
less  and  disappeared  on  pressure.  In  two  of  the  cases  there  was  acute  nasal  catarrh  and  in 
three  herpes  labialis;  convalescence  was  rapid;  the  hair  did  not  fall;  moreover,  c|uinine 
seemed  to  exert  a  specific  rather  than  an  antipvretic  influence.  Here  are  none  of  the  char- 
acteristic signs  of  typhoid  fever;  on  the  contrary  several  are  inconsistent  with  the  generally 
accepted  clinical  history  of  that  fever.  All,  however,  agree  with  the  records  of  a  subcon- 
tinued  malarial  fever  modified  by  inefficient  spe<-'ific  medication. 

The  malarial  element  in  all  may  lie  granted;  but  Dr.  Hoff  claims  that  since  a  specific 
typhoid  was  present  in  the  fatal  case,  it  must  have  been  present  likewise  not  only  in  the 
other  cases  that  occurred  in  this  command  but  in  all  <jther  cases  of  so-called  mountain  fever. 
He  considers  it  reasonable  to  assume  that  the  external  causes  of  disease  are  identical  when 
tlie  outward  conditions  of  the  patients  are  similar.  Believing  that  this  will  be  conceded  he 
argues  that  the  diseases  known  under  the  name  of  mountain  fever  have  no  essential  differ- 
ences, and  since,  in  his  fifth  case,  the  disease  was  truly  typho-malarial,  all  mountain  fever 
cases  must,  therefore,  be  typho-malarial.  But,  as  we  know  by  our  war  experience,  the  out- 
ward conditions  of  the  patients  in  cases  of  adynamic  remittent  and  continued  fevers  were 
frequently  so  .sirnilar  to  those  of  typhoid  fever  as  to  be  indistinguishable  from  them.  To 
concede  that  these  cases  were  due  to  the  sanie  external  causes  is  impossible  without  allowing 
the  identity  of  the  malarial  and  typhoid  poisons;  and,  in  view  of  our  present  knowledge  of 
these  poisons,  this  would  be  absurd.    The  same  argument,  rallying  on  ilie post-mortem  appear- 


CONTINUED    FEVERS.  525 

ances  reported  by  Caestens,  White  and  Worthington,  us  pertaining  to  the  typlio-malarial 
lever  of  civil  life,  would  lead  to  the  equally  false  conclusion  that  there  is  no  tyjihoid  element 
in  this  fever.  In  both  instances  the  erroneous  conclusion  is  the  result  of  the  inadmissible 
assumption  introduced  into  the  argument-. 

The  clinical  experience  of  our  medical  ofHcers  in  tlio  Westei'u  Territories  from  (he  time 
of  the  overland  invasion  of  the  gold  fields  of  California  cannot  be  offset  by  a  case  of  death 
from  typhoid  perforation  of  the  intestine.  Twenty  years  before  Dr.  HoFF  recordetl  tliis  case 
Bartholow  reported  similar  cases  with  the  'post-mortem  appearances  in  every  instance  indi 
eating  the  presence  of  specific  typiioid  fever, — indeed,  there  are  few  W<^stern  posts  from 
which  typhoid  fever  has  not  been  re})orted;  but  this  does  not  appear  to  have  hnl  our  medical 
officers  or  the  civilian  practitioners  in  that  part  of  the  country  to  believe  that  all  the  febrile 
cases  coming  under  their  observation  are  cases  of  specific  typhoid, — on  the  contrary  they 
recognize  the  prevailing  fever  to  be  a  malarial  remittent  on  account  of  its  amenability  to 
quinine  and  its  persistence  in  the  abseiu^e  of  antiperiodics.  Tlie  rarity  of  fatal  cases  at 
present,  when  medical  attendance  and  quinine  can  be  had  in  almost  all  parts  of  the;  country, 
as  compared  with  the  fatality  of  the  disease  in  the  early  davs  of  settlement  and  overland 
emigration,  when  the  means  of  treatment  were  unattainable  or  ndsunderstood,  points  It)  the 
absence  of  the  typhoid  element  in  the  majority  of  the  cases;  in  fact,  the  present  death-rate 
is  alone  sufficient  to  show  the  absence,  as  a  geiiei'al  rule,  of  a  specific,  typhoid  fever. 

Nevertheless,  it  is  probable  that  in  most  of  the  fatal  cases  of  fever  in  the  li,ockv  INbiuii- 
tain  region  typhoid  ulcerations  will  be  discovered  notwithstanding  the  greatiT  ]irevalenc(;  of 
malarial  remittents  in  the  locality.  It  has  been  already  pointed  out  that  altiiough  malarial 
remittents  during  the  war  predominated  over  typhoid  in  the  proportion  of  3.7  to  1,  the 
chances  in  favor  of  discovering  t\'phoid  lesions  in  a  fatal  case  ol'  low  fever  wi'i'e  as  high  as 
7  to  1 ,  and  that  in  the  third  year  of  flic  war,  when  the  great  ty]ilioid  epidemics  had  sulisideil 
and  the  remittents  outmunbered  the  typhoid  cases  more  than  sixfold,  the  chances  were  still 
5.4  to  1  in  favor  of  the  discovery  of  specific  lesions  after  death  from  a  low  form  of  fever.* 
The  fatal  cases  do  not  therefore  indicate  the  nature  of  the  prevailing  disease  in  the  febrile 
cases  under  discussion. 

Where  facilities  for  post-mortem  observation  are  to  l)e  found  there  are  usually  also 
facilities  for  treatment  that  give  the  malarial  case  a  more  desirable  termination,  ft  is  among 
the  hunters,  herders  and  prospectors  who  fall  victims  at  a  distance  from  medical  aid  that  post- 
mortem illustrations  of  the  formerly  fatal  malarial  remittents  are  to  be  expected,  but  in  such 
cases  the  investigation  can  seldom  be  made.  Moreover,  it  iiuist  be  remembered  that  the 
negative  character  of  i\\e  j^ost-mortem  testimony— in  cases  where  typhoid  fever  is  not  j)res- 
ent — deprives  it  of  one  of  the  methods  of  record,  that  by  preservation  of  the  specimen. -|- 

The  sanitary  environment  of  the  miners,  lumbermen,  pros2)ectors,  surveyors,  herders, 
settlers  and  soldiers  on  scouting  duty,  who  are  the  chief  sufferers  from  this  mountain  fever 
of  the  West,  has  been  and  even  now  is  similar  to  that  of  our  troops  during  the  war.  They 
are  subject  to  great  fatigue,  exposures  by  night,  climatic  and  weather  changes,  with  imper- 
fect, badly  constructed  and  oftentimes  overcrowded  shelters,  deficient  clothing  and  bedding, 
monotonous  and  sometimes  scanty  diet  and  impure  water  supplies.  Naturally  we  should 
expect  to  find  the  same  diseases  developed  in  both  classes  of  men,  and  it  is  contended  here 

*  Supra^  page  375. 

f  Probably  ffw  niediral  men  would  mount  and  preserve  a  piere  of  apparently  sound  ileum  by  way  uf  illustrating  its  condition  in  a  case  of  so-called 
typho-malarial  fever  as  was  done  by  Dr.  G.  B.  Eali-h,  of  "i'onliers,  S.  Y. 


526  ETIOLOGY    OF    THE 

that  this  expectation  is  realized;  that  there  is  aggregated  under  the  term  niountain  fever  the 
malarial  and  typhoid  fevers  and  the  association  of  botli  that  constituted  tlie  camp  tiivers  of 
the  war.  The  application  of  the  term  typho-malarial  to  tliem  is  iu  principle  as  much  to  be 
deprecated  as  its  original  introduction  in  1862,  when,  as  has  beeu  seen,  it  gave  official  license 
to  confound  together  febrile  conditions  which,  to  be  studied  with  satisfaction,  shouhl  have 
been  left  apart. 

Important  practical  results  hinge  upon  the  application  or  disuse  of  this  term.  To 
authorize  its  application  is  to  acknowledge  the  inability  of  rpiinine  to  remove  the  disease, 
and  cases  which  might  have  been  cured  in  a  few  days  will  terminate  fatally,  as  in  tlie  first 
of  those  reported  by  Surgeon  Geo.  A.  Otis,  U.  S.  Army;'^'  or  the  unnecessary  prolongation 
of  the  attack  will  exert  a  dangerous  strain  on  the  constitution  of  the  individual,  as  is  plainly 
illustrated  by  the  third  of  Dr.  Hoff's  own  cases. 

From  this  brief  survey  of  the  use  of  the  term  typho-malarial  since  the  war,  it  is  seen 
that  although  a  more  accurate  knowledge  of  the  restrictions  on  its  application  has  been 
acquired  by  the  profession  than  was  possible  during  the  war,  it  is  still  capable  of  involving 
in  uncertainties  the  cases  to  which  it  is  applied  uidess  associated  in  every  instance  with  an 
explanation  of  the  views  that  dictated  its  use.  If  the  term  be  retained  in  our  medical  nomen- 
clature it  should  be  restricted  to  typhoid  fever  modified  by  acute  malarial  manifestations. 
Preferably  it  should  be  abandoned.  Its  use  daring  the  past  twentv  years  has  tended  to  the 
detriment  of  individual  cases  and  the  retardation  of  medical  progress.  At  the  yiresent  day 
we  are  ready  to  fall  back  to  the  position  occupied  before  the  war,  arranging  these  continu('(l 
fevers  for  clinical  as  well  as  scholastic  jiurposes  into  the  tlu'ee  classes: 

Ephemeral  and  continued  fevers,  the  causes  of  -which  are  obscure,  some  being  apparently  due  to  overfatigue  and 
exposure,  others  to  emanations  into  air  and  percolations  into  water  from  cesspools,  sewers  and  other  hotbeds  of 
fermentative  action ; 

Typhoid  fever,  a  specitio  fever  of  miasmatic  origin,  propagated,  especially  iu  older  settlements,  by  various  modes 
of  indirect  infection, 

And  malarial  fevers,  due  to  a  spccilic  and  extensively  diffused  miasm  practically  free  from  infectious  qualities. 

Eventually  niodical  men  will,  no  doubt,  become  able  to  discriminate  between  an  obscui'e 
case  of  typhoid,  a  cessjiool  fever,  complicated  or  not  with  malarial  manifestations,  and  a  con- 
tinued or  remittent  malarial  fever  which  has  assumod  a  tvphoid  ty|)e;  but  this  assuredly 
will  not  be  hastened  by  confounding  all  such  cases  in  the  meantime  under  the  title  of  tyjjho- 
malarial. 

v.— TYPHUS  FEVER. 

Although  most  of  the  cases  reported  under  tliis  heading  by  medical  officers  serving  with 
troops  in  tlie  field  were  probably  ty[ihoid  fevers  aggravated  by  malai-ial  complications  anil 
an  insanitary  environment,  it  is  impossible  to  dispose  in  this  manner  of  the  epidemic  that 
affected  the  Salisbury  prisoners  at  Wilmington,  X.  C.  This  disease  must  liave  been  typhoid, 
malarial,  typhus  or  some  unknown  malignant  fever  of  unusual  character  and  peculiar  origin. 
The  last  supposition  cannot  be  entertained  in  the  absence  of  positive  and  affirmative  testi- 
mony to  some  at  least  of  its  unusual  characteristies.  The  rapid  spread  of  the  disease  to  th(^ 
garrison  and  citizens  of  AVilmuigton  is  inconsiste'nt  with  our  ex]X'rience  of  typhoid  exce|>t 
as  suddenly  propagated  ly  the  eMuiaminatioii  o'i  a  general  water-supply;  but  we  are  leu 
to  understand  that  the  main  fa.-tor  in  the  extension  of  this  epidemic  was  a  direct  contagion 
from  the  sick  to  the  well.      Medical  olficei-s  in  attendance  were  taken  sick  and  died;   most 


527 

CONTINUED   FEVERS.  ' 

of  tliB  men  employed  on  the  steamers  used  in  tlie  transportation  of  tlie  prisoners  to  \V  d- 
mington  suffered  from  the  fever;  even  isolated  settlements  in  the  surroundmg  country 
were  invaded  by  the  disease  through  the  medium  of  negroes  seeking  safety  by  flight  from 
the  contagion  of  the  camps  and  city.  i\Ioreover,  the  infection  of  so  large  a  proportion  of 
the  lOTsoners,  3,400  out  of  8,600.  with  typhoid  is  inconcx'ivable,  for  most  of  these  men  must 
have  been  insusceptible  to  the  disease  by  virtue  of  the  exposures  incidental  to  their  service 
before  capture  together  with  tlie  even  greater  e.xposures  to  the  typhoid  miasm  that  attended 
their  period  of  confinement,  liemitteiit  fevers  were  common  in  that  dejiartment,  and  MoRK- 
HEAD  refers  to  an  adynamic  remittent  fever  of  suspected  infectious  character;'^  but  had  the 
fever  that  affected  and  spread  from  the  prisoners  been  of  a  malarial  nature  the  mild(>r  ot  tlu; 
epidemic  cases,  by  their  amenability  to  quinine,  would  liave  tlmtwn  light  upon  the  more 
serious  cases.  Medical  officers  who  had  served  for  four  years  in  malarious  localities  would 
assuredly  have  demonstrated  the  character  of  this  fever  if  it  had  been  a  malarial  remittent. 
It  must,  therefore,  have  been  a  true  typhus,  as  diagnosticated  by  Dv.  Hand  and  the  medical 
officers  serving  with  him  during  the  epidemic.  Moreover,  this  view  appears  to  have  the 
support  of  the  few  post-mortem  investigations  tliat  were  made. 

It  may  be  well,  before  proceeding  further,  to  submit  what  is  known  with  regard  to  the 
history  of  these  men  prior  to  their  appearance  at  Wilmington.  The  records  of  this  office 
are  silent  on  the  subject;  but  fortunately  the  Report  of  the  Committee  of  tlie  40th  Congress 
on  the  treatment  of  Prisoners  of  War  by  the  llrbcl  Authorities  gives  much  iiiforniaticn  con- 
cerning their  condition,  containing  among  other  papei-s  a  rejiort.  of  an  insp(>clioii  made  by 
Captain  T.  G.  Hall,  under  orders  ti'om  tiie  Confederate  War  I)epartment  and  at  the  instance 
of  Governor  Vance,  of  North  Carolina,  on  February  17,  1865,  a  few  days  before  the  pris- 
oners were  exchanged. 

The  priisoii  at  Salisliiiry,  N.  V...  consistcil  of  a  luick  factory  four  Ktoiirs  luf;li,  foity  liy  oiii'.  liiiiidri'il  fiTt,  with 
fivd  buiWiiifis  foniicrly  usrd  as  hoardiiif^  houses  for  thr  o]iiMa lives.  A  lioaril  fl■Ill■l^  siii'loMiidcil  tlic  liiiildiiifis,  I'lichisiiif; 
at  tii'st  tivo  acii'S  of  f;''""ii"l!  a  spai'c  afterwards  eiilar{;e<l  to  eleven  aeri's.  In  Oetolier,  IX(>I,  ten  thousand  men  were 
sent  to  this  deiiot,  erowding  tlie  enclosure  to  Its  n  I  most  caiiacity.  The  linlldint;s  wen^  soon  11  lied  with  I  he  sud;  and 
dyinj;.  Those  who  were  nnable  to  olitain  admission  renniined  wilhont  shelti'r  oilier  than  one  Sildey  tent  for  each 
hundred  men,  and  were  ex|)Osed  to  the  rigors  of  the  followiii};  winter.  Altera  little  while  they  wi'iit  to  iligging  hides 
and  tunnels  in  the  ground  with  any  toids  tliey  eould  procure,  such  as  ease-knives  and  liroken  canteens.  In  these 
holes  tliev  slept  at  night  and  staid  most  of  the  dayl  inie.  The  soil  was  a  si  ill'  tenacious  clay  which,  after  a  rain  or 
snowfall,  liecanie  converted  into  a  i)erfect  bog  and  remaineil  wet  for  a  long  time.  No  elliciiuit  details  were  made  for 
the  purpose  of  policing  the  grounds;  filth  of  every  kind  was  allowed  to  be  deposited  and  to  remain  anywhere  and 
everywhere  around  the  <iuarters,  unsightly  to  the  eye  and  generating  ort'ensive  and  no  doubt  dangerous  odors.  It 
was  considered  that  in  warm  weather  the  sinks  would  not  fail  to  prove  a  source  of  great  annoyance  and  ])ossibly  of 
pestilence  not  only  in  the  yirison  but  in  the  town  of  Salislmry.  The  regular  ration,  according  to  one  of  the  prisoners 
who  testitied  before  the  conlmitte(^,  was  bread,  rice  and  soup,  the  bread  licing  sometimes  made  of  cornmeal,  some- 
times of  cornmeal  ground  from  the  cobs  as  well  as  the  grain  ;  wlieaten  and  mixed  breads  werealso  issued.  T'lie  ration 
of  bread  was  from  four  to  eight  ounces;  of  sou]i  about  half  a  jdnt.  Oc<asionally  a  few  s]ioon  fills  of  molasses  and  now 
.and  then  soino  small  potatoes  were  aibled  to  the  ration.  About  two  ounces  of  nn'at  were  issued  once  in  six  or  ten 
days.  Inspector  (ieneral  Hall's  account  of  the  ration,  derived  from  a  statement  on  )>aper  of  the  amounts  issued  between 
February  1  and  l"),  is  somewhat  different  in  its  tenor,  '■('omiiared,"  he  says,  "in  iiiiantity  and  kind  with  the 
rations  issued  to  our  own  troops  in  the  lield,  it  will  be  seen  that  on  this  score  tliejirisoners  have  no  cause  to  complain. 
The  rations  are  cooked  before  they  are  issued,  and  pains  have  been  taken  by  (ieneral  John.son  to  see  that  no  frauds 
are  committed  in  this  department  to  the  injury  of  the  prisoners.     Bread  and  meat  (or  sorghum  in  lieu  of  meat)  are 


*  Researches  on  hisettse  in  Intlifi,  by  Charles  Moiifheaii,  Lontloii,  18rt(1.  i>.  !">.').  Itc  is  (if  (tpinitin  tlmt  nialHriiil  O'ViTs  iirc  fns<'*'|itit»I('  nf  (issiiniiiiK  an 
adynamic  type  from  the  state  of  the  rmistitution  of  tlif  indiviihial  .ittackeii  ami  inferti<»iis  prnpi-rtii-s  frimi  tiltli,  crowilins  anil  bad  vcntiiatiim  in  lii>n.srft 
and  villages.  Clark  and  LlNp  held  the  sanie  views.  AlthuuKh  the  Kn-ater  attenti<ni  paid  In  rIeanlilM'ss  and  ventiiatiuii  in  reeeiit  times  has  peliiTally 
prevented  any  develeimient  of  infection  in  eimneetion  with  remittent  fevers,  (M-easional  instanees  have  been  reetirded  :  Fruin  isl.',  to  Is-Jll  an  adynamic 
febrile  disease  prevailerl  at  Kattywar,  Kiitcli  and  parts  of  c;n/.erat.  A  similar  alTection  at  I'ali  in  Marwar  in  .Inly,  lS:i(i,  extended  to  the  towns  in  the 
adjacent  districts  nj)  to  the  middle  of  18;i8.  Dr.  Forbes  descrit>es  the  di.si'ase  as  seen  by  him  at  Pali  in  1S4H. — Trans.  Meilicaland  Phynenli^wietij  «i  liomhuij. 
So.  2,  p.  14.  His  deserilition  bears  much  resemWame  to  that  kIvimi  by  I'Ri.vcii.E  of  jail  or  hospital  fever.  The  fever  was  recarded  as  infections,  bat  in  no 
great  degree  unless  tliere  had  been  continued  exposure  to  the  emauatiuiis.  This  infectious  remilteut  was  observed  in  IMU  in  tiurhwal,  in  Kumaoii  and 
in  1^^  in  Bohilcuud. 


528  ETIOLOGY   OF   THE 

Issued  every  morning,  rice  or  i>ea-sonp  iu  the  afternoon.  The  bread  which  I  inspected  in  the  hakery  was  of  averajje 
quality  and  of  the  average  weight  of  tive  iioiiuds  to  the  double  loaf.  A  half  loaf,  therefore,  the  daily  allowance  of 
each  prisoner,  will  average  twenty  ounces  of  bread,  the  eciuivalent  of  sixteen  ounces  of  tiour."'  The  water-supply  was 
limited  and  iu)t  more  than  surticient  for  cooking  and  drinking  purposes.  It  was  derived  from  wells  in  the  yard  and 
from  a  cr<'ek  about  half  a  mile  distaut,  to  which  the  prisoners  were  penuitted  to  go,  a  certain  number  at  a  tiiue,  under 
guard,  with  buckets  and  barrels.  The  want  of  a  running  stream  within  the  prison  enclosure  for  purposes  of  washing 
and  general  sewerage  was  greatly  felt.  The  persons  of  the  men  were  dirty,  their  clothing  filthy  and  ragged.  They 
suffered  more  than  from  any  other  cause  from  the  want  of  sufficient  and  suitable  clothing.  They  were  generally  desti- 
tute of  blankets  and  had  no  other  clothing  than  that  which  they  had  on  at  the  time  of  their  capture.  Shortly  before 
Hall's  inspection  three  thousand  blankets  and  one  thousand  pairs  of  trousers  had  been  received  from  the  United 
States  for  distribution  auiong  them;  further  sujiplies  were  expected.  One  of  the  most  painful  features  connected 
with  the  i)rison  was  the  absence  of  adecinate  provision  or  accommodation  for  the  sick.  With  few  exceptions  all 
the  l)uilding8  in  the  prisou  yard  were  used  as  hospitals.  There  was  an  entire  absence  of  hospital  comforts,  bedding 
and  necessary  utensils.  The  reason  assigned  for  this  was  that  the  articles  if  supplied  would  be  inevitably  stolen, 
since  no  guaril  was  kept  inside  the  prison  enclosure.  The  nund>er  of  sick  iu  hospital  on  February  15  was  olt). 
There  were  bunks  for  not  more  than  one-half  of  this  number;  the  rest  lay  on  the  ffoor  or  ground  with  nothing  over 
them  but  a  little  straw  which  had  not  been  chauged  in  four  weeks.  For  a  period  of  nearly  one  mouth  in  Deceuiber 
and  January  the  hospitals  were  without  straw,  although  the  county  (Rowan)  was  one  of  the  largest  wheat-growing 
counties  of  the  State  and  thirty  horses  were  standing  idle  in  the  prison  quartermaster's  stable.  The  supply  of  fire- 
wood was  also  needlessly  limited.  From  Oct.  5,  18(34,  to  the  date  of  Captain  Hall's  inspection  there  died,  according 
to  the  surgeon's  rei>ort,  2,t'18  of  10,321  prisoners;  but,  according  to  the  burial  report,  since  Oct.  21,  1864,  a  less  period 
by  sixteen  days,  3,479  bodies  had  been  buried.  This  discrepancy  was  explained  Tiy  the  fact  that,  in  addition  to  the 
deaths  in  hospital,  six  or  eight  meu  died  daily  in  quarters  without  the  knowledge  of  the  surgeons  and,  of  course, 
without  medical  treatment.  Pneunu)nia  and  bowel  affections  were  the  prevailing  diseases;  but  the  prisoners  appeared 
to  die  more  from  exposure  and  exhaustion  than  from  actual  disease. 

The  experictiee  of  mtiny  years  and  many  epidemics  Iras  demonstrated  tlie  connection 
between  poverty,  famine  and  their  tittending  conditions  on  the  one  liand  and  tlie  jjrevalence 
of  typlms  fever  on  tlie  otlier.  In  Ireland  the  worst  developments  of  this  fever  have  always 
occurred  as  a  sequence  to  failures  of  tlie  food-supply.  Within  the  enclosure  at  SaHsbury 
there  was  an  accidental  or  artificiallv  induced  poverty,  whicli,  however,  was  attended  with 
all  tlie  exposures  and  hardships  that  belong  to  the  condition  when  resulting  from  natural 
famine  causes.  Whether  the  ration  of  bread  was  twenty  ounces,  as  reported  by  the  con- 
federate inspector  from  the  official  ration  returns  of  the  prison,  or  six  to  eight  ounces,  according 
to  the  evidence  of  some  of  the  consumers,  it  is  certain  that  the  men  confined  iu  this  prison 
bore  tlie  impress  of  semi-starvation  on  their  arrival  in  New  York,  although  in  the  meantime 
every  effort  at  recuperation  had  been  made  by  the  United  States  authorities  and  the  U.  S. 
Sanitarv  Commission.  Tliey  had  thus  been  exposed  to  one  of  the  most  powerful  influences 
that  predispose  to  typhus  fever, — but  not  more  so,  indeed  not  sd  much  so,  as  tlie  unfortunates 
at  Andersonville,  among  whom  typhus  did  not  mak(.>  its  ap}ietirance.  Famine,  therefore, 
while  strongly  predisposing  to  the  development  of  the  fever  wtis  not  the  essential  element 
in  its  causation. 

But  some  of  the  conditions  associated  with  famine,  as  filth,  personal,  domestic  ami  civic, 
from  want  of  facilities  and  energy,  overci'owding  fi-oiu  deficiency  of  shelter,  and  in  cold 
weather  the  inhibition  of  ventdation  c(jnset:|Uent  on  insullicient  (dothiiig  and  fuel,  have  been 
shown  to  be  more  intimately  connected  with  the  dev(dopiiient  of  the  disease  than  the  famine 
itself,  inasmuch  as  in  its  absence  they  alone  have  tijipcared  sufficient  in  some  insttiiices  to 
determine  an  outbreak  of  the  disease.  Indeed,  m;iii\'  writers  of  the  past  consideretl  the 
fever  to  orighiate  in  a  human  miasm  generated  under  the  conditions  mentioned.  Thus,  they 
explained  its  appearance  in  crowded  jails  before  the  assizes  which  were  to  dispose  of  their 
inmates;  in  slave,  emigrant  and  ti'onp-ships;  m  barraidvs  and  in  the  overcrowded  and  filthy 
slums  of  large  cities  before  air-space,  ventilation  and  cleanliness  were  recognized  as  efficient 
ao-ainst  what  was  po]>ularl}'  regarded  as  a  visitation  of  Providence.  Many  medical  men, 
liowever,  at  the  present  dav.  although  regarding  these  conditions  as  favorable  to  the  devel- 


CONTINUED    FEVER?. 


529 


opment  and  spread  of  the  disease,  consider  tliern  incompetent  to  generate  it  in  the  absence 
of  the  contagion  from  a  previous  case.  One  of  our  hitest  writers  *  states  that  there  are  cer- 
tain endemic  centres,  such  as  Irekmd,  Ttalv  and  liussia,  and  that  wlienevertlie  disease  occurs 
in  other  localities  it  is  due  to  importation:  Imt  this  conclusion  is  derived  from  the  investi- 
gation of  one  epidemic  in  New  York  Citv,  which  was  traced  back  to  Ireland  fi'om  Ixdlevue 
hospital  by  way  of  a  Mulberry  street  tenement  house  and  a  transatlantic  immigrant. 

On  the  other  hand,  medical  literature  is  full  of  illustrations  of  the  outbreak  of  tlie  dis- 
ease, under  the  conditions  mentioned,  where  the  previous  case  can  only  be  admitted  upon  the 
most  absurd  assumptions.  The  germ  theory  has,  during  recent  years,  done  much  to  clear 
away  obscurities  surrounding  the  causes  of  certain  diseases,  and  the  results  ha\e  been  inval- 
uable to  preventive  medicine;  but  there  is  a  danger  that  the  enthusiastic  adoption  of  this 
theory  in  all  cases  of  specific  disease  may  lead  to  error.  The  facts  in  the  case  of  tyi>hus 
fever  are  such  that  at  one  time  Lebert  believed  in  its  spontaneous  origin. f  He  explained 
in  this  way  certain  facts  observed  in  the  Crimean  war,  as  its  rapid  and  unexpected  origin 
before  Sebastopol  with  the  occurrence  of  tlie  cold  damp  season,  its  breaking  out  in  a  war 
vessel  fifty  days  after  her  departure  from  Kamiesch,  and  many  other  sudden  and  unexpected 
outbreaks  unconnected  with  any  probable  mode  of  importation  or  transmission  from  a  pre- 
vious case.  Recently,  however,  he  has  changed  his  oi>inion,  considering  that  these  facts 
admit  of  another  explanation  :  '"Small  quantities  of  typhus  germs  may  have  remained  latent 
in  these  places,  or  their  importation  may  have  taken  place  iVom  typhus  regions  by  inlecled 
articles,  which  may  have  escaped  the  closest  scrutiny.  Tiiis  cliange  of  opinion  is  not  based 
upon  any  new  information  afTecting  the  observed  facts,  but  on  a  consideration  of  the  incon- 
sistency of  a  spontaneous  origin  with  the  doctrine  of  tlu'  germ  theory.  Will  kncnvh'dge  and 
lingering  wisdum  be  I'l'aclied  in  this  way, — by  assorting  facts  to  si'cui'o  umlni-mity  In  precon- 
ceived ideas, — nr  must  we  aerejit  them  as  thev  are?  W'liei'e,  Inr  mstam-e,  are  W(!  i<>  Imik  toi' 
the  previous  case  tliat  gave  birth  to  tli<'  epidemic  among  the  t^alisbury  prisoners  on  their 
liberation  from  the  prison  eni-losure?  if  typhus  fever  existed  at  that  time  in  tlu}  Ignited 
States  of  America,  the  cases  were  few  in  ninnber  and  conrmed  (o  nortliern  cities  hundreds  ot 
miles  tVom  the  [ilaee  of  captivity  of  these  men,  and  sepai'ated  iroui  it,  by  the  lines  ot  hostile 
armies.  The  confederacy  itself  was  in  fact  at  that  time  cut  off  IVoiii  connnunication  witii 
the  outer  world  as  effectually  as  were  its  pristmers  at  Salisbury.  The.sc  unfortunates  were 
so  thoroughly  guarded  against  the  intrusion  of  typlius  fever  that  if  the  disease  api)eared 
among  them,  and  there  seems  no  doij^it  of  the  fact,  it  originated  fiom  causes  that  were  in 
operation  witliin  the  limits  of  their  stockade. 

At  first  sight  it  is  diificult  to  say  why  the  Salislnu-y  prisoners  should  have  been  taken 
with  typhus  while  those  at  Andersonville  were  spared.  The  condition  and  environment  of 
both  bodies  of  men  were  similar  in  character:  Both  were  exposed  to  the  inclemencies  of  the 
weather  with  scanty  and  ragged  clothing,  insufficient  shelter  and  food;  and  both  sufTered  in 
consequence.  Both  were  filth v  in  the  extreme  and  closely  packed  within  their  stockades. 
Both  were  similarly  deficient  in  hospital  accommodations.  Patients  died  in  camp  in  holes 
in  the  ground  and  were  buried  unknown  to  the  hospital  surgeons.  Admission  to  hospital 
brought  with  it  but  little  improvement  in  their  mode  of  life;  many  of  them  had  to  lie  on  the 
floor  or  ground  without  blankets  and  without  straw.      But  there  was  one  important  difterence 


*A  Te-rl-took  of  Priwtical  MtHicme,  by  A.  L.  LOOHIS,  New  Y..rk,  l.-M.  |..  71 1.     S..'  ^ils.,  Iiis  Lerlnres  I'li  h'enn,  N.'W  York,  1ST7,  [i.  212. 
f  See  his  article  on  thi*  disease  in  the  Fir^t  Volutm  of  the  Atm-ri>-<ui  Trau.^t<ili"if  'f  Zk  »!>■>•■  x's  ( •>i<'l<'i„:ilin,  p.  ;itM;. 

Med.  Hist.,  Pt.  Ill— 67 


530  f.ttoloctY  of  the 

in  the  hospitals  of  tlie  two  ramps:  At  Anderson viUe  tlie  hospitals  consisted  of  some  tattered 
tents  and  unfinished  harrack  sheds,  rooted  and  floored,  hut  open  at  the  sides, — practically, 
the  patients  were  in  the  open  air.  At  Salishury  the  hospital  building  consisted  of  a  four- 
story  lirick  factory  and  some  smaller  huildings  formerly  used  as  boarding-houses  for  the 
factory  operatives, — practically,  patients  crowdetl  into  tlie  rooms  of  these  buildings  wei'e 
under  the  precise  conditions  that  have  so  otten  been  recognized  as  productive  of  typhus  fever. 
What  the  amount,  of  ci'owding  may  have  been  if  exjtressed  in  air-s]iace  per  patient  is 
unknown,  and  probably  if  known  would  be  of  little  value,  as  the  foulness  of  the  air  in  a,  room 
occupied  by  a  number  of  inmates  depends  more  upon  deficient  ventilation  than  upon  a  few 
hundred  feet  of  air-space  more  or  less  per  man.  In  accordance  with  what  is  known  of  the 
management  of  these  prison  hospitals  we  may  suppose  that  the  floors  of  the  rooms  occupied 
by  the  sick  were  well  covered.  The  point  to  be  considered  is,  that  during  the  cold  winter 
weather  of  the  occupation  of  the  prison  the  shivering  patients,  without  blankets,  without 
even  straw  and  with  a  deficient  supply  of  fuel,  would  be  more  likely  to  stifle  in  the  vitiated 
atmosphere  that  had  been  warmed  by  their  own  bodies  than  to  throw  open  the  windows  and 
effect  such  a  ventilation  of  the  room  as  was  possible.  During  the  typhus  epidemic  of  the 
Crimea  the  months  of  prevalence  were  those  in  which  the  soldiers  shut  themselves  up  in 
their  quarters  in  seeking  protection  from  the  external  cold;  the  months  of  decadence  of  the 
disease  were  those  in  which  the  weather  coneluced  to  free  ventilation  and  an  open-air  life. 

Wliether  the  disease  was  generated  in  some  of  the  pris(3n-wards  at  Salisbury  is  of  course 
unknown,  Imt  on  this  theory  only  can  its  subsequent  epidemic  development  be  explained. 
The  fever  might  have  caused  frequent  deaths  among  the  inmates  of  an  infected  ward  without 
attracting  special  notice,  so  great  was  the  indifference  of  the  Confederate  authorities  at  these 
prison-pens  to  loss  of  life  among  their  prisoners,  and  without  spreading  to  the  occupants  of 
the  enclosure,  protected  as  they  were  from  contagion  by  their  open-air  life;  but  when  the 
prisoners  were  packed  with  these  typhus  foci  on  the  trains  which  were  to  convey  them  to 
North  East  on  the  Cape  Fear  River,  and  were  subsequently  repacked  on  the  small  river 
boats  for  transmission  to  Wilmington,  every  facility  was  aflPorded  the  disease  to  spread  from 
man  to  man  and  appear  as  a  generally  diffused  epidemic  on  their  arrival.  Their  subsecjuent 
distribution  among  the  hospitals  and  barracks  of  Wilmington  suffiriently  accounts  i\>v  tlie 
extension  of  tlie  disease  to  the  citizens  and  local  garrison.  Cases  occurred  among  men  who 
were  considered  fit  to  travel  northwards  to  their  homes;  but  as  these  made  the  journey  in 
well-ventilated  and  thoroughly  appointed  hospital  transports  the  disease  did  not  spread, 
although  those  primarily  affected  were  delivered  at  David's  Islanrl,  New  York  Harbor,  suf- 
fering, according  to  Medical  Inspector  George  II.  Lyman,  U.  S.  A.,  from  a  disease  which  in 
its  essential  features  resembletl  true  typhus  more  than  any  <jther  ft-ver  he  had  ever  met  witli.^' 

On  this  view,  not  famine,  filth  nor  overcrowding  is  the  essential  element  in  determin- 
ing the  evolution  of  typhus  fever,  but  the  cmicentration  of  the  human  emanations  developied 
by  those  in  confined  and  un  ventilated  spaces.f     There  was  no  typhus  in  our  Northern  prisons 


*  See  siipra,  page  3.3.'J. 

t  JAf<jVOT,  from  his  exiM-rienco  of  the  ('rinicHii  fi»id"-mir,  waa  so  strini^I.v  iitiprcssed  with  tlie  i-i«.iitaneoiis  nrij^Iii  of  typlius  from  -a  Iniiiian  miasm 
under  sueh  eonditiotis  as  liave  been  mentionetl  in  tlie  text  that  he  wrote  of  the  disease  :  We  rmt  ijpverntt^  it  nt.  trilL  "tin  |H'nt  faire  naitre  le  typhus  a 
Vfdutite,  pour  alusi  dire  ;  rien  dr-  jiari-il  pour  la  fievre  typho'ide." — iHi  Tijphtm  df  V.-irmt'e  d' fh'ii-nt,  Paris,  18.58,  p.  :tO."i,  Gt'tl.l.KMlN  states  that,  contmry 
to  the  opinion  commonly  entertainf^ii.  typhns  <w.rurred  in  the  city  of  Mi-tz  dnrins  the  siege  of  187"..  Physicians  practicing  there  W(;n!  almost  unanimous 
upon  this  question  ;  and  some  of  them,  who  ha'l  forme. riy  t»een  in  the  army,  had  studied  the  disease  during  the  ( 'i-irncan  w  ar.  It  never  hecaTite  general  nor 
a.ssinned  the  gravity  observed  in  the  ("rini'.a  or  .\lgeria  for  the  suflicient  reason  that  its  causes  had  not  been  either  so  long  in  action  or  so  intense. 
5U:rv  is  cited  as  sjtying:  "I  saw  tlnjre  {in  Met/,)  the  diw-ase  pursuing  the  same  course  that  it  followed  on  its  apparition  iTi  the  Crimea  in  18.'i4-.'>.'.,  and  if 
the  Mo<:kade  had  continued  longer  we  should  have  had  a  secuud  editioQ  of  the  Crimean  disaster." — See  The  I*raclUioner,  London,  Vol.  XII,  1874,  p.  2'.M. 


CONTINUED    FEVERS.  531 

undoiihtedlv  because  the  needful  concentration  was  nut  effected.  Our  pavilion  barrack- 
bulldintrs,  althouo-li  generally  provided  with  three  tiers  of  beds  and  frequently  affording  only 
200  cubic  feet  of  space  per  man,  had  always  some  atteinjit  at  ventilation,  usually  by  the 
rido-e;  and  were,  niureover,  oftentimes  satisfactorily  ventilated  by  the  very  imperfections  of 
their  constructiun.  Nevertheless,  in  many  such  overcrowded  quarters  a  malignant  character 
was  assumed,  especially  by  typhoid  fever  and  acute  malarial  and  pulmonary  diseases,  which 
obscured  thi'ir  clinical  features  and  rendered  their  diagnosis  from  true  typhus  a  matter  of 
difficulty.*  And  in  certain  of  these  instances  even  the  suggestion  of  a  contagious  quality  was 
nut  wanting.  It  may,  therefore,  be  claimed  with  some  degree  of  plausibility  that  our  typhus 
cases,  or  those  that  seemed  to  our  medical  officers  to  be  typhus,  did  not  require  for  their 
develo])ment  the  introduction  of  a  specific  ferment,  poison  or  germ  elaborated  in  the  system 
of  a  pre-existing  case  of  the  disease,  but  were  generated  by  a  coalition  of  favorable  condi- 
tions, of  which  the  chief  was  overcrowding  with  deficient  ventilation. 

On  this  view,  typhus  as  affecting  the  soldier  should  become  an  unknown  disease.     The 
measures  to  effect  this  are  so  obvious  that  their  formal  presentation  is  unnecessary. 


VII.— TREATMENT  OF  THE  CONTINUED  FEVERS. 

The  functions  of  the  Army  Medical  Officer  are  twofold.  He  is  the  Health  or  Sanitary 
Officer  of  his  command  charged  with  the  duly  of  preserving  the  men  in  their  best  condition, 
that  their  aggregate,  the  military  machine,  may  b(!  enabled  to  e.xercise  its  maximum  of 
power.  From  the  governmental  point  of  view  this  is  the  raiso7i  d'  etro  of  the  military  medical 
man.  His  duty  as  Sanitary  Officer  requires  a  careful  sujiervision  of  the  clothing,  diet,  shelter 
and  lal)ors  of  the  men,  that  they  may  be  protected  fmm  all  avoidable  influences  of  a  per- 
nicious character,  including  invasion  by  endemic  or  infectious  diseases.  But  if,  notwith- 
standmg  his  efforts  in  this  direction,  disease  should  attack  the  command,  he  then  becomes 
the  physician  in  attendance  on  the  individual  case.  • 

These  functions,  although  distinct,  are  so  intimately  co-related  that,  as  regards  the  con- 
tinued fevers,  the  measures  adopted  for  the  protection  of  tlie  command  are  oftentimes  those 
best  calculated  to  lessen  the  danger  in  individual  cases;  the  prevalence  and  the  fatality 
of  an  epidemic  are  frequently  direct  and  proportionate  results  of  the  same  insanitary  condi- 
tions.    The  treatment  of  the  continued  fevers  resolves  itself  therefore  into  a  consideration  of: 

let.  Measures  for  the  protection  of  the  command  against  their  introduction ; 
2d.    Measures  to  restrict  their  spread  and  free  the  coiinnand  IVoni  tlieir  presence; 
3d.    Measures  for  tlie  relief  and  recovery  of  individuals  attacked. 

1st. — Preventive  measures  have  already  been  indicated  in  discussing  the  etiology  of 
these  fevers.  As  protective  against  common  continued  fevers  all  unnecessary  overfatigue 
and  deprivation  of  sleep,  exposure  to  excessive  heat  or  chill,  to  contaminated  soil  or  foul 
neighborhoods,  the  use  of  tainted  articles  of  food  and  of  impure  water-supplies,  should  be 
especially  avoided.     Exposure  to  such  influences  is  oftentimes  inseparably  connected  with 


*  A  similar  iimlifjnanry  was  ulwiTvcd  in  the  hospitals  of  Paris  duriii}:;  tlui  siege  in  ISTC.  Patients  fell  into  a  condition  in  many  respects  nseeinblinf; 
that  priHlncetl  by  typhus  f.-vi-r,  ami  to  this  waa  due  a  considenible  amouTit  of  the  niortjility  anionfx  tliern.  The  published  stitistics  of  the  siege  contained 
no  rase  of  pure  typhus  ;  nevertheless — "There  is  indeed  nineli  reason  to  i)eliove  that  eases  of  pure  typhus  whirh  did  oecnr,  instead  of  being  shown  sepa- 
rately in  the  returns  have  been  included  annuig  the  typhoid  ;  and  it  may  i)e  fairly  donldeii  if,  during  ttieeontiuuauee  of  tlie  siege,  the  stri<'t  line  of  diagnosis 
Itetweeu  these  forms  of  disease  was  drawn,  as  it  usually  is  in  Englaufi  and  tloobtiess  would  have  been  iu  PariB  uuder  normal  conditions." — C.  A.  Gyuuos, 
LtssiiriB  on  Hijgicne  and  tjurgery  /rotn  the  i^wico-I^rttsxum  Wur,  London,  187;i,  p.  '^^5. 


532 


TREATMENT    OF    THE 


the  duty  on  which  the  troops  are  eiigaijjeel,  in  \vhi«h  case  continued  fevers  and  other  diseases 
thus  originating  must  be  accepted  as  part  of  the  price  paid  for  the  achievement  of  the  mili- 
tary result.  Usually  the  lists  of  killed  and  wounded  pass  current  under  this  title,  but  these 
fail  to  give  lull  expression  to  the  price  if  sickness  and  mortality  from  disease  be  not  incor- 
porated. Nevertheless,  with  earnest  medical  officers  and  intelligent  comnianders,  much 
unnecessary  loss  to  the  command  may  be  avoided  even  in  the  most  active  of  campaigns. 
Just  as  hastil}'  constructed  breastworks  or  rifle-pits  are  used  to  lessen  danger  from  a  hostile 
fire,  so  certain  sanitary  precautions  should,  even  in  the  face  of  an  enemy,  be  used  for  the  pro- 
tection of  the  men  from  diseases  incidental  to  a  campaign,  whenever  they  can  be  applied 
without  hazard  to  the  military  issues. 

As  has  been  seen,  no  exercise  of  sanitary  supervision  will  be  efficient  at  all  times  in 
preventing  attack  from  typhoid  fever;  but  much  may  be  done  in  the  way  of  protection  by 
the  avoidance  of  all  communication  with  suspected  foci  or  contaminated  materials. 

Nor  can  protective  measures  be  in  all  cases  efficient  against  the  development  of  con- 
tinued malarial  fevers,  although  their  frequency  and  gravity  may  be  materially  lessened  by 
preventing  unnecessary  exposure  at  night,  by  filtering  the  supplies  of  water  for  drinking, 
and  by  using  quinine  as  a  prophylactic  in  movements  involving  conditions  known  to  be 
specially  dangerous. 

Typhus  fever,  on  the  other  hand,  may  be  blotted  from  the  list  of  camp  diseases  by 
excluding  contagion  and  j)reventing  the  spontaneous  origination  of  the  disease.  In  camps 
and  garrisons,  and  during  service  in  the  open  field,  tlie  ordinary  sanitary  measures  for  the 
preservation  of  health  will  prevail  against  it,  but  durhig  long-c<intinued  sieges  troops  in  bomb- 
proofs  and  the  civil  population  occupying  basements  and  cellais  will  require  active  sanitary 
supervision  to  prevent  an  unnecessary  disaster. 

2d. — Measures  to  restrict  the  spread  of  febrile  diseases  and  free  the  command  from  their 
presence  have  in  view,  under  our  present  heading,  only  the  typhoid  and  typhus  infections. 

In  the  case  of  typhoid,  removal  from  the  miasmatic  locality  is  needful  if  the  outbreak 
seems  due  to  purely  miasmatic  influences.  Removal  Is  also  required  if  the  outbreak  is  due 
to  a  contaminated  soil,  as  from  a  prior  occupation  by  infected  troops.  If  the  place  must  be 
held,  veteran  regiments  that  have  undergone  their  typhoid  seasoning  should  be  sent  to 
occupy  it.  If  the  disease  is  attributed  to  an  infected  water-supply,  a  new  source  should  be 
obtained,  and  until  this  is  accomplished  the  suspected  water  should  be  used  only  after  having 
been  boiled; — filtration  is  untrustworthy  as  against  typhoid  fever.  When  the  onset  is  less 
sudden,  pointing  to  an  accidental  intrusion  from  other  commands  or  localities,  every  new 
case  as  soon  as  detected  should  be  removed  from  quarters  to  hospital,  where  its  infectious 
material  may  be  under  medical  control.  Meanwhile  obnoxious  features  in  the  sanitary 
arrangements  of  the  camp  should  be  obliterated.  Its  area  should,  if  possible,  be  extended; 
any  tendency  to  overcrowding  in  particular  tents  or  huts  should  be  obviated;  tent  floors 
should  be  exposed  daily;  Infected  sinks  disused,  and  those  in  use  disinfected  daily  lest  they 
become  contaminated  by  some  new  and  as  yet  undiscovered  case. 

The  typhous  malignancy  assumed  by  other  diseases  should  undoubtedly  have  led  to  the 
removal  of  the  insanitary  conditions  which  evoked  it  long  before  the  continuance  of  those 
conditions  could  evolve  a  true  contagious  typhus  fever.  But  in  the  event  of  the  occurrence 
of  such  cases  their  removal  to  hospital,  the  abandonment  of  the  infected  site,  or  failing  that, 
its  thorough  purification  by  aeration  and  an  efficient  system  of  personal  and  camp  police, 


CONTINUED    FEVERS.  533 

togethei'  with  strict  attention  to  general  liygienic  laws,  would  certainly  suppress  the  ejiideniic 
before  it  attained  disastrous  proportions. 

3d. — It  is  well  that  so  much  can  be  accomplished  tVom  the  sanitary  or  preventive 
stand-point.  It  offsets  the  incompetency  of  professional  methods  applied  for  the  cure  of  the 
individual  case.  The  clinical  records  and  medical  descriptive  lists  of  the  war  are  tilled  with 
notes  of  the  treatment  employed  in  cases  of  continued  fever,  but  it  does  not  appear  that  any 
systematic  effort  was  made  to  determine  the  relative  value  of  different  methods.  Patients 
died  from  exhaustion,  diarrhcea,  coma,  peritonitis,  hemorrhage,  pneumonia,  etc.,  while  others 
submitted  to  the  same  remedial  methods  made  a  rapid  recovery.  Some  progressed  unfavor- 
ably for  several  weeks,  but  ultimately  rallied  from  the  most  profound  typhoid  state  and  con- 
valesced satisfactorily  under  treatment  which,  in  other  cases,  did  not  prevent  a  suddenly 
fatal  issue  notwithstanding  the  seeming  absence  of  all  grave  symptoms  until  the  closing 
hours.  Others  recovered  with  no  other  treatment  save  that  which  protected  them  from 
harmful  influences.  In  fact,  the  closest  study  of  the  records  fails  to  show  that  the  disease 
was  influenced  beneficially  by  any  system  of  medication,  or  even  tliat  individual  remedies 
had  a  notable  effect  on  the  result  in  individual  cases.  In  many  instances  the  administra- 
tion of  a  certain  medicine,  a  laxative,  astringent,  diaphoretic,  calmative,  refrigerant,  antipy- 
retic, etc.,  modified  favorably  for  the  time  being  the  symptoms  which  called  for  its  exhibition, 
but  it  cannot  be  shown  that  the  ultimate  issue  of  these  cases  was  in  any  wise  affected. 

It  must  not  be  supposed,  however,  that  professional  care  was  valueless  in  the  treatment 
of  the  continued  fevers.  Regulation  of  the  diet  in  the  late  as  well  as  in  the  early  stages  of 
the  disease  no  doubt  saved  many  lives  by  lessening  intestinal  irritation  and  promoting  the 
cicatrization  of  ulcerated  pat(thes.  The  administration  of  suitable  nourishment  at  regular 
times  saved  tlic  strength  nf  the  patient.  Watchful  care  and  control  during  the  period  of 
delirium  nut  tmlv  preserved  the  j)atient  from  direct  and  inunediate  accidental  death,  but  pre- 
vented that-  nivoluntary  violence  of  action  and  those  unconscious  exposures  which  would 
have  tended  to  death  by  subsequent  exhaustion  or  local  congestive  jirocesses.  The  removal 
of  retained  urine  by  catheterization  sometimes  quieted  delirium,  relieved  hypogastric  pain 
and  prevented  local  injury.  Careful  nursing  economized  the  patient's  strength  by  affording 
assi.stance  in  all  his  desired  and  permitted  movements.  Th«i  use  of  the  bedpan  certainly 
decreased  the  fatality  of  continued  fever:  Exhaustion  was  ra[)id  in  cases  associated  with 
active  diarrhcea  when,  from  want  of  facilities,  the  patient  had  to  leave  his  bed  on  every 
alviiie  movement;  moreover,  sudden  death  was  not  uncommon  among  asthenic  patients  who 
made  the  effort  to  attend  to  their  own  necessities  in  this  regard.  Oareful  nursing  also  pro- 
tected the  fevered  soldier  during  the  night,  when  a  }>neunioiiic  complication  might  have 
resulted  from  a  continued  displacement  of  the  bedclothes;  and  by  constant  attention  and 
frequent  change  of  position  and  pressure,  it  prevented  the  development  of  exhausting  and 
distressing  bedsores,  keeping  the  skin  of  the  patient  clean,  his  bedding  fresh  and  the  air  in 
his  vicinity  comparatively  pure. 

Much  was  possible,  therefore,  independent  of  medication.  Much,  also,  was  accomplished. 
But  it  may  be  readily  gathered  from  a  perusal  of  the  records  that  on  account  of  crowded 
hospitals,  overworked  nurses  and,  in  rare  cases,  defective  discipline,  everything  that  should 
have  been  done,  and,  indeed,  in  exceptional  cases,  everything  that  might  have  been  done  on 
behalf  of  the  patient  was  not  always  effected. 

In  the  field,  facilities  for  the  jjroper  care  of  continued  fever  patients  were  not  always  at 


534  TREATMENT    OK    THE 

hand.  Nevertheless,  it  is  believed  tliat  eases  treated  in  the  iield  hospitals,  as  when  the 
army  was  in  winter-quarters,  did  better  than  their  comrades  who  were  sent  to  well-equipped 
hospitals  at  the  base  of  operations  or  in  Xorthern  cities.  The  superior  comforts  which  sur- 
rounded the  patient  on  his  arrival  at  the  geueral  ho>pital  failed  to  oti'set  the  injuries  inflicted 
on  him  during  the  journey.  This  will  readily  be  understood  by  those  who  have  seen  a 
wagou-train  of  sick  soldiers  en  route  to  the  rear.  Suffering  and  danger  assailed  the  patient 
on  every  hand.  The  hot  sun  and  stifling  dust  of  the  summer  were  as  dangerous  as  the  cold 
rains  or  snows  of  winter.  The  irregular  jolting  over  deeply-rutted  country  roads,  and  the 
continuous  and  intolerable  agony  caused  by  the  passage  of  those  that  had  been  corduroyed, 
were  enough  of  themselves  to  have  transformed  the  headache  of  fever  into  its  delirium.  Tlie 
innumerable  occasions  when  the  utmost  strength  of  the  patient  was  taxed  to  enable  him  to 
fulfil  the  necessities  of  existence  under  these  conditions  rendered  him  less  able  to  withstand 
the  hardships  that  had  yet  to  be  borne.  Dietetic  arrangements  were  generally  im])erfect; 
perhaps  the  onlv  refreshment  which  the  fever-stricken  soldier  was  able  to  take  during  the 
journey  was  an  occasional  swallow  of  coffee  from  his  canteen. "='  The  transfer  to  rail  or  boat 
involved  further  efforts  that  increased  his  prostration.  The  tedium  and  exposures  of  this 
second  journey,  and  the  want  of  proper  attention  during  the  whole  route,  often  brought  him 
to  his  destination  in  a  state  of  exhaustion,  delirium  or  unconsciousness.  Hence  the  imper- 
fection of  so  many  of  the  records  of  cases  treated  in  the  general  hospitals;  the  previous  his- 
tory of  the  patient  was  unknown  or  received  at  second  hand  from  some  of  his  travelling 
companions. 

From  the  mass  of  records  relating  to  the  treatment  adopted  in  individual  cases  of  con- 
tinued fever  there  is  little  to  be  learned  that  may  not  be  gathered  from  the  articles  on  the 
treatment  of  typhoid  fever  by  Wood,  Watson  and  Bennett.-J"  The  works  of  these  authors 
were,  at  the  beginning  of  the  war,  on  the  Supply  List  of  the  Army  Medical  Department. 
Their  doctrines  were  thus  invested  with  official  sanction,  so  far  as  this  might  with  propriety 
be  conceded  in  unsettled  matters  of  a  professional  nature,  and  there  is  no  doubt  that  they 
exercised  the  \erv  strongest  influence  on  the  tnanner  in  wliich  our  soldiers  were  treated. 

AVooD  was  precise  in  his  statement  of  tbe  metliod  of  treatment  to  be  adopted :  Irritating  matter  ninst  be  removed 
from  the  bowels,  but  this  must  be  ett'eoted  by  the  gentlest  of  hixntives  on  aeemint  of  the  existence  of  a  liigh  degree 
of  susceptibility  to  the  intlnence  of  cathartic  medicines.  Bleeding  was  doubtfully  suggested  to  ])revent  local  and 
disorganizing  inflammations,  but  the  danger  of  injury  to  the  system  by  induced  deliility  was  strongly  set  forth. 
Refrigerating  diaphoretics  were  recommended  as  useful  from  the  earliest  period  of  the  disease;  citrate  of  ])otas8a 
as  a  neutral  or  ett'ervescing  mixture  was  jireferred,  in  conjunction  with  tartar  emetic  if  the  stomach  and  bowels 
were  quiet,  with  some  preparation  of  oi>inni  if  these  organs  were  irritable  and  with  spirit  of  nitric  ether  if  nervous 
symptoms  began  to  ajipear;  Dover's  powder  was  approved  for  use  at  bedtime;  s|>onging  the  siiiface  with  cold  water 
or  with  alcohol  and  water  was  also  rec(numi'nde<l  as  a  refrigerant.  In  addition  local  manifestations  required  treat- 
ment: Headache  by  cold  applications  or  leeches;  aUlominal  pain  and  tlatulent  distention  l)y  cupping,  warm  fomenta- 

*  If  M.  le  Doctenr  Guillasse,  Ancien  Medecin  i)rinfii»!il  We  In  Marine,  fails  to  contribute  much  to  our  knowlwlge  in  lii.s  Gutmy  Df  la  FiKrre  Tifplionle. 
Etude  Pliiisiiilutjiipif.  .Si  \atnrt: — m/u  TruU^meitl,  I'ari^,  1S7S,  iu'  ccrtiiilily  furniblies  eiMiif  utnilscniynt  tu  tliuse  wlm  I'liiilice  nptin  liis  |»at;c.s  in  t\n-  progrt- Hij  of 
their  Htuiiy  nf  tlie  litemtiire  of  tile  Knb.jei-t.  He  tells  us  that  in  tlie  absence  cif  other  means  of  investigation  he  hatl  reeiiui-se  to  inetlioils  whicli  every 
tbiukin;^  man  may  employ — analysis  and  imiiiction — anil  he  miMle.-tly.-ubmits  his  results  that  niankiud  may  be  the  better  tV)r  them  if  they  are  t'orreet,  or 
leave  tlient  in  ob>eurity  if  they  are  erritnevms.  An  erethism  of  tin-  nervous  system  of  animal  life,  oeeasinneil  aiel  sustaiiieil  by  a  eei-taiu  congested  state 
of  the  brain  due  to  a  stasis  of  venous  blo.jd  in  the  capillaries  ..f  the  orga[t,  produi-es  a  siijisiie"iic  interference  with  the  organic  functions.  This  is  all  there 
is  in  typhoid  fev«T,  or,  indeed,  in  any  of  tlie  other  essential  fevers.  Iri  typlaoid  the  s[«ism  is  manifested  ou  the  Joirt  of  the  liver  by  the  secretion  of  all 
acrid  bile,  v^liich  t>ccasioDB  irritation,  iiitlamniation  and  lierforation  of  the  parts  of  the  intestine  with  which  it  remaius  in  colita<-t  for  Boliie  length  of 
time,  as  in  the  lower  |jart  of  the  ileum,  wliere  it  finds  an  obstacle  to  its  passage  in  the  ileu  ca-cal  valve.  The  pathology  having  bei*n  determiutsi  to  M. 
Gt  iLi.A8sn's  satisfaction,  it  remained  for  him  to  find  an  agent  wliicli,  by  removing  this  erethism  of  the  brain  and  its  ctmsecjiieut  spasm  of  the  nervous 
gysteoi  of  organic  life,  would  l»eiiiiit  the  fiinctiolis  to  resume  their  natural  and  healthy  action.  This  he  discovered  in  cotfee.  To  cure  typhoid  fever  it  is 
only  needful  that  "Ou  dtuilie  deux  ou  truis  cuiUerees  de  fort  cafe  noir  ( Je  dis  cafe  et  lion  [mis  chicoreel,  toiites  les  ileux  heures."  After  having  admitiis- 
tered  the  cotTee  he  found  to  his  great  surprise  that  its  action  was  as  prompt  as  it  was  decisive.  "  Kn  etlet,  a  peine  nos  malades  eii  euient-ils  pris  qnebpies 
cuiUerees  que  b-nrs  traits  se  deteiidirent  et  nuils  reprirenl  coniiaissance,"  etc.  *  Our  sillTering  soldiers  en  r.iutc  t.i  tla-  general  hosjiitals  in  tlie  rear  failed 
to  realize  the  benefits,  altluulgh  cejtainly  their  ci.tlee  was  the  real  article  and  not  a  chicory  mixture. 

t  GF.OK.iK  H.   Wooli-J    T,.Ml,-r  i,„  lliv    fl'.e  (|c.- ..,/  .licbciie  ,    TllO.MAs  \\   VTSmN— ItctlOC-  ..„  Iht  I',„„,j,U^  •la.l  Pin.ln-    ./  ,1/,  ,(iti,„  ;    JoUN  llliillES  BkS- 

NKTT — iA'tHKul  Lttturts  on  thf^  PrtHtijite^  mid  i*ractice  u/  Medicine, 


CONTINUED   FEVERS.  535 

tioiis,  emollient  cataplasms,  rubefacients  or  blisters;  diarrhoea  by  opium  and  ipecacuanha  with  or  without  acetate  of 
lead,  kino,  extract  of  rliatany  or  tanuin;  nervous  symptoms  by  sweet  spirit  of  nitre,  Hoffmann's  anodyne,  caiiiplior- 
water  or  opiates.  In  mild  cases  no  other  remedy  than  those  mentioned  was  considered  necessary;  but  in  less 
favoralile  cases,  when  about  the  niutli  day  there  was  a  loss  of  vital  enerfjy  with  no  diminution  in  the  vjulriice  of 
the  disease,  which  was  characterized  by  defective  secretions  and  some  de!;ree  of  (hlirinni,  stupor  and  tympanites, 
mercury  in  small  doses  to  affect  the  gums  slightly  was  higlily  approved.  I'nder  its  inlluence  it  was  said  that  tlie 
tongue  not  unfVecpU'Utly  became  moist,  the  skin  relaxe<l  and  the  symptiuiis  generally  anu'liorated,  tlie  patient  recov 
ering  without  further  treatment.  The  value  of  turpentine  was  also  highly  lauded.  It  was  considered  useful  in  all 
cases  in  the  advanced  stage  of  the  disease,  when  the  tongue  was  dry  and  the  pulse  not  strong.  In  cases  having  the 
tougJie  red,  dry  and  smooth,  after  or  during  the  process  of  parting  with  its  fur,  and  in  which  this  was  associated  with 
an  aggravation  of  tlie  symptoms,  notably  of  the  tympanites,  an  amelioration  of  the  patient's  condition  within  twenty - 
four  or  forty-eight  hours  alter  a  resort  to  the  oil  of  tur])entine  was  confidently  predicted.  Under  its  influence  the 
tongue  was  said  to  become  gradually  nujister,  covering  itself  with  a  whitish  fur;  the  tymjianitic  distention  eea.sed 
to  augment  and  after  a  time  diminished  ;  the  pulse  became  less  frequent;  the  skin  less  dry  and  harsh  and  tlm  patient 
entered  slowly  but  regularly  into  convalescence.  Stimulants  were  reconnnended  in  the  debility  of  the  later  stages 
and  also  in  the  earlier  periods,  when  they  were  found  on  cautious  administration  to  lessen  the  freiiuency  and  increase 
the  fulness  of  the  ])ulse,  to  relax  the  skin,  nmderate  delirium,  relieve  nervous  disonler  and  jiromote  refreshing  slee|). 
Wine-whey  and  carbonate  of  anuuonia  were  suggested  when  a  more  dillusible  im]Mession  was  desirable,  l^uinine 
was  recommended  in  small  doses  as  a  tonic.  When  collapse  was  imminent,  powirful  rubefacients,  as  hot  oil  of  tur- 
pentine, cayenne  pe])per  in  brandy,  diluted  solution  of  ammonia,  sinapisms  anil  blisters  were  approved  in  connection 
with  internal  stimulation. 

The  treatment  suitable  to  local  affections  or  incidental  com]>lications  was  also  indicated:  Shaving  and  blister- 
ing the  scalp  in  obstinate  delirium  and  coma;  musk,  assafietida  and  camphor  in  sul>snltns  ami  Jactifation ;  musk  in 
singultus;  acetate  of  lead,  kino  and  extract  of  rhatany  with  opium  in  hemorrliage  from  fln^  bowids:  i)liigging  tin' 
nares  after  the  failure  of  astringent  solutions  or  other  measures  in  e]iistaxiN;  mucilaginous  a]iplications  or  the  local 
use  of  silver  nitrate  or  iodine  in  erysipelas;  opium  in  i>eritonitis;  the  catheter  in  retentitui  of  urine;  the  iiiineral  acids 
and  vegetable  bitters  in  exhausting  night-sweats;  and  change  of  position,  sixinging  with  alcohol  and  water,  and  pro- 
tection from  pressure  by  pillows  and  lead  jdaster  in  threatening  bedsores.  Strict  attention  to  diet  was  en joini'd.  At 
first  all  nourishment  was  reiiuircd  to  be  in  the  liijnid  form,  as  barley-water,  rice-water,  etc.;  during  the  seiciml  week 
farinaceous  preparations  of  gelatinous  consistence  were  allowed;  subseipiently  milk  was  permitted,  an<l  in  the  stage 
of  prostration  animal  broths,  eggiu)g,  iStc. 

WatsoX  discountenanced  efforts  to  cure  the  fever  hy  medication  or  powerful  imjiressious  on  the  system.  Ills 
pr.actice  was  to  guide  the  fever  and  obviate  the  tendency  to  death,  and  the  nu'ans  he  adopted  to  elVeet  these  olijects 
were  in  general  similar  to  those  in<licaled  by  Dr.  Wood.  Among  the  remedies  which  in  his  opinion  fornuil  fheKta))Ie 
of  the  treatment  were:  fold  to  the  shaven  head;  the  local  alistractiou  of  blood  whenevt^r  there  existe<l  unr<ini\  ocal 
evidenc^e  of  local  inflamnuition;  an  active  purge  at  first,  and  mild  aperients  afterwards,  if  the  bowels  were  contini'd  or 
sluggish  ;  moderate  astringents,  as  extract  of  catechu  or  Dover's  powder,  to  control  diarrlnea;  opium  in  more  eflieient 
doses  when  nervous  symptoms  were  prominent,  particularly  sleepless  delirium  and  restlessness;  in  certain  cases  snuill 
and  repeated  doses  of  some  nu-rcurial,  and  in  certain  others  early  support  by  animal  broths  and  even  by  wine.  "  The 
rational  objects  of  treatment  are  to  mitigate  the  urgency  of  symptoms  that  cannot  Im-  w  holly  subdued;  to  redress  (.so 
far  as  art  may  redress^  those  dangerous  complications  which  are  in<idental  lint  not  essential  to  the  d  isea.se;  and  to  aid 
the  conservative  efforts  of  nature  when  these  uuinifestly  laiignish  and  fail.''  'I'he  tendency  to  death  by  asfhi'nia  was 
strongly  impressed,  and  the  danger  of  beginning  thes>ip)iorting  treatment  a  little  too  early  was  set  down  as  infinitely 
less  than  the  risk  of  Ijeginning  it  a  little  too  late. 

Hexnett  recommended  the  use  of  mild  laxatives  when  required,  cold  to  llie  beail,  salines,  such  as  the  acetate 
of  ammonia  with  tartar  emetic,  and  beef-tea  ami  stimulants  when  the  jiulse  became  soft  and  weak  although  retaining 
its  fre<|uency.  He  considered  active  depleting  measures  as  never  useful  and  as  seldom  failing  to  increase  the  danger 
by  lowering  the  vital  powers.  He  believed  that  the  disease  might  be  al)orte(l  by  the  early  u.se  of  enu-tiis;  and  con- 
sidered quinine  incompetent  in  large  doses  to  establish  a  cure  and  of  doubtful  value  in  snnill  doses  as  a  tonil^ 

One  only  of  tliose  authors.  Professor  G.  B.  Wood,  adverted  to  tlie  possible  eoinjilica- 
tion  of  the  typhoid  case  by  specitic  malarial  causes,  and  suggested  the  treatment  apjiropriate 
to  this  condition,  liis  reference  to  this  appears  at  the  close  of  a  paragraph  devoted  to  a 
brief  mention  of  certain  special  plans  of  treatment,  as  by  emetics  or  bloodletting  in  the  early 
stages,  the  use  of  nitrate  of  silver,  alum,  chloride  of  sodium,  etc.      He  i^ays: 

When  there  is  reason  to  believe  that  the  disease  is  complicated  with  remittent  or  bilious  fever,  and  especially 
when,  under  such  circumstances,  it  terminates  in  intermittent  fever,  sulphate  of  quinia  should  be  used  withwit  hesi- 
tation and  with  a  freedom  proportioned  to  the  urgency  of  the  symptoms. 

From  this  casual  reference  it  may  be  inferred  that  in  civil  practice  before  the  war 
typhoid  fever,  notably  complicated  by  the  malarial  poison,  was  of  infrequent  occurrence. 
But,  as  a  rule  for  the  guidance  of  our  medical  officers  during  the  war,  a  paragraph  similar 


536  TRKATMENT    OF    THE 

to  that  just  quoted  slioulil  liave  been  jilaceil  at  the  beginning  of  everv  article  on  the  treat- 
ment of  the  continuoil  levers.  Typhoid,  moditieil  l)v  nuvlarial  influences,  instead  of  lieing 
the  occasional  or  exceptional  case,  was  the  rule  in  our  regimental  epidemics,  and  among  these 
modified  enteric  cases  were  plentifully  scattered  cases  of  ]iseudo-tvplioid  in  wliich  the  clinical 
features  of  enteric  fever  were  impressed  on  a  purely  malarial  disease.  Quinine,  used  without 
hesitation  and  with  a  freedom  propiortioned  to  the  urgency  of  the  symptoms,  i-emoved  one 
of  the  febrile  factors,  at^ter  which  tlie  typhoid  disease  not  unfrequently  ran  a  mild  course. 
The  free  use  of  this  remedy  was  especially  required  where  paroxysmal  fevers  were  endemic, 
for  in  the  early  stages  it  was  often  inijiossible  to  say  whether  an  individual  case  would 
ultimately  prove  to  be  enteric  fever  complicated  by  co-existing  malaria,  the  latter  susceptible 
of  cure  by  quinine,  or  a  remittent  which,  in  the  absence  of  specific  treatment,  would  speedily 
tall  into  a  dangei-ous  condition  characterized  bv  tvphoid  symptoms. 

The  uncertainty  attaching  to  the  real  nature  of  a  case  in  which  typhoid  symptoms  were 
developed  led  at  first  in  some  instances  to  a  hesitancy  in  the  treatment.  Brigade  Surgeon 
Jas.  Bryan  gives  expression  to  this  where  he  says  that  in  North  Carolina  no  two  medical 
officei's  appeared  to  agree  upon  any  [ilan  of  treatment  for  the  continued  fevers.*  Surgeon 
Samukl  Kneeland,  45tli  Mass.,  also  referring  to  the  fevers  of  North  Carolina,  stated  that 
they  were  usually  treated  from  the  commencement  with  quinine,  whiskey  and  beef-tea,  but 
as  the  results  of  this  metliod  of  practice  were  not  satisfactory  he  pursued  an  expectant  plan, 
employing  refrigerants,  diaphoretics,  camphor  and  carbonate  of  ammonia. "|"  At  Fortress 
Monroe,  Va.,  quinine  was  found  inefficient  in  all  the  stages  of  the  disease,  and  the  treatn^ent 
by  emetics  in  the  early  period  was  institutrd.J  According  to  Dr.  Thomas  T.  Smiley,  a  stim- 
ulant treatment  was  followed  in  the  hos])ital  at  Hilton  Head,  S.  C;  but  the  patients  when 
received  were  already  in  the  later  stages  of  the  disease,  with  the  tongue  dry,  brown  and 
cracked,  and  the  pulse  feeble. §  Tn  the  New  York  Hospital  for  Volunteers  stimulants  were 
freely  given  regardless  of  infiainmati)ry  cumplications.|| 

But  it  wouhl  lie  unjust  to  the  |>roressi(jn  to  assert  that  this  uncertainty  as  to  the  proper 
treatment  of  the  continued  fevers  was  at  all  general  or  long  continued.  Indeed,  at  a  very 
early  period  of  the  war  the  malarial  complication  of  typhoid  fever  was  recognized  and  appro- 
priately treated  by  quinine.  Tn  December,  ISGI,  Surgeon  Rohrer,  10th  Pa.  Resei'ves, 
described  a  fever  with  rose-colored  spots,  which,  in  view  of  a  malarial  influence,  he  treated 
successfully  with  a  mild  purge  of  calomel,  a  large  dose  of  quinine,  fifteen  to  forty  grains, 
durincr  a  morning  remission,  with  calomel  and  iiK'cacuaidia  at  intervals  of  four  hours  and 
turpentine  when  the  tongue  became  dry.^  In  March,  1862,  Surgeon  C.  J.  Walton,  21st 
Ky.,  liad  already  given  expression  to  the  principle  on  which  was  afterwards  based  the 
systematic  treatment  of  the  continual  levers  of  the  army:  As  it  is  often  impossible  to 
determine  at  the  beginning  to  what  extent  the  case  is  influenced  by  malaria,  it  is  wdl  to 
begin  with  a  few  doses  of  quinine,  when,  if  the  fever  be  a  malarial  remittent,  it  will  jje  con- 
trolled; but  if  it  be  enteric. — or,  he  might  have  added,  a  continued  malarial  fever  in  which 
secondary  lesions  are  already  established, — no  specific  action  will  be  manifested.** 

The  Seminary  hospital  records,  whieh  have  been  presented  as  giving  a  full  view  of  the 
clinical  characters  of  the  febrile  cases  sent  to  AViishingtoii  from  the  ai-iiiy  in  the  winter  of 

*  Observatiims  cm  the  IHsfunea  of  the  Anny  in  the  Departmetil  of  N«vth  t'arnUmt. — Ilosttm  Med.  ami  ^tny.  Jinir.,  Vitl.  LXAT,  lStJ2,  p.  :i«4. 
^Botlon  Med.  aiidfiifrg.  ./..ui-.,  Vul.  hX\1.  1»(J2,  p.  'JS(I.  X  Amerieall  Med.  Times,  New  York,  Vc.l.  HI,  l«lll,  p.  ;iSO. 

I  BmlMi  Med.  uiul  .Sc"!/.  Ji.i'r..  Vul.  LXVII,  18«2,  p.  27u.  |]  Amaican  Med.  Timm,  Ni-n  Turk,  Vol.  IV,  MM'i,  p.  303. 

^Set'  bid  rt-jturt,  supra,  l-agf  318.  **Sitpra,  Iiagf  31tj. 


u 


OONTINUEB    FEVKRS.  537 

1861-62,  subserve  anotlier  purpose  in  illustrating  the  methods  of  treatinent  adopted.  ]\rore- 
over,  as  the  records  of  this  hospital  do  not  differ  in  their  general  tenor  from  those  of  other 
large  establishments  of  the  same  hind,  the  methods  whicli  they  indicate  may  be  accepted  as 
illustrative  of  those  in  general  use  by  our  medical  officers. 

Althougli  these  eases  were  treated  in  the  earl v  jieriotl  of  the  war,  several  months  before 
the  term  typho-malarial  was  introduced  to  direct  the  attention  of  the  profession  to  the  com- 
plication of  typhoul  tever  liy  the  uialai'ial  jioison,  it  is  evident,  from  the  freipK'nt  use  of  (|ui- 
niiie,  that  this  complication  was  already  recognized.  Certain  cases  that  wei'e  hrought  in 
from  the  h'ont  along  with  the  prevailing  typhoid  were  recognized  as  remittent  fever,  cases 
52-5(S  for  instance,  and  treated  successfully  with  mercurials,  saline  purges  and  quinine.* 
Certam  cases,  1 13— 120,  regarded  as  remittent,  hut  which  |n'esented  more  or  less  e\-idenee 
the  co-existence  of  typhoid  fever,  were  treated  with  antiperiodics  in  atldition  to  the  meas- 
ures adopted  in  view  of  a  possible  typhoid. f  Thus,  in  case  1  Ui,  fifteen  grains  of  (juinine,  six 
of  blue-pill  and  two  of  o|iium  were  given  in  two  doses  separated  by  an  interval  of  two  hours, 
and  were  followed  by  four  grains  of  quinine  everv  two  hoiu's,  while  in  1  U)  and  120  Fowler's 
solution  was  emj)loyed.  CV'rtain  cases  of  t-vphoid  lever,  r)0-112,  in  which  iiittM-mitti^nt  or 
remittent  paroxysms  ])receded  or  accom|)anitHl  the  symptoms  of  typhoid,  oi'  in  whieh  there 
was  more  or  less  evidence  of  the  complication  of  the  enteric  fever  by  malarial  influences, 
were  treated  with  quinine  before,  during  or  alter  the  exhibition  of  the  remedii's  specially 
directed  to  the  continued  fever  and  its  intestinal  h>sions.  Thus,  in  61,  91,  99  and  105, 
am(ing  ofhei's,  qunnne  was  given  b(^iore  the  use  ol'  the  remedial  agents  called  loi'  li\-  thi' 
ty|ihuid  disease;  in  78  an<l  79  it  was  given  along  with  the  i-eme(lies  l\>v  tvphoid,  and  in  71 
and  75  it  was  tried  aftei'  they  had  been  in  u.s(^  for  some  time.  Indeed,  in  some  of  the  <'asi's, 
1-51,  in  which  the  evidence  of  a  malarial  complication  was  hy  no  means  strong,  spiM-ilic 
medication  was  employi'il  ii,  the  eflorl  to  henelit  the  patient.  (Quinine  was  thus  given  in 
8,  11,  17,  29,  )vS  and  others  in  unstated  ([uantities;  in  case  9  eight  gram  doses  were  given 
thci'e  timi.'S  a  da\';  iii  2f)  two  grams  e\'ei'v  hour;  in  11  tweh'e  grams  da d_y  for  several  da\'s, 
and  in  49  five  grains  every  tw'o  hours.  In  'M)  the  exhihition  of  this  I'emedy  was  followed 
1.)}'  a  manifest  but  pnjbablj-  inconsequent  improvement;  in  41,  on  the  contrary,  an  active 
delirium,  which  led  to  accidental  death,  supervened  on  the  administration  of  twenty-four 
grains  in  twelve  hours. 

Surgeon  S.  ]\.  To\yLK,  30th  Mass.,  in  his  extensive  ex])erience  of  the  fevers  affect- 
ing the  troops  in  the  Mississi])pi  Valley,  recognized  that  many  of  the  cases  registered  as 
typhoid  were  of  malarial  origin.  These  had  not  the  rose-colored  eriijition,  and,  mi  admission 
to  hospital,  had  already  lost  the  early  diagnostic  features,  retaining  onlv  the  |)roslrated, 
semi-conscious  condition  of  the  last  third  of  severe  typhoid  fever.  Enteric  fever  itself  was 
seldom  seen  in  an  unmodified  form  except  in  recruits  recently  arrived  from  New  England. 
He  considered  it  indisputable  that  all  cases  did  better  after  the  introduction  of  full  doses  of 
quinine  into  the  treatment  in  the  early  stages,  and  that  cases  in  which  this  reme(ly  had  not 
been  employed  at  first  were  often  benefited  by  its  use  in  smaller  doses  at  a  later  date.;]: 

A  failure  to  recognize  the  malarial  element  in  the  typhoid  case — no  matter  whether 
the  case  in  question  was  a  true  enteric  development  or  an  adynamic  sequence  of  a  remittent 
or  continued  malarial  fever — would  have  handicapped  the  physician  in  conducting  the  con- 
tinued fever  to  a  successful  issue  ;  but  this  was  a  fault  in  the  method  of  treatment  that  was 


*  Supra,  iiage  22i1.  t  Supra,  page  240.  ^  J  See  mpra,  page  313. 

Mej>.  Hist.,Pt.  Ill— 68 


538 


TEF.AT:\rKXT    OF    THK 


rarely  observed  altliougli  noted,  as  has  already  been  seen,  bv  Surgeon  Gkorge  A.  Otts,  U.  S. 
Arniy.=-'  A  failure,  on  the  other  hand,  to  i-eeognize  the  typhoid  element  led  sometimes  to  a 
persistence  in  the  use  of  large  doses  of  quinine  which,  while  incompetent  to  effect  a  cure, 
may  not  have  been  in  all  instances  free  from  injurious  effects.  As  already  explained,  the 
febrile  cases  of  the  general  hospitals  were  mostly  enteric,  while  those  that  did  not  reach 
these  hospitals,  but  terminated  speedily  in  recovery  or  in  coma  and  death  in  the  regimental 
establishments,  were  in  general  due  to  malarial  influences.f  Quinine  freely  administered  was 
regarded  as  essential  to  recovery  in  these  cases.  When  a  t}-phoid  outbreak  occurred  in  a 
regimental  camp  where  the  malarial  factor  was  recognized  as  potent,  some  time  usually 
elapsed  before  the  enteric  essential  of  'the  camp  fever  was  distinguished,  and  during  this 
period  a  failure  to  control  the  disease  was  attributed  to  inefficient  specific  medication  in  the 
early  stages.  Quinine  under  these  circumstances  was  occasionally  used  with  a  freedom  which 
was  not  continued  after  the  presence  of  the  unimpressionable  typhoid  element  was  appreci- 
ated. For  instance,  in  the  service  of  the  27th  Conn,  during  the  months  of  February,  March 
and  April,  1SG3.J  cases  1-6.  four  of  which  terminated  in  death,  were  treated  with  fifty  or 
sixty  grains  daily  in  repeated  ten-grain  doses;  in  case  2,  two  hundred  grains  were  consumed 
in  four  days;  in  5,  two  hundred  and  forty  grains  in  five  days;  in  6,  three  twenty-five-grain 
doses  in  one  day.  But  the  intestinal  lesion  of  typhoid  fever  discovered  in  the  body  of  Dolph 
(case  330  of  the  post-mortem  records)  on  March  20  put  an  end  to  this  lavish  administration 
of  quinine. 

Typhoid  fever,  whether  in  its  pure  or  modified  form,  was  almost  invariably  treated  by 
what  has  been  called  tlie  rational  method.  Efforts  were  made  to  restrain  the  violence  of 
abnormal  actions,  to  protect  the  patient  against  harmful  influences,  to  support  his  failing; 
energies  until  the  febrile  course  had  ended,  and  to  reliabilitate  his  system  after  the  attack. 
A  few  extracts  Worn  sanitary  rejwrts  are  herewitli  submitted  : 

Suri/fuii  M.  R.  Gage,  25ih  Wis.,  Cohimhiis.  Kij.,  March  31, 1863.— At  the  outset  the  intestines  should  be  cleared  I>y 
an  aetive  ]>urj;arive.  and  laxatives  iiipsciibed  from  day  to  day  to  keep  them  open  if  they  do  not  act  unaided;  hut  when 
the  vital  forces  are  much  depressed  or  the  symptoms  indicate  ulceration  of  the  intestinal  glands,  purgatives  should  be 
avoided,  and  if  anything  is  reciuired  only  the  mildest  laxatives  should  l>e  used.  Cold  water  is  applied  to  the  head  by 
means  of  a  linen  rag  frequently  renewed.  If  tliereseem  to  be  hepatic  derangement,  mercury  is  administered  in  altera- 
tive doses  anil  with  caution  atfeeting  the  gums,  but  not  pushing  the  remedy  to  salivation.  If  diarrho-a  ensue  or  there 
be  mucli  nervous  manifestation,  Dover's  jiowder  may  be  ]ires(ribe(l  with  benefit ;  and  if  intestinal  ubeiation  be  diag- 
nosticated fomentations  to  the  abdomen  and  cupping  an-  frc(iuently  beneficial,  as  also  the  internal  use  of  spirit  of 
turjientine.  Effervescing  draughts  may  be  ])rescribed  from  time  to  time  in  tliis  disease  with  good  effect,  allaying 
thirst  and  dissipating  fever,  except  in  cases  troubled  with  diarrhiea,— and  even  in  these,  if  a  little  Dover's  powder  be 
given  to  conlnd  the  relaxed  bowels,  they  may  still  be  lesorted  to:  solution  of  acetate  of  anmionia,  weak  lemonade 
and  an  ocfasional  slice  of  orange  do  much  to  gratify  the  patient  and  no  doubt  prove  serviceable  by  allaying  excessive 
heat  and  that  unpleasant  dryness  and  parched  condition  of  the  mouth  and  throat  so  distressing  to  sufierers  from  fever. 
Bathing  or  sponging  once  or  twice  in  twenty-four  hours  with  water  of  a  temperature  which  feels  comfortable  to  the 
surface,  and  to  which  a  small  ((uantity  of  carbonate  of  soda  has  been  added,  is  very  grateful  to  the  feelings  and  of 
some  value  in  kec))ing  the  skin  in  a  proper  condition  to  exhale  the  poisonous  nuitters  so  constantly  and  rapidly  gen- 
erated within  the  bo<ly.  When  the  cas(^  is  protracted  and  nuinifests  increasing  prostration  of  the  vital  forces  resort 
may  be  had  to  beef-tea,  wine,  carbonate  of  ammonia,  etc.,  to  siistaiu  the  enervated  and  sinking  powers. 

A^Ht  Surgeon  O.  Peahody,  23(?  Iowa,  Holla,  Mo.,  Xor.  30,  1862.— \one  of  our  purely  typhoid  fevers  have  spent 
their  entire  force  upon  the  bowels,  and  we  believe  that  we  have  diverted  it  from  them  by  the  avoidance  of  all  active 
purgation  in  theprogressof  the  disease.  We  have  depended  almost  wholly  on  the  very  mildest  of  purgatives,  S])onging 
ot  the  surface  daily,  citrate  of  potassa  as  a  diuretic  and  diaphoretic,  veratruni  viride  to  control  vascular  action  when 
necessary  and,  in  the  later  stages,  turpentine  emulsion  and  wine  freely  with  beef-tea.  No  case  has  been  jnotiacted 
beyond  five  weeks,  three  weeks  I)eing  probal)ly  the  average  <liiration. 

Surgion  Pnii.li>  Hauvev,  liK/,  loua,  SprhiijJhM,  Mo.,  Dii:  1,  1862.- Fevers  of  a  typhoid  character  have  presented 
the  usual  symptoms,  as  dry  tongue,  soides,  tendency  to  stupor  and  diarrluea  with  asthenia.  In  their  treatment  l)ut 
little  medication  was  employed:  Saline  effervescing  draughts  in  the  early  stages,  guarding  against  diarrhoea  in  the 


*  Snpra,  page  373.  ^  ft„j„.„_  p^ge  24'j. 


\  see  .■'Hj»-u,  julge  'A>u. 


rOA^TTNT'EB    FEVRES.  539 

progress,  and  moderate  venous  stimulation  in  the  decline  constituted  the  method  of  cure;  and  its  results  were  satis- 
factory. 

Sitryeon  C.  \V.  Stearns,  3(7  X  }'.,  Fort  McHenrii,  JM.,  Jan.  1,  1862. — Experience  in  the  course  and  treatment  ot 
typhoid  fever  in  this  ref;ion  has  l)een  very  instructive.  Eliiniuatiug  remedies,  all  of  which  helong  to  the  class  of 
depressents,  if  used  at  all,  must  not  he.  continued  lieyond  the  first  or  second  day,  after  which  a  tonic  and  stimulant 
course  must  he  begun  and  continued  with  little  regard  to  local  symjitoms  or  Comidications.  The  truth  of  this  has 
been  illustrated  in  the  opposite  results  of  two  recent  cases  of  typhoid  pnenmouia:  In  the  first,  that  of  CorjMiral 
Kessler,  I  could  not  resist  the  temptation  to  employ  some  simple  and  not  very  depressing  remedies  to  relieve  cough, 
pain  and  other  |)ulmonary  symptoms.  The  patient  died.  In  the  second,  that  of  Private  Martin,  the  chest  symptoms 
were  even  more  urgent  and  distressing,  but  I  resolutely  abstained  from  prescribing  any  of  the  so-called  appropriate 
remedies,  continuing  instead  the  frequent  use  of  stimulants  and  tonics.  He  is  now  recovering.  Two  other  cases 
may  be  mentioned  as  of  interest:  Private  Morgan,  with  tyjihoid  fever  cliaracterized  by  all  the  worst  symptoms,  as 
coma,  subsultus,  involuntary  discharges,  a  dark  cold  surface  and  some  rigidity  of  the  muscles,  is  -.low,  under  stinni- 
'ant  treatment,  nearly  well  enough  for  duty.  Corporal  Hagedore  liad,  as  a  se(|uel  of  remittent  fever,  an  enornu)us 
o'dema  of  the  scrotum  and  prepuce,  which  terminated  in  sloughing  of  the  integuments  so  that  the  testicle  and  body 
of  the  penis  were  left  wholly  bare.  Hectic,  with  numerous  small  abscesses,  aujiervened.  Yeast  i)oultices,  with  char- 
coal, tincture  of  iron,  porter  and  good  diet  were  employed  in  ilue  course,  and  the  patient  is  now  regaining  tiesh  and 
strength,  while  nature  is  rapidly  replacing  the  lost  integument. 

StirgeonR.'W.  Hazlett,  5tlt  West  Va.  Cav.,  Elkwater,  Va.,  Oct.  1, 1861. — Typhoid  fever  predominated  in  September. 
Our  success  in  its  treatment  is  attril)utable  to  careful  nursing  rather  than  to  medication.  Supy)orting  diet  with 
judicious  stimulation  has  restored  many  unfavorable  cases. 

Surgeon  W.  H.  Thaykk,  14(/i  X  H..  OrJ'utt'n  Croim  Iloail.t,  Md.,  .Janiiari/,  lSti:{. — The  proportion  of  fatal  cases  of 
typhoid  fever  was  large  although  the  general  character  of  the  fever  was  mild.  Death  occurred  in  one  case  from  ])rofuse 
intestinal  hemorrhage  and  in  another  from  exhausting  diarrhiea;  in  neither  of  these  was  there  any  cerebral  disturb- 
ance. In  three  delirium  was  the  princi])al  syiuptom,  coiitiuuing  until  death  in  the  second  week.  Kose  spots  have 
not  been  found  in  all  cases  and  only  in  a  few  instances  have  they  been  abundant.  (Eilemaof  the  extremities  followed 
the  fever  in  four  cases.  Sulphate  of  quinia  or  of  einchonia  has  lieen  employed  in  every  case, — in  mild  cases  the  former 
in  three-grain  doses  daily,  or  the  latter  in  twelve-grain  doses,  has  been  the  sole  medical  treatment.  The  (piantity 
administered  has  depended  upon  the  severity  of  the  case;  sulphate  of  (piinia  having  sometimes  been  given  to  the 
anmunt  of  twelve,  twenty  or  even  sixty  grains  daily.  When  there  was  great  debility  whiskey  was  em|)loyed,  or 
brandy  if  urgent  diarrhiea  was  present.  When,  in  addition  to  debility,  there  was  much  pulmonary  congestion  or 
extensive  bronchitis,  carbonate  of  ammonia  was  also  exhibited  in  frequently  repeated  doses,  lieel-juico  and  milk  were 
given  as  nourishm<nt.  Convalescents  were  fed  on  beef,  eggs,  milk  and  bread.  Diarrhiea  was  met  with  opiate  iujei'- 
tions;  a  drachm  or  a  drachm  ami  a  half  of  laudanum  usually  checked  the  evacuations  for  about  twelve  hours,  and  in 
some  cases  after  two  or  three  administrations  the  inti'stinal  condition  became  apparently  much  improved.  Sinajiisms 
were  employed  for  the  relief  of  abdominal  pain.  Koasted  apple  was  allowed  to  every  patient.  Latterly  cold  tea  has 
been  used  instead  of  water  as  a  drink,  on  the  suspiciim  that  the  water  of  this  region  iiroduced  a  teiultMU'y  to  diarrhiea. 
One  case  deserves  particular  mention:  J.  M.,  age  20,  in  the  third  week  of  typhoid  began  to  fail  mi  account  of  the 
severity  of  the  diarrhu-a.  About  the  eighteenth  day  he  vomited  everything  and  aiipeared  moribund,  his  eyes  sunken 
and  surrounded  with  dark  areohe  and  his  extremities  cold.  All  attempts  to  administer  food  or  iiiedicino  were  discon- 
tinued. After  some  hours  fasting  the  vomiting  ceased  and  the  patient  began  to  take  champagne  in  half-ounce  doses. 
This  was  continued  three  or  four  times  an  hour  until  the  one  small  bottle  that  hiid  been  procured  was  finished ;  after 
this  cider  was  given,  two  or  three  ounces  every  hour  for  thirty -six  hours.  Then  we  ventured  on  lieef-tea  in  small 
i|iiantities,  and  on  the  fourth  day  gave  milk,  with  a  little  hard  bread  on  the  followiugday.  'i'hero  w;is  no  siibsei|iient 
vomiting;  the  jiatieiit  improved  slowly  from  the  day  alter  tlu'  change  took  place.  After  live  days  of  constipation  an 
eniMua  brought  away  an  abundant  ami  well  formed  dejection.  Thirteen  days  liavi;  now  elapsed" since  he  began  to 
improve  and  no  untoward  symi>tom  has  a])peared.  He  sits  u))  a  little  daily;  his  food  consists  of  eggs,  l)eel'steak, 
milk,  apples  and  bread  and  tea.  No  medicine  has  been  employed  during  his  convalescence,  and  the  cider  has  lieeii 
discontinued  for  several  days. 

Surgeon  J.  T.  Cai.houx,  Hth  X.  T.,  Camp  Kcornij,  Ahrandria,  )"«.,  Oct.  10,  IWiL'. —  Ihe  troatment  consisted  of  a 
mild  cathartic  at  the  outset,  followed  by  diaphoretics;  as  soon  as  tlii'  debility  characteristic  of  the  disease  showed 
itself  stimulants  were  given  freely, — ([uinine,  whiskey  and  oil  of  turpentine  were  used  with  turpentine  frictions  to  the 
abdomen.  When  cerebral  disturbance  was  tronblesiune  llort'mann's  anodyne  was  mostly  relied  ujion.  With  the  stimu- 
lants a  rich  diet  was  allowed;  beef-tea,  eggiiog,  milk-iiunch  and  oyster  or  chicken  soup, — but,  although  we  had  a 
large  hosjiital  fund,  it  was  often  difticnlt  to  follow  out  this  line  of  treatment.  The  unfriendly  inhabitants  refused  to 
sell  to  us,  and  communication  with  the  outside  world  was  indirect  and  uncertain.  The  scanty  allowance  of  alcoholic 
stimulants  permitted  in  the  field  fell  a  prey  to  the  teamsters  during  its  transit  from  Washington,  and  we  had  to 
depend  for  our  supjily  upon  liiiuor  contiscated  from  trading  sloops  which  carried  on  an  illicit  trade  with  the  soldiers. 
Oysters  we  could  generally  juocure  and  oyster  soup  was  a  stand-by.  Eggs  were  bought  at  fabulous  jirices  when 
obtainable.  No  less  than  three  of  my  jiatients  died  after  the  establishment  of  convalescence  because  proper  food  could 
not  be  jirovided  for  them  during  a  temporary  siis|)ension  of  fresh-meat  issues. 

Surgeon  R.  N.  Kauk,  'MUh  Ohio,  Sitmmeri-ille,  Va.,  Xov.  1,  18(51. — There  has  been  a  comparatively  large  number  of 
fever  cases,  and  what  is  peculiar,  every  case  of  illness  of  whatever  character  sjieedily  assumed  a  typhoid  form  and 
yielded  slowly  to  treatment.     In  most  cases  my  reliance  is  on  quinine,  whiskey  or  brandy  in  large  and  repeated  doses. 


540  TRKATMENT    OF    THE 

Wlien  I  dimininli  or  omit  these  remedies  my  patients  ra|)i<lly  sink  exhausted.  The  epidemic,  for  such  it  is,  does  not 
api)ear  to  Lave  reached  its  climax,  nor  is  it  confined  to  the  sohliery,  lint  aft'ects  al-so  the  inhaliitants  of  the  surround- 
inj;  country.  »  *  »  'I'lie  season  h:is  heen  nnnsnally  wet :  iheneliing  rains  have  fallen  for  days  together.  Kesident 
phj'sicians  ascrilie  the  e]iideniic  to  this  cause  and  look  confidently  for  its  disappearance  when  cold  weather  sets  in.* 

Attempts  to  sn|)i>rfS8  or  favorably  iiioilifv  the  disease  by  emetics  in  the  early  period 
were  rarely  made.  A  \'rw  instan<>fs  of  this  kind  may  be  found  in  the  seryice  of  the  19th 
Mass.,  cases  3,  4,  10  and  12.f  Tlu'  i>lan  appears  to  haye  been  tried  also  at  Fort  Monroe,  Va. 
Usually,  howeyer,  on  the  arriyal  of  a  feyer  patient  at  a  general  hospital  the  first  means 
adopted  to  promote  liis  well-bein^  were,  in  the  absence  of  peremptory  indications  for  other 
measures,  a  much-needed  bath  and  a  full  dose  of  Doyer's  powder.  These,  with  a  few  hours 
of  rest  and  cpiiet,  jierhaps  of  sleep,  tended  to  free  the  case  from  much  of  the  temporary 
e.Kcitement  or  exhaustion  due  specially  to  the  fatiguing  journey  from  the  front. 

The  relaxed  condition  of  the  bowels,  so  intimately  associated  with  the  essential  lesion 
of  typhoid  feyer,  was  frequently  lidd  in  check  by  the  Doyer's  powdt-r  or  other  opiate  admin- 
istered as  an  anodyne,  calmatiye,  sudorilic  or  hypnotic.  Enemata  of  starch  and  laudanum 
and  pills  of  acetate  of  lead,  tannin  and  opium  were  favorite  remedies  when  diarrhoea  was 
actiye  and  threatening.  The  use  of  the  former  may  be  noted  in  cases  27,  62  and  97  among 
others  of  the  Beminary  series;  of  the  latter  in  18,  45,  47  and  86  of  the  same  series,  and  in 
51  of  the  post-moriem  records;  chalk  mixture  was  employed  in  case  11  of  these  records, 
nitrate  of  silyer  and  ojiium  in  B5  and  snbnitrate  of  bisnuith  in  85;  catechu  in  32  and  46  of 
the  Seminary  series. 

But  although  the  pathological  tendency  was  to  diarrhcea  few  of  the  cases  ran  their  course 
without  being  sul.)jected  at  some  period  to  tlie  action  of  laxative  or  active  purgative  medi- 
cines. In  case  38  of  the  Seminary  rt-cords  the  object  of  the  cathartic  was  apparently  to 
allay  cerebral  coiKfestion,  and  in  1)'>  repeated  doses  of  castor  oil  and  extract  of  senna  were 
administered  on  account  of  headache  and  dizziness  towards  the  favorable  close  of  the  case; 
but  ill  most  instances  th'^  movement  of  the  bowels  was  the  primary  object  in  the  exhibition 
of  laxative  or  cathartic  medicaments.  Sometimes  tliis  was  effected  by  enemata,  as  of  soap- 
suds in  36,  46  and  S^).  In  2V)  no  stool  was  obtained  without  the  aid  of  castor  oil  except  on 
the  day  of  admission.  In  8,  9,  13,  15,  38.  39,  62,  63,  67,  73,  75  and  108  such  cathartics 
as  calomel,  jalap,  compound  cathartic  mass,  blue-pill  and  sulphate  of  magnesia  produced  no 
undue  effects,  although  in  some  of  these,  as  73,  increa.sed  tenderness  of  the  bowels  was  noted 
after  the  administration;  but.  on  the  other  hand,  the  benefits  derived  or  expected  to  be 
deriyed  from  their  use  are  not  clearly  indicated.  Moreover,  in  case  6  there  was  no  promi- 
nent abdominal  affection  until  after  tlie  administration  of  castor  oil;  in  79,  also,  an  exhaust- 
ing diarrhcea  followed  the  use  of  this  laxative  agent.  In  21  two  six-grain  doses  of  calomel 
were  followed  by  diarrhoeal  stools,  with  much  abdominal  tenderness  and  tympanitic  disten- 
tion; in  103  calomel  and  jalap  induced  frequent  evacuations  which  were  associated  with 
acute  abdominal  tenderness.  In  case  8  of  the  record  of  the  27th  Conn,  three  compound 
cathartic  pills  gave  rise  to  eight  small  bloody  passages,  with  pain  in  the  right  iliac  and  epi- 
gastric regions,  and  an  ounce  and  a  half  of  sulphate  of  magnesia,  subsequently  administered, 
induced  six  copious  ^vatery  evacuations.  The  patient  recovered;  but  it  is  difUcult  to  con- 
ceive in  what  manner  this  irritant  action  on  the  already  inflamed  and  ulcerated  mucous 
membrane  of  the  intestine  contrilmted  to  the  favorable  result.  In  fact,  the  claims  of  actiye 
cathartics  to  a  place  in  the  rational  mo<le  of  treatment  of  ty|)hoid  fever  do  not  appear  from 
the  records  to  lie  well  srounded. 


•  Ste  Ueport,  mpra,  page  327.  f  See  mpra,  pp.  2S5-257. 


CONTINUED    FEVERS.  541 

As  directecl  against  the  coinplexus  of  symptoms  constituting  the  febrile  condition  ipe- 
cacuanhii  and  o|iiiun,  in  tlie  form  of  Dover's  powder,  was  generally  employed.  Usually  it 
was  given  at  bedtime  to  induce  a  restful  night.  Sometimes  in  mild  cases  no  other  treat- 
ment was  prescribed,  as  in  the  tvphoid  left  after  the  suppression  of  the  malarial  element  in 
case  109.  Occasionally,  as  in  86  and  110,  sweet  spirit  of  nitre  was  used  to  sujiplement  the 
effects  of  the  Dover's  powder.  To  these  a  saline  solution  was  sometimes  added — the  ac(^tate 
of  potassa,  as  in  107,  or  the  corresponding  ammonia  salt,  as  in  38,  99  and  119.  Camphor 
was  used  witli  the  ethereal  spirit  in  25;  digitalis  in  49,  and  veratrum  viriile  in  lOo,  in 
which  the  pulse  was  frequent,  quick  and  strong,  with  pulmonary  inflammation  threatening. 
Nitrate  of  potash  was  used  to  control  the  febrile  action  in  some  of  the  cases  that  occurred  in 
the  19th  Mass.;  tincture  of  aconite  in  65  and  6S  of  the  posf-mo7-tem  records. 

Small  doses  of  mercurials,  usually  calomel  or  blue-pill  in  conjunction  with  opium,  were 
given  in  many  cases,  as  82,  83  and  85,  for  a  few  days  at  a  time,  evidently  with  the  view  of 
controlling  the  deposits  in  the  intestinal  and  mesenteric  glands;  in  99,  lOO  and  105  these 
were  combined  with  quinine,  and  in  84,  90  and  101  with  antimony;  but  so  far  as  shown  by 
the  records  the  constitutional  effects  of  the  remedy  were  not  prodnci'd  in  any  of  tlu'se  cases. 
In  123  liquid  effusion  in  the  j^ericardium  or  pleura  was  promptly  absorbed  on  the  occurrence 
of  salivation.  Ptyalism  in  case  17  of  the  post- mortem  records  did  not  iircvrnt  death  from 
perforation  of  the  ulcerated  patches.  In  some  cases  in  which  jaundice  appeared  as  a  symp- 
tom, as  in  121  of  the  Seminary  series,  small  doses  of  calomel  and  dpium  were  administered; 
in  others,  as  in  67  and  112,  blue  pill  and  (piinine  constituted  the  treatment. 

Cold  was  applied  to  the  head  by  means  of  wet  cloths  when  hea<laclie  was  vioU'nt  or  in 
the  presence  of  cerebral  hyperaemia,  as  in  cases  36  and  38.  Sometimes,  as  in  257  of  the 
pod-mortem  records,  blisters  were  applied  to  llu;  liack  of  the  neck  to  coinitei-act  the  ellects 
of  intra-cranial  congestion.  Sponging  the  body  with  tepid  or  cold  water  was  frequently 
employed  as  a  means  of  reducing  febrile  heat  and  conducing  to  the  comfoil  of  the  patient. 
The  re|iorts  of  Surgeons  Walton,*  GRANGKnf  and  IIkad;!;  refer  to  the  bi'iielicial  results  of 
this  practice.  In  case  46  muscular  pains  in  the  limbs  are  said  to  have  been  relieved  by 
sponging  the  surface  with  alcohol. 

Turpentine  was  as  extensively  used  as  if  it  had  lieen  considered  a  specific  in  typhoid 
fever.  Generally  it  was  given  when  the  tongue  became  dry  and  brown,  and  particularly 
when  this  organ  was  dry,  red  and  glossy,  or  when  the  al)domen  was  tympanitic  and  tendcM". 
It  was  administered  in  doses  of  ten  or  fifteen  drops,  repeated  every  thi'ee  or  four  hours;  an 
emulsion  made  with  gum  arable,  sugar  and  cinnamon-water  was  fiequeutlv  preserdied.  Its 
use  was  continued  only  for  a  day  or  two  at  a  time;  but  in  case  268  of  the  pod- innrtrm  records 
it  was  employed  for  eight  consecutive  days. 

Some  medical  ofiicers  have  expressed  much  satisfaction  at  the  favorable  results  obtained 
by  the  administration  of  this  remedy. §  The  frequency  of  its  use  also  testifies  to  a  high 
estimation  of  its  virtues.  But  when  the  individual  cases  that  have  been  piesenied  in  this 
chapter  are  examined  with  reference  to  this  point  the  beneficial  effects  of  the  remedy  do  not 
appear  to  be  so  definitely  established.  Notes  of  the  administration  of  tur[ientine  are  found  in 
seventy-two  of  the  cases  already  presented  from  the  clinical  records  of  the  Seminary  hospital. 
the  19th  Mass.  and  27th  Conn.;  but  the  records  of  some  of  these  are  .so  imperfect  in  their 

» .Siijirn,  pagp  316.  t '"<";"".  F'Kf '^IT.  }  fii/m,  [lage  MT. 

fi  Spp,  for  inetanro,  the  report  of  .\ss"t  burg.  ,1.  c.  McKee,  I  .  S,  Army,  nnprn,  p.  tjO. 


542  TKEATMEXT    OF    THE 

details  of  progress  tlint.  althuugli  the  cases  tenninated  favorably,  they  cannot  l>e  admitted 
as  evidence  of  tli(>  value  of  the  remedy.  On  account  of  similar  imperfections  the  i('<'(jrds  of 
fatal  cases  cannot  he  used  to  testify  to  the  inetficacy  of  the  remedy, — the  treatment  liy  tur- 
pentine was  ill  some  instances  begun  such  a  short  time  before  the  fatal  teraiiuation  that  then- 
records  cannot  with  propriety  be  considered  in  an  investigation  of  this  nature.  It  seems 
{iroper,  also,  to  exclude  cases  in  which  the  mildness  of  the  attack  gave  no  opportunity  to 
emphasize  the  action  of  the  medicine,  as  well  as  those  which,  although  grave  in  their  gen- 
eral aspect,  did  not  present  a  higli  develojiment  of  the  symptoms  which  the  oil  of  turpentine 
was  assumed  to  control.  On  these  gruunds  twenty  of  the  seventy-two  cases  may  be  dropjjed 
from  consideration. 

Some  im})rovement  was  observed  to  follow  the  use  of  turpentine  in  nineteen  of  tlie 
remaining  fifty-two  cases;  no  improvement  in  thirty-three.  But  it  is  questionable  if  the 
alteration  in  the  condition  of  the  patient  can  be  with  propriety  attributed  to  this  particular 
medicine  in  all  the  cases  in  which  the  symptoms  were  favorably  modified  subsequent  to  its 
use.  When  the  improvement  in  a  febrile  case  is  general  and  not  confined  to  the  condition 
of  a  particular  organ  or  set  of  symptoms  its  cause  must  be  ascribed  to  influences  affecting  the 
system  as  a  whole.  A  remedy  directed  to  a  specific  object  may  not  be  credited  with  a  local 
beneficial  result  wdiich  would  have  happened  irrespective  of  it  as  a  j^art  of  a  general  eff'ect. 
It  will  be  shown  hereafter  that  turpentine  had  no  influence  on  the  cerebral  symptoms  of 
typhoid  fever.  When,  therefore,  in  a  case  of  this  fevei-  the  administration  of  turpentine  for 
a  dry  glazed  tongue  and  tympanitic  abdomen  was  followed  by  relief  not  only  to  these  condi- 
tions but  to  all  the  other  symptoms  of  the  comjilex  febrile  state,  the  local  improvement  must 
be  regarded  less  as  the  effect  of  the  remedy  than  as  a  part  of  a  larger  eff'ect  produced  by  some 
general  influence,  as  a  crisis  or  lysis  at  the  natural  termination  of  the  febrile  attack.  Probalil  v 
in  at  least  seven  of  the  nineteen  cases  in  which  favorable  results  followed  the  use  of  turpen- 
tine a  doubt  mav  be  reasonably  entertained  as  to  the  cause  of  the  improved  condition ;  these 
are  15,  19,  38,  40,  68,  71  and  86  of  the  Seminary  series. 

There  remain,  tliere fore,  but  twelve  cases,  22,  27,  31,  36,  44,  45,  51,  93,  99,  113,  114 
and  119  in  which  an  improved  condition  of  the  tongue  or  an  amelioration  of  the  intestiiuil 
symptoms  may  be  attributed  to  the  internal  administration  of  the  oil  of  turpentine;  and 
even  these  are  not  without  qualification:  In  some,  as  27,  45  and  119,  the  improvement 
may  have  been  in  a  measure  due  to  the  astringent  remedies  given  at  the  same  time;  in 
some,  as  36  and  93,  the  relief  was  but  temporary,  the  intestinal  symptoms  recurring  at  a 
later  date;  and  in  one,  113,  the  connection  between  the  condition  of  the  .skin  and  the  presence 
or  absence  of  diarrhoea  appears  to  have  been  decidedly  more  intimate  than  that  between 
the  intestinal  symptoms  and  the  administration  of  turpentine. 

To  offset  these  thei'e  are  among  the  fifty-two  cases  thirty-three  in  wliich  the  details, 
given  with  precision,  discountenance  the  idea  of  a  beneficial  effect  from  the  turpentine 
treatment.  In  twenty-four  of  these  the  abdominal  symptoms  persisted  or  became  aggravated 
after  the  administration  of  the  remedy,  and  in  nine  they  were  actually  developed  shortly 
after  its  use.      These  are  particularized  in  the  subjoined  analysis. 

Similar  results  are  obtained  from  a  study  of  the  cases  submitted  as  the  post-mortem 
records  of  the  continued  fevers.  In  seven  only  of  this  large  nundjer  of  cases  was  some 
improvement  noted  after  the  use  of  turpentine.  In  one,  case  96,  the  remedy  is  said  to  liave 
disagreed  with  the  patient.      In  thirteen  cases   in  which  a  reference  to  turpentine  has  been 


CONTINUED    FEVERS.  543 

preserved  in  the  published  records,  by  way  of  keeping  in  view  tlie  nature  of  the  medication 
adopted  in  these  cases,  no  intimation  of  a  favorablo  change  can  be  drawn  from  tlie  state- 
ments given,  in  many  otliers  in  wliich  references  to  the  treatment  have  been  suppressed 
in  the  published  records  as  valueless  by  reason  of  their  isolation  from  unrecorded  correlated 
facts,  nothing  is  shown  by  the  original  papers  except  that  although  turpentine  was  used  at 
some  statie  of  the  malady  the  ultimate  result  was  death. 

The  absence  of  any  restraining  influence  exercised  by  this  remedy  on  sympt(jms  uncon- 
nected with  the  intestinal  canal  maybe  readily  gathered  from  an  examination  of  the  cases: 
In  22  delirium  continued  for  six  days  after  diarrliu^al  symptoms  had  subsided  subsequent  to 
the  use  of  turpentine.  In  23  delirium  supervened  on  the  day  after  turpentine  was  ailmin- 
istered,  and  persisted  for  eight  days  thereafter.  In  24  all  the  symjitoms  that  are  usually 
regarded  as  unfavorable  prognostics,  excepting  those  connected  with  the  local  lesion — as 
exhausting  diarrhoea,  intestinal  hemorrhages  and  indications  of  peritonitis  from  perforation 
of  the  gut — were  present  for  nearly  two  weeks  alter  turpentine  was  used.  Among  other 
instances  of  the  continuance  of  cerebral  symptoms  cases  28,  32,  84,  87  and  97  may  be 
specially  mentioned. 

Analysis  of  Cases  of  Continued  Fkveu  in  which  Tuhpkntink,  \va«  iiskh  to  imoiuiy  tiik  condition  ok  the 
Tongue  ou  mitigate  thk  uiuiENcv  ok  Intk.stinai,  Sy.mimoms. 

Cases  in  which  an  improved  condition  of  the  ioiigne  or  on  nmilinrdlion  of  llii-  iiitnitinal  sjimptoms  iikii/  Iw  tiltiihiitrd  hi  llif  inlininl 

use  (if  thi'  rtmedji.' 

Cask  22. — Tlio  toiijino  cleaned  and  diaiiluia  Hiilisided  within  t'oiii  days  al'tei-  the  leinody  wan  used,  lint  feliiih! 
delirium  continued  iVir  six  days  lonjjer. 

Cask  27. — When  tnipentino  was  ^ivcn  in  this  case  the  patient  was  nintt<MinK  in  the  delirium  of  typhoid,  his 
toiif^ue  Urownish-gray  in  the  centre,  red  at  the  tij)  and  nnirjjins  and  liis  howols  loose  an<l  lender.  Two  days  later  the 
tongue  was  cleaning  as  part  of  a  permauent  imjirovement ;  hut  ojiiate  enemata  were  used  in  conjunction  with  the 
emulsion  on  behalf  of  the  intestinal  symiitonis. 

C.VSK  SI. — Turpentine  given  late  in  the  ilisease,  when  the  tongu<'  was  dry  from  pulmonary  complications,  was 
followed  by  an  improvement  in  the  patient's  condition. 

CA.>iK  36. — The  tongue  became  moist  and  the  tyni)>aniti-sdiminislic(l  after  the  admin ist rat  ion  of  the  remedy  on  the 
twentieth  day;  but  diarrlnea,  involuntary  stools  and  ahilominal  ti'nilcrness  were  noted  at  a  later  dale. 

C'asb  44. — A  moistening  of  the  dark-iolored  tongue  followed  llic  use  of  turjientine,  but  otherwise  thesymptoins 
appeared  unchanged. 

Case  45. — Diarrluca  and  meteorism,  treated  with  turpentine  on  the  ninth  day,  became  relieved  in  a  few  days, 
and  the  liowels  thereafter  remained  (juiet  or  with  not  more  than  one  movement  ilaily;  but  acetate  of  lead,  tannin  and 
opium  were  used  coincidently. 

Case  51. — Treatment  by  turpentine,  support  and  sliniulation  was  IbllowtMl  by  a  subsidence  of  diarrhu'a  and 
return  of  appetite. 

Case  93.^ — -A  temporary  improvement,  involving  the  disappearance  of  meteorism  and  of  the  fur  from  the  tongue, 
followed  the  use  of  the  remedy;  but  (liarrho'a  contiuueil,  and  the  case  tcrniiuate<1  fatally  with  hemorrhage  from  the 
bowels  and  laryngeal  and  pulmonary  inHannnatory  comiplications. 

Case  99. — In  this  case  the  tongue  was  dry,  and  although  the  bowi'ls  were  cpuet  iiwre  was  some  tenderness  and 
meteorism.  After  the  use  of  turpentine  the  condition  of  the  tongue  remained  unehanged,  but  an  improvement  was 
manifest  in  the  cerebral  and  abdominal  symptoms. 

Case  113. — Diarrlnea  subsided  temporarily  after  the  use  of  turpentine,  but  abdominal  tenderness  and  distent  ion 
persisted.  In  this  case  the  connection  between  the  couditioii  of  the  skin  and  the  presence  or  almenco  of  diarrliwa 
appears  to  have  been  more  infinuite  than  that  between  the  intestinal  symptoms  and  the  administTation  of  turpentine. 

Case  114. — Kelaxation  anil  tcmlerness  of  the  bowels,  which  apjieared  in  the  list  of  symptoms  before  the  use  of 
turpentine,  were  not  noted  after  its  em])loyment,  although  the  general  symptoms  continued  grave  for  some  tinu'. 

Case  119. — Diarrlnea  was  controlled  but  tenderness  ami  distention  continued.  Acetate  of  lead,  tannin  and 
opium  were  given  at  the  same  time. 

Canes  in  uhkh  a  favorahle  modificalion  of  the  sijnqitnms  fotlnirhi;/  the  nnr  of  turpentine  mnij  with  propriety  be  suggested  as  due 

to  other  eoin<ideHl  conditions. 
Case  l."!. — Two  days  after  tht^  institution  of  the  tn'atmeni  by  turpentine  the  tongue  wasideauingand  the  bowels, 
although  slightly  tympanitic,  were  (juiet  and  free  from  tenderness;  but  as  this  occurred  at  a  somewhat  late  period 
of  the  attack  and  was  gradually  followed  by  convalescence,  the  probability  of  a  natural  lysis  is  snggested. 


*  Wbru  nut  otherwist'  btatt'd  the*  caws  citPvi  are  from  tho  Semiiiiuy  ho>iiLtiil  serif.'fi. 


644  TREATMENT   OF   THE 

Case  19. — The  defervescence  which  took  place  two  days  after  the  use  of  turpentine  was  prol)al)ly  a  natural 
crisis  by  perspiration. 

Casb;  38. — The  dry,  hard  and  fissured  tongue  became  moist  and  clean  after  turpentine  was  administered,  but 
the  general  character  of  the  improvement  sugf;ests  a  natural  defervescence. 

Ca.<k  10. — The  improvement  followinfj  the  use  of  the  remedy  may  be  attributed  to  the  subsidence  of  the  pul- 
monary intlammation  which  preceded  the  attack  of  ty])hoid.  The  tongue  became  dry  and  brown  and  the  bowels 
tender  thougli  not  very  loose  in  the  subseciuent  febrile  course. 

Cases  68,  71  and  86. — -The  general  character  of  the  improvement,  and  the  period  at  which  it  took  place,  raise 
a  doubt  as  to  its  causative  agency. 

Cases  in  which  the  records  do  not  shoic  that  any  beneficial  effect  resulted. 

In  cases  78,  82,  95,  100  and  117  the  want  of  precise  details  of  the  progress  of  the  disease  prevents  the  beneficial 
effects  of  turpentine,  if  any  were  exercised,  from  being  known. 

In  cases  12,  48  and  91  of  the  Seminary  series,  and  in  13  of  the  19th  Mass.,  the  institution  of  the  treatment  by 
turpentine  was  so  delayed  that  the  speedy  approach  of  death  prevented  any-  manifestation  of  its  assumed  remedial 
powers. 

Casj;  18. — When  turpentine  was  given,  on  the  eighteenth  day  of  the  attack,  the  patient  was  much  exhausted  by 
night-sweats:  his  tongue  was  ilry  and  brown,  but  he  had  no  diarrhn'a.  The  record  does  not  show  that  any  improve- 
ment resulted. 

Cask  32. — Turpentine  certainly  did  not  exercise  any  favorable  influence  on  the  cerebral  symptoms  in  this  case; 
nor  is  it  clear  from  the  record  that  the  diarrhiea,  borborygmus,  tenderness  and  tympanites  were  immediately  relieved. 

C.\SE  80. — The  remedy  was  administered  after  the  abdominal  symptoms  had  ceased  to  be  distressing. 

Case  104. — No  special  action  of  the  turpentine  can  be  inferred  from  the  record.  Perhaiis  the  large  (jnantity  of 
urinepassedduring  the  twenty-four  hours  immediately  succeeding  its  administration  may  have  been  duo  to  its  diuretic 
action;  but  that  any  favorable  impression  was  made  on  the  intestinal  symptoms  is  doubtful,  as  a  blister  was  applied 
to  the  abdomen  on  the  seventh  day  after  the  emulsion  was  prescribed. 

Cases  in  which  it  is  difficult  to  assign  a  faronihle  action  to  the  turpentine  on  account  of  the  want  of  ijraviti/  in  the  abdominal 

symptoms  for  which  its  use  is  recommended. 

C.\SE  7. — The  tongue  was  red,  smooth  and  glossy;  the  teeth  blackened;  some  abdominal  tenderness  and  gurgling 
was  present  but  no  meteorism.     Turpentine  was  given  on  the  ninth  day  and  convalescence  established  on  the  fifteenth. 

Case  13. — The  abdominal  symptoms  were  prominent  neither  before  nor  after  the  use  of  turpentine  in  the  third 
week  of  the  attack. 

Case  14. — A  light  febrile  case  which,  though  of  sonu'  duration,  did  not  present  any  of  the  inilicatioiis  men- 
tioned by  Professor  Woi>l>  as  calling  for  the  use  of  turpentine. 

Cask  23. — Delirium  supervening  on  the<lay  after  the  turpentine  treatment  was  commenced  continued  for  eight 
days,  but  the  abdominal  symptoms  were  not  i>rominent. 

Cask  24. — This  case,  after  admission  on  the  twenty-second  day  of  the  disease  and  the  institution  of  the  turpen- 
tine treatment  on  the  folio  wing  day,  presented  a  series  of  grave  symptoms — including  delirium,  unconsciousness.  Hordes, 
dilation  of  the  pupils,  floccitatio,subsultu8,  inability  to  articulate,  otorrho-a,  bedsores  and  vilnces — that  did  not  sub- 
side until  the  thirty-tifth  day,  when  a  less  frequent  pulse,  cleaning  tongue,  returning  intelligence  and  moist  skin 
indicated  the  commencement  of  convalescence. 

In  60  and  lli»  the  abdominal  symptoms  were  so  mild  that  the  influence  of  turpentine  as  a  remedial  agent  cannot 
be  determined  from  the  records. 

Cases  in  which  diarrhera  or  other  abdominal  symptoms  persisted  or  became  aggrarated  after  the  use  of  turpentine. 

Case  2.t. — Fie<tuent  stools,  sometimes  passed  involuntarily,  delirium,  sordes,  etc.,  persisted  for  many  days  after 
the  use  of  the  emulsion. 

Case  26. — This  case  presented  a  red,  dry  and  glossy  tongue,  diarrhnea  of  some  frequency,  much  meteorism,  but 
no  tenderness.  These  symptoms  persisted  for  n  week  notwithstanding  the  administration  of  turpentine,  stupor  and 
delirium  meanwhile  supervening,  the  tongue  becoming  dry  and  dark  and  the  teeth  covered  with  sordes, 

C.A^SE  28. — Uiarrhfpa,  abdominal  tenderness,  gurgling  and  meteorism  appear  to  have  been  as  distressing  after 
as  before  the  use  of  the  remedy.  Not  until  three  weeks  afterward  did  the  cerebral  syniptoms  subside,  and  with  them 
the  manifestations  of  the  intestinal  lesions. 

Case  2{). — Tenderness  and  tympanites  in  this  ease  do  not  seem  to  have  been  favorably  nioditicd. 

Case  34. — The  tongue  was  dry,  fissured  and  brown-coated,  the  teeth  covered  with  sordes  and  tln^  abdomen 
tympanitic  when  turpentine  was  given.  No  notable  change  followed  until  eight  days  later,  when  the  tongue  cleaned 
and  delirium  subsided. 

C.\SE  37. — Tliis  was  characterized  by  two  i)assages  daily,  with  slight  tenderness  and  gurgling;  tongue  brown 
in  the  centre,  its  margins  red.     Turpentine  did  not  ett'ect  any  change  in  these  conditions. 

Case  43. — There  was  much  tenderness,  some  tympanites,  little  diarrhiea  and  a  moist  tongue,  coated  except  at 
the  edges.  After  the  use  of  turpentine  the  tongue  became  dry  and  the  intestinal  symptoms  persisted,  if,  indeed,  they 
did  not  become  aggravated. 

('.\SE  4ti. — Turpentine  was  used  on  the  seventeenth  day,  the  bowels  at  the  time  licing  loose  and  tender,  the  tongue 
smooth  and  dry  in  the  middle  and  moist  at  tlie  edges.     Next  day  the  bowels  were  quiet  but  meteorized  and  acutely 


CONTINUED    FEVERS.  "        545 

tender.  The  tenderness  persisted  on  the  nineteenth  day,  but  the  tympanites  was  reduced  and  the  bowels  relaxed, 
an  enenia  of  soapsuds  having  been  administered  meanwhile.  On  the  twenty-first  day  the  tongue  was  smooth,  glossy 
and  dry,  and  the  bowels  loose,  tender  and  meteorizid.     The  tongue  did  not  become  clean  iintil  the  twenty-sixth  day. 

Case  47. — No  improvement  resulted  from  turpentine  administered  on  the  seventh  day;  for  the  grave  symptoms, 
including  diarrhoea,  were  not  relieved  until  five  days  later,  when  the  tongue  became  moist  and  began  to  clean  in 
patches.  "■ 

Case  50. — Turpentine  was  not  beneficial  in  this  case,  for  from  the  time  of  admission  the  condition  of  the  patient 
gradually  changed  for  the  worse,  the  stools  becoming  involuntary  and  the  prostration  extreme. 

Case  64. — When  remitting  fever  gave  place  to  a  continued  form  in  this  case  turpentine  was  substituted  for 
quinine,  the  patient  having  a  dry  tongue  and  frequent  stools.  Its  further  progress  was  marked  by  abdominal  symp- 
toms, which  appeared  rather  to  alternate  with  perspirations  than  to  indicate  the  influence  of  any  special  medication. 

Ca8p:  70. — Severe  diarrhuia  and  abdominal  pain  persisted  for  ten  days  after  turpentine  was  prescribed  on  the 
seventeenth  day. 

Case  74. — Turpentine  was  given  on  the  eleventh  day  for  intense  abdominal  tenderness.  From  this  time  to  the 
end  of  the  fourth  week  the  patient's  general  condition  remained  unchanged;  his  tongue  flabby  and  yellow-furred; 
bowels  moved  from  one  to  seven  times  daily,  with  general  and  occasionally  umbilical  and  left  iliac  tenderness,  and 
with  sometimes  slight  tympanitic  distention. 

Case  75. — Turpentine  was  given  on  the  eighth  day;  but  for  several  weeks  after  this  there  was  a  notable  relaxa- 
tion of  the  bowels,  with  more  or  less  tenderness,  chiefly  in  the  umbilical  and  left  iliac  regions. 

Case  77. — Involuntary  diarrhceal  stools,  abdominal  tenderness  and  distention,  with  a  dry,  brown  tongue  and 
sordes,  persisted  for  a  week  after  the  use  of  turpentine. 

Case  81. — The  beneficial  effects  are  not  manifest  in  this  case,  as  sulisecment  to  the  use  of  the  remedy  sordes 
appeared  on  the  gums,  the  stools  were  passed  involuntarily,  and  eight  days  afterward  the  tongue  was  dry  and  tremu- 
lous and  the  bowels  loose. 

Case  84. — After  turpentine  was  given  cerebral  symptoms  were  manifested,  while  diarrlima  and  tympanites 
appear  to  have  been  aggravated.     Treatment  was  complicated  by  the  administration  of  calonusl,  opium  and  antimony. 

Case  87. — For  three  days  after  turpentine  was  used  there  was  but  little  improvement;  diarrhiea  continued, 
cerebral  symptoms  were  developed  and  afterward  ])ulmonary  inflammation. 

Case  90. — Intestinal  and  cerebral  symptoms  persisted  for  nine  days  after  the  use  of  turpentine. 

Case  97. — Diarrluea  was  aggravated  and  cerebral  symptoms  developed  after  the  use  of  turpentine,  all  leading 
to  a  fatal  result  thirteen  days  later. 

Case  111. — The  intestinal  symptoms  do  not  appear  to  have  been  favorably  modified  by  turpentine;  tenderness 
or  looseness  of  the  bowels  was  noted  on  the  days  following  the  nse  of  the  remedy. 

Case  118. — On  the  thinl  day  after  the  administration  of  turpentine  the  condition  of  the  patient  remained 
unchanged.     At  this  time  an  enema  of  castor  oil  and  turpentine  relieved  the  tympanites. 

Case  7,  lUth  Mass. — The  fre([uent  but  bloody  and  scanty  stools  which  characterized  this  case  were  not  favorably 
nioditied  nor  were  the  general  syiniitoms  alli^viuted. 

C.A.SE  4,  27tli  Conn. — Following  the  administration  of  lurpentim^  for  abdominal  distention  the  tongue,  which 
had  been  somewhat  moist,  becanu^  dry,  cracked,  dark  and  bloody;  tympanites  was  not  relieved  until  six  days  later. 

Casfn  in  which  intt'stiiial  HijmplomK  wire  develojud  strikiHijli/  uftir  the  a<lmhiinlratio>i  of  turjieiitini'. 

Case  6. — The  remedy  was  given  as  the  eruption  appeared,  the  tongue  being  dry  in  the  centre  but  moist  at  its 
edges,  and  the  patient  having  had  no  diarrh<ea,  tenderness  or  tympanites.  Two  days  later  the  tongue  became  red,  dry 
and  glossy,  and  diarrhiea  with  umbilical  pain  was  developed,  castor  oil  having  lieen  administered  in  the  meanliiue. 

Case  16. — The  tongue  was  dry,  red  and  glazed,  and  the  bowels  quiet  when  turpentine  was  given,  but  the  further 
somewhat  prolonged  progress  of  the  case  was  characterized  by  diarrhiea  of  three  to  five  stools  daily,  meteorism,  and 
right  iliac,  umbilical  and  general  abdominal  tenderness. 

Case  21. — Turpentine  did  not  prevent  the  occurrence  of  three  or  four  stools  daily,  with  much  abdominal  ten- 
derness and  tympanites,  w  hieli,  however,  may  have  been  due  to  mediitatioii  by  calomel  and  not  alone  to  the  morbid 
processes  induced  by  the  fel)rile  poison. 

Case  69. — Four  days  after  the  use  of  turpentine  diarrhiea  appeared  as  a  jirominent  symptom,  speedily  associated 
with  tenderness,  especially  acute  in  the  right  iliac  region. 

Case  79. — In  this  case,  as  in  Gand  21,  the  efl'ects  of  turpentine  were  complicated  by  the  use  of  purgative  remedies. 

Case  94. — A  fatal  issue,  with  much  diarrhiea  and  meteorism,  was  not  ])revented. 

Case  96. — All  the  grave  symptoms  in  this  fatal  case  were  developed  after  the  administration  of  turpentine;  but 
the  intestinal  symptoms  were  not  prominent. 

Case  101. — A  few  days  after  turpentine  was  administered  for  intestinal  distentiiui  diarrhiea  was  developed, 
which  continued  for  more  than  a  week,  associated  with  pain  in  the  epigastric  region  and  gurgling  in  the  right  iliac 
fossa  and  along  the  track  of  the  colon. 

Case  116. — Two  days  after  the  use  of  turpentine  the  bowels,  which  had  been  quiet,  became  loose. 

Tuupentine  in  the  C.^^ses  of  the  Pcst-mortem  Kpxouds. — The  notes  of  treatment  in  many  of  the  cases  sub- 
mitted 3,8  post-mortem  records  were  omitted  in  preparing  tlie  cases  for  imblication ;  but  tliey  were  retained  in  every 
instance  in  which  they  were  recorded  with  precision  and  also  in  several  in  which  they  merely  indicated  the  method 
adopted. 

No  intimation  of  even  a  temporary  improvement  from  the  use  of  turpentine  is  found  in  the  records  of  10,  11, 
Med.  Hist.,  Pt.  Ill— 69 


546  TREATME^■T    OF    THE 

35,  40,  78,  83,  89,  95,  111,  247.  248,  258  and  264,  or  in  :uiy  of  those  in  which  the  references  to  treatment  have  been 
suppressed  as  valueless. 

In  9t)  turpentine  is  said  to  have  been  tried,  and  discontinued  on  account  of  disafj;reeinfi;  with  the  patient. 

In  seven  cases  some  iniprovenieut  was  noted,  as  follows:  17. — The  diy,  red  and  j;lazed  tongue  became  moist  and 
sordes  disappeared,  but  death  was  precipitated  by  perforation  of  the  intestine.  43. — The  dry,  dark,  cracked  and  glazed 
tongue,  sordes,  diarrha>a,  abdominal  tenderness  and  tympanites  were  favorably  modified  by  the  use  of  turpentine 
for  about  three  days,  when  fatal  pnennu)nia  supervened.  79. — The  patient  suftered  from  typhoid  delirium;  tongue 
dry,  red  and  gashed;  bowels  loose  and  tympanitic.  After  the  use  of  turpentine  the  tongue  became  moist  and  the 
bowels  checked,  but  diarrlicea  suddenly  recurred  and  death  took  place  in  a  short  time.  88. — Progress  was  favorable 
under  turpentine  until  abdominal  jiains  set  in  a  few  houis  before  death  by  coma.  105. — A  temporary  improvement, 
the  nature  of  which  is  not  precisely  stated,  resulted  from  the  use  of  iiuinine,  turpentine  and  stimulants.  117. — Under 
the  influence  of  small  doses  of  emulsion  of  turpentine  and  laudanum  delirium  subsided,  the  tongue  became  souuiwhat 
moist  and  the  pulse  less  rapid,  but  diarrhoea  was  sub-sequently  established.  268.— Under  the  use  of  turpentine,  con- 
tinued for  eight  days,  tympanites  sul)sided  and  the  tongue  liegan  to  clean,  but  a  fatal  stupor  came  on  at  a  later  date. 

In  case  300  the  tongue,  notwithstanding  turpentine,  continued  red  and  dry  for  several  weeks. 

The  testimony  on  behalf  of  turpentine  is  not  encouraging;  nor  is  this  unexpected  when 
the  pathological  conditions  are  held  in  view.  The  tenderness  and  tympanitic  distention  of 
the  intestine  and  that  dry  and  dark  or  scaling  and  glazed  tongue  which,  in  accordance  with 
army  practice,  suggested  the  use  of  the  remedy,  were  generally  associated  with  extensive 
ulcerations  that  admitted  of  no  sudden  reparation  and  return  of  the  affected  parts  to  a  healthy 
state.  A  mitigation  of  the  urgency  of  distressing  or  dangerous  symptoms  was  all  that  could 
be  hoped  for  under  the  conditions.  This  was  sometimes  obtained.  Hence  it  is  probable 
that,  were  these  cases  to  come  up  anew  for  treatment  at  the  present  time,  turpentine  would 
be  as  generally  used  as  in  the  past,  in  the  absence  of  any  more  trustworthy  method  of  exer- 
cising a  salutary  influence  on  the  sloughing  or  granulating  patches  of  the  affected  mucous 
membrane. 

That  part  of  the  rational  method  of  treatment  which  looked  to  the  support  of  the  failing 
energies  of  the  system  became,  in  many  cases,  of  so  much  importance  that  in  practice  it  ceased 
to  be  known  as  a  part  of  the  expectant  plan.  It  became  the  supporting  or  stimulant  method 
of  treatment.  In  some  mild  cases  its  use  was  unnecessary.  Few,  however,  of  the  serious 
or  protracted  cases  reached  their  termination  without  undergoing  systematic  treatment  by 
quinine,  iron,  alcohol  and  nutritives.  The  so-called  typhoid  symptoms — increasing  prostra- 
tion and  tremulousness,  muttering  delirium,  dark  tongue,  sordes,  subsultus,  etc. — were  inva- 
riably met  by  support  and  stimulants;  but  these  were  often  employed  long  before  the  devel- 
opment of  such  dangerous  symptoms.  In  many  cases  as  sooti  as  the  pulse  lost  its  fulness 
tincture  of  iron  was  prescribed  in  doses  of  twenty  drops  three  times  a  day,  with  alcoholic 
stimulants,  small  doses  of  quinine  and  the  use  of  beef-essence  at  short  and  stated  intervals. 
This  was  continued  to  the  end  of  the  attack  and  in  favorable  cases  well  into  the  period  of 
convalescence.  Citrate  of  iron  and  quinine  were  employed  in  some  cases.  Quinine  was 
generally  given  in  one-grain  doses  three  times  a  clay.  Whiskey,  in  the  form  of  milk-punch, 
was  the  stimulant  in  common  use;  but  wine,  wine-whey  and  brandy-punch  were  also  largely 
employed.  The  quantity  of  stimulants  varied  with  the  necessities  of  the  case  as  recognized 
by  the  prescribing  physicians.  Some  medical  officers  dispensed  them  with  a  liberal  hand. 
In  case  2  of  the  post-mortem  records,  whiskey  to  the  amount  of  six  ounces  was  given  daily, 
and  this  quantity  was  afterwards  increased  to  sixteen  ounces  on  account  of  prostration. 
Practically,  in  such  cases,  the  patient  took  all  that  he  could  from  time  to  time  be  prevailed 
upon  to  swallow.  As  a  contrast  to  this,  the  patient  in  case  249  used  only  half  an  ounce 
of  brandy  three  times  a  day.  Suggestions  of  pulmonary  and  peritoneal  inflammation  prob- 
ably kept  the  quantity  at  a  minimum  in  this  case;  but  in  other  instances  stimulants  were 
given  freely  irrespective  of  inflammatory  complications,     li\  some  cases,  when  the  patient 


CONTINUED    FKVERS. 


547 


was  unable  to  swallow,  stimulants  were  given,  as  in  84  of  the  Seminary  series,  by  eneraata. 
The  beneficial  effects  of  this  plan  of  treatment  are  not  evidenced  by  the  records,  for  cer- 
tainly a  larger  quantity  of  alcohol  was  given  to  the  average  protracted,  serious  or  fatal 
case  than  to  the  typical  mild  case  ending  in  speedy  recovery.  Nor  can  the  fatality  of  the 
disease  as  thus  treated  be  compared  favorably  witli  the  results  of  other  tri'atment  in  civil 
practice  before  or  since  the  war.  But  as  this  svstcm  of  treatment  aimed  with  all  the  power 
of  the  therapeutics  of  the  period  at  obviating  the  pronounced  tendencv  to  deatii  from  exhaus- 
tion, it  seems  probable  that  had  suitable  comparisons  been  available  a  i'avoraljle  exhibit 
would  have  been  presented. 

In  a  few  cases  chlorate  of  potash  was  used  as  a  remedial  agent  when  tvphoid  symptoms 
were  jjresent,  as  in  95  of  the  post-mortem  records;  in  111  of  the  same  series  it  was  given  in 
a  more  active  stage  of  the  fever  without  producing  any  a)>parent  beneficial  effects.  The 
following  extracts  relate  to  the  use  of  this  salt  in  the  continued  fevers: 

Surgeon  Ezra  Re.\i>,  21st  hid.,  Fort  Mamhall,  Ballimore,  ^ft^.,  .Aim.  14,  1M2. — lu  tlio  treatnifiit  ol"  t.vplioid  fover  I 
havereli(Hi  m])oii  a  liht'ial  useof  riuiniiican<l  a  Niipportini;  diet.  Wlieio  tliu  tim^iio  hicaiiu!  ii'<l  and  very  <liy  I  admin- 
istered chlorate  of  potash  in  live-grain  dose.s  every  three  or  four  hours  with  great  heiielit.  For  several  years  I  liave 
used  it  iu  like  cases,  and  can  recommend  it  with  mucli  confidence.  It  diminishes  the  redness  and  restores  the  natural 
moisture  more  readily  than  any  other  remedy  which  1  have  used.  For  a  like  purjiose  I  have  not  omitted  the  use  of 
turpentine  iu  ten-drop  doses  every  three  or  four  hours  where  it  seemed  indicated.  Well-ventilated  rooms,  scrupulous 
attention  to  cleanliness  and  frc(iuent  Npoiigiug  the  body  with  tepid  water,  alone  or  mixi'd  with  vinegar  or  whiskey, 
are  absolute  essentials  in  the  successful  niauagenicnt  of  the  disease. 

Siiri/eon  KoiiEiiT  lIi'iiD.Mtl),  I'lh  Coiin.,  llrook'K  Slation,  I'li.,  Mmili,  ISO:!. — The  treatment  of  this  disease  liy  nutri- 
tious diet  and  stimulants,  of  which  milk-punch  has  seenu'd  to  operate  the  best,  and  when  the  tong\ie  anil  uuiuth  aro 
dry  and  sore  the  exhibition  of  (luiniuo  with  turpentine  emulsion  or  chlorate  of  ]iotassa  has  been  successful  except  in 
one  instance  associated  witli  an  intractable  and  exhausting  diarrluea.  Nearly  all  tli«^  eases  of  fever  have  had  diar- 
rhtea  as  a  prominent  symi>tom  ;  but  it  has  usually  yielded  to  stimulants  anil  farinaceous  diet,  with  condensed  milk. 
Opiates  and  astringents  have  been  used  only  when  there  was  much  sleeidessness  and  jiersistiiig  diarrluea. 

Chlorate  of  potash  was  used  as  a  local  application  in  many  cases  in  which  t\io.  tongue, 
mouth  or  throat  was  abraded  or  ulcerated.  It  may  \)v  noted  tdso,  with  reference  to  the  con- 
dition of  the  tongui;,  that  in  249  of  ilic  post- Dwrft'iii  ivcords  an  eilnrt  was  made  to  prevent 
an  excessive  dryness  of  its  surface  by  the  local  use  of  glycerine. 

Opium,  which  was  used  so  frequently  in  the  form  of  Dover's  powder  in  the  early  stages 
to  control  fever  and  allav  cer,fbral  excitement,  and  at  a  later  date  with  astringents  to  restain 
diarrhcea,  was  also  largely  used  when  an  aggravation  of  the  al>dominal  pain  suggested  a 
possibility  of  peritoneal  inflammation.  The  frequent  occurrence,  iu  the  course  of  tlie  fever, 
of  therapeutic  indications  which  could  be  best  fulfilled  by  means  of  this  drug  rendered  it 
an  important  agent.  In  fact,  it  may  be  said  of  some  hospitals  that  Dpium  and  brandy  con- 
stituted tlie  essentials  of  treatment.  In  cases  13  and  14  of  the  poHf-hiortem  series,  from  the 
Ladies'  Home  hospital,  New  York,  the  treatment  is  said  to  have  been  etl'fcted  in  the  one  case 
by  laudanum,  brandy,  beef-extract  and  milk,  and  in  the  other  by  anodynes,  alcoholic  stim- 
ulants and  sustaining  diet.  Cases  19,  20,  82  and  226  of  the  same  series  may  be  noted  as 
illustrations  of  the  use  of  opium  to  alleviate  the  intense  pain  of  ])eritoneal  infiunimation ; 
in  50,  the  drug  was  given  by  enema  on  account  of  gastric  irritability.  The  hypodermic 
syringe  had  not  yet  found  its  way  into  the  hands  of  our  officers.'" 


*  It  was  not  until  iiftfr  tlm  rlosi*  of  tho  war  tliat  liyititilcrmatM'  mcdiration  iK'paii  to  b*.  tlisoil?w)'<l  in  our  modical  journals.  Ri'itaner's  treatise 
nn  IT!ipn<l,'nnir  Inivctimm  was  not  publislKHl  until  l.SU.'i,  ultliou;:h  in  iHtwl,  in  tin-  Il'<^<m  Mnlh-iil  .oj.f  Siiijiritl  J"iirnnl,  its  autlior  calji-d  tin.  attt^ntion  of  tho 
profession  to  tlu-  valuf  (jf  thf  syringe  in  tli*"  treatment  ttf  nenrali^ia.  Bahthoi.ow,  in  liis  Miiuual  of  Ifi/po'lrnuir:  M''thrtttiin>^  T'tiijadelphia,  lRr.9,  ascribps 
tiio  new  art  to  the  discovery  of  the  practicability  and  utility  of  introducing  nn-dicinca  unibT  the  skin  for  the  relief  of  hn-al  Jiain,  liy  Ai.kxani>f.r  Woon 
(►f  Edinburgh  in  1843,  and  the  demonstration  by  Mr.  Charles  Hcntf.r  of  London  in  18.")n  of  the  important  fact  that  tlie  application  of  the  injection  to 
tliu  painful  points,  as  contended  for  by  >Vooit,  was  really  unnecessjiry,  as  equally  gotxt  effects  followed  tliu  intnuiuction  of  the  injection  into  a  distant  part. 


548  TEEATMK]S'T    OF    THE 

For  the  relief  of  abdominal  (tain  local  applications  were  frequently  employed.  Warm 
fomentations,  poidtices,  cuppinu:,  turpentine  stupes  and  blisters  were  used  according  to  the 
urgency  of  the  symptoms.  In  case  300  of  the  poat-raortem  records  woolen  packing  of  the 
abciomen  was  substituted  for  the  poultice.  A  blister  was  applied  to  the  abdomen  in  85  of 
the  Seminary  series  on  account  of  pain  along  the  track  of  the  colon  and  the  passage  of  blood 
from  the  bowels.  Blisters  were  applied  iu  94,  V}6,  98  and  119  of  the  same  series  on  accomit 
of  excessive  tenderness  and  tympanites;  in  50  and  93  of  the  pod-mortein  records  the  resort 
to  cantharides  was  occasioned  by  pain  following  perforation  of  the  bowel.  In  the  last-men- 
tioned case  gray  spots  appeared  on  the  blistered  surface,  and  thi-ee  days  later  an  erysipela- 
tous redness  extended  downward  to  the  thigh:*  liquor  sodte  chlorinatse  and  a  strong  solu- 
tion of  nitrate  of  silver  were  apjtlied,  without  benefit,  as  a  dressing  to  the  sloughing  surface. 

Blisters  and  other  counter-irritants  were  also  used  on  account  of  pain  in  the  chest  con- 
nected with  pneumonic  complications,  as  in  36,  38  and  41  of  the  Seminary  series.  In  such 
cases  the  local  applications  were  often  associated  with  general  medication,  as  by  small  doses 
of  sulphate  of  magnesia  and  tartar  emetic,  calomel  and  opiun:i,  stimulants,  expectorants,  etc 

Tympanites,  which  was  frequently  the  cause  of  abdominal  pain,  was  relieved  in  some 
instances,  as  in  88  and  118  of  the  Seminary  series,  by  enema,  and  in  one,  96,  by  the  passage 
of  a  tube  into  the  intestinal  canal.  Occasionally,  also,  the  removal  of  retained  urine  was 
followed  by  relief  to  abdominal  pain;  the  catheter  is  reported  to  have  been  used  in  121  of 
the  Seminary  series,  and  in  6,  83  and  268  of  the  post-mortem  records;  retention  was  some- 
times treated  by  extract  of  buchu,  as  iu  28,  110  and  119  of  the  former  and  65  of  the  latter 
series  of  cases. 

Hemorrhage  from  the  bowels  appears  to  have  called  for  the  use  of  persulphate  of  iron 
in  109  and  335  of  the  post-mortem  series. 

Aromatic  sulphuric  acid  was  generally  employed  to  control  the  exhausting  perspirations 
which  recurred  nightly  in  many  cases  at  a  late  period  of  the  disease,  although  in  18, 19  and 
112  of  the  Seminary  series  it  does  not  appear  to  have  been  very  successful  in  checking  them; 
in  the  first-mentioned  of  these  the  surface  was  sponged  with  alcohol  and  dihited  nitro-mu- 
riatic  acid,  and  in  83  with  alcohol  alone,  as  a  means  of  lessening  the  perspiratory  action. 

When  collapse  was  imminent  warmth,  frictions  and  ruljefacients  were  applied  exter- 
nally, while  capsicum,  ammonia  and  brandy  were  freely  prescribed. 

Bedsores  were  prevented  and  treated  Ijy  cleanliness,  change  of  position,  special  padding 
and  sponging  with  alcohol.  In  113  of  the  Seminary  series  a  water-bed  was  used.  Keen 
speaks  of  the  valuable  results  produced  on  bedsores  by  applying  ice  for  fifteen  minutes  and 
following  this  with  a  hot  flaxseed  poultice  for  two  or  three  hours. f  One  of  the  few  reports 
relating  to  the  treatment  of 'typhoid  fever  on  file  in  this  office  urges  the  advantages  to  be 
derived  from  change  of  position  during  the  course  of  the  fever. 

Surgeon  Charles  .A.BBOTT,  'l<Mh  Me.,  Union  lioiige,  La.,  January,  186H. — Typlioid  finer  appears  to  be  eudoniic,  and 
in  its  treatment  we  find  it  necessary  to  vise  stimulants  freely  and  easily  digested  animal  food;  also  to  cliauge  fre- 
quently the  position  of  tlie  patient.  This  last  point  we  consider  of  f^reat  importance,  being  satisfied  that  the  loss  of 
one  of  our  cases  was  wholly  the  result  of  persistence  iu  lying  on  the  right  side,  thus  producing  passive  congestion  of 
the  lung. 

During  the-  war  Mr.  Huxter  was  eugagt-d  in  extc'nding  the  ust'  of  the  hyiiodermic  methud  from  Edinburgh  and  Dublin,  where  it  was  first  employed. 
It  waa  tried  and  reported  upon  favonibly  by  furuTY  of  MuntiM-lIier,  Hi'iikir  of  Parit*,  Scanzo.m  of  Wurtzburg,  Opi'olzer  of  Vienna,  Cir.vss-  of  Berlin  and 
many  others  who  established  its  use  in  Europt? ;  and  very  shortly  afterwanls  tlie  hypmtemiic  syringe  t)erame  naturalized  in  this  country. 

*I)r.  Jas.  L.  Cabell  reported  two  fatal  ca.<e&  of  sloughing  from  the  same  cau.se  in  the  Confederate  hospital  at  Charlottesville,  Ya. — Uirhiiimni  Mt'd. 
Jour.,  Vol.  I,  wr>i\  p.  ■I5;i. 

t  See  Ills  paui|ihlet,  cited  ttupra,  piige  2I'T,  where  he  says,  page  32  :  '■  The  treatment,  first  proposed,  I  believe,  by  liRnwN-Sf:gi'AKi>,  of  ire  poultices 
forfifteen  minutes.  f.tUowed  by  hot  flaxseeil  poultices  for  two  or  three  hours,  often  stimulates  the  niosf  indolent  bedsores  to  heal  with  surprising  rapidity. 
Paring  and  since  the  war  I  have  repeatedly  and  auccessfuUy  tried  this  plan  of  treatment." 


CONTISrUED    FEVEES.  "  549 

A  communication  filed  by  Surgeon  A.  L.  Cox,  U.  S.  V.,  advocates  the  use  of  arsenious 
acid  in  typhoid  fever.  He  claims  value  for  it  as  exercising  a  specific  influence  on  the  intes- 
tinal glands, preventing  their  ulceration  when  administered  in  the  early  stages,  and  promoting 
granulation  and  cicatrization  when  given  at  a  later  pei»iod.  Fowler's  solution  was  inadmis- 
sible on  account  of  the  gastric  disturbance  which  it  excited,  but  the  solid  acid,  taken  after  a 
small  quantity  of  prepared  arrowroot,  rice,  custard  or  other  suitable  food,  acted  with  an  almost 
magical  curative  power.  One-tenth  of  a  grain  was  administered  three  times  a  day  combined 
in  the  form  of  pill  with  an  equal  quantity  of  opium.  It  is  claimed  that  two  days  of  this 
treatment  induced  a  marked  improvement  in  the  symptoms,  five  days  sufficed  to  suppress 
the  febrile  action  and  ten  days  effected  a  thorough  cure.  Two  cases  given  as  illustrations 
of  its  use  are  briefly  as  follows : 

1.— Captain  Palmer,  26th  N.  Y.,  was  attacked  at  Sharpsbnrg,  soon  after  the  battle  of  Aiitietaiu,  with  loss  of 
spirits  and  appetite,  slight  headache  and  a  disposition  to  avoid  all  exertion.  At  the  end  often  days,  when  Snrgeon 
Cox  was  called  in  consultation  hy  W.  H.  Covkntry,  the  regimental  surgeon,  tlie  patient  had  duskinens  of  oonnte- 
nance,  epistaxis,  right  iliac  tenderness,  some  tympanites,  temporal  headache,  ))iingent  heat  of  skin  and  accelerated 
pulse,  110,  wliich  led  to  a  diagnosis  of  typhoid  fever.  I'ills  of  aisenions  acid  and  oi)iMm  were  administered,  and  an 
application  w,as  lodged  for  leave  of  absence  tliat  the  benefit  of  home  treatment  miglit  he  olitaineil.  Ten  dayselajjsed 
before  the  leave  of  absence  was  obtained,  hut  by  this  time  the  fever  had  beiMi  subdued  and  tlu'  )iatient  was  so  well 
that  the  propriety  of  accepting  the  leave  seemed  doubtful. 

2. — A  teamster  attached  to  brigade  headi|uarters  was  taken  seriously  sick  on  a  certain  Friday.  Within  a  day 
or  two  he  became  irrational,  continually  attempting  to  get  up;  and  in  one  of  these  eftbrts  he  h.ad  fallen  from  Ids 
wagon  to  the  ground,  where  he  was  found  at  night  helpless  and  unconscious.  Dr.  Ciiai-ei.i.k,  medical  oiliciT  of  the 
battery  on  duty  with  the  brigade,  saw  him  on  Sunday  and  learned  that  some  of  liis  comrades,  recognizing  typhoid 
symptoms,  had  given  him  whiskey  and  (]uinine.  The  quantity  was  not  known  Imt  was  sujiposeil  to  have  been  large, 
as  on  Monday,  when  seen  by  Dr.  Cox,  the  jiatient  had  symptoms  wliich  wi're  rei-ognized  as  indicative  of  meningitis. 
His  pulse,  110,  was  hard  and  strong,  his  C(nintenance  lluslied  and  eyes  bloodshot,  lint  the  delirium  was  low  and  mut- 
tering. He  could  be  roused  from  his  alnuist  comatose  condition  by  speaking  in  a  sharp  toni',  and  lu^  made;  inell'ectual 
efforts  to  protrude  his  tongue  whey  directed  to  do  so.  The  tongue  had  a  white  streak  in  its  centre,  its  edges  were 
scarlet;  sordes  apjieared  on  the  lips  and  teeth ;  tlie  abdomen  was  hard,  tymjianitic  and  tender,  and  there  was  a  tend- 
ency to  diarrhcea.  The  patient  was  considered  to  be  suffering  from  the  etl'eels  of  injudicious  stimulation.  Ten  grains 
of  calomel  were  administered.  Next  day  the  violent  sym])toms  bad  subsided;  the  ]>ulse  had  lost  its  hardness,  the 
eyes  their  preternatural  redne.ss;  the  face  had  assumed  its  natural  color,  fair  and  fresh  as  that  of  a  widl-nourished 
Englishman;  hut  the  semi-comatose  condition  persisted,  with  inability  to  jirotrude  tlu-  tongue  or  s|)cak  colierently; 
the  abdominal  symptoms  and  the  fre(|uency  of  the  pulse  al.so  eoiitinue<l.  Tills  of  arsenious  ,icid  and  opium  were 
prescribed  for  administration  three  times  a  <lay;  nothing  else  was  given  but  wattu'  as  a  drink  and  small  ({uantities  of 
farinaceous  food.  On  Wednesday  the  patient  answered  ii  nest  ions  intelligently.  On'I'hursday  lie  was  greatly  improved. 
His  condition  on  Friday  is  not  stated.  On  Saturday  he  was  despat<'lied  to  Washington  as  a  convalescent.  On  the 
afternoon  of  that  day  Dr.  Cox  saw  him  at  the  railway  station,  Warrenton,  \';i..  and  loosening  his  clothing,  made  an 
examination  of  the  abdomen,  on  whicli  some  roseate  spots  were  to  be  seen.  Dr.  Moski.kv,  Surgeon-in-Chief  of  the 
division,  passed  at  the  moment,  and  noting  these  said — "'That  is  ))erf'ectly  conclusive  as  to  the  nature  of  the  case." 
The  record  closes  with  an  account  of  an  accidental  nu'cting  between  Dr.  Cox  and  ''a  stalwart  ])edestrian  crushing 
under  him  the  brush  and  briers  wliich  were  in  his  way, — a  man  of  brilliant  countenance  and  fine  proportions  with 
every  expression  of  health  and  strength,"  who  proved  to  be  the  recently  sick  teamster.  This  meeting  took  place 
on  the  eighteenth  day  after  the  patient  had  been  obliged  to  give  up  his  duties  on  account  of  sickness. 

Surgeon  Cox's  favorable  experience  of  the  use  of  arsenious  acid  in  typhoid  fever  does 
not  appear  to  have  led  other  medical  officers  to  report  similar  results,  although  the  field 
hospitals  at  all  times  afforded  facilities  for  testing  a  question  of  this  nature.^' 

Acting  Assistant  Surgeon  B.  Brandies  thus  describes  the  treatment  adopted  by  him  in 
the  wards  of  Hospital  K^o.  1,  Nashville,  Tennessee: 

*  L.  DiTTERicH,  mutter  far  Heihcisseiiscli'ift,  Slunicii,  Jan.  ;jl,  1871,  in  recording  the  n-sultri  nf  an  fxiierioiu-e  uf  twenty-fix  years  in  the  arsenical 
treatment  of  typhoid  fever  says,  tliat  after  the  nse  of  the  remedy  far  two  or  tliree  days  moisture  retnrns  to  tlie  dry  and  cracked  lips  and  tonpne  and 
the  dark  coating  of  the  latter  disajipears;  hemorrhage,  from  whatever  source  it  may  proceed,  becomes  less  and  in  five  or  six  days  ceases  entirely:  at 
the  siime  time  delirium  and  sulisultus  subside,  petechia?  fade,  the  small  tremulous  pulse  improves  in  character,  the  eyes  become  brighter  and  the  counte- 
nance regains  its  natural  expression.  Iliarrhcea,  meteorism  and  splenic  swelling  suliside  more  slowly  and  disapfiear  only  in  the  period  of  convalescence. 
Bedsores  sclilom  form  ;  anil  the  disease  runs  a  shorter  and  milder  cour>e.  Arsenic  is  of  no  advantage,  and  indeed  may  do  harm  so  long  as  there  is  only 
a  catarrhal  state  of  the  mucous  niemhranes,  whether  of  the  respiratory  p.assagea  or  alimentary  tnict ;  tint  wiien  nervous  disorder  becomes  decided  and 
the  se'cretions  dry  up,  the  tongue  liecoining  dark  and  cracked  ami  the  at'donien  tympanitic,  the  remedy  proves  of  value.  It  is  given  in  the  form  of  Fow- 
ler's solution  of  which  five  drops  only  are  used  in  the  first  twenty-four  hours  ;  on  the  second  day  ten  drops  are  administered.  The  patient  can  seldom 
take  fifteen  droi>s  w-ithout  distressing  the  stomach. 


550  TREATMENT    OF   TTTE 

I  constantly  abstain  from  three  tluii<;.s — luerenry,  purgative  medicines  generally  and  emetics.  My  tri'atnient 
may  be  divided  into  that  of  the  disease  itself  and  that  of  its  eoniplications.  Assiimiii!;  that  the  disease  is  dependent 
on  a  poisoned  condition  of  the  blood.  I  direct  medication  af;ainst  that  condition  by  adniinisterin<;  chlorine  or  muri- 
atic acid.  I  regard  these  as  equally  jiowerful.  The  former  is  contraindicated  by  cough  and  extensive  bronchial 
catarrh  ;  the  latter  by  diarrh(>>al  tendencies.  I  pay  particular  attention  to  i)urity  of  air  and  cleanliness  of  the  jii'rson 
and  Ix'dclothes.  frequently  sponging  the  surface  with  aromatic  vinegar  and  water.  A  light,  nourishing  diet  is 
enjoined,  as  of  beef  soups,  milk,  good  strong  coffee,  and  as  a  drink  water  or  lemonade.  I  meet  hciiiUiche.  with  appli- 
cations of  cold  water:  active  (leliriuiii  with  hyoscyamns  and  camphor;  and  ojiisthotonos,  which  I  regard  as  a  localization 
of  typhoid  material  on  the  mednlla  or  its  membranes,  with  cupping  on  the  nape  of  the  neck  and  camphor  or  musk. 
S'lccUiiifi  of  the  parotid  gland  is  treated  by  the  application  of  a  camphorated  iodine  ointment  with  flannel,  and  when 
suppuration  is  nnmifest  po\iltices  and  the  lancet.  Senega  or  squill  with  carbonate  of  ammonia,  or  cani])lior  with 
opium  or  hyoscyamns,  relieves  hronchitic  cunqilicaiioitii.  rulnioiuiry  coniicntioii  is  treated  by  fre(iuent  changes  of  position, 
(|ninine.  brandy  and  muriate  of  ammonia.  For  nmisea  or  roiiiitiiiji  neutral  mixture  is  prescribed,  with  blisters  over  the 
stomach:  aipia  lauro-cerasi  or  acetic  ether,  in  live-  or  ten-drop  doses  on  sugar  every  hour,  is  sometimes  beneficial. 
I  have  often  permitted  coitxtijxitioii  to  go  on  for  live  or  six  days  with  great  benefit  to  the  Jjatient.  Instead  of  purgatives 
1  use  an  enema  of  turpentine  and  olive  oil,  or  of  equal  parts  of  vinegar  and  water;  the  latter  acts  promptly.  In 
iliarrliiiii  I  do  not  interfere,  if  there  are  not  more  than  four  or  five  characteristic  typhoid  dejections  in  the  twenty-four 
liours,  but  if  the  stools  be  in  excess  of  tliis  I  ejideavor  to  control  them  with  alum  and  opium  in  gum  arabic  mixture; 
when  they  are  sanguinoleut,  the  same  prescription  or  diluted  sulphuric  acid,  sometimes  with  ;ilum  or  sulphate  of 
iron,  is  successfully  used:  wlieu  they  assume  a  chocolate  color  and  very  otfensive  odor,  I  prescribe  charcoal  with 
aromatic  powder.  The  latter  remedy  is  also  useful  in  tympanites.  Indications  of  peritonitis  or  perforation  are  met  with 
large  and  rei>eated  doses  of  opium  and  the  application  of  ice-water  to  the  abdomen.  Helenlion  of  urine  is  treated  by 
systematic  catheterization,  a  practice  which  is  needful  in  all  cases  of  coma,  as  well  to  prevent  involuntary  defilement 
of  the  bed  as  to  relieve  distention.  One  case  which  presented  a  2)araly!<is  of  the  bladder,  even  after  convalescence, 
was  treated  successfully  with  ergot  in  five-grain  doses  every  four  hours;  in  another,  complicated  during  convales- 
cence with  c((tarrh  of  the  Madder,  injection  of  a  solution  of  nitrate  of  silver  removed  the  trouble.  Bedaoren  were 
prevented  by  fre(juently  changing  the  position  of  the  patient,  by  the  use  of  clean  sheets,  and  particularly  by  India- 
rubber  water  ctishions;  an  ointment  of  lead,  tannin  and  camphor  or  the  charcoal  poultice  was  used  when  sloughing 
had  already  commenced. 

The  only  other  paper  relating  to  the  treatment  of  typlioid  fever  on  tile  in  tliis  otiico  is  a 
coiumunicntion  recently  received  from  Dr.  George  j\I.  Ramsay,  formerly  Surgeon  95tli  N.  Y. 
The  following  abstract  and  quotation  are  submitted: 

Typhoid  fever  is  emphatically  a  low  and  slowly  progressive  fever.  Its  diagnostic  symptoms  are  low  fever  and 
restlessness,  furred  toutiiie.  slight  constipation  and  scanty  urine.  In  its  treatment  we  must  abate  the  fever,  calm  the 
nervous  system  and  restore  the  secretions  and  excretions  to  their  normal  condition.  Scanty  urine  and  consti]>ation 
are  always  associated  w  itli  fever.  They  result  from  it  and  require  treatment.  The  diarrhcea  that  follows  is  a  rea('tion 
of  the  system — an  effort  of  nature  at  recovery.  To  allay  the  fever  give  one  grain  of  (luiniue  in  half  a  drachm  of  sweet 
spirit  of  nitre  three  or  four  times  in  twenty -four  hours.  To  restore  the  secretions  and  excretions  use  the  following 
pill,  one  or  more,  or  less  than  one  daily,  so  as  to  obtain  one  movement  of  the  bowels  every  twenty-four  hours :  A  half- 
grain  eai-h  of  iodide  of  mercury,  ipecacuanha  and  extract  of  hyoscyamns,  and  one  grain  each  of  camphor  and  com- 
pound extract  of  colocyuth.  with  .syrup  as  an  excipient.  The  fever  will  abate,  the  tongue  clean  off  and  the  ai)petite 
return  withiit  forty-eight  hours  after  this  treatiuent  has  been  commenced.  Dry  toast  and  tea  with  milk  may  be  given 
as  nourishment. 

"I  ado]ited  this  method  of  treatment  at  Belle  Plain,  Va.,  in  1862-63,  but  before  I  had  become  fully  satisfied  of 
its  potency  I  peiiuitted  a  patient  to  sink  into  the  typhoid  condition:  Pulse  100;  tongue  dry  as  a  chip,  much  swollen, 
black-brown  in  the  centre,  concave  on  its  dorsum  and  curled  up  at  the  edges.  I  gave  him  a  dose  of  the  solution  of 
(luinine  in  nitrous  spirit  and  repeated  it  in  fifteen  minutes.  In  ten  minutes  more  I  gave  him  a  third  dose,  and  in 
five  minutes  after  this  last  dose  the  tongue  had  become  moist  and  rounded.  Then  I  ordered  tea  and  toast,  of  which 
he  ate  sparingly.  Under  the  continued  use  of  the  quinine  and  nitre-drops  three  or  four  times  daily,  and  the  pill  as 
described,  this  patient  steadily  imjiroved  and  was  returned  to  duty  in  ten  days.  Several  cases  of  typhoid  fever  were 
treated  in  shelter-tents  at  Sharpsburg,  Md.,  during  very  inclement  rainy  and  cold  weather.  Under  the  treatment  as 
specified  the  cases  terminated  favoralily  in  ten  days.  Again,  in  the  winter  of  1863,anu)St  aggravated  case  was  treated 
in  the  regimental  hospital.  The  command  had  marched  to  Kaccoon  ford,  ten  or  twelve  miles  distant,  and  returned  to 
its  old  camp  next  day,  where  I  found  that  this  fever  case  had  been  without  shelter  from  the  rain  and  cold  for  twenty- 
four  hours,  the  quartermaster  having  taken  down  and  carried  away  the  hospital  tent.  As  a  result  thi^  patient  had 
become  much  worse;  he  muttered  and  was  incoherent:  pulse  lOOandweak.  It  was  feared  thathe  wasbeyond  recovery; 
bnt,  under  the  treatment  described,  his  tongue  became  moist  and  clean  in  forty-eight  liours,  ami  convalescence  pro- 
gressed rapidly.     After  twenty  years  of  civil  practice  I  continue  to  place  implicit  reliance  on  this  mode  of  treatment." 

(jfreat  stress  was  laid  on  the  alkalinity  of  the  urine  as  a  therapeutic  indication  liy  Surgeon 
George  I).  Winch,  42d  Wis.,  who  directed  special  treatment  to  this  condition.'^'  He  reported 
that  of  thirty-three  cases  treated  at  Cairo,  111.,  only  one  terminated  fatally.      In  most  of  these 

»C'*iiUj/u  MeJkalJimmal,  Vol.  -V.VII,  I8I1.5,  \>.  1.5. 


I 


CONTINUED   FEVEES.  551 

an  alkaline  state  of  the  urine  was  present  throngliout  the  attack  unless  corrected  by  acids. 
In  cases  of  relapse  this  alkalinity  persisted  after  convalescence  from  the  primary  attack,  even 
after  return  to  duty,  and  was  found  when  the  patient  was  readmitted  to  hospital.  Tlie  gravity 
and  duration  of  the  case  were  in  direct  proportion  to  the  intensity  of  the  alkaline  condition. 
In  mild  cases  Surgeon  Winch  gave  fifteen  drops  of  diluted  hydrochloric  acid  three  times  a 
day,  beef-tea  every  three  or  four  hours,  small  doses  of  some  alcoholic  stinuilant,  opium  if 
necessary  to  quiet  wakefulness,  and  stimulating  expectorants  for  pulmonary  affections.  In 
cases  of  a  more  aggravated  character  tincture  of  opium  was  used  in  conjunction  with  the 
acid,  and  one  or  two  grains  of  quinine  were  given  four  or  five  times  a  day,  or,  when  there 
was  much  anaemia,  tincture  of  iron  with  compound  tincture  of  gentian. 

The  diet  of  the  continued  fever  cases  of  the  war  was  usually  precisely  indicated.  Our 
medical  officers  recognized  the  necessity  for  a  constant  reparative  supply  in  a  prolonged  disease 
cliaracterized  by  rapid  waste  and  progressive  asthenia;  but  at  the  same  time  they  exercised 
a  judicious  care  in  the  management  of  the  dietary  in  view  of  the  implication  of  the  alimentary 
canal  in  the  diseased  action  produced  by  the  fever-poison.  Liquid  ])ropiiriiti<)ns  and  concen- 
trations were  employed  during  the  progress  of  the  attack,  and  in  many  instanci's  the  return 
to  a  normal  dietary  was  not  permitted  until  convalescence  was  well  ailvanct^l.  Patients 
treated  in  the  regimental  hospitals  of  stationary  camps,  as  during  the  occupation  of  winter 
quarters,  were  usually  well  cared  for  in  this  respect.  Th(>v  were  under  tlie  observation  of 
their  own  medical  and  company  officers,  personal  friends  and  perhaps  relatives  in  the  ranks, 
who  made  special  efforts  to  procure  for  them  whatever  was  recomniciKlccl  outsiile  of  the 
limited  resources  of  the  hospital.  In  the  field  division  hospitals,  which  wimt  |ir;u'tic:illy  a 
consolidation  of  the  regimental  establishments,  large  hospital  funds  enahit'il  th.'  surgtH)n  in 
charge  to  purvey  through  his  subsistence  officer  occasional  supplies  of  milk,  eggs  and  chickens, 
and  a  constant  supply  of  fresh  meat  for  the  preparation  of  animal  Itroths.  These,  with  the 
beef-extract,  condensed  milk  and  farinas  of  the  regulation  sup|ily  list,  fnrnish(^d  materials  t'or 
a  dietary  the  real  value  of  which  depended  on  the  conipctcncc  of  the  culinarv  knowledge 
which  superintended  its  pre|)arati<jn.  The  general  hospitals  in  northern  cities,  with  large 
funds  and  open  markets,  found  no  difficulty  in  perfecting  the  dietetic  arrangements  of  their 
special  diet  kitchens.  As  a  rule,  hut  few  cases  of  lever  suffered  at  any  time  from  the  want 
of  appropriate  food.  These  e.xeeptional  cases  were  takt'n  sick  while  their  commands  were 
in  active  service,  when  the  fatigues  and  privations  of  the  march,  the  arrangements  tor  antici- 
pated battle,  and  the  primary  disposition  of  large  numbers  of  wounded  men  often  [ireveuted 

that  assiduous  attention  to  their  wants  which  would  have  been  accorded  them  in  the  general 

o 

hospitals  or  in  quieter  times  at  the  front. 


GHAPTEK  v.— ON  THE  DISEASES  ALLIED  TO  OR  ASSOCIATED  WITH  THE 
PAROXYSMAL  AND  CONTINUED  FEVERS. 


The  fevers  which  prevailed  in  our  camps  were  readily  divisible  into  two  groups,  the 
paroxysmal  and  continued.  Each  of  these  was  as  readily  susceptible  of  subdivision  into 
groups  of  lesser  magnitude,  the  one  into  intermittent,  congestive,  remittent  and  sub-continued 
malarial  fevers  with  adynamic  tendencies;  tlie  other  into  common  continued,  typhoid,  typho- 


552  DISEASES    ALLIED    TO    OR    ASSOCIATED    WITH 

malarial  and  typhus  fevers.  Large  numbers  of  what  may  be  regarded  as  typical  cases  of 
each  of  these  wore  no  doubt  observed,  but  it  must  be  acknowledged,  from  the  records  tliat 
have  been  presented,  that  clinicallv  there  were  no  dehnite  boundaries  to  the  groups.  Each 
was  overlapped  Ijv  the  other.  Even  the  two  grand  groups  had  a  common  territory  where 
tlie  malarial  fevers  became  continued.  Looking  at  the  paroxysmal  cases  as  a  whole,  there 
may  be  said  to  have  been  no  break  or  missing  liidv  between  the  well-defined  simple  inter- 
mittent on  the  one  hand,  and  the  pernicious  congestive  case  or  the  sub-continued  malarial 
fever  with  its  typhoid  tendencies  on  the  other.  Looking  at  the  continued  fevers  as  a  whole, 
there  may  be  said  to  have  been  no  break  between  the  ephemeral  fever  simi;lating  a  single 
paroxysm  of  the  intermittent,  the  prolonged  typhoid  case  with  intestinal,  pudmonary  or  cere- 
bral developments,  and  the  more  rajiidly  fatal  cases  tliat  were  clinically  undistinguishable 
from  those  usually  ascribed  to  the  jiowerful  operation  of  tlie  cause  of  typhus,  cercbro-spinal 
fever  or  pneumonic  consolidation,  Moreo\-er,  the  two  grand  groups  were  interlocked  as 
well  in  their  pernicious  phases  as  in  their  protracted  course;  for  while  in  the  former  they 
bore  a  strong  general  resemblance  to  each  other,  in  the  latter  they  were  attended  with  intes- 
tinal, lung  and  brain  symptoms  that  connected  tliein  clinically  with  each  other  and  with 
diarrhoea  and  dysentery,  pneumonia  and  cerebro-spinal  meningitis. 

Having  considered  the  mutual  relations  of  malarial  and  typhoid  fevers,  it  seems  advisable 
now  to  refer  to  the  relations  that  existed  between  these  fevers  and  those  diseases  that  seemed 
so  closely  allied  to  them  as  to  be  ia  some  instances  undistinguishable  from  them  clinically, 
and  in  others  to  arise  as  a  direct  result  of  hyperiemic  conditions  determined  by  their  mor- 
bific causes. 


I.— CEREBRO-SPINAL  EEVER. 


L— CLINICAL  AND  POST-MORTEM  RECORDS. 


The  number  of  cases  of  cerebro-spinal  fever  that  occurred  among  the  troops  is  not  known. 
The  official  reports  of  sick  and  wounded  did  not  provide  a  specific  heading  for  the  segrega- 
tion of  cases  of  this  disease ;  hence  no  statistics  can  be  submitted  bearing  on  the  absolute  or 
relative  sickness  and  mortalitv  caused  by  it.  A  few  of  the  cases  were  perhaps  reported  as 
inflamniation  of  the  membranes  of  the  brain;  the  proportion  of  deaths  reported  from  this 
cause  in  every  thousand  men — viz.,  .36  in  the  first  year  of  the  war,  when  cerebro-spinal 
fever  was  unobserved — was  slightly  greater  than  the  corresponding  ratios  of  the  subsequent 
years,  .32,  .33,  .28  and  .19  respectively,  when  this  fever  assumed  some  degree  of  promi- 
nence. Probably  some  of  the  cases  were  returned  among  the  non-specified  diseases  of  the 
miasmatic  order,  as  the  percentage  of  fatality  of  tliese  rose  considerably  after  the  first  year. 
Most  of  the  cases,  however,  appear  to  have  been  entered  on  the  reports  as  congestive,  typhus, 
typhoid  or  typho-malarial  fever. 

The  case-books  of  tlie  general  hospitals  testify  to  the  occasional  occurrence  of  the  dis- 
ease, and  even  to  its  epidemic  prevalence  in  certain  commands;  but  from  these  records  no 
estimate  can  be  formed  of  the  number  of  cases  that  occurred  in  the  field.  The  suddenness 
of  the  attack  and  the  rapidly  fatal  issue  usually  prevented  those  struck  down  in  camp  from 
reaching  the  hospitals.      It  is  certain,  however,  that  at  no  time  were  the  cases  numerous: 


THE   PAROXYSMAL    A\D   CONTINUED   FEVERS.  553 

When  prevailing  as  an  epidemic  in  the  camps  around  New  Berne,  N.  C,  only  a  few  men 
became  affected  in  each  regiment. 

One  hundred  and  hve  cases  are  presented  below.  T^one  of  these  occurred  during  the  year 
ending  June  oO,  1S62,  wlien  tvphoid  fever  was  at  the  height  of  its  prevalence;  neverthe- 
less there  is  every  reason  to  believe  that  the  disease  was  present,  although,  on  account  of 
the  absence  of  a  proper  designation  for  it  in  the  reports,  Ijut  little  record  of  its  existence  has 
been  left.  The  following  extract  from  a  l('ttc>r'''  of  Surgeon  R.  11  Bontecoit,  U.  S.  Vols., 
shows  that  it  occurred  as  earlv  as  .Januarv,  l.S(>2,  in  the  hospital  at  Fort  Monroe,  Va.: 

Seven  cases  of  a  veiy  interesting  eliiiiacter.  namely,  eeiel>r(i-s]iin:il  meningitis,  were  treated,  Imt  all  died,  with 
the  exception  of  one,  soon  after  admission.  This  one  lingered  for  some  wi'elis,and  linally  sank  from  smlden  increase 
of  etfusion  in  the  ventricles.  All  these  were  examined  after  death,  and  extensive  deposits  of  lymph  or  pns  were  fonnd 
in  the  cavity  of  the  spinal  arachnoid  and  over  the  medulla  oblongata :  and  in  one  case  over  the  entire  cerebrnm  and 
cerebellum,  on  the  vLsceral  and  peripheral  surfaces  of  the  i)ericardiuni  and  in  all  the  Joints,  but  without  iullammatory 
indications  in  the  peritoneum  or  tunica  vaginalis  testis.  In  one  tlie  lateral  ventricles  were  greatly  enlarged  and  dis- 
tended with  sero-purulent  lluid,  but  the  other  cases  presented  no  unusual  enlargement  of  these  cavities. 

During  the  same  winter  the  disease  appears  to  have  been  observed  in  the  44th  N.  Y., 
encamped  at  Halls  Hill,  Va.,  near  Washington,  1).  (!.  Medical  Inspector  Vollum,  IJ.  8. 
Army,  reported  of  this  regiment  as  follows: 

There  has  been  considerable  typhoid  fever  and  four  <'ase8  of  ty|.h(>id-|ineunioiiia;  fcmr  cases  of  cerobro-spinal 
meningitis  have  also  occurred.  These  jiroved  fatal  in  from  six  hours  to  f(Hir  days,  the  patients  without  exception 
becoming  deliriousand  remaining  so  until  death.  An  autopsy  in  twoof  the  cases  showed  large  etVusion  on  the  liraiu 
and  spinal  cord. 

Some  details  of  these  cai^es  have  been  made  public  by  the  Regimental  Surgeon,  W. 
FROTHiNGHAM.f  Measles,  typhoid  and  malarial  f(>V('rs  were  ]>revailing  in  tliis  command  at 
the  time  of  the  outbreak  of  cerebro-spinal  fever. 

The  winter  "W.as  mild  and  damp.  The  soldier's  cjuarters  were  about  seven  feet  siiu.ire,  the  walls  (wo  or  three 
feet  high,  built  of  logs  plastered  with  mud  and  roofi'd  in  by  a  wedge-tent.  Each  of  these  can  vas-roofeil  huts  was  occu- 
pied by  six  or  seven  men.  No  attention  was  jiaid  to  ventilation  at  niglil,  notwithstanding  the  etVorts  of  thi?  medical 
officers  in  this  l>eliair.  There  had  been  during  the  winter  some  two  or  three  hundred  eases  of  nu-asles  in  the  reginu'ut, 
and  intermittent,  remittent  and  typhoid  fevers  prevailed.  Four  ciises,iill  in  young  and  roliust  men.  were  reported; 
in  none  of  them  were  any  petechia'  present  to  ccuistitute  spotted  fever. 

1. — The  ])atient  complained  in  tlie  night  of  severe  pain  in  the  head,  and  at  dayliglit  was  founil  with  his 
hands  ])res.sed  up(Ui  his  abdomen,  groaning  and  insensilile.  One  arm  and  leg  were  jiaralysed,  and  there  were  oica- 
sional  convulsive  movements  of  the  rest  of  the  liody  exce])!  the  face.  Th(^  pupils  were  insensilile  and  somewhat 
dilated,  the  conjunctiva'  duU-reil,  the  face  darkly  tlushed,  thi'  tongue  and  teeth  coated  with  s(U<l('s,  t  be  pulse  freiiuont 
and  feeble  and  the  breathing  stertorous.  He  died  in  the  afternoon.  The  treatment  consisted  of  blisters  to  the  tem- 
ples and  back  of  the  neck  and  croton  oil  internally. 

2. — The  patient  was  attacked  one  morning  with  ii  eliill  followed  by  fever  and  severe  headache.  In  the 
afternoon  he  felt  better  and  the  disease  seenu'd  to  be  an  ordinary  malarial  fever.  Suljihate  of  i|ulnim'  was  ordered, 
and  the  patient  was  ([tiiet  during  the  night :  but  next  morning  be  was  iittacdied  with  fVe(|nent  and  violent  opistho- 
tonic  convulsions.  The  face  was  pale  and  frye  from  convulsive  movements  :  the  eyes  sulius<d  and  dull,  thi'  pupils 
insensible  and  somewhat  dilated.  Consciousness  was  lost  ami  the  evacuations  were  i)assed  involuntarily,  lleclied 
at  noon.  Chloroform,  given  to  control  the  sjiasm,  and  mustard  along  the  spine,  constituted  the  treatment.  I'axt- 
wior((Hi  examination  revealed  some  congestion  of  the  dura  nuiter,  and  a  layer  of  exudation  beneath  the  arachnoid, 
slight  over  the  cerebellum  and  anterior  lobes  of  the  cerebrum  but  more  abundant  over  the  posterior  lobes  of  the  latter, 
the  base  of  the  brain  and  the  medulla  oblongata.  The  spinal  cord  was  not  examined.  The  pericardium  was  highly 
congested  and  contained  three  or  four  ounces  of  turbid  serum.     All  the  other  organs  were  normal. 

3. — The  patient  complained  of  pain  in  the  head  and  chilliness  followed  by  fever.  Next  day  pain  in  the  head 
and  neck  was  intense;  the  i>ul.-^e  was  rapid  and  feeble.  Cujis  aiul  counter-irrit.'ints  weie  ajiplied.  Meanwhile  the 
pain  increased,  and  towards  the  close  of  the  secon<l  day  the  patient  becanu;  dull  and  soon  after  sank  into  a  stupor 
from  which  he  could  with  ditticulty  be  roused.  He  died  comatose  on  the  third  day.  No  convulsions  were  observed 
in  this  case.  At  the  autopsy  of  a  similar  ca.se  in  a  regiment  near  by,  the  brain  lesions  were  similar  in  character  to 
those  of  case  2,  but  the  effusion  was  of  a  greenish-yellow  color  and  not  so  dilHuent.  The  spinal  cord  was  abundantly 
coated  with  a  greenish,  semi-diffluent  plastic  exudation.  This  patient  had  been  bled  freely,  but  died  after  thre^ 
or  four  days  illness. 


•Published  in  the  Mei!i.,it  ,in.l  Smykal  Reporlfr,  Philu.,  Pa.,  Vul.  VI,  1801-Ui,  p.  49G.  i American  Medic<d  Timea,  Vol.  VIII,  IWA,  p.  207. 

Med.  Hist.,  1>t.  111—70 


554  DISEASES   ALLIKP    TO    OR    AsSOCTATl-^D    WITH 

4. — The  patient  had  chills,  a  rapid  hut  feeble  pulse,  dull  and  inji'cted  eyes,  furred  tongue  and  constipation. 
He  Buttered  from  excruciating  pain  in  the  back  of  the  head.  Some  relief  was  obtained  by  tlie  application  of  leeches 
to  the  teniides  and  neck — a  remedy  renewed  four  or  five  times  during  the  day.  The  symptoms  gradually  disappeared 
leaving  only  great  debility,  from  which  he  recovered. 

E.  Y.  Yager  of  Chillicotho.  Mo.,  state?  that  four  oases  were  witnessed  by  liim  in  April, 
1862.  in  the  3d  Mo.  Cav.,*  then  stationed  in  the  town  mentioned.  An  extensive  epidemic 
of  measles  was  prevailing  at  the  time. 

The  symptoms  were  chills,  severe  headache,  high  fever,  soreness  and  pain  in  the  muscles  of  the  neck  and  jaws 
and  tenderness  along  the  spine,  delirium  and  retraction  of  the  head.  Two  of  the  cases  recovered  and  two  terminated 
fatally  in  less  than  sixty  hours.  In  one  of  the  latter  several  paroxysms  of  convulsions  came  on  within  a  few  hours 
after  the  attack.  The  survivors,  a  few  days  after  the  commencement  of  the  complaint,  fell  into  a  typhoid  condition 
from  which  they  did  not  recover  for  weeks.     Kecovery  in  one  case  was  perfect. 

The  epidemic  which  produced  these  and  other  cases  at  Chillicothe  and  its  vicinity  made  its  appearance  in 
February  and  continued  until  May.  It  prevailed  to  some  extent  anu)ug  the  population  at  large,  but  particularly 
auiong  those  civilians  who,  as  political  ottenders,  were  confined  in  the  guard-house.  Among  these  no  case  of  recovery 
was  noted;  as  many  as  five  deaths  a  month  occurred  among  a  number  of  men  never  greater  than  twelve  or  fifteen. 

Dr.  Yauer  also  reports  that  in  February  five  cases  appeared  in  the  23d  Mo.,  also  stationed  at  Chillicothe.  He 
did  not  see  these,  but  was  informed  that  three  ended  fatally  by  coma  in  less  than  forty-eight  hours  and  two  recovered 
after  a  protracted  convalescence.  These  men,  on  the  night  preceding  their  attack,  had  been  exposed  while  on  guard 
to  a  snow-storm  which  had  been  ushered  in  by  a  dense  fog  and  chilly  east  wind. 

The  disease  was  terribly  fatal.  In  many  localized  epidemics  no  patient  was  known  to 
have  recovered.  Of  the  one  hundred  and  five  cases  recorded  below  only  seven  evaded  the 
fatal  issue;  but  this  statement  exaggerates  the  deadly  nature  of  the  disease,  for  in  some  of 
the  hospitals  only  those  cases  that  came  to  the  jjost-moriem  tables  were  recorded.  At  New 
Berne,  N.  C.  four  of  twenty-seven  patients  whose  cases  are  recorded  survived  the  attack; 
but  fifty-two  cases  were  believed  to  have  bt'on  under  treatment,  and  of  this  number  thirty- 
six  died  and  sixteen  recovered. 

The  Xew  Bei-ne  epidemic  occurred  during  January  and  February,  1863.  The  regiments 
that  suffered  most  were  the  44th,  45th  and  51st  Mass.  nine-months  men,  who  had  seen 
but  little  service.  They  were  quartered  on  the  banks  of  the  Nense  and  Trent  in  huts  built 
of  green  lumber.  The  barrack  of  each  company  was  fitted  with  bunks,  in  three  tiers,  for 
one  hundred  men,  and  gave  180  feet  of  air-space  per  bunk;  but  as  the  companies  did  not 
average  more  than  sixty  men  the  air-space  per  man  at  the  time  of  the  outbreak  was  about 
300  cubic  feet.  Ventilation  was  effected  by  shafts  through  the  ridge  and  apertures  near 
the  floor  between  the  bunks.  The  site  was  a,  sandy  and  sterile  plain,  broken  occasionally 
by  stagnant  pools  and  marshy  spots:  it  was  elevated  only  a  few  feet  above  the  level  of  the 
water  of  the  rivers.  Beyond  this  ]>lain  the  country  was  covered  with  pine  forests,  swamps 
and  tan^rled  undersrowth. 

The  regimental  records  do  not  show  how  many  cases  occurred,  as  the  disease  can  be 
identified  on  the  monthly  reports  of  sick  and  wounded  of  but  one  medical  officer,  Surgeon 
Samuel  Kneeland,  45tli  Mass.  Tn  .January  this  officer  reported  1  case  of  typhoid  fever 
and  5  of  malarial  cerebral  disease.  Fn  February  his  command  was  free  from  miasmatic 
diseases,  which  he  attributed  to  a  change  of  station,  the  regiment  having  been  removed  to 
New  Berne  for  guard  duty.  Surgeon  Gp:oroe  Jewett,  51st  Mass.,  reported  in  January 
21  cases  of  typhoid,  7  of  typho-malarial,  12  of  remittent  fever  and  1  of  inflammation  of  the 
membranes  of  the  brain,  with  two  deaths,  ]  from  congestive  chill  and  1  from  typho-mala- 
rial fever.  In  February  he  reported  17  cased  of  typhoid,  9  of  typho-malarial  fever  and  13 
remittents,  but  no  other  cases  which  might  be  conceived  to  I'epresent  the  disease  then  cou- 

»  Chicago  Med.  Examiner,  Vol.  V,  1864,  p.  396. 


THE  PAROXYSMAL   AND   CONTINUED    FEVERS.  555 

bidered  epidemic  in  his  camp;  the  only  death  returned  during  this  month  was  said  to  have 
been  caused  by  typho-malarial  fever.  In  March  the  report  shows  1  case  of  typhoid,  12  of 
remittent  fever  and  1  of  inflammation  of  tlie  membranes  of  the  brain  ;  no  death  occurred, — 
tlie  regiment  meanwliile  had  changed  camp  to  Beaufort,  N.  C.  Surgeon  R.  Ware,  44tli 
iMass.,  reported  in  January  2  cases  of  typhoid  and  19  of  typho-malarial  fever,  3  of  the  latter 
having  proved  fatal.  In  February  no  case  of  typhoid,  typho-malarial  or  congestive  fever 
was  reported,  nor  in  fact  of  any  disease  which  might  be  supposed  to  represent  on  j)aper  tlio 
cases  received  into  the  New  Berne  hospitals.  Nevertheless  Ass't  Surgeon  Theo.  W.  Fisher, 
who  was  in  charge  of  the  regiment  when  the  report  for  March  was  furnished,  nmiarked  on 
the  report  that  the  epidemic  of  cerebro-spinal  meningitis  which  prevailed  in  the  command 
in  January  and  February  was  now  abating  as  only  one  case  had  occurred  during  the  month, 
and  yet  the  body  of  his  report  shows  no  case  that  could  be  regarded  as  tlie  one  in  question, 
if  those  entered  under  the  headings  typhoid  and  typho-malai'ial  fevers  are  excluded  from 
consideration.  Manifestly  the  cerebro-spinal  cases  of  the  Stanley  and  Academy  hospitals 
were  the  typhoid  and  typho-malarial  fevers  of  the  regimental  reports,  and  in  view  of  the 
small  number  of  deaths  in  the  regimental  camps  those  hospitals  may  be  supposed  to  have 
received  most  of  the  cases. 

Dr.  Upham  in  his  Hosjntal  Notes  and  Memoranda*  refers  to  a  clear  and  able  report 
of  the  disease,  for  which  he  was  indebted  to  Surgeon  Gkoroe  Jewett,  Hist  Mass.  He  quotes 
from  this  report  and  states  that  of  the  fourteen  cases  connnunicatcd  Iiy  that  olHcer  all  were 
fatal.  The  inference  from  this,  tliat  fourteen  men  j^erished  in  the  regimental  cump  of 
the  51st  Mass.,  in  addition  to  those  that  died  in  the  New  I'erne  lio.spitals,  is  inconsistent 
with  the  facts.  Surgeon  Jewett  joined  the  regiiu(Mit  in  Decomb(-r,  l.*^()2,  dm-iiig  which 
month  no  fatal  case  of  disease  occurred  in  his  camj),  and  the  sulistance  of  his  reports  of  sick- 
ness Tor  the  epidemic  months,  so  far  as  relates  to  the  subject  in  qiicstion,  has  already  been 
suljinitti'd.      The  following  probably  formed  tlie  basis  of  the  report  to  i'r.  Ti'ILVM: 

Siirii(0)i  (iKoRCE  .Iewf.tt,  'il«t  Musk.,  Nnv  Ikrnc,  \.  C,  Feb.  M,  lsi;:t. — In  .Iiniii;irv,  a  fcMil'iiI  r|ii(lcMiic  broke  out 
ill  our  loniuicut  wliioli  was  at  I'list  Hiiiiposcd  to  lio  coiij^cstive  or  tyjilio-uialarial  fevrr.  Alter  m'ViMal  dcalliH  had 
occurred  an  autop.sy  revealed  the  true  cliaracter  ol'tlie  di>iease,  which  |)ro\ed  to  l)e  rere1>io-s|iiiial  iiieiiin;;itis. 

Tlie  first  ca.se  occurred  on  the  lOtli.  A  druiiiuier  hoy  was  taken  willi  nausea,  voiiiitiii;;  and  j;eui'ral  fehrile  Nyiup- 
tonis;  jiain  in  the  head  and  hack;  face  and  eyes  sullused,  piqiils  dilated;  skin  moist  and  warm:  retention  of  urine; 
tongue  slightly  covered  with  a  thin  white  coat ;  pulse  lajiid  and  at  lirst  leehU\  'I'liese  symptoms  soon  lieeainc^  aggra- 
vated; the  pulse  increased  in  force  and  fre(|uency;  great  restlessness  (^ame  on  with  Jactitation  and  delirium  ;  a  <u)piou8 
viscid  secretion  filled  the  throat  and  nari^s.     The  patient  died  by  ajMid'a  in  tliirty-six  Ikmiis.     No  auto|isy  was  held. 

From  .lanuaiy  11  to  this  date  lift  ecu  deaths  have  occurriMl  in  the  regiment,  all  liut  oin^  from  intlammation  of  the 
brain  and  spinal  cord.     The  single  exception  was  a  case  of  tyi>lioid  fevi-r  with  jiromiiu'nt  cerehral  symptoms. 

There  has  been  a  remarkable  nniformity  of  notable  syin|)toms.  Tlie  ilisease  attarked  tlii^  ycniiig,  active  and 
vigorous  and  those  of  apparently  the  greatest  vital  power.  Tlie  eldest  was  thirty  years  of  agi',  tll(^  youngest  sixteen; 
the  average  age  twenty  years.  The  greatest  duration  of  the  disease  was  twenty-Iliree  days — the  h-ast  one  day.  It 
generally  came  on  much  like  malarial  fever,  with  pain  in  the  head  and  back  and  fugitive  jiains  in  various  partj  of 
the  body.  Often  it  was  ushered  in  by  a  rigor  followed  liy  nausea  anil  vomiting.  In  a  few,  and  these  the  most  severe 
cases,  no  moan  or  sound  of  any  kind  cscajied  the  patients;  Imt  there  was  nianifested  a  fearful  ristlessness,  wliicli 
ceased  only  with  death.  In  others  there  was  much  moaning;  in  a  single  case  pleasing  di^lirium  was  noticed  with 
much  locjuacity.  I'.rotic  desires  were  observed  in  about  one-third  of  the  cases.  In  about  a  tliird,  also,  there  was 
more  or  less  stiffness  of  the  muscles  of  the  liack  and  neck,  with  o]iisthot<Mios;  in  one  there  was  paralysis  of  the 
glosso-pharyngeal  nerve.  The  skin  was  uniformly  moist;  the  tongue  generally  moist,  but  in  a  few  instances  the 
disease  assumed  a  typhoid  character,  w  ith  the  tongue  dry  ami  blow  n.  The  face  was  often  sufl'usi'd  and  the  conjunc- 
tiviK  congested.  In  two  or  three  cases  there  was  occasionally  s(|uiiiting.  In  all  the  violent  cases  the  urine  was 
retained  The  bowels  were  often  loose  and  the  discharges  oflensive,  but  constipation  was  occasionally  present. 
Decubitus  was  dor.sal  in  but  a  sii  gle  ease;  in  the  others  the  patient  lay  upon  the  side  until  the  close  of  life.  No 
petechial  spots  were  noticed  in  any  of  the  fourteen  cases,  although  such  were  frequently  observed  in  cases  occurring 
in  other  regiments.     The  pathognomonic  symptom  was  a  vioieut  pain  in  the  back  of  the  head. 


*  lloKl,;i  MkI.  .c,„I  Air.j.  Jour.,  Vol.  XLVIII,  r-  ^10. 


556  DISEASE?    ALLIET)    TO    OK    ASSOCIATED    WTTJI 

Post-mortem  observations  vrero  made  in  live  cases.  Of  tliose  I  select  two  for  illustration;  one  terminated  in 
twenty-four  hours,  the  other  was  jirotracteil  for  twenty-three  days:  In  the  first  the  arachnoid  and  jiia  mater  were 
firmly  adherent,  iiarticnlarly  on  the  right  side;  the  subarachnoid  space  was  tilled  with  straw-colored  serum.  There 
was  more  tluid  in  the  ri^ht  ventricle  than  in  the  left;  the  surface  of  the  lirain  was  highly  congested,  and  small  patches 
of  lymph  were  found  at  the  base  of  the  cerebellum.  The  cerebro-spinal  tluid  was  greatly  increased  in  quantity,  of  a 
milky  a|ipearance  and  yellowish  color;  the  membranes  were  congested  and  the  cord  softened.  In  the  second  the 
lateral  ventricles  were  tilled  with  straw-colored  tluid,  the  vessels  of  the  choroid  plexus  strongly  injected,  and  the 
fourth  ventricle  tilkd  with  serum  and  pus;  deposits  of  lymph,  three  lines  in  thickness,  were  observed  about  the  pons 
A'arolii  and  jnferior  surface  of  the  medulla  oblongata.  The  meniliranes  of  the  cord  were  much  congested;  one  and  a 
half  ounces  of  sero-puruleut  matter  draiued  from  the  sjiiual  canal ;  the  cord  was  enveloped  in  a  layer  of  lymph  from 
two  to  three  lines  in  thickness :  its  substance  was  softened  in  the  lower  dorsal  regiou  and  the  caiula  eiiuina  and  sacral 
nerves  were  coated  with  lymph.  In  all  the  cases  w  hich  I  have  thus  far  examined  the  organs  of  the  thorax  and  abdo- 
men were  in  a  normal  condition  but  for  an  increase  of  fluid  in  the  pericardium  in  one  instance  to  the  amount  of  two 
and  a  half  ounces. 

The  causes  of  this  peculiar  form  of  disease  are  various — and,  firstly,  as  a  predisposing  canse  climatic  influences; 
secondly  and  mainly,  the  ciuiditioii  and  diameter  of  the  barracks.  These  had  been  recently  constructed  of  green, 
hard  pine  boards,  and  the  logs  having  lain  long  in  water  were  saturated  with  sap  and  moisture.  When  first  occu|>ied 
they  were  almost  without  windows  and  poorly  ventilated.  The  air-space  per  man  was  about  ISO  cubic  feet.  One 
important  fact  liearing  on  this  point  is  that  a  large  proportion  of  those  that  died  occupied  the  highest  tier  of  liunks; 
eight  cases  were  taken  from  this  row;  three  occurred  among  tlu'  iiieii  in  each  of  the  other  rows.  The  facilities  for 
warming  are  slight.  There  is  a  fire-place  and  chimney  in  each  room,  but  so  l)adly  constructed  as  to  prevent  the  radia- 
tion of  heat;  hence  the  barracks  are  cold,  dark,  damp  and  poorly  ventilated.  The  food  of  the  men  has  been  of  good 
quality  and  well  prepared. 

As  to  treatment  little  can  be  said.  In  the  first  cases  the  attack  was  supposed  to  lie  of  a  malarial  character,  and 
quinine  and  stimulants  were  given  in  large  quantities;  lint  after  recognizing  the  true  character  of  the  disease  cups, 
both  wet  and  dry,  were  applied  along  the  spine,  with  blisters  to  the  najie  of  the  nei'k  and  along  the  spinal  column, 
while  internally  mercurials  with  ojiium  were  freely  given  and  four  grains  of  iodide  of  potassium  every  three  hours. 
But  a  single  case  has  recovered  under  my  treatment  after  the  disease  had  become  fully  established.  In  this  mercurial 
ointment  was  rubbed  along  the  spine  twice  daily,  while  tincture  of  iron  in  twenty-drop  doses  was  given  every  three 
hours,  with  opiates  as  required:  the  patient  remained  in  a  low  condition  for  some  days  and  convalescence  was  tardy. 

A  numl)er  of  men,  apparently  in  the  incipient  stage,  were  successfully  treated  by  large  doses  of  opium  repeated 
until  convalescence  was  fully  established. 

The  following  is  the  account  given  February,  1863,  by  Surgeon  R.  Ware,  44th  Mass.: 

The  regiment  was  recruited  at  Boston  and  mustered  Sept.  12,  1862,  numbering  nine  hundred  and  seventy-one 
men.  It  embarked  October  22  on  the  transport  Mcrrimac  for  Kew  Berne,  N.  C.  On  this  steamer  was  also  placed  one 
battalion  of  the  3d  Mass.  Over  fifteen  huiiilred  men  were  thus  crowded  into  the  vessel.  The  space  between  decks 
was  dark  and  ill  ventilated ;  if  inclement  weather  had  compelled  the  men  to  remain  l>elow  serious  injury  to  their  health 
would  have  resulted;  but  tine  weather  enabled  us,  by  keepiug  the  main  deck  always  crowded,  to  give  all  the  men  in 
turn  the  benefit  of  light  and  fresh  air.  The  accommodations  for  cooking  were  very  limited  in  view  of  the  number  of 
men  to  be  fed;  there  were  no  facilities  for  washing,  and  the  privies  were  miserably  inadequate. 

The  regiment  disembarked  at  Morehead  City  October  26,  and  reached  New  Berne  by  rail  the  same  day.  Next 
day  they  occupied  their  present  camp-ground,  two  companies  housed  in  barracks  which  had  jtist  been  closed  in  and 
the  others  in  Sildey  tents.  But  on  the  30th  the  regiment,  in  light  marching  order,  went  on  board  transports  for 
Washington,  X.  C,  which  was  reached  next  day.  During  the  following  week  an  expeditionary  march  of  12.5  miles 
was  made,  in  part  through  rain  and  snow.  The  commaud  returned  from  Plymouth  to  New  Berne  November  15,  and 
occupii'd  the  barracks  which  had  been  completed  during  its  absence.  These  are  situated  on  the  Neuse,  about  half  a 
mile  from  the  town,  and  just  lieyond  a  small  swampy  stream  which  empties  into  the  river.  They  are  so  near  the  edg(! 
of  this  swamp  that  the  space  allotted  for  the  sinks,  refuse  pools,  etc.,  is  much  too  small  for  a  permanent  camp  and 
too  near  the  barracks.  The  (luarters  are  built  of  green  pine,  the  sills  laid  directly  upon  the  ground.  Each  is  58x24x 
8i  feet  to  the  top  of  the  plate.  They  are  very  inadequately  lighted  and  are  warmed  both  by  open  fire-places  and 
by  stoves.  On  December  11  the  regiment,  equipped  with  blankets  and  overcoats,  started  on  au  exjiedition  towards 
Goldsborougli,  and  returned  to  New  Berne  on  the  20th,  having  in  ten  days  marched  one  hundred  and  fifty  miles, 
bivouacking  at  night.  It  participated  in  the  actions  at  Kingston,  Whitehall  and  Goldsborougli  bridge.  The  weather 
during  this  march  was  clear  with  hot  days  and  frosty  nights.  On  the  first  day  three  men  were  sunstrnck.  Every 
day  a  number  of  men  fell  out  of  the  column  because  of  sore  feet,  but  rejoined  at  night.  The  conimand  embarked 
February  1  for  Plymouth,  where  it  remained  seven  days.  It  returned  to  New  Berne  on  the  10th,  having  been  two 
days  on  the  transport.     Since  then  it  has  remained  in  camp. 

Camp-fever  in  the  form  of  cerebro-spinal  meningitis  has  been  the  most  serious  epidemic.  This,  and  measles, 
from  which  the  regiment  is  at  present  sutfering,  have  been  the  only  fatal  diseases;  catarrhal  bronchitis,  diarrhtva 
and  tonsillitis  have  Ijeen  prevalent  at  various  times  but  havi^  never  assumed  a  serious  form;  six  cases  of  luieumonia 
occurred,  none  of  which  were  fatal.  Cerebro-spinal  meningitis  first  apjieared  Dec.  25,  and  up  to  the  present  date 
nineteen  cases  have  been  developed,  twelve  of  which  have  ended  fatally.  No  fresh  cases  liave  occurred  since  ,Ianu- 
ary  19,  when  the  first  heavy  rains  fell.  A  long  spell  of  dry  weather  jireceded  the  outbreak  of  the  disease.  TIk;  first 
symptoms  in  most  of  the  cases  were  those  of  sadden  and  intense  cerebral  congestion :  but  in  some  the  indications  of 


THE   PAROXYSMAL   AND    CONTINUED   FKVEES.  557 

serious  inflammatory  disease  of  the  brain  came  on  gradually,  and  wereocrasionally  preceded  by  symptoms  of  ordinary 
catarrh.  One  case  was  ushered  in  by  violent  convulsions,  which  were  followed  by  coma  lasting  nearly  ten  days; 
another,  which  proved  fatal  in  twelve  hours,  was  characterized  by  sudden  collapse,  the  patient  beconiing  cold  and 
pulseless,  though  retaining  his  senses  till  death,  which  was  preceded  by  a  copious  petechial  eruption,  retechial 
blotches  were  preseut  in  nearly  all  the  cases,  generally  appearing  during  the  tirst  twenty-four  or  thirty-six  hours. 
The  disease  may  be  divided  into  three  stages  or  periods:  The  first,  that  of  attack,  is  characterized  by  intense  head- 
ache, stupor,  a  small  quick  pulse,  duskiness  of  couutenjiuce  and  a  condition  appniacliiug  coIlai>se — one  man  died  in 
this  stage.  This  is  followed  by  reaction  with  noisy,  almost  maniacal  delirium,  deal'ncss,  siiuinting,  slight  oi)istho- 
tonos  and  sl(H^))lessness,  ending  in  coma:  most  of  the  deaths  have  occurred  in  this  stage.  The  thinl  seems  to  be  a 
typhoidal  state,  which  gradually  replaces  the  more  acute  symptoms  of  the  seconil  stage.  I'oKt-mnrlciit  examination 
has  shown  in  most  cases  a  dei)osit  of  lymph  and  pus  ui)on  the  membranes  of  the  biain  and  spinal  coril  ;  in  some 
instances  there  was  intense  pericarditis;  one  case  was  complicated  with  iritis  and  another  with  ett'usion  into  the 
synovial  capsules  of  the  knee  and  elbow.*     There  is  no  evidence  that  the  disea.se  as  it  appeared  heie  was  ccmtagious. 

Until  within  the  jiast  two  weeks  fresh  vegetables  have  been  issued  tliree  times  a  week.  I'otatoesare  now  pur- 
chased out  of  the  company  fund.  The  average  meat  issue  has  lieen  one  day's  ration  of  |)ork,  four  of  salt  beef  and 
five  of  fresh  beef  in  each  ten  days. 

Several  facts  connected  with  the  history  of  camp-fever  in  this  department  lead  nu;  to  the  opinion  that  the  dis- 
ease is  not  duo  to  malaria  alone,  nor  is  it  purely  typhus  in  its  origin.  It  arises,  i>erhaiis,  from  the  combined  action 
of  these  two  causes;  but  the  cases  occurring  in  any  one  regiment  are  too  few  to  warrant  a  definite  opinion. 

A  few  cases  readied  the  hospitals  in  New  Eerne  from  some  of  the  other  regiments  in 
the  vicinity,  and  as  these  were  camped  under  canvas,  tiie  green  himber  used  in  the  con- 
struction of  barracks  was  reheved  from  tlie  imputation  of  liaviiig  caused  the  disease.  Indeed, 
in  view  of  this  and  of  the  fact  that  the  45th  Mass.  escaped  attack  in  February  by  its  detail 
to  duty  in  the  city,  while  the  51st,  and  perhaps  the  44th,  continued  to  suffer,  tiie  locality 
rather  than  the  quarters  should  be  indicted.  Surgeon  E.  P.  MoRONti,  2d  Md.,  in  charge  of 
the  Foster  hospital,  New  Berne,  reported,  April  1.  1863,  as  follows: 

The  disease  made  its  appearance  about  Januaiy  1:  it  apjiroacheil  an  ei)idemic  form  in  the  41th  and  Tilst  Mass., 
but  was  sjjoradic  in  character  in  the  depart mcut  at  large.  I  have  seen  no  new  cases  within  the  jiast  four  weeks,  but 
I  learn  that  two  have  been  admitted  into  the  Stanley  hospital.  The  two  regiments  named  aliove  li:ive  ha<l  about 
twenty-five  cases  each  ;  the  l.jth  and  IGth  Mass.  had  .several ;  the  KJSth  I'a.  threi?  or  four,  and  the  \'M  Mass.  one  case. 
The  disease  was  confined  to  the  new  troops  that  <'ame  out  in  Novemlier  and  Di'ceinlier,  1K()2,  unacclimated  both  to 
camp  life  and  this  locality.  The  4Uli,  -l.">th  and  olst  Mass.  were  unarti-red  in  barracks  deficiiMit  in  light  and  venti- 
lation, with  not  more  than  litO  cubic  feet  of  air  to  each  man.  The  Hd,Tith,  IHd  and  K'th  Mass.,  the  lOStli  and  17Uh 
Pa.  were  ixuartered  in  tents,  the  Sibley,  I  believe,  but  there  were  less  than  fifteen  cases  all  told  in  these  si.\  regiments. 
The  17th  and  21th  Mass.,  the  8.")th  N.  V.  and  lOUd  Pa.  (old  regiments)  were  also  iiuaitered  in  barracks  of  similar  ecm- 
strnction,  but  the  disease  did  not  nuike  its  appearance  among  them.  While  acting  Medical  Director  I  had  the  51st 
ordered  away,  l)elieving  that  the  disease  would  thus  be  arrested.  The  regiment  went  out  to  Deep  (iuUy,  about  ten 
miles  distant,  and  cami)ed  for  five  days  in  shelter-tents.  It  rained  three  days  out  of  the  five.  There  have  been  no 
new  cases  since.  The  di.sease  was  arrested  in  the  41th  in  conseciueni'eof  a  similar  move  and  the  fact  that  the  barracks 
of  this  regiment  were  whitewashed  and  improved  tluring  its  tempoiary  absence. 

Dr.  Upham  regarded  the  disease  as  partaking  of  the  nature  of  typhus  in  a  severe  and 
malignant  form,  and  having  in  this  instance  ;i  special  direction  to  the  membranes  oi  the 
hrain  and  spinal  cord,  as  in  other  typhus  epidemics,  the  weight  of  tin;  morbihc-  influence 
has  at  one  time  fallen  on  the  brain  and  at  anotlicr  on  tlie  lungs  oi'  otln'r  impnrlaut  llmracic 
or  abdominal  viscera.  Kneeland,  on  the  contrarv,  supposed  the  disease  due  to  malarial 
influences.     He  remarks  in  his  Monthly  Report  for  .laimnry  as  follows: 

*Fr.EDERlf'K  D.  Lente,  writing  .Tune  2.'»,  1SG4,  to  the  American  M'-diral  Tiiiicx,  f;iv«'s  tin-  lii.<tin\v  i>f_a  nixf  nf  spi.ttr<l  firrr  in  whirli  the*  eynovial  niom- 
liranes  ■ncre  speL-iiilly  affected.  The  patient,  Dr.  C,  40th  N.  Y.,  af;e  43,  wiu«!  at  ttie  time  uf  tlie  attai'k,  Fetiniary,  ISthl,  at  a  hutel  in  New  Yorlt  aw.iit- 
ing  tlio  emtiarkation  of  tiis  regiment.  One  day  soou  after  dinner  he  wjis  talien  witli  nansea  and  Iieadarlie.  s.n>n  followed  I'V  di//iiiess  and  feveri.-^lmess. 
Ne.vt  day  lie  was  somnolent  and  in  tlie  evening  unconscious.  Strong  riiiinler-irritation  to  tlie  iia|ie  of  tin*  iiccli  and  along  tlie  sjiiio'  restored  4-on»ciousne98 
before  morning ;  but  tlie  patient  was  very  wealv  and  suffered  from  Iieadadie  and  mental  confusion.  ()u  the  lliird  day  tin-  right  i-ye  was  higlily  injected 
and  the  siglit  lost,  witli  little  or  no  pain  tlieu  or  subsequently.  .\t  tliis  time  liis  wliole  surface,  with  the  exce|ttion  of  tlie  face,  was  covered  with  jiurplish 
unelevated  spots  from  the  size  of  a  pin-head  to  that  of  a  three-cent  piece  ;  there  was  numifest  effusion  into  the  knee  joints,  and  tlie  extremities  below  the 
joints  were  tumefied ;  pain  in  the  lumbar  and  sacral  regions  extended  along  the  crest  of  the  ilium  and  down  the  thigh  to  tlie  knee.  He  rontinued  for 
several  weeks  much  prostrated  and  occasionally  slightly  delirious.  A  febrile  inovenient  occurred  for  some  time  every  afternoon.  The  sjKits  liegan  to  fade 
soon  after  they  were  first  noticed,  and  disujiiieared  in  i\  few  days ;  but  on  the  e.xposcd  parts.  a.s  the  hands,  they  dried  into  thick  dark  scales  and  iM-eleil  off. 
Tht*  tumefaction  of  the  extremities  subsided,  but  the  Joints  coutinui'd  affected  in  .Tune,  when  the  account  of  the  case  was  written.  The  ball  of  the  right 
eye  had  become  atrophied  and  soft,  the  cornea  hazy,  the  pupil  contracted  and  insensible  to  light  and  the  lens  cataractous.  Tlie  patient  was  gaining  flesh  ; 
his  general  appearance  wiis  good  ;  but  he  still  complained  of  pain,  aggravated  by  tile  slightest  exercise — in  fact  he  was  perfectly  at  ease  only  when  lying 
down.    See  also  the  c^ao  mentioned  by  Ristecoi:  in  his  report  mpni,  page  r>o:i. 


558  DISKASKS    ALLIKO   TO    OR   ASSOCIATED    WITH 

There  have  l)(«eii  five,  oases  of  what  lias  been  generally  called  "  congestive  fevor,"  but  as  they  differ  very  much 
from  the  congestive  fever  jirevalont  here  in  suniiiier  tln'V  have  in  this  rejiort  been  put  under  "  braiu  fever,"  the 
symptoms  and  potit-morhin  appearances  indicating  the  brain  and  its  membranes  as  the  seat  of  tho  disease.  As  the 
same  disease  was  seen  last  sunnner  here,  occurring  with,  but  markedly  difterent  from,  congestive  intermittent  fever, 
the  prognosis  being  different,  it  niaj-  be  naturally  inferred  that  they  are  distinct  diseases,  though  originating  prob- 
ably from  the  same  cause,  malaria.  Since  this  cause  cannot  ordinarily  be  supposed  active  at  this  season,  I  am  inclined 
to  seek  its  origin  in  tho  green  pine  wood  of  which  the  barracks  are  built ;  most  if  not  all  the  cases  have  bi'en  in 
regiments  quartered  in  barracks,  and  none,  I  think,  in  regiments  living  in  tents  or  the  city  proper.  Tho  healthiest 
and  stoutest  men  have  been  taken,  and  every  case  has  terminated  fatally;  neither  general  nor  local  bleedings,  sina- 
pisms or  other  stimulating  applications  to  the  skin,  quinine  stiiiuilauts,  mercurials  or  narcotics  have  had  any  per- 
ceptible effect  in  arresting  the  diseas(^  After  the  occurrence  of  the  first  case,  .Tannary  5,  three  grains  of  quinine  were 
administered  at  night  to  every  man  going  on  guard,  and  afterwards  coffee  and  hard  liread  were  issued  to  the  guard 
during  the  night.     Of  tho  five  cases  reported  three  died  in  camp  and  two  in  general  hospital. 

Twenty-seven  cases  from  the  records  of  tlie  Stanley  and  Academy  hospitals  at  New 
Berne  are  given  below  in  tlie  order  of  tlieu"  occurrence: 

Case  1. — Private  Daniel  B.  Richmond,  Co.  H,  8th  Mass.,  was  taken  Dec.  5,  1862,  with  pain  in  the  bowels  and 
back  of  the  head  and  neck.  He  fainted  while  at  the  regimental  sink,  but  recovered  and  returned  to  his  tent,  where 
lie  had  a  decided  chill.  Three  or  four  hours  later  he  was  sent  to  hospital  in  an  almost  unconscious  state — delirious, 
cold,  breathing  heavily  and  at  times  excited  and  incoherent;  pulse  116,  small,  irregular  and  unequal;  tongue  dry 
and  red;  spots  of  purpura  covered  his  arms  and  legs.  Hot  applications  were  prescribed,  with  ten  grains  of  quinine 
in  camphor-water  aud  sweet  spirit  of  nitre,  to  be  repeated  every  four  hours.  On  the  7th  there  were  symptoms  of 
iritis.  On  the  9th  the  dark  spots  were  sloughing.  Next  day  the  mind  became  clear,  but  the  cornea  was  opaque  and 
green.  After  this  the  indications  of  cerebro-spinal  meningitis  gradually  disappeared,  but  the  iritis  became  chronic. 
Quinine  was  continued,  with  belladonna  ointment  and  an  occasional  blister  to  the  temple.  The  patient  was  dis- 
charged from  the  service  Slarch  27, 1863. 

Case  2.— Frank  Doughty,  a  deck-hand  on  steamer  Patnxent;  age  23;  was  admitted  Dec.  20,  1862,  violently 
excited  and  with  contracted  pupils  and  tenderness  at  the  nape  of  the  neck  :  his  pulse  was  not  much  quickened.  He 
improved  for  three  weeks  under  calomel  and  ipecacuanha,  with  cups  and  blisters,  but  his  mind  continued  confused. 
Iodide  of  potassium  was  tried  for  a  week,  during  which  he  was  able  to  sit  up  aud  give  rational  answers  in  most 
instances:  but  after  this  heljecame  suddenly  worse,  and  died  Jan.  24, 1863.  Post-mortrm  examination:  The  pia  mater 
was  much  injected  :  yellowish  lymph  was  deposited  in  the  sulci  of  the  upper  surface  of  the  brain  and  thick  ])urulent 
matter  in  the  pons  Varolii  aud  nu>dulla  oblongata :  the  lateral  ventricles  contained  two  ounces  of  serum.  The  spinal 
column  was  not  examined.     The  thoracic  and  abdominal  viscera  were  healthj-. 

Case  3. — Private  John  Cramer,  Co.  G,  132d  X.  Y.;  age  17;  was  admitted  Jan.  10,  1863,  his  previous  history 
being  unknown.  He  was  delirious  and  had  a  hot  and  dry  skin,  frequent  and  feeble  pulse,  a  dry  tongue  which  was 
protruded  with  difJicvilty,  dyspncea,  coldness  of  the  extremities,  lividity  of  the  surface,  a  tympanitic  abdomen  and 
black,  involuntary  stools.  He  died  on  the  loth.  The  treatment  consisted  of  the  administration  of  one  grain  of  blue 
mass  every  hour,  two  of  quinia  every  two  hours,  whiskey  and  beef-tea,  with  hot  applications  to  the  back,  abdomen 
and  extremities;  a  grain  of  ipecacuanha  was  sulisequently  added  to  the  mercurial,  the  quinia  increased  to  three  grains 
and  towards  the  end  of  the  case  to  tive,  when,  also,  blisters  were  ajiplied  to  the  chest  and  back  of  the  neck.  I'out- 
moitem  examination:  Body  livid.  The  membranes  of  the  brain  were  somewhat  congested,  the  arachnoid  having  a 
slightly  clouded  appearance;  the  cerebral  substance  presented  a  larger  number  of  puncta  than  usual.  The  lungs 
were  greatly  engorged;  the  heart  normal.  The  liver  was  slightly  enlarged  and  congested;  the  spleen  nearly  double 
its  usual  size  and  greatly  engorged  ;  the  kidneys  normal.  Some  of  Peyer's  patches  were  thickened  and  friable,  with 
apparent  ulceration  in  one  of  them. 

Case  4. — Private  Elijah  H.Wellington,  Co.  D,  4litli  Mass.;  age  31;  one  of  the  healthiest  and  strongest  men  of 
his  company,  having  been  on  duty  all  day  Jan.  11,  1863,  felt  unwell  in  the  evening  and  about  midnight  went  to  the 
regimental  hospital  to  get  medicine  for  a  headache.  Hoffmann's  anodyne  was  given.  Later  in  the  night  he  had  a 
severe  chill  with  headache  and  pain  in  the  bones,  for  which,  next  morning,  ten  grains  each  of  calomel  and  quinine 
were  administered,  moving  the  bowels  in  a  few  hours  but  failing  to  relieve  the  headache.  Nitrate  of  potash,  Dover's 
powder,  capsicum  and  quinine  were  given,  after  which  he  perspired  freely  and  expressed  himself  as  having  less  pain, 
although  the  headache  persisted.  At  midnight  he  l)ecame  comatose,  his  pupils  fixed,  one  dilated,  the  othi^r  natural, 
aud  large  ecchymoses  ajjpeaicd  on  the  surface  of  the  globes;  the  jaws  were  locked  and  respiration  performed  in  a 
hissing  manner  through  the  tightly  shut  teeth,  but  there  was  no  rigidity  other  than  the  trismus;  pulse  125,  moder- 
ately strong,  compressible.  At  2.30  A.  M.  of  the  13th  the  respiration  became  slow  and  interrupted,  the  pulse  fell, 
and  death  took  place  quietly.  Pont-moricm  examination :  Body  well  formed  and  nourished  ;  conjunctiva'  injected  ami 
ecchynuised.  The  meningeal  vessels  were  engorged  with  blood;  tho  cerebral  masses  were  less  firm  than  usual,  the 
upper  part  of  the  left  liemis)diere  being  niaikedly  softened.  The  heart  was  large  and  flabliy,  its  right  cavities  filled 
with  dark  fluid  blood.  Both  lungs  were  engorged  with  dark  blood,  especially  in  their  posterior  parts.  Tho  liver 
was  nearly  twice  its  usual  size  and  weight,  pale-yellow,  fatty  and  frial)le,  its  veins  much  engorged;  the  spleen  was 
slightly  congested;  the  kidneys  enlarged;  the  other  abdominal  viscera  healthy. 

Case  5. — Private  James  McConib,Co.  F,45th  Mass.;  age  21 ;  was  admitted  .Tan.  14, 1863,  in  an  algid  condition, 
exhausted  and  delirious,     tie  was  seized  on  the  12th  with  a  chill  followed  by  high  fever  and  deliriiun.     H«  had  b(!cn 


THE  PAROXYSMAL  AND  PON T I  M '  K D  FEVERS.  559 

treated  by  cups  at  the  nape  of  the  neck,  (luiniiie  and  stimulants.  Delirium  con  tinned,  with  jactitation  and  subsultus; 
the  pulse  was  80  and  veryiveak,  the  skin  cool  and  moist,  the  respiration  (juiet  and  tlie  bowels  open.  He  died  at  mid- 
night of  the  15th.  I'ost-mortein  examination:  Both  ventricles  of  the  brain  were  dist<'nded  with  a  scmi-o])a(iue  liquid 
having  a  pus-like  deposit  at  the  bottom;  a  lymph-like  deposit  was  ob.served  at  the  base  of  the  cerebellum,  and  par- 
ticularly about  the  origins  of  the  nerves  of  sense,  where  it  resembled  a  false  membrane.  The  right  lung  was  congested. 
The  pericardium  contained  three  ounces  of  serum.  The  liver,  spleen  and  kidneys  were  normal.  The  stomach  was 
slightly  congested;  Peyer's  patches  were  somewhat  prominent. 

Case  6. — Private  George  15.  Young,  Co.  (J,  Ittli  Mass.;  age  22;  was  admitti-d  .Ian.  II,  lX(i:i,  having  had  a  con- 
gestive attack  on  the  previous  morning,  with  intense  headache  and  vomiting.  Five  ounces  of  blood  v.  .re  removed 
from  the  neck  by  cupping,  and  forty  grains  of  quinine  given  in  twi^nty-four  h(uirs.  ( )n  admission  his  mind  was  clear 
although  the  pujiils  were  dilated;  pulse  86,  moderately  full;  skin  moist  and  cool ;  tongue  moist  ami  slightly  furred; 
abdomen  natural  and  bowels  regular.  He  improved  under  treatment  by  quinine  until  the  2'Mh.  when,  coincident 
with  the  occurrence  of  severe  headache,  the  pulse  became  <iuick  and  full,  tlie  resiiiration  embarrassed  and  the  tongue 
dry.  In  the  evening  delirium  supervened,  but  subsided  gradually,  so  that  on  February  1  the  i>atienfs  mind  was 
again  (|uite  clear;  nevertheless  the  headache  continued  with  convergent  strabismus  of  the  right  eye ;  a  slight  diar- 
rhcea  also  occurred.  Next  day  he  appeared  somewhat  better,  but  on  the  H<1  he  died  rather  suddenly  witlnmt  any 
symptoms  of  exhaustion.  Post-mortem  examination:  Body  but  little  emaciated.  There  was  some  eloudiiu'ss  of  the 
arachnoid  and  a  slight  subjacent  deposit  of  lymph  in  the  sulci  of  the  upper  cerebral  surface;  th<>  ci'rebellum  and 
medulla  oblongata  were  covered  on  the  inferior  aspect  by  a  layer  of  lymi)li  about  one-sixth  of  an  inch  in  thickness, 
firm  and  ligamentous  in  texture;  both  lateral  ventricles  contained  about  an  ounce  of  tlakv  lii|nid  with  a  small 
quantity  of  pus  in  the  inferior  horns  ;  the  cerebral  substance  was  of  natural  consistence.  The  lungs  were  slightly 
congested  in  their  posterior  parts.     The  heart  and  abdominal  viscera  were  healthy. 

Case  7. — Private  O.  W.Washburn,  Co.  R.  10th  Conn.;  age  22;  was  admitted  .Ian.  1."),  18(!;!,  having  been  suddenly 
attackedon  the  13th  with  fever  and  violent  headaehe.  On  admission  th<>))at  lent  was  delirious  and  ti'e(|uently  attempted 
to  get  out  of  bed;  the  pulse  was  79,  full  and  moderately  strong:  the  skin  hot  ;  the  tace  dusky  :  the  respiration  easy. 
An  ounce  of  wine  every  two  hours,  six  grains  of  {[uinineevery  tlireci  hours  and  fifteen  grains  of  lalomel  :is  a  cathartic 
were  prescribed ;  carbonate  of  ammonia  was  given  subse(iuently.  The  fevi'r  declined  but  the  delirium  increased;  a 
few  spots  appeared  on  the  left  forearm.  Death  oecurri'd  on  tli(>  22d.  I'oHi-moilvin  examination  t'ouud  the  dura  mater 
healthy,  but  the  upper  surface  of  the  brain  slightly  engorgiMl ;  around  the  origin  of  the  nerves  of  sense  anil  upon  the 
medulla  oblongata,  sheathing  it  completely,  was  a  dejiosit  of  consistent  pus-like  lymph,  about  two  lines  in  thickness, 
extending  thence  into  the  crevices  of  the  brain;  a  similar  deiiosit  was  also  found  in  the  lateral  ventricles  together 
with  a  copious  (Hrty-looking,  semi-opa<|ue  liquid.  The  heart  was  normal.  The  left  lung  was  he])atize<l  red  and  its 
bronchial  tubes  filled  with  a  lymi>h-like  substance,  tenacious  enough  to  be  pulled  out  with  aforceiis.  The  stonnich 
and  kidneys  were  nornuil ;  the  liver  slightly  congested  ;  the  s])leen  small  and  light  coloreil;  Peyer's  palch<^s  normal. 

C.VSE  8. — Private  ,1.  Moody,  Co.  F,  I4th  Mass.;  age  21;  was  admitted  umonseious  and  with  insensible  pupils 
Jan.  16,  18t)H,  having  been  sud<lenly  and  violently  taken  sick  during  the  pievioiis  night.  He  hail  frei|Ui'nt  ejiileptic 
spasms.  He  died  on  the  17th.  I'onl-mortcm  examination  :  The  ineinbranes  of  the  brain  wi'ie  much  congested,  the 
substance  slightly  congested  ;  a  pus-colored  liiiuid  was  found  in  the  ventricles,  on  the  base  of  the  brain  and  on  the  lobes 
of  the  cerebellum.  The  lungs  were  congested,  especially  in  their  posterior  parts.  The  heart  contained  a  fibrinous 
deposit  in  both  ventricles.  The  stomach,  intestines,  liver  and  kidneys  werc^  healthy.  The  spleen  was  of  normal 
size  but  highly  congested. 

Case  9. — Private  S.  Parsons,  Co.  F,  51st  Mass.;  age  32;  was  admitted  .Inn.  Hi,  lK(i3,  in  a  moribund  condition, 
having  been  taken  sick  suddenly  on  the  previous  day.  Quinine  and  whiskey  »  Ith  capsicum  were  freely  given,  and 
an  enema  of  brandy  and  oil  of  turpentine  administered.  Next  morning  his  hi'ad  was  throw  n  back  and  he  groaned 
heavily  as  if  in  great  pain;  he  was  roused  w  ith  dilficulty;  the  jmlse  was  120  and  wciik,  skin  moist  and  moderately 
warm,  tongue  dry  and  dark  ;  sordes  appi^ared  on  the  teeth  and  peteehia'on  the  limbs.  He  dii'd  on  the  mornlMgof  the 
18th.  rost-mortcm  examination:  Body  not  emaciated  ;  rigor  strongly  marked  ;  a  few  petechial  sjiots  on  the  arms  and 
hands.  The  membranes  of  the  brain  were  engorged  with  venous  blood,  aiul  underlying  them  a  purulent  lymph-like 
substance  was  spread  over  the  surface  of  the  hemispheres,  on  the  base  and  lobes  of  the  cerebellum,  and  more  abund- 
antly on  the  surface  of  the  medulla  oblongata  and  about  the  origin  of  the  cerebral  nerves;  a  similar  substance,  but 
thicker  and  more  opaque,  was  found  in  the  lateral  ventricles.  The  lungs  were  congesteil  posteriorly.  The  inner 
surface  of  the  pericardium  w  as  tmiformly  congested  and  covered  with  ditlluent  lymph ;  the  ventricles  were  filled  with 
dark  fluid  blood  which  afterwards  clotted  in  the  basin.  The  spleen  was  of  a  ileep  maroon  color,  enlarged  and  slightly 
softened;  the  liver  and  kidneys  healthy.  The  intestines  were  normal  with  the  exception  of  a  slight  thickening  of 
one  or  two  of  Peyer's  patches,  and  in  one  of  them  a  loss  of  substance  not  amounting  to  ulceration. 

Case  10.— Private  J.  W.  Merrill,  Co.  F,  45th  Mass.;  age  21;  admitted  ,Iau.  17,  1863.  Died  20th.  rost-mortem 
examination;  The  surface  of  the  cerebrum  beneath  the  arachnoid  was  covered  with  a  questionable  dilHuent  and 
greenish-yellow  lyin])li,  most  abundant  along  the  longitudinal  fissure  and  in  the  sulci  between  the  hemispheres;  a 
larger  dejiosit  was  found  at  the  base  of  the  cerebellum,  between  its  lobes  as  well  as  over  its  surface:  there  was  a  free 
deposit  also  at  the  crossing  of  the  optic  nerves,  along  the  roots  of  the  nerves  generally  and  in  the  posterior  horn  of 
the  left  lateral  ventricle;  the  pia  mater  seemed  noruial.  The  cavities  of  the  heart  contained  firm  fibrinous  clots.  The 
abdominal  organs  were  healthy. 

Case  11. — Private  Frank  L.  Moore,  Co.  I,  51st  Mass.;  age  27;  was  admitted  Jan.  18,  1863,  having  been  taken 
with  a  chill  on  the  previous  evening.     He  was  in  a  state  of  semi-stupor;  pulse  85,  feeble;  extremities  cool;  tongue 


560  DISEASES    ALLIED    TO    OE    ASSUCLVIEB    WITH 

clean.  The  ca.se  was  tn-atcd  ^vith  iiuiiiiue.  caluinel  and  cuiipinj;,  luit  no  iinprovcuu'Ul  was  iiiaiiift'stod  until  tlio  24tli, 
■when  medication  was  discontinued.  .V  day  or  two  after  this  he  luid  pain  in  the  face  and  head,  tenderness  at  the  nape 
of  the  neck  and  hebetude  of  mind.  At  tiuu's  his  symptoms  appeared  neuralgic  and  at  other  times  intlannuatory.  He 
was  treated  with  quinine,  calomel,  cups,  tonics,  stimulants  and  counter-irritation,  and  on  March  7  was  gaining  strength 
and  taking  iron  and  fluid  extract  of  cinchona  as  a  convalescent.  He  was  sent  to  Foster  hospital  on  .\pril  8  [where 
he  died  of  cerebro-spinal  meningitis  on  the  2titli]. 

Case  12.— Private  Walter  Hradbury,  Co.  C,  -Uth  Mass.,  was  taken  Jan.  19,  1X1)3,  with  chills,  followed  by  hot 
skin,  full,  quick  and  frequent  pulse,  the  surface  soon  afterwards  becoming  cool  and  moist.  During  the  day  eighty 
grains  of  iiuinine  were  administered  with  stinuilants  and  beef-tea,  an<l  the  patient  was  cupped  to  the  e.xtent  of  five 
ounces.  His  condition  on  admission  to  h.ospital  at  7  r.  Ji.  was  as  follows:  Intense  headache  but  no  active  delirium; 
recognized  his  friends  readily:  intelligence  good  when  aroused;  general  powers  good;  some  deafness;  face  dusky; 
eyes  natural;  lies  upon  right  side:  tongue  dry,  tending  to  brown  at  base,  with  a  pasty  yellowish  stripe  along  its 
sides,  natural  at  tip;  respiration  2S;  some  dulness  on  percussion;  mucous  rales  at  left  base;  pulse  regular,  rather 
full,  hard,  182:  skin  n\oderateIy  warm,  somewhat  moist  and  covered,  except  on  the  face,  with  typhus-like  sjjots 
from  the  size  of  a  pin-head  to  a  split  pea.  dark-colored,  i)ersistent,  not  prominent  to  the  tonch  but  seemingly  imbedded 
in  the  substance  of  the  skin;  tlu-re  was  slight  fulness  of  the  abdomen;  an  enema  of  tnrpentine  had  produced  one 
dejection.  Active  delirium  soon  after  set  in  accompanied  with  spasms  of  the  facial  nniscles  and  convergent  strabis- 
mus. There  was  tumultuous  action  of  the  heart  with  a  well-detiued  Irijilicate  sound.  The  patient  gradually  grew 
worse  till  his  death,  which  occurred  without  much  apparent  exhaustion  on  the  22d. 

Case  13. — Private  Charles  ]!urdock,Co.  H,  10th  Conn.;  age  18;  was  admitted  Jan.  19,  18(53,  in  a  moribuiul  con- 
dition, having  been  attacked  the  d.iy  before  with  chills,  headache  and  delirium.  To  relieve  these  symptoms  cups  to 
the  back  of  the  neck,  cathartics  and  the  free  use  of  quinia  had  been  resorted  to.  On  admission  the  resj^iration  was 
44,  irregular,  difficult  and  accompanied  with  groaning;  the  skin  had  a  mottled  or  petechial  appearance.  He  died  at 
4  p.  M.  rost-mortem  examination:  Tlie  brain  was  but  slightly  congested;  at  its  base  was  a  deposit  or  membrane-like 
exudation  with  a  pus-colored  fluid,  most  abundant  around  the  origin  of  the  nerves  of  sense  and  on  the  base  of  the 
cerebellum;  a  simular  exudation  was  found  in  the  ventricles.  The  lungs  were  extensively  congested  and  in  their 
superior  portions  tuberculous:  they  presented  some  well-defined  spots  resembling  those  of  pulmonary  apoplexy.  The 
heart  contained  large  fibrinons  clots  in  both  ventricles.  Tlie  liver  and  spleen  were  enlarged  and  congested,  the  latter 
being  twice  its  normal  size.     The  kidneys  and  intestines  were  normal. 

C.vSE  14. — Private  (ieorge  Boyntou,  Co.  G,  41th  ilass.;  age  21 :  was  suddenly  seized  with  symptoms  of  a  severe 
cold  and  some  disposition  to  paralysis  of  the  tongue  and  muscles  of  tlie  face.  Incomplete  reaction  came  on  after 
cupping  the  nape  of  the  neck  to  the  amount  of  five  ounces  and  administering  i|uiuine  in  half-drachm  doses,  with 
stinuilants  and  beef-tea.  Delirium  supervened  Jan.  10,  181)3,  and  a  few  hours  att<-rward  he  was  admitted  from  the 
regimental  hospital  in  a  state  aiiproaching  collapse  ;  he  died  shortly  after  admission.  I'dst-mi/rteiii  examination  :  Arms, 
chest  and  legs  studded  with  petechial  spots  from  one  to  three  lines  in  diameter.  There  was  but  little  congestion  of 
the  cerebral  membranes,  although  the  arachnoid  was  slightly  opaque.  The  lungs  were  engorged,  especially  at  the 
posterior  and  dependent  portions.  The  pericardium  contained  six  or  eight  ounces  of  sero-purulent  liquid  with  large 
masses  of  flocculent  lymph  floating  in  it;  its  surface  was  covered  with  a  layer  of  lymi)h,  membranous  in  tenacity  and 
thickness;  the  ventricles  contained  fibrinous  clots.     The  liver,  spleen,  kidneys  and  inte.stines  were  normal. 

Case  1."). — See  case  of  private  Davis  X.  Hosnu>r,  No.  303  of  tht^  jxinl-mortciii  records  of  the  continued  fevers. 

Case  16. — Private  Edwin  F.  Whitney,  Co.  H,  5th  Mass.:  age  18 :  was  admitted  .Tan.  30, 1863,  with  violent  delirium 
and  opisthotonos,  which  came  on  after  a  slight  chill  on  the  previous  afternoon.  His  pukse  was  full,  90;  tongue  clean 
and  moist;  nape  of  neck  tender.  A  powder  containing  two  grains  of  calomel  and  half  a  grain  of  ipecacuanha  was 
given  every  two  hours,  with  wet  cups  to  the  neck  and  mustard  to  the  s]>ine.  He  died  on  the  morning  of  February  3. 
Post-mortem  examination:  There  was  a  ileposit  of  lymph  on  tlie  ujiper  surface  of  the  cerebrum  and  cerebellum  and 
some  effusion  in  the  ventricles;  the  bloodvessels  of  the  brain  were  much  engorged.  The  thoracic  and  abdominal 
viscera  were  healthy. 

Case  17. — Private  Forrest  L.  Whittridge,  Co.  I,  41th  .Mass.;  age  20;  was  admitted  .Ian.  31,  1863,  ha\  ing  liad  a 
chill  at  noon,  followed  by  a  slight  fel)rile  action.  One  c.ithartie  jiill  was  given  at  l>edtime.  Xext  day  at  noon  he 
was  suddenly  seized  with  violent  delirium  and  great  excitement,  rei|iiiring  force  to  restrain  him  in  bed;  pulse  90; 
pupils  contracted;  back  of  neck  tender,  .\pplied  cups  to  the  neck,  mustard  to  the  .s])ine  and  extremities  and  ga%'e 
eight  grains  of  quinine  and  five  of  calomel,  the  dose  to  be  re])eated  at  9  P.  M.  and  at  six  o'clock  next  morning. 
On  February  2,  the  symptoms  being  unchanged,  two  grains  of  calomel  and  half  a  grain  of  ii)ecacuanlia  were  ordered 
and  the  cupping  repeated.  This  treatment  was  continued  until  the  .">th,  when  conjunctivitis  was  developed  with  an 
eczematous  eruption  around  the  lids.  The  patit'iit  l)ecame  weaker  but  the  delirium  les.sened.  Half  an  ounce  of 
whiskey  with  milk  was-given  every  three  hours  and  two  grains  each  of  calomel  and  iiuinine  every  four  hours.  Next 
day  the  delirium  suljsided  and  the  patient  gradually  recovered  without  further  medication  than  that  directed  locally 
to  the  eyes.  On  March  7  he  was  sitting  up  and  appeared  to  be  well  but  for  the  conjunctivitis.  [He  was  transferred 
to  Foster  hospital  April  8,  and  discharged  from  service  May  2,  ISli;!.]  '   - 

Case  18.— Private  Henry  (i.  Longley.  Co.  C,  ,")lst  .Mass.:  age  21;  was  admitted  i'cb.  2,  1863.  While  in  perfect 
health  this  man  had  been  taken  with  chilliu(^.^s  followed  l)y  violent  delirium,  during  which  liis  pulse  was  full,  8."). 
skin  moist  and  tongue  clean  and  moist.  Cups  were  applied  to  the  napi'  of  the  neck,  mustard  to  the  spine  and 
extremities,  and  two  compound  catliartic  pills  were  I'iven  with  repeated  doses  of  calomel  and  i|uinine,  ipecacuanha 
being  afterwards  substituted  for  the  latter.     ( )n  the  ."ith  opisthotonos  wa-  diveloped  and  the  pulse  became  more  rapid 


THK    PAROXYSMAL    AND   CONTINUED    FEVERS.  561 

and  feeble.  After  tlii.s  the  case  progressed  slowly,  tlie  mind  fref|ncntly  dwelling  on  erotic  snlijeets.  At  the  end  of 
the  second  week  the  spasm  of  the  nuiseles  of  the  neck  relaxed,  but  ten  days  later  it  returned,  and  lie  died  on  the  24tli. 
His  nourishment  consisted  chieliy  of  milk-punch.  I'ost-mortem  examination:  The  cerebral  membranes  were  very  red 
and  the  sinuses  filled  with  lihiek  blood:  the  brain  was  somewhat  softened  and  its  ventricles  contained  three  ounces 
of  serum;  the  medulla  oblongata  and  spinal  cord  were  covered  with  a  thick  yellowish  exudation,  and  the  sheath  of 
the  cord  contained  a  yellowish  eti'usion. 

Cask  19. — Private  Jno.  D.  Manter.  Co.  H.  3d  Mass.,  was  admitted  Feb.  1.  18(i3,  having  been  taken  .sick  on  tlic 
previous  day.  He  had  violent  ileliriuiu:  pulse  feeblr.  80.  The  treatment  consisted  of  cu|)S  to  the  neck,  mustard  to 
the  s]iiiie.  turpentine  enemata  and  repeated  doses  of  calomel  and  i])ecacuanlia.  He  died  on  the  morning  of  the  tith. 
Post-iiiurtcm  examination:  The  ])ia  mater  of  the  brain  was  congested  and  lyiiiiih  was  deposited  in  the  sulci  and  over 
the  medulla  oblong.ata  and  pons  Varolii;  the  pia  mater  of  the  cord  was  congested  and  the  sheath,  in  the  lower  dorsal 
region,  contained  some  etfusion. 

C.\SE  20. — Private  Henry  J.  Kendall,  Co.  C,  ,")lst  Mass.;  age  19;  was  admitted  Feb.  -1,  ISO.S,  having  been  taken 
sick  on  the  night  of  the  2d  with  chilliness  and  headache,  followed  n<'xt  day  by  delirium,  for  wliieh  large  doses  of 
quinine  had  been  given.  On  admission  he  was  quite  delirious,  and  the  cervical  s])ine  was  so  tender  that  he  cried  out 
violently  when  pressure  was  made  over  it ;  the  pupils  were  contracted,  tongue  clean  and  moist,  iml.se  84  and  full.  He 
was  treated  witli  wet  cups,  mustard,  tiir]ientine  enemata  and  calomel  and  iiH'iaeuanha.  Next  day  tlio  head  was 
thrown  back  l)y  spasm  of  the  muscles.  Un  the  Ctli  the  i>ulse  lieeame  (luick  and  feeble,  the  other  symptoms  romainiug 
unchanged.  Beef-tea,  milk  and  whiskey,  with  small  doses  of  iininine  and  calomel  were  taken.  Not  until  March  '.i 
did  the  mind  become  clear,  after  which  the  jiatient  continued  to  improve  slowly.  On  April  8tli  lie  was  transferred 
to  the  Foster  hospital.     [The  records  of  this  hosjiital  show  tliat  Kendall  died  April  19,  of  curebro-spinul  meningitis.] 

Case  21. — Corporal  Austin  A.  Darling,  Co.  K,  .Mst  Mass.;  age  19,  taken  with  headaeho  and  chilliness  on  the 
evening  of  Feb.  10,  1863;  admitted  next  day  in  a  state  of  violent  delirium:  jmlse  90  and  feeble;  eouiiteiianco  pale: 
pupils  contracted;  skin  moist ;  tongue  furred  and  moist.  Ho  was  treated  with  cujis,  mustard,  turiieutine  enemata. 
quinine,  calomel,  ipecacuanha  and  milk-pnncli.  His  bowels  were  moved,  but  bis  condition  otherwise  reiu/iined 
unchanged  until  the  14th,  when  the  tongue  became  swollen  and  dry,  the  throat  slightly  reddened  and  the  puiiils  con- 
tracte<l.  Cups  and  blisters  were  aiqilied  to  the  back  of  the  neck.  After  this  he  lieiaini'  weak,  ])ulse  120,  mind  dull 
and  pn])ils  dilated.  He  ilied  on  the  17th.  I'osI- mortem  examination:  The  sinuses  of  the  lirain  were  engorged  with 
blood;  the  pia  mater  uniformly  injected;  a  deposit  of  yellow  lymph  covered  the  cerebrum,  cerebellum,  ]ions,  mediill.i 
oblongata  and  sjiinal  cord  ;  serum  wiHi  some  ])us  was  coirtaincd  in  the  ventricles,  and  a  yellowish  liijiiid  in  the  sheath 
of  the  cord.  [The  medulla  oblongata  and  cerebellum  of  this  case  constitute  .Specimen  32,  Army  Medical  Museum. 
The  lymph  masses  which  originally  coated  their  surface  were  to  a  great  extent  washed  away  during  the  trausporta 
tion  of  the  siiecimeii  to  the  Museuiii.] 

Case  22. — Corporal  Edwin  II.  liliss,  Co.  C,  .51st  Mass.;  age  23  years;  was  taken  with  violent  headaclie  early  in 
tlie  nnnning,  Feb.  11,  18()3,  and  admitted  in  the  evening:  Pulse  lOt!,  res]>iration  liurritMl.  jiiipils  n.-itnral,  tongue  dryisli 
and  skin  moist.  Cui)S  were  ajiplied  to  the  back  of  the  neck  and  mustard  over  the  spine  ;  a  tin  pent  iiie  enema  was 
given,  and  cjiiinine,  calomel  and  ipecacuanha  by  the  month.  His  bowels  were  ojiened  so  freely  tluit  o]iiates  had  to 
be  n.sed;  but  in  other  resjiects  his  condition  remained  unchanged  until  the  lltli,  when  th<'  ]ml.se  fidl  to  80,  the  pujiils 
became  contracted,  the  eyes  injected  and  the  tongue  dry  and  brown  A  blister  was  applied  to  the  back  of  the  neck. 
Next  day  the  pulse  had  risen  to  130;  he  was  very  feeble  and  batheil  in  iiorspiration ;  he  died  at  10  P.  M.  rost-mnrtrm 
examination  ;  The  sinuses  of  the  brain  were  engorged  with  black  blooil ;  the  pia  mater  highly  injected ;  one  ounce  ot 
serum  was  found  in  the  lateral  ventricles  and  a  deposit  of  lymi)li  over  the  entire  surface  of  the  cerebrum,  cerebellum, 
medulla  oblongata  and  spinal  cord.  The  thoracic  and  abdominal  viscera  weri^  he;illhy.  [Specimen  33.  .\rniy  Medical 
Museum,  is  from  this  ease — a  i)iece  of  the  right  lobe  of  the  eerebruiii  on  which,  near  the  middle  of  the  longitudinal 
fissure,  is  au  opaque  layer  of  lymph.] 

Case  23. — Private  Cieorge  W  Moore,  Co.  C,  5tli  Mass.,  was  taken  Feb.  11,  18G3,  with  nausea,  vomiting,  head- 
ache and  depressed  circulation,  and  admitted  at  0  p.  .M.  almost  puhseless,  stupid  and  with  contracted  pupils.  Ciijis, 
mustard,  turpentine  enemata,  and  calomel  at  first  as  a  purgative  and  afterwards  in  two-grain  doses,  with  ipecacu- 
anha, were  employed,  but  without  result  until  midnight  of  the  12tli,  when  the  bowels  were  moved  several  times, 
after  which  the  calomel  was  discontinued.  Next  morning  he  showed  signs  of  salivation,  and  in  the  evening  w.as 
rational,  answering  questions  clearly  and  readily;  his  ]iu)nls  also  had  become  sensitive  to  light.  The  case  progres.sed 
with  copious  salivation,  but  with  no  other  untoward  event,  until  March  10,  wlii'U  the  patient  was  returned  to  duty. 

Case  24. — Private  Charles  W .  Haven,  Co.  C,  ."ilst  Mass.:  age  18;  was  taken  sick  on  the  morning  of  Feb.  17, 
1863,  and  admitted  at  G  p.  M.  He  was  unconscious  but  very  restless,  his  skin  and  pupils  natural,  pul.so  90  and 
full.  The  removal  of  twenty-four  ounces  of  black  blood  caused  the  patient  to  remain  (jiiiet  for  twenty  minutes,  but 
thereafter  the  jactitation  became  aggravated.  A  turpentine  enema  was  given,  and  a  jiowder  consisting  of  live  grains 
of  calomel  and  two  each  of  opium  and  camphor  was  vomited  as  soon  as  swallowed.  At  8  p.  M.  the  powder  was 
repeated  and  retained.  Muscular  action  being  very  vio'.eut  and  the  pulse  80  and  strong,  sixteen  ounces  of  blood  were 
removed  while  the  patient  was  held  upright  in  bed,  but  no  syncope  resulted  nor  any  diminution  of  the  muscular 
action.  Two  grains  of  calomel  were  ordered  to  be  taken  every  two  hours.  Death  occurred  at  8  P.  M.  of  the  18th. 
Pont-morlem  examination:  The  bloodvessels  of  the  brain  were  much  congested  ami  the  dura  mater  strongly  adherent 
to  the  skull  along  the  longitudinal  sinus;  the  entire  surface  of  the  cerebrum  and  medulla  oblongata  was  clouded; 
the  ventricles  contained  one  ounce  of  ctt'used  serum,  and  the  choroid  vessels  were  much  congested;  the  spinal  conl 
presented  evidences  of  inflammation  along  its  whole  length  and  the  lower  part  of  the  canal  contained  turbid  serum. 
Med.  Hist.,  Pt.  111—71 


obi:  niSKA.-KS    AI.I.rKli    TO    OK    ,\SS(HTATKI>    WITH 

Cask  2't. — I'rivato  L.  (i.  raikcr.  Co.  O.  J.'itli  Mass.,  was  ailmitteil  Fell.  19.  IfUVS.  liaviiif;  had  a  slight  cUiU  on  the 
17th,  followed  i|uickl,v  liy  fever  and  delirium.  On  admission  ho  was  wholly  tmconscious,  pulse  124,  small  and  corded, 
surface  hot,  tongue  dry  and  eoveied  with  a  dark  fur,  respiration  somewhat  accelerated,  iibdomen  natural  and  liowels 
regular;  there  were  petechial  spots  ou  the  aims  and  breast.  Decided  relief  followed  the  renuival  of  eighteen  ounces 
of  Mood:  the  jiatient  became  semiconscious,  the  pulse  fuller  and  less  frequent  and  the  respiration  easier.  As  deglu- 
tition was  impossible  i|uinine  and  turpentine  were  given  by  injection  every  three  hours.  His  jirogress  was  gradual 
but  satisfactory.  Ou  the  21th  he  was  perfectly  rational,  pulse  110,  respiration  10,  skin  moist  and  cool.  A  slight  diar- 
rh(va  occurred  about  this  time.  Next  day  he  asked  for  more  food,  and  on  March  4,  his  strength  being  good,  he  insisted 
upon  getting  up.  After  this  his  pulse  fell  to  70  and  ho  was  manifestly  improving,  when,  ou  the  lOtli,  his  skin  became 
hot  and  dry  and  delirium  recurred,  with  frontal  headache  and  great  pain  in  the  limbs  anil  back  of  the  neck,  which 
persisted  with  more  or  less  intensity  until  the  18th,  when  he  became  unconscious,  muttering  and  sometimes  singing 
in  a  low  delirium  and  catching  at  objects  real  or  imaginary.  Bedsores  appeared  about  the  15th,  On  the  20th  ho 
answered  questions  correctly  and  then  relapsed  into  stupor:  vision  was  lost  or  greatly  impaired.  Next  day  the  head 
was  persistently  thrown  back.  On  tlie  22d  an  eruption  appeared  on  the  face  and  abdomen  ;  the  tongue  was  dry,  brown 
and  cracked.  On  the  21th  the  patient  possessed  no  intelligence;  his  limbs  wore  cold;  he  died  at  midnight.  I'ont- 
iiiortini  examinatiim:  I!ody  but  little  emaciated:  rigor  mortis  well  marked.  The  cerebral  membranes  ])resonted  no 
unusual  appearance  on  their  external  aspect,  but  the  veins  beneath  were  somewhat  engorged  ;  the  surface  of  thi'  cere- 
brum showed  sjiots  of  thin  milky  tin  id  with  clots  of  pns-like  lymph  near  the  longitudinal  tissure;  on  its  base,  covering 
the  origins  of  the  nerves  of  sense,  pons  ^'arolii,  medulla  oblongata,  posterior  fissures  of  the  cerebellum,  and  apiiar- 
ently  extending  <lown  the  spinal  cord,  was  a  mass  of  tenacious  yellowish  lymph  three-eighths  of  an  inch  in  thickness 
and  by  estimate  from  half  to  three-fourths  of  an  ounce  in  quantity,  A  deep  longitudinal  incision  through  the  ])ons 
and  mednlla  oblongata  caused  three  ounces  of  slightl.v clouded  serum  to  well  up  with  some  force;  the  lateral  ventri- 
cles were  tilled  with  serum  holding  in  suspension  a  (jnantity  of  pus-like  matter.  The  lungs  were  healthy;  the  peri- 
cardium normal;  the  right  ventricle  of  the  heart  contained  two  or  three  drachms  of  "partially  organized  lymph." 
The  liver  was  iu)rmal :  the  gall-bladder  disteiuied  witii  dark  li(|uid  bile  ;  the  spleen  natural.  One  of  Peyer's  patches 
was  a  little  thickened  aiul  others  presented  the  shaven-beard  appearance,  but  otherwise  the  intestines  were  healthy. 

Case  26. — Private  Perley  Ooddard,  Co,  E,  51st  Mass.;  age  28  years;  was  admitted  Feb.  22,  18C3,  having  been 
taken  suddenly  sick  with  headache  and  pain  in  the  back  of  neck  :  pulse  '.tO  and  full:  tongue  clean  and  moist.  Cups 
to  the  neck,  mustard  to  the  spine,  with  a  purgative  of  calomel  and  jalap  were  ordered.  The  bowels  were  freely  opened 
during  the  night,  and  next  day  powders  of  calomel  and  ipecacuanha  were  ilirected  to  be  given  every  four  hours,  and 
continued  until  the  28th,  when  the  improved  condition  of  the  patient  warranted  their  discontinuance.  Ho  was 
returned  to  duty  March  10. 

Case  27. — Private  A.  Wolf.  Co.  L>.  103d  Pa.:  age  20:  was  admitted  March  17,  18ti3,  having  been  taken  sick  on 
the  previous  night  while  on  picket  after  a  fatiguing  march  of  sixty  miles  in  two  days.  The  attack  began  with  a  chill 
and  vomiting,  followed  by  headache,  pain  in  the  limbs,  fever,  jactitation  and  next  morning  delirium.  On  admission 
he  was  collapsed  and  pulseless,  yet  the  restlessness  continueil:  his  skin  was  cold  and  livid  and  covered,  on  Uw,  legs 
and  body,  with  purpuric  spots.  He  was  violently  restless  until  death  took  place  at  11  P.  M.  Post-mortt-ni  examina- 
tion: Body  well  developed,  rigid  and  almost  covered  with  purpura.  A  thin  layer  of  lymph  coated  the  upper  surface 
of  the  cerebral  hemispheres  and  to  a  less  extent  the  base  of  the  cerebellum,  the  mednlla  oblongata  and  the  origins 
of  the  nerves  of  sense;  lymph  was  also  seen  in  the  lateral  ventricles  and  "a  fungoid  growth  appeared  attache<l  to  the 
floor  of  each  ventricle,  being  each  about  fifteen  lines  long  and  four  lines  thick;''  the  spinal  cord,  examined  to  the 
extent  of  three  inches,  was  app.irently  healthy.  The  cavities  of  the  heart  were  filled  with  firm  lymph  of  a  bright  lemon 
color, — the  right  auricle  containing  a  complete  cast  of  the  cavity,  with  an  extension  into  the  superior  cava.  The 
lungs  were  congested.  The  liver  was  one-half  larger  than  usual  and  somewhat  congested;  the  spleen  enlarged,  con- 
gested and  softened:  the  kidneys  healthy  but  with  a  small  quantity  of  lluid  lymph  in  the  pelvis  of  each.  The 
stomach  and  intestines  were  healthy. 

Eleven  of  the  Xew  Berne  ca.ses  were  reported  brietiy  Ij}' Surgeon  MoRONG  of  the  F'xster 
hospitah      Two  of  tliese  cases  made  a  perfect  recovery: 

Private  ,Tohn  Hook,  Co.  G,  Marine  Artillery,  was  ailmitted  Dec.  .30,  181i2,  with  opisthotonos  strongly  marked. 
On  the  third  day  the  muscles  of  the  neck  and  back  became  so  rigidly  contracted  as  to  prevent  the  patient  from  lying 
flat  on  his  back.  He  was  returned  to  (|uarters  on  the  twelfth  day  perfectly  convalescent.  Treatment  was  by  wet 
cups  to  the  neck,  beef-tea  ami  stinmlants. 

Private  Henry  E.  Fuller,  Co.  G,  43d  Mass.,  was  admitted  .Ian.  3,  18G3,  and  returned  to  ([uarters  March  12. 

Two  others  recovered,  one  with  partial  paralysis  of  the  face,  the  other  with  complete  deafness.  Seven  cases 
died,  but  in  one  only  was  au  examination  made  after  death; — the  usual  inflammatory  deposits  were  discovered. 

During  the  continuance  of  the  epidemic  at  New  Berne  some  cases  occurred  in  the  llth 
Me.  and  lOlth  Pa.  on  the  coast  of  South  Carolina.  These  regiments,  aggregating  1,200 
men,  had  been  confined  for  twenty-two  days  on  board  the  transport  Cuhawha.  On  the 
twentieth  dav  a  member  of  tlie  104th  died  of  congestive  fever.  Next  day  two  men  of  the 
lltli  were  attacked,  one  of  whom  died  on  that  day.  The  regiments  hvnded  February  10, 
and  witliin  a  week  after  this  seven  men  died.      A  lioard  of  medical  officers,  con.^isting  of 


THK    I'Ai:0.\V>>rAl,    AMI    lOXTIXTKli    FKVKKS.  563 

Sar-'oous  \Y.  ^.  Woons,  .j^a  Pa.,  ^l.  S.  Ki rriN^iKi;.  KHUh  X.  Y..  ami  AV.  T.  INinixsox,  104tli 
Pa.,  eonvcuoil  to  inquiri'  iiilu  tlio  rau.-ation  ami  luvvotiU.in  o(  this  deadly  alici'tioii,  reportrd 
it  due  to  malaria,  (icldcsis  and  ddii-iiMu-v  ot  tood. 

The  >[eilical  lioaril  apjioiiiti'd  to  oiHiuiiv  into  the  causes  of  morlality  in  tlie  lltli  Jfaine  rej;inient  met  1-Vl).  i"), 
1N63,  at  St.  Helena  Islaud.  S,  C.  and  ie.s)ieetl'uny  re]Hiit  tliat  tliey  have  iiia(li>  a  earel'nl  investi^jation  into  the  eireuni- 
stances  attendant  upon  the  .sickness  and  deaths  hitely  reiiorted:  tliat  they  liavi>  insiieetcd  thoionjjhly  llie  Im'atiou  of 
the  camp  and  the  condition  of  tlie  men  as  to  cleanliness  and  health,  the  manner  of  I'oolcin^,  the  poliein.ii  of  tin'  camp 
and  the  situation  of  the  sinks  :  that  they  have  attended  the  Surijeon's  call  and  carefully  examined  I  he  eases  that  were 
presented  for  treatment  and  the  prescriptions  for  these  cases;  that  tlu'y  have  examined  the  records  of  the  sanitary 
condition  of  the  regiment  for  the  past  six  months,  and  find  that  the  fatalit,v  attendant  upon  ea.ses  (U'cnrriny;  in  thi.s 
command  is  accounteil  for  in  their  minds  by  the  kuo\Yledf{e  of  the  fact  that  five-sixths  of  the  cases  that  have  ]iroved 
fatal  were  in  the  persons  of  recruits  enlisted  in  the  State  of  Maine  in  August,  18()2,  and  transferred  thence  to  York- 
town,  Va.,  in  September:  These  men  came  from  the  northern  counties  of  the  state,  where  the  miasmatic  inlluenecsof 
a  southern  climate,  so  productive  of  di.seaso  to  those  unused  to  the  exposure,  are  entirely  unknown,  at  a  season, 
too,  when  tliisniiasm  was  most  alive  in  all  its  deadly  vi<deiice,  and  on  their  arrival  at  Yorktown  they  oecii)>ied  a  camping 
ground  notoriously  unheal tli.v  and  uiitit  liv  its  peculiar  location  for  the  occii]iancy  of  any  troops  at  that  .sf'ason  of  the 
.year.  These  recruits,  suddenly  transferred  from  civil  to  military  life,  from  the  active  duties  of  home  life  to  the  iiioro 
confined  ami  passive  duties  of  garrison  life,  and  sub.iect  to  this  i>oison  of  miasm  in  all  its  malignity,  soon  succumbed 
to  its  baneful  influence,  many  dying  during  their  first  months  of  service  and  many  otliers  remaining  jirostrated  by 
disease.  This  was  the  condition  of  things  from  which  the  regiment  was  slowly  rallying  when  il  left  that  jdace  for 
active  service  in  IJecemlier,  the  constitutions  of  the  men  so  sadly  impaired  that  climatic  iiitliiences,  producing  no 
serious  consequences  to  troops  perfectly  healthy  and  strong,  proved  more  than  their  weakened  systems  could  bear 
and  almost  necessarily  fatal.  Certain  influences  not  elimatie  liad  great  weight  in  connection  with  tliis  matter,  as  for 
instance  the  impaction  of  the  command  for  twenty-two  days  on  the  fransjiort  Cnhawha.  Many  of  the  men  ocenpied 
the  upper  deck  and  were  sulyeeted,  with  scarcely  any  protection  fiom  the  weather,  to  groat  and  sinhlen  changi's  of 
teiTiperature;  others  were  crowded  almost  to  sullbcation  in  conlined  and  badly  policed  (|iiarters  ludow.  During  this 
time  the  regiment  was  obligi'd  to  subsist  on  half  rations  for  want  of  jiroper  facilities  for  cooking.  'I'lie  jiollcing  of 
the  camp  was  found  by  inspectimi  to  be  thoioiigli  and  thi'  iiii'ii  creditably  neat  in  llwir  persons  and  clothing.  Tlie 
reasons  here  given  are  in  m\v  minds  sullicient  to  account  for  tln'  peculiar  siisceiitibility  of  the  men  of  this  regiment 
to  climatic  diseases. 

Tiiis  rcgiiiioiit,  tlic  Jllli  Maine,  had  a  few  similar  ciscs  in  .\iiril.  al'Iri'  a  conrmoinciit 
(>r  rinjil  <lavs  (ju  lK.)ard  a  lrans]H)rt..  Medical  [ns[)ceii»r  W.  11.  .Mrs,<i:v,  \\\in  \va<  pi-eHent  at 
the  /i(i.sf-i/i(irff'iii  i>xamination  i.i'  one  ot'  these  eases,  eoiisidered  i  lial  eliiiiean\'  and  anat'iinieally 
the  fatal  alTertioii  was  identical  with  that  wliudi  was  |irevailinu'  nt   New   P.ci-|ie. 

J''.\clusive  (if  these  mill ii'eidvs  ill  North  and  Sniitli  Carolina,,  cudv  live  cases  su^nestivo 
of  the  pivsenco  of  eerebro-spiiial  meningitis  were  recorded  durino-  Ksii:).  Pin  in  this  coii- 
noctiou  reference  should  be  made  to  the  cases  reported  as  congestive  ftA'er/-' 

Cask  '2H. — Private  Oscar  ]{ond<'busli,  Co.  K,  111th  I'a.;  age  22  years:  was  adiiiittcd  Feb.  I.'i.  lX(i;i.  w  ith  aphonia. 
On  March  2(ith  tlie  conjunctiva  became  slightly  congested,  and  ni'Xt  day  he  complained  of  si'vere  ]iains  in  the  back 
and  tightness  across  the  temples:  his  voice  returned  and  his  cries  of  jiain  were,  heard  at  a  distance  of  sixty  rods. 
Cold  water  was  applied  to  the  small  of  the  hack  and  morphia  administered  every  two  hours,  ]iroducing  considerable 
relief  and  some  sleep  during  the  night.  On  the  28tli  the  ]iulse  was  120,  very  wi>ak  anil  compicssibh":  the  ocular 
con  June  tivachemosed  and  nearly  black;  the  skin  ]iurpli'  with  dark  B]>ots,not  removed  by  ]iiessnte:  the  fongiU'  covered 
with  a  thick  dirty- white  coat  ;  blood  oozed  into  fhemoutli,  giving  a  sweetish  taste  to  everything,  and  the  urine  Uxikcd 
like  blood.  At  8  r.  m.  the  pulse  was  130;  res|iiration  30;  temperature  llll°.  At  3  p.  m.  of  tln^  2!lth  violent  delirium  en  mo 
on,  followed  by  coma  and  death  next  morning,  ront-mordm  examination:  Kigor  mortis  marked;  body  muscular;  trunk 
and  extremities,  even  to  the  fingers  and  toes,  covered  with  dark-purple  spots  about  one  and  a  half  lines  in  diameter, 
which  did  not  disappear  on  pressure;  face  comparatively  free  from  purple  spots;  ocular  coiyunctiva  ecchymosed  and 
overlapping  the  cornea;  iiupils  each  two  lines  in  diameter.  The  brain  appeared  healthy.  The  mucous  membrane  of 
the  larynx  and  trachea  were  softened  and  discolored  with  purple  spots.  There  was  some  h.y postal ic  congestion  of 
the  lungs;  the  pleura  presented  reddish  and  purplish  patches  of  irregular  shape.  An  ecchymosis  two  inches  long 
was  found  at  the  base  of  the  iiericardium,  and  there  were  black  spots  under  its  visceral  portion:  ecehymoses  were 
also  found  in  the  right  auricle,  on  the  outer  aspect  of  the  pnlinouarv  artery  and  between  the  aorta  and  the  (csopluigns. 
The  mucous  membrane  of  the  U'sopliagus  was  eroded  in  two  jilaces,  each  nine  lines  in  length.  The  peritoneum  was 
ecchymosed  in  spots.  The  liver,  ninety-four  ounces,  was  pale  in  color  ;  the  pancreas,  four  ani\  a  (|uart<'r  ounces,  was 
also  pale  ;  the  spleen,  fourteen  ounces  and  a  half,  was  reddish-purple  and  firm.  The  mucous  membrane  of  the  stomach 
was  much  congested  and  covered  with  bright  red  spots,  especially  at  its  fundus.  The  duodenum  was  small  and  its 
mucous  membrane  of  a  dull  ochre  color.  The  villi  of  the  small  intestine  were  highly  in.jected  ;  I'eyer's  patches  were 
congested  and  one  was  ecchymosed ;  the  solitary  glands  were  somewhat  enlarged.     The  vermiform  appendix  was 


564  :)isEASf:s  allikd  to  or  associated  with 

ecchyinosed;  the  lar<;i!  iutestiuc  was  distoniUnl  iind  its  mucous  uieiubiaiie  covered  with  briglit  red  spots.  The  right 
kiduey,  ten  ounces,  was  covered  with  eccliymoses,  its  pyramids  dark-cohtred,  pelvis  and  ureter  disintegrated,  rough- 
ened, mamniillated  and  dark  red;  the  left  kidney,  eU'ven  ounces,  was  ecehymosed;  the  pelvis  blackish  and  roughened 
with  minute  papilhe.  the  cortical  substance  of  a  bright  pink  color;  the  mucous  membrane  of  the  bladder  was  ecehy- 
mosed.— IJncoIit  llospittil,  Tl'iinkiniitoit,  I>.  C 

t'AsK  29. — Private  Alexander  Smedes,  Co.  K,  2.")th  X.  Y.,  was  admitted  .lune  22,  18t)3,  in  a  comatose  condition. 
Xothing  of  his  previous  history  was  ascertained  except  that  he  had  been  ill  but  a  short  time  and  had  lieen  delirious. 
He  died  on  the  24th.  I'o^t-mortem  examination :  There  was  an  abundance  of  lymph  beneath  the  arachnoid,  at  the 
superior  and  lateral  portions  of  the  cerebrum  and  at  the  inferior  portion  of  the  cerebellum.  The  liver  and  kidnej'S 
Were  fatty  and  the  urine  albuminous. — Act.  Asii't  Siirij.  Austin  Flint,  Ladiea'  Home  Hospital,  Xew  Yorl-. 

Case  30.— Private  Charles  V.  Woolard,  Co.  F,  115th  111.,  was  admitted  Sept.  12,  1863,  with  .severe  headache, 
confusion  of  mind,  giddiness,  staggering  gait  and  a  small  and  wiry  pulse,  120.  His  lower  extremities  were  paralj'zed 
on  the  17th.  Xext  day  the  jmralysis  became  general  and  he  died.  Vost-mortem  examination:  Body  well  nourished. 
The  membranes  of  the  brain  were  opaijue  and  thickened;  they  contained  a  large  ([uantity  of  serum  and  their  vessels 
were  distended  with  dark  blooil:  the  brain-substance  was  healthy,  but  the  lateral  ventricles  contained  two  ounces 
of  turbid  serum.  The  spinal  vessels  were  highly  injected  and  the  membranes  inflamed  in  the  cervical  region,  beyond 
which  the  examination  was  not  carried. — Hospital,  TuUahuma,  Tcnn. 

C.^SE  31. — Private  S.  C.  Scott,  Co.  I,  2.jth  Iowa,  was  admitted  Xov.  14,  18G3,  with  active  cerebral  symptoms. 
Coma  supervened  on  the  18th,  on  which  day  he  died,  roxt-mortim  examination;  Body  well  nourished.  The  ves.sels 
of  the  dura  uuiter  were  distended  with  dark  blood ;  a  few  patches  of  lymph  were  found  on  the  surface  of  the  convo- 
lutions and  an  ounce  of  clear  serum  in  the  ventricles,  but  the  substance  of  the  brain  was  healthy.  The  abdominal 
cavity  jiresented  evidences  of  general  peritonitis:  it  contained  eight  ounces  of  straw-colored  serum.  There  were 
patches  of  inllammation  in  the  ileum;  otherwise  the  intestine  was  healthy.— if «s^)i7((?,  Tullahoma ,  Tenn. 

Case  32. — Sergeant-llajor  Philip  Beaufort,  33d  X.  J.,  was  admitted  Dec.  18,  1863.  While  on  the  march  he  was 
taken  with  a  chill  followed  by  fever,  constipation,  headache  and  inability  to  sleep.  On  admission  he  had  severe  pain 
and  great  tenderness  in  the  lower  part  of  the  spine,  shooting  pains  in  the  thighs,  obstinate  constipation,  headache, 
delirium  and  wakeftilness.  He  afterwards  suti'ered  from  constriction  about  the  abdomen,  dysuria,  opisthotonos  and 
gradual  loss  of  motion  and  sensation  in  the  left  arui  and  both  lower  extremities;  there  was  hypera'Sthesia  with  a 
wheal  of  large  size  on  the  anterior  surface  of  the  trunk:  his  pupils  were  dilated:  he  had  frei|uent  rigors  and  was 
usually  delirious.  After  a  continuance  of  two  weeks  these  symptoms  began  to  subside;  the  head  symptoms  disap- 
peared and  the  sjiasms  became  less  frequent.  The  paralysis  of  the  lower  extremities  continued  for  some  time  after 
the  dysuria  and  constipation  had  ceased.  Sensation  returned  by  degrees,  and  afterwards  motion.  Treatment  con- 
sisted of  counter-irritants  to  the  spine,  purgatives,  calomel  and  conium,  and  lastly  iodide  of  potassium  and  tonics, 
with  iodine  as  a  local  aj'plication. — -Act.  An/i't  Surgfon  J.  )('.  l)iijbij.  Hospital,  Chattanooga,  Tom." 

The  I'ulluwing  i^'xtract  from  the  report  fur  January,  1864,  of  Surgeon  Ed.  E.  Phelps, 
U.  S.  Vuls,,  (reneral  liospital,  Brattleboro',  Vermont,  refers  to  the  occurrence  of  the  disease 
ami;ng  the  recruits  .stationed  in  the  barracks  at  that  place: 

During  this  month  recruits  have  been  assembled  at  the  U,  S.  Barracks,  less  than  half  a  mile  from  this  hospital, 
and  their  sick  form  the  greater  part  of  those  brought  under  my  care.  Among  them,  it  will  be  seen,  are  six  cases  of 
*erebro-spinal  meningitis.  These  were  brought  in  presenting  a  variety  of  symptoms,  having  been  attacked  suddenly 
with  nausea  and  vomiting  or  with  violent  headache ;  two  were  admitted  in  a  state  approaching  collapse.  They  have 
all  died  but  one.  In  these  cases  the  ordinary  symptoms  of  epidemic  cerebro-spinal  meningitis  were  observed, — nausea 
and  vomiting,  cephalalgia,  rachialgia,  delirium,  retraction  of  the  head,  obstinate  costiveness,  loss  of  consciousness, 
cutaneous  eruptions,  together  with  the  accidental  or  less  constant  symptoms  of  temporary  or  fugitive  febrile  reaction 
and  moderate  paralysis.  Nausea  and  vomiting,  which  were  not  always  the  earliest  symptoms,  were  neither  severe 
nor  obstinate.  Cephalalgia  was  the  most  prominent  and  constant  of  the  symptoms;  it  occurred  early,  and  alth(nigh 
remitting,  did  not  entirely  disappear  until  consciousness  was  lost.  The  pain  was  usually  in  the  frontal  region  at 
first,  but  as  the  disease  progressed  it  became  more  general,  extending  to  the  occiput,  neck  and  back.  It  was  described 
as  hard  and  steady:  the  patient  complained  of  it  but  did  not  cry  out  from  its  intensity.  Opium,  when  use<l,  had  a 
hai>py  effect  in  moderating  it.  Rachialgia  was  present  in  one-half  of  the  cases  but  was  by  no  means  severe,  and  was 
much  although  not  entirely  relieved  by  dry  cupi)ing  and  opium.  Delirium  was  noticed  in  all,  in  some  low  and  mut- 
tering, in  others  more  active;  the  patient  could  easily  be  aroused  by  a  direct  question,  which  would  be  answered 
correctly.  It  did  not  persist  continuously  during  the  progress  of  the  disease  but  occasionally  intermitted.  Retrac- 
tion of  the  head  was  but  slightly  marked  in  two  of  the  cases;  in  the  others  it  was  a  ]>rouiinent  and  characteristic 
symptom:  in  two  it  entirely  prevented  the  dorsal  decubitus  and  in  one  the  head  was  twisted  on  the  neck.  In  those 
cases  in  which  it  was  severe  it  continued  throughout  the  attack.  Obstinate  constipation  existed  in  all,  occurring 
somewhat  earlier  in  some  than  in  others.  Loss  of  consciousness  was  of  gradual  origin  except  in  two  cases,  in  which 
it  was  sudden  and  the  earliest  evidence  of  the  disease;  usually  it  was  not  a  prominent  symptom  until  the  later  stages; 
luost  of  the  patients  died  comatose.  Cutaneous  eruiitions  weie  ))resent  in  three  of  the  cases;  they  were  herpetic  and 
api>eared  on  the  face  and  neck;  in  one  a  petechial  discoloration  was  noticed  on  the  parts  of  the  body  stibjected  to 
pressure.     Febrile  reaction  was  incomplete  in  every  case;  at  times  a  hectic  condition  was  developed  in  a  few  hours, 


*  IJr.  Ruot:kts  Baktholhw  imMishrd  th:^  rtis,-  in  tlits  CiiictUH'ili  Lmicvt  ami  Ohfi^n-r,  July,  lsri4. 


THE    PAROXYSMAL    AND    COXTIXUKD    FKVERS.  565 

liut  in  all  the  cases  the  slLin  was  iHit  inclined  to  ^le  al)ove  the  normal  temperature.  Insomnia,  iwrvous  a<;itatiou, 
paralysis  and  diarrluva  seemed  to  l>e  accidental  symjuoms.  occurring  each  in  only  a  sinjjle  case.  J'lml-iiiiirlciii  exami- 
nation in  all  except  one  revealed  the  foUowinj;  appearances:  Opacity  of  the  arachnoid,  both  cerebral  and  spinal.  an<I 
injection  of  the  cerebral  i>ia  mater:  exudation  of  yellowish  and  brownish  serum  beneath  the  arachnoid  and  in  the 
cavities  of  the  brain  varying  from  two  to  eight  ounces;  copious  infiltnyion  of  the  choroid  plexus  with  turbid  serum 
and  purulent  exudation  beneath  the  arachnoid  in  the  meshes  of  the  pia  nuiter.  In  some  cases  nearly  two  ounces  of 
pus  covered  the  V)ase  of  the  brain  in  front  of  the  pons  Varolii  and  extended  by  the  side  of  the  medulla  oblongata  and 
spinal  cord  quite  into  the  lower  dorsal  region.  The  pns  varied  in  character,  in  some  linid  or  seniilluid  and  in 
others  thicker;  it  was  nearly  concrete  in  one  case  on  the  lateral  aspect  of  the  sjiinal  cord  and  on  the  toj)  of  the  cere- 
brum, dipping  down  between  the  convolutions.  Jlicroscopic  examination  showed  it  to  consist  of  a  N)>arjngly  fibrous 
stroma,  with  pus  corpuscles  more  or  less  changed  and  an  immense  nundier  of  fat  globules.  The  thoracic  and  abdom- 
inal viscera  were  generally  but  little  altered.  The  spleen  was  usually  very  small  and  hard;  its  section  showed  a 
surface  much  studded  with  white  shreds  as  of  newly-organized  material.  The  liver  in  all  cases  was  small,  lather 
har.'l  and  fatty.  In  fact  most  of  the  tissues,  while  tbey  appeared  to  the  eye  natural,  were  highly  i-harged  witli  fat. 
Such  was  the  case  with  the  heart,  the  muscles  of  the  thorax,  the  walls  of  the  intestines  and  the  kidiu'ys.  I'us  in 
small  (luantity  was  found  in  the  pelvis  of  one  kidney. 

Dr.  tS.  W.  BowLKs,  uu  duty  a.s  assistunt  at  this  hospital,  gives  furtlu'r  inl'iirinatiou  con- 
ceriiino;  tliese  cases  :  ■^" 

Of  eight  ])atients,  two  lived  two  days,  one  four  days,  one  five  days,  one  nine  days,  one  twenty-eiglit  days,  one 
thirty  days  and  one  recovered.  The  last  case  was  subject  to  the  whole  catalogue  of  diagnostic  symptoms  for  twenty- 
four  to  thirty-six  hours,  after  which  the  jiatient  was  ipiite  himself  in  every  way  for  several  days,  h'epeated  relajises 
were  followed  by  intermissions  of  increasing  duration  until  coiiv  alesi'ence  was  established. 

The  disease  manifested  itself  in  the  northern  part  of  the  state  before  apjiearing  at  the  barracks.  It  caused 
deaths  in  the  town  after  its  aiipearanco  at  the  barracks,  but  no  case  originati'il  in  the  hospital,  allh<Migh  the  cases 
received  were  not  isolated  from  patients  atlected  with  other  diseases.  Some  of  the  recruits  who  left  the  barracks  anil 
returned  to  their  homes  were  seized  with  the  disease  after  their  arrival  at  home.  The  barracks  were  in  a  remarkably 
healthy  location  ;  they  were  well  ventilated  and  moderately  clean.  For  a  month  before  the  outbreak  they  had  been 
crowded;  each  building  contained  a  hundred  men,  the  strength  of  the  camp  being  two  thousand.  The  rations  were 
of  the  best  quality  and  well  cooked.  The  weather  for  a  month  before  and  at  the  time  of  the  outbreak  was  good 
winter  weather. 

I)i'.  Bowles  states  that  there  had  been  iiu  tyjilmiil  ur  typhus  I'ever  during  the  wiuler; 
but  in  one  of  tlio  protracted  cases  of  cerebro-spinal  ineniugitis  examined  liy  biiu  tlie  piitches 
of  Beyer  were  sHglitly  ulcerated,  ami  the  inonthlv  ri|"irts  of  the  hospital  slmw  that  iu 
November,  1863,  fifteen  eases  of  t\'pliiii(l  were  ivdmilti'd,  in  Berember  liitci.-n  cases  in  Jan- 
uarv,  B'^(i4,  six  cases  and  in  February  four  eases. 

A.ctiniT  Asst.  Suruedii  J.  '^^OK^"E  refers,  in  a  rciioil  d;Ui'd  .lanuarv  B  i^^'>L  tu  the  l>rev- 
aleiice  of  this  disease  in  the  In^spital  at  Kansas  ('it v.  Mn.: 

Cerebro-spinal  meningitis  has  lately  been  ]irevailing  in  this  district.  In  the  report  of  this  hospital  for  thti 
month  of  November  a  death  rejiortedas  tyjihus  should  have  been  credited  to  this  <lisease.  A  strong  tyjihous  condition 
is  undoubtedly  present.  The  jiatient  is  taken  with  a  chill,  the  pulse  rising  to  IdOor  IL'O;  intense  pain  in  some  i)artic- 
ular  spot  along  the  course  of  some  of  the  larger  nerves  near  their  origin,  but  usually  no  headache  ;  complete  jjara lysis 
of  some  of  the  limbs  involving  both  motion  and  sensation,  the  jiaralytie  induence  being  in  certain  cases  mel.'istatic. 
The  whole  body  becomes  covered  with  large  jietechiie  containing  grumous  lilood.  If  punctured  phli'gmonous  erysip- 
elas at  once  supervenes.  Obstinate  ciuistiiiation  is  usually  ]iicseiit.  The  lungs  are  g<'iierally  o)iprcssed,  and  upon 
liercussion  more  or  less  dulness  is  frei|Uently  detected.  A  few  hours  after  the  disease  has  manifi'sted  itself  di'Iirium 
sets  ill  with  opisthotonos,  wild  rolling  of  the  eyes,  stertorous  breathing  and  heat  in  the  occiput.  These  symjitoms 
terminate  in  death  in  from  six  to  twenty-four  hours. 

Quiiiia  seems  to  be  powerless;  o]iium  and  stimulants  have  succeeded  betti'r.  (ciiinti'r-in  ilants  at  the  occiput 
develope  erysipelas  ;  along  the  course  of  the  s])ine  they  prove  of  great  value.  Inui,  opium,  stimulants  and  counter- 
irritants  constitute  my  present  treatment.  Of  seven  cases  during  the  month  of  December,  ISlilt,  three  have  died. 
Recovery  is  tedious,  and  during  convalescence  ulcers  form  in  various  parts  of  the  body  and  erysipelas  appears  u])ou 
the  slightest  irritation.  The  organs  of  special  sense  are  deranged  and  there  is  a  constant  tendency  to  ulceration  in 
cicatrices.     Every  indication  of  an  irritated  condition  of  the  blood  is  present. 

I  have  cxamineiX post-mortem  in  five  cases  during  the  month.  The  following  is  an  illustrative  specimen:  John 
Martin,  a  Wyandotte  Indian,  private,  Co.  E,  l.")th  Kansas  Cav.;  age  22.  l!ody  covered  with  large  petechia'.  Nearly 
three  ounces  of  purulent  serum  were  found  between  the  membranes  of  the  brain:  the  s]iinal  cord  C(Uitained  a  largo 
i|iiautity  of  similar  liquid.  The  membranes  adhered  to  each  other  by  lymph,  ])riii<'i|ially  along  the  longitudinal 
fissure.  Adhesions  covered  the  cerebellum  over  its  whole  surface,  also  the  jions  A'arcdii,  medulla  oblongata  and 
nerves  arising  therefrom.     The  nerves  involved  were  of  a  pinkish  color  throughout  their  substance.     All  the  tissues 


*  Jill/.  Xew  Yarli  Acad.  Med.,  Vul.  II,  p.  2tW. 


566  DISKASf'.S    ALLIEP    TO    OK    ASSOCIATED    WITH 

iiiijilioati'd  in  till'  disease  were  siit'tened,  and  a  reniarkalde  feaiure  was  the  want  of  coaiinlabiiity  of  tlie  lilood.     Tlie 
lungs  were  engorged,  the  liver  nearly  normal,  the  spleen  eiiornionsly  engorged.     The  intestines  were  not  ulcerated. 

Ill  1S64  tlio  roconloi]  cases  became  more  numerous,  and  in  the  followinu'  rear  the 
disease  was  observed  with  coinpanttive  frequeiicv  in  the  field  liospitals.  Sui'u-oon  Charles 
^^.  C'l.AKK,  3iUh  in.,  appears  to  have  been  tiie  only  niuilical  officer  who  preserved  a  full 
I'ecord  ot'  his  observations.  Puriuo-  the  iirst  rjuarter  of  the  year  1865  a  number  of  cases 
occurred  in  the  24tli  Army  Corps,  and  of  those  treated  in  the  held  liospital  he  made  notes 
of  fifteen  which  are  summarized  bi.Iow.  '■■ 

The  country  occupied  by  the  troops  was  high,  rolling  and  heavily  timbered,  about  three  miles  back  from  the 
James  Kiver.  near  Vienna  I-anding.  The  season  had  been  remarkal)ly  wet,  and  intermittent,  remittent  and  typlio- 
nialarial  fevers  prevailed  extensively.     The  men  had  also  been  continuously  exposed  to  fatigue  and  excitement. 

C'.vsj;  38. — Private  Samuel  Farnsworth..Co.  11,  10th  X.  H.,  was  admitted  Dec.  21,  1864,  with  a  coated  tongue, 
dry  and  burning  skin,  pulse  120,  severe  cough,  ditticult  respiration,  diarrhcea  with  involuutary  discharges  and  con- 
stant pain  in  the  back  of  the  head  and  neck.  Delirium  occurred  on  the  2M,  and  he  died  on  the  24th.  I'ost-mortcm 
examination:  The  dura  mater  was  intensely  congested:  the  brain-tissue  softened,  the  ventricles  dry;  the  cerebellum 
covered  with  lymph  ;  the  membranes  of  the  cord  congested  in  the  cervical  region.  The  right  lung  was  hepatized  and 
the  lower  lobe  of  the  left  infiltrated  with  jius.  the  pleura  on  both  sides  being  slightly  involved.  The  heart,  liver, 
spleen  and  kidneys  were  normal.  The  mucous memlirane  of  the  intestinal  tract  was  congested  throughout  and  ulcer- 
ated in  the  caecum  and  lower  part  of  the  rectum,  where  the  congestion  was  of  a  dark-mahogany  color. 

Case  34.— Private  John  Hughes,  Co.  O,  158th  X.  Y.:  age  24;  was  admitted  Dec.  24, 1864,  without  history.  His 
face  was  tiushed.  pupils  contracted,  pulse  120  and  full,  skin  hot  and  dry  and  respiration  hurried;  ho  talked  inco- 
herently and  had  a  disposition  to  tonic  spasm.  He  died  on  the  day  of  admission.  I'ost-mortcm  examination:  The 
membranes  of  the  brain  were  highly  congested:  the  cerebrum  was  covered  in  spots  with  a  yellow  exudation  and  on 
the  left  hemisphere,  near  the  longitudinal  sinus,  the  arachnoid  was  raised  by  a  collection  of  turbid  serum  about  a 
half  drachm  in  (|uantity ;  each  of  the  lateral  ventricles  contained  a  drachm  of  milky  serum ;  the  base  of  the  cerebel- 
lum was  coated  with  a  )ius-like  exudation:  its  substance  was  ]>ultaceous:  the  spinal  cord  was  congested  throughout 
but  no  exudation  was  apparent.  Nothing  unusual  was  discovered  in  the  chest  or  abdomen  except  a  slight  enlarge- 
ment of  the  liver. 

C.vSK  3.5. — Private  Arthur  Smith,  Co.  (i,  7th  Conu.:  age  23;  wa.s  admitted  Jan.  6,1865,  having  becit  tiiken  with 
a  chill  followed  by  fever  and  general  pain:  he  vomited  a  greenish  matter  occasionally.  Ko  change  in  the  symiitoms 
occurred  until  shortly  before  death,  when  delirium,  dilatation  of  the  pupils  and  tonic  spasms  were  develojied.  He 
died  connitose  on  the  22(1.  I'ost-mortem  examination:  Body  slightly  emaciated.  The  membranes  of  the  brain  were 
distended  with  serum ;  its  surface  was  covered  with  pus  and  its  substance  softened,  the  cerebellum  in  particular  was 
so  soft  that  a  stream  of  water  disorganized  it;  the  ventricles  contained  no  etfusion;  the  S]>inal  cord  was  congested. 
The  right  lung  w  as  norma! :  the  left  congested,  its  upper  lobe  coated  with  recent  lymph.  The  pericardium  contained 
eight  ounces  of  serum:  the  heart  was  normal,  the  blood  in  its  cavities  li(iuid.  The  liver  was  hypertrophied;  the  gall- 
bladder distended:  the  spleen  somewhat  enlarged:  the  kidneys  normal;  the  bladder  nearly  empty.  The  small  intes- 
tine was  congested  and  the  ileum  ulcerated  in  patches  throughout  its  extent.     The  colon  was  healthy. 

C.v.sE  36.— Private  F.  M.  Dwyre,  Co.  C,  9th  Me.;  age  23:  was  admitted  Jan.  15,  1865,  with  high  fever,  pulse  120, 
dry  and  brown  tongue,  jaundiced,  dry  and  harsh  skin,  injected  eyes,  contracted  pupils,  epistaxis  and  severe  pain  in 
the  back.  Soon  after  admission  he  became  delirious  and  so  continued  until  death.  For  the  first  three  days  the  cathe- 
ter was  re(]uired,  and  the  urine  withdrawn  had  a  high  color,  strong  odor  and  heavy  reddish  sediment;  but  after  this 
it  became  more  cojiious,  light-colored  and  jiassed  naturally.  The  pupils  remained  contracted;  trismus  and  dysphagia 
became  manifest.  On  the  fifth  day  there  was  some  jactitation,  and  the  hearing  and  vision  were  very  obtuse.  He 
continued  with  no  other  noticeable  change  of  symptoms  until  death  on  the  24th.  Post-mortem  examination:  Body 
greatly  emaciated  and  jaundiced.  The  dura  mater  was  intensely  congested  and  the  pia  mater  covered  with  lymph 
and  pus,  especially  over  the  base  of  the  cerebellum,  medulla  oblongata  and  optic  tract;  the  cerebrum  was  softened 
in  places,  the  cerebellum  very  soft  and  almost  disorganized:  the  lateral  ventricles  were  full  of  l)loody  serum  with 
pus  in  the  eornua:  the  membranes  of  the  cord  were  distendird  with  serum  and  pus.  The  right  lung  was  healthy  but 
the  left  was  in.process  of  hepatization,  and  recent  lymph  was  eft'usod  on  its  pleura.  The  heart  was  healthy.  The 
liver  was  fully  one-third  larger  than  normal,  its  surface  mottled  and  its  substance  soft  and  friable:  the  gall-bladder 
was  empty:  the  spleen  and  kidneys  normal.  The  stomach  and  transverse  colon  Avere  intlated,  the  latter  measuring 
fifteen  inches  in  circumference;  the  vessels  of  the  whole  intestinal  tract  were  injected  and  the  mesenteric  glands 
enlarged;  three  inches  of  the  ileum  were  intussuscepted  at  one  place  and  four  inches  at  another;  the  appendix  vermi- 
forniis  was  enlarged  and  congested;  the  right  colon  considerably  congested. 

C.\.SE  37. — Private  G.  AV.  Bean,  Co.  C,  9th  Me.;  age  24 ;  was  admitted  Jan.  16, 1865,  with  what  was  considered  a 
tvell-marked  eruption  of  rubeola  together  with  slight  fever,  jiulse  98,  a  red  and  <lrv  tongue,  severe  pain  in  the  right 
aide,  dyspua-a,  cough  and  ru.sty  expectoration.  The  eruption  ajipeared  three  days  before  admission.  In  the  progress 
of  the  case  complaint  was  made  of  severe  pain  in  the  head  and  down  the  back,  l^elirinm  came  on  and  the  jiatient 
continued  insensible  until  death  on  the  31st.     Post-mortem  examination:  Body  greatly  emaciated.     The  membranes 


j^urgf'ou  Clark  pnM'ihfd  liis  cases  in  the  t'lik-ifjn  MMirnl  Jom-iKil,  Jjiiiiuuv  ami  .^lal>■lI,  IS'J", 


THE    PAKOXVSMAL    AND    COXTINrKD    FKVERS.  567 

of  the  brain  witi-  f;roatly  coiiiresteil  anil  ilistciuleil  with  siTuin.  the  aracliiinid  thickonoil:  the  ci'ioliniiii  and  coiohellinn 
well'  covered  with  ])atches  of  lyniiih.  the  optie  tract  witli  ])us:  the  brain-tissne  was  softened,  but  no  eti'nsion  was 
fonnd  in  the  ventrieles;  the  nienibraiies  of  t lie  cord  were  infiltrated  witli  serum.  Tlie  hd't  Innj;  was  sli};litly  con,i;ested 
and  its  broncliial  tubes  contained  )iiis:  tlie  rijjlit  was  hejiatized  in  its  upper  and  in  a  portion  of  its  lower  lobe.  The 
heart  was  noriual.  The  liver  was  enlarged  one-third  and  mottled:  the  gall-bladder  nearly  emiity:  the  spleen  normal: 
the  kidneys  slightly  congested.     The  intestines  were  noruiai :  the  uicseiiteric  glands  enlarged. 

Cask  38. — Frivato  Joshua  J.  Ihake.  Co.  II.  lH'.ith  I'a.:  age  2(i:  was  iuliuitled  .Tan.  \X.  IKii.'i,  \vith  well-marked 
typhoid  symiitoius:  tongue  dry  and  brown,  teeth  eiii-nisted  with  sordes.  imlse  full  and  rapid.  IL'O.  urine  scanty,  an 
occasional  cough,  marked  subsultus  and  furious  delirium.  These  syiuiitoms  continued  with  an  incri'ase  of  the  sub- 
.snltns  and  a  tendency  to  oi)isthotonos,  ei)istaxis,  suifiision  of  the  eyes  ami  eonia-like  stupor,  but  w  ithont  change  in 
the  pupils.  }le  died  on  the  22d.  I'osl-iiiortviii  examination  :  Body  emaciated,  abdiiincn  discolored,  toes  bluish.  The 
dura  mater  was  highly  engorged  ;  the  pia  mater  contained  sernni  with  lymi)li  esiiecially  over  the  cerebellum,  and  ]mis 
especially  over  the  optic  tract ;  the  substance  of  the  brain  was  softened,  but  there  was  no  etl'usioii  in  the  ventricles : 
the  membranes  of  the  cord  were  distended  with  serum.  The  upper  lobe  of  the  left  Inng  was  consolidated  and  the 
lower  highly  congested;  pus  exuded  from  sections  of  the  right  lung.  The  ])ericardiuni  contained  eight  ounces  of 
serum,  with  manifestations  of  the  ]>resence  of  iiitlainmation;  the  blood  in  the  ventricles  was  not  coagulated,  but  the 
right  auricle  contained  an  albuminous  clot.  The  liver  was  enlarged  one-third:  t  he  gal  l-l)ladder  enormously  distended  : 
the  spleen  weighed  one  iiound  and  a  half;  the  kidneys  were  normal.  The  intestines  were  generally  healthy,  but  there 
was  some  congestion  of  the  jejunum,  and  the  ileum  was  contracted  fully  two-thirds  in  calibre:  the  colon  was  tilled 
■with  ficces  and  the  bladder  distended  with  urine. 

Cask  30. — Private  Pavid  .'^inall.  Co.  I,  ihh  Me.:  age  l(i :  was  admitted  .Ian.  IH,  IXtri,  with  a  well-marked  eruption 
of  rubeola;  rapid  juilse,  120;  hot  skin;  red  and  dry  tongue:  hurried  resi>iration  ;  cough;  natural  pupils  :  no  delirium 
liut  some  duliie.ss  of  intellect.  The  ]iatieiit  afterwards  became  delirious  and  showed  a  tendency  to  keep  the  head 
thrown  back;  the  pupils  were  contracted.  He  died  on  the  23d.  I'ost-morlem  examinutiou  :  IJody  extremely  emaciated. 
There  was  arterial  and  venous  congestion  of  the  cerebral  luembranes,  with  deposits  of  lyin])h  and  jiatches  of  tloccu- 
lent  pus  under  the  arachnoid  and  around  the  o])tic  commissure  ;  a  quantity  of  serum,  about  six  drachms,  was  found 
in  the  left  lateral  ventricle,  none  in  the  right ;  the  cerebellum  and  pons  were  softened ;  the  membranes  of  the  spinal 
cord  were  loaded  with  serum.  The  left  lung  was  normal  ;  the  lower  lobe  of  tlu^  right  lung  was  inliltrated  with  pus. 
its  jiosterior  surface  coated  with  recent  lymjdi  and  lying  in  a  small  i|Uantily  of  exuded  serum.  The  perlcarilinni  con- 
tained four  ounces  of  serum  :  the  heart  was  atrophied  and  its  subslani'c  softened.  The  liver  was  one-third  larger 
than  noriual,  its  tissues  congested:  the  gall-bladder  atrophied,  congested  and  empty;  the  s|deen  normal  :  the  kiilne\  » 
slightly  enlarged.  The  intestines  were  engorged  with  blood  and  there  was  an  intussusception  of  eight  inches  of  the 
ileum,  the  mucous  menibran«  of  the  containing  i)art  being  much  thickened  and  congested. 

Case  40.— Private  James  Kirkpatrick,  Co.  C,  lltiHh  I'a.,  admitted  .Jan.  20.  lK(;."i.  Died  IVbruaiy  2.  roKi-mortmi 
examination:  The  dura  mater  was  congested,  the  arachnoid  blackened,  and  there  was  considerable  etVusion  licmalh 
them,  with  a  large  deposit  of  lyin]di  over  the  right  cerebral  hemisiihere  and  jius  over  the  oidic  tract ;   the  lira  in -tissue 

was  soft  and  ventricles  jiarlly  tilled  with  turbid  serum;  the  spinal  cord  was  mui'h  congested.      I'lie  upper  lol f  the 

left  lung  was  engorgedand  adherent;  the  right  Inngwas  bound  down  by  old  adhesions.  The  pericardium  contained 
three  ounces  of  serum:  the  substance  of  the  heart  was  llabby  and  its  veins  greatly  enlarged.  The  liver  was  enlarged, 
the  gall-bladder  empty,  the  spleen  and  the  kidneys  niirmal.  The  peritiuieal  cavity  contained  some  etinsion:  the 
omental  vessels  were  engorged  and  the  intestines  congested.       v 

Case  11. — PrivatcH.Manshur,  Co.  E,2d  N.  II.,  was  admitted  Keb.  0,  lH(i.">,  having  been  sick  for  two  wi'cks  in  regi- 
mental hospital  with  chills  followed  by  fever  and  diarrlura.  On  admission  he  had  delirium  with  contracted  ]iuiiils. 
dry  and  discolored  tongue,  hurried  respiration  and  pulse  130.  In  the  ))rogress  of  the  case  there  aiipeared  well-niarked 
trismus  and  opisthotonos,  with  rigidity  of  the  abdominal  lunscles,  dilatation  of  the  jiupils.  involuntary  dejeelions. 
some  petechia' on  the  body  and  a  ipur])lish  color  and  coldness  of  the  hands  and  feet.  He  dieil  on  the  10th.  J'onl-mortem 
examination:  The  meinbranesof  the  brain  were  iiuH'ed  out  with  lli|uidexce])t  the  iiia  mater,  which  was  closely  adherent : 
the  convolutions  were  covered  with  lyni]di  and  in  some  ]ilaces  with  jiatches  of  pus:  the  substance  of  the  I'crebrum 
and  cerebellum  was  softened  and  each  of  the  lateral  ventricles  contained  a  drachm  of  llaky  serum:  the  spinal  meiu- 
braues  were  inliltrated  with  serum,  'f  he  heart,  lungs  andkidneys  were  healthy.  The  liver  and  spleen  were  slightly 
enlarged:  the  gall-bladder  distended.  There  was  a  well-marked  appearance  ti(  jntlainmation  over  the  stomach  and 
peritoneum  generally;  the  small  intestine  was  impacted  with  fieces,  the  ileum  ulcerated  throughout  its  whole  extent , 
the  colon  distended. 

Cask  42. — Private  .James  Keynolds,  Co.  I,  HSHh  N.  Y.;  age  21;  was  admitted  Feb.  7,  IHO.".  He  had  been  taken 
sick  January  17  with  a  chill,  severe  pain  in  the  head,  back  and  extremities  and  iiersistent  vomiting.  About  twelve 
hours  after  this  seizure  colhqi.se  threatened,  but  by  the  free  use  of  stimulants  reaction  was  induced.  He  had  no 
delirium,  convulsions  or  paralysis,  but  his  head  was  disposed  to  be  thrown  back  and  there  was  some  dysuria.  His 
hearing  was  very  acute,  the  least  noise  disturbing  him.  The  pains  gradually  left  him.  On  admission  he  had  slight 
fever,  and  although  very  restless  in  body  evinced  no  derangement  of  mind ;  he  was  not  disjiosed  to  talk,  but  answered 
(luestions  correctly  and  fully.  His  eyes  were  greatly  injected,  pniiils  dilated,  tongue  thickly  coated  :  he  did  not  desire 
food,  but  took  toast  and  tea  or  cotl'ee  at  the  usual  hours.  His  kidneys  acted  freely  and  naturally,  but  his  bowels 
were  on  several  occasions  moved  inviduutarily.  He  died  comatose  on  the  13th.  J'i)nt-worle)ii  examination  :  The  dura 
mater  was  extensively  congested:  turbid  .serum  was  fuuiid  in  large  quantity  in  the  inembranes  and  ventricles:  the 
brain-tissue  was  softened;  a  thick  layer  of  pus  covered  the  medulla  oblongata;  pus  was  found  also  on  the  cervical 


568 


nrSKAsKS    ALLIKD    TO    OR    ASSOCIATKD    WITH 


portion  of  tlic  siiinal  cord,  the  sulistaiu-o  of  which  was  softi-iieil.  The  U'ft  Iiiiif;  was  tuhercuhir,  the  riglit  healthy. 
The  livef  was  ciij;i>ij;e(l :  the  f;alI-lih\(UUT  i;ieatly  distended:  the  s|)leeii  and  kidneys  normal.  A  lumbiieoid  worm 
was  discovered  in  the  Jejunum  :  the  ileum  was  thinned  and  congested  but  not  ulcerated  ;  the  transverse  and  descending 
portions  of  the  colon  were  contracted. 

C.vsE  J3. — Private  Dennis  Brow.  Co.  il.  1th  Mass.  C'av.:  age  20;  was  admitted  Feb.  10,  18G5,  snfiering  from  a 
severe  chill,  delirium  and  much  dyspniea.  He  had  been  taken  sick  on  the  previous  day.  His  tongue  was  red  Avith 
a  brown  centre,  eyes  snti'nsed,  pupils  natural,  pulse  scarcely  jierceptible,  l'Jl.l-l.")0,  respiration  short  and  quick,  respi- 
ratory murmur  clear:  he  had  diarrhcea  with  involuntary  discharges  and  some  abdominal  tenderness;  he  was  very 
restless  and  indisposed  to  talk  or  to  answer  questi<nis:  irarpnric  spots  appeared  over  the  whole  surface  of  the  body. 
Xext  morning  there  was  an  increase  of  the  jiiirpura,  and  the  skin  was  cold  and  moist  but  hypera'Sthetic ;  there  was 
a  putVy  condition  of  the  face  and  neck.  The  patient  conld  retain  nothing  on  his  stomach  an<l  occasionally  vouiited 
a  greenish  matter  ;  his  pupils  were  dilated.  Ho  sank  gradually,  and  died  at  2.'M  v.  vr.  I'oDt-inortem  examination  :  The 
dura  mater  presented  petechial  discolorations  over  the  whole  of  its  upper  surface  and  considerable  etl'nsion  beneath 
it:  the  arachnoid  was  thickened:  the  pia  mater  injected  and  streaked  with  purple  ;  bloody  serum  was  found  in  the 
lateral  ventricles  and  pus  in  patches  in  the  cerebral  pia  mater  generally,  and  over  the  optic  tract,  the  cerebellum  and 
in  the  fourth  ventricle  and  spinal  canal.  The  right  lung  was  adherent  but  healthy.  The  pericardium  presented 
numerous  purple  streaks  of  congestion  and  contained  two  ounces  of  purulent  serum :  the  lieart  was  covered  with 
patches  of  pus.  especially  around  the  aortic  sinuses,  and  its  muscular  tissue  was  condensed,  cutting  like  cartilage; 
the  left  ventricle  contained  an  ounce  of  thin  bloody  serum.  The  liver  was  softened  and  eongesteil  in  patches  both 
externally  and  internally,  the  left  lobe  presenting  a  small  itlceration:  the  s]deen  was  one-third  larger  than  usual ;  the 
kidneys  normal.     The  intestinal  tract  was  covered  with  hemorrhagic  spots  but  was  otherwise  healthy. 

Case  44. — Private  Benjamin  Hyman,  Co.  F,  11th  West  Va.;  age  20;  was  admitted  Feb.  20, 18G5.  He  was  fiercely 
delirious,  constantly  changing  his  position,  often  breaking  into  loud  exclamations  and  moans,  starting  up  with  a 
wild  expression  of  countenance  and  re(iuiring  restraint  to  keep  him  in  bed:  his  jinlse  80^  tongue  moist  and  natural, 
skin  dry  and  cold,  Lands  and  feet  purplish,  pupils  slightly  contracted,  tirine  scanty  and  bowels  constipated.  Soou 
after  admission  he  vomited  a  large  quantity  of  greenish  matter.  Next  day  petechiie  appeared,  niostlj-  on  the  fore- 
arms and  legs,  but  other  than  this  no  marked  change  in  the  symptoms  took  place  until  the  2t)th,  when  the  i>upils 
became  dilated  and  the  delirium  subsided  in  a  comatose  tendency.  He  had  involuntary  passages,  trembling  of  the 
limbs,  opisthotonos,  a  recurrence  of  bilious  vomiting,  dysphagia,  deafness  and  a  gradually  failing  pulse.  Just 
prior  to  death  jiustules  of  aene  appeared  on  the  face  and  neck  and  a  few  on  the  arms  and  legs.  He  died  March  utli. 
rDnt-morlem  examination  :  The  dura  mater  was  generally  injected  with  both  arterial  and  venous  blood;  the  arachnoid 
had  a  shiny  opalescent  look  and  was  thickened  at  the  vertex  on  either  side  of  the  longitudinal  tissure :  lymph  anid 
pus  were  found  in  the  pia  mater :  a  thick  layer  of  pus  covered  the  pons  Varolii,  optic  tract  and  base  of  tlie  cerebellum  ; 
when  the  brain  was  placed  on  tlie  table  slight  pressure  caused  the  escape  of  about  six  ounces  of  serum  from  the  mem- 
branes and  ventricles;  pus  was  found  in  the  third  and  fourth  ventricles  and  in  the  anterior  and  posterior  horns  of 
the  lateral  ventricles;  the  cortical  portion  of  tlie  brain  was  soft  and  pultaceous,  but  the  white  substance  appeared 
unaltered  except  by  an  increase  in  the  number  of  vascular  points  ;  a  large  quantity  of  serum  and  pus  flowed  from  the 
membranes  of  the  spinal  cord.  The  viscera  of  the  chest  and  abdomen  presented  nothing  abnormal  except  that  the 
under  surface  of  the  liver  had  a  dark  shining  look. 

C.\SE  45. — Private  William  Statlen,  Co.  C,  15th  West  Va.;  age  21 ;  was  admitted  Feb.  26, 186.5,  with  high  fever, 
restlessness,  delirium,  contracted  pupils,  vomiting  of  small  quantities  of  greenish  li(iuid  and  petechial  spots  over  the 
whole  surface,  most  marked  on  the  chest  and  abdomen.  He  could  not  be  arotised  or  made  to  understand  anything; 
pnlse  120.  He  died  comatose  at  noon  of  the  28th  without  presenting  any  notable  change  of  symptoms  in  the  interval. 
I'oft-mortem  examination:  Body  not  emaciated.  The  whole  cerebral  surface,  i)articularly  the  pons  Varolii,  was  covered 
with  lymph  and  pus:  the  brain-tissue  was  congested  and  softened  and  one  drachm  of  bloody  serum  was  found  in 
each  lateral  ventricle :  the  membranes  of  the  cord  were  iiitiltiated  with  pus,  two  ounces  of  which  were  collected  on 
section  through  the  cervical  region.  The  lungs  were  normal.  The  heart  looked  auiemic  and  felt  hard  and  horny; 
the  ventricles  contained  large,  tiriii  and  hard  albuminous  clots  which  extended  into  the  auricles.  The  liver  was 
normal:  gall-bladder  disteiidi-d:  sjileen  hypertrophied :  kidneys  normal.  The  calibre  of  the  ileum  was  contracted; 
the  mesenteric  glands  eidarged.  The  bladder  was  greatly  distended  with  decomposing  urine  and  its  walls  intiamed 
and  discolored. 

C.iSE  46.— Private  F.  R.  Spillen,  Co.  H,  109th  Pa.;  age  26;  was  admitted  Feb.  26, 1865,  without  history,  but  with 
high  fever,  furred  tongue,  hot  skin,  rapid  pulse,  120,  sutiused  and  watery  eyes,  hurried  respiration  and  considerable 
cough.  Next  day  an  eruption  was  noticed  over  the  w  hole  surface  of  the  body,  and  the  patient  complained  of  great 
pain  in  the  head  and  soreness  in  the  lungs;  afterwards  delirium  and  jactitation  sujiervened,  and  he  die<l  March  1. 
I'o!tt-iiiorUm  examination:  Body  emaciated;  rigor  marked,  (jieat  ett'usion  was  found  beneath  th<'  arachnoid,  which 
was  thickened;  the  pia  mater  was  congested  and  the  cerebrum  and  cerebellum  covered  with  lymph ;  the  brain  was 
much  softened  but  the  ventricles  contained  no  serum ;  the  spinal  cord  was  not  examined.  The  lungs  were  normal.  The 
pericardium  contained  some  eft'usion,  the  right  cavities  of  the  heart  coagulated  blood  and  the  left  ventricle  a  large 
fibrinons  clot.  The  liver  was  normal:  gall-bladder  disten<led;  spleen  fully  two-thirds  smaller  than  usual;  kidneys 
healthy.  The  peri'oneum  contained  four  ounces  of  liquid;  the  mesenteric  glands  were  enlarged;  the  intestines 
congested  and  spotted. 

Case  47, — Privrte  Kmory  Wells.  Co.  D,.30tli  111.;  age  25;  was  admitte<l  at  10  a.  M.,June  14,  1805,  in  a  comatose 
condition  :  Eyes  sutiused,  jiupils  largely  dilated,  respiration  rapid,  pulse  140-150,  tongue  moist  but  not  furred;  he  had 


THE    PAROXYSMAL    AXD    CONTINUED    FEVERS.  569 

a  great  ilisposition  to  tonic  spasm,  keeping  the  head  thrown  back.  Tliis  man  had  been  apparently  in  his  usual  health 
on  theilay  before  admission.  He  died  at  11.30  P.  M.  Ponl-morliiii  examination  :  Hody  emaciated.  The  dura  niatcr  was 
greatly  injected ;  tliere  was  a  large  deposition  of  thick  yellowisli  ])us  under  Ilie  visceral  ara<'linoid ;  tlie  ventricles  were 
filled  with  turbid  bloody  serum,  and  the  brain-tissue  was  congested  and  softened,  a  slight  stream  of  water  sutiicing  to 
wash  it  away ;  the  medulla  oblongata  and  cervical  portion  of  the  cord  were  intiltrateil  with  pus.  The  kidneys  were 
I'utty.     All  the  other  organs  appeared  healthy. 

Tlie  records  of  the  field  hospitals  liave  preserved  only  the  five  cases  which  follow: 

C.xsE  48. — Private  Albert  R.  Turner,  Co.  A,  1st  Me.;  recruit ;  age  17;  was  admitteil  Jan.  1, 1865.  He  had  severe 
headache  and  Avas  so  stujiid  as  to  be  unable  to  tell  his  name;  liis  pupils  were  dilated,  juilse  KK)  and  full.  A  blister 
was  applied  to  the  back  of  the  neck  and  a  liniment  of  chloroform,  amnioniii  and  oil  to  the  spine:  castor  oil  with 
turpentine  was  given  as  a  cathartic.  About  midnight  the  bowels  aiul  bladder  were  moved  involuntarily  and  the 
patient  vomited  freely;  the  stools  were  very  fetid;  ccmia  came  on,  and  next  morning  petechial  sjiots  were  found 
thickly  and  evenly  ilistril)uted  over  the  entire  surface;  the  pupils  were  contracted  and  there  was  o]>isthi>tonos  with 
hyiienesthcsia,  the  least  touch  inducing  spasm.  At  noon  he  began  moaning,  lying  unconscious  and  motiiuiless,  the 
puise  100  and  feeble  and  the  extremities  cold.  The  liniment  was  continued  to  the  back  and  extremities:  ([uinine  in 
five-grain  doses,  with  tincture  of  iron  and  brandy,  was  given  every  four  hours.  At  midnight  very  fetid  matters 
were  vomited.  An  emetic  of  sulphate  of  zinc  was  given  which  ojjerated  freely,  and  two  hours  later  twenty  grains  of 
calomel  produced  free  evacuations.  On  the  following  morning  he  spoke  for  the  lirst  tinui  since  ailniission,  asking  for 
water.  The  hypera'sthesia  and  opisthotonos  continued,  with  complete  deafness;  the  tongue  was  brown  and  dry  but 
protruded  at  command;  pulse  about  90;  pupils  natural.  His  condition  renniined  unchanged  until  the  ittli,  when  he 
moaned  constantly  and  was  very  restless,  the  opistliotonos,  general  rigidity  and  hypera'sthesia  continuing,  the  pupils 
dilated  and  the  petechial  spots  fading.  The  quinine  was  omitted  twice,  on  the  !tth  and  again  on  the  12th,  and  on  both 
occasions  this  was  followed  by  an  aggravation  of  the  symjitoms;  but  on  renewing  and  eoutinuing  the  mi'dicine  his 
improvement  was  steady.  Beef-tea  ami  egguog  were  freely  given.  The  rigidity  disapjieared,  the  s]iots  faded  and  the 
patient  regained  the  use  of  his  arms  suliiciently  to  assist  in  turning  himself  in  bed.  On  his  transfer  to  hospital  at 
City  Point,  Va.,  February  1,  he  was  much  im])roved  and  had  full  use  of  his  arms,  but  eould  not  stanil  alone  or  turn 
himself  in  bed  without  assistance;  his  pupils  were  gn'atly  <lilated  and  on  altem])ting  to  read  he  found  he  could  not 
seethe  letters;  he  had  headache  and  was  entirely  deaf;  but  his  apjM'tite  was  gooil,  bowels  regulai'.  |iulse  K>,  minil 
clear  and  occupied  with  what  was  going  on  in  the  ward,  [lie  was  moved  to  liultimore  and  tlienci'  to  I'hilaiblpliia. 
where,  on  May  10,  the  JlcClelliKi  hosi)ital  records  show  him  as  undergoing  sulphur  treatment  for  scaliii's  and  taking 
milk-i)unch  and  citrate  of  iron  ami  (|uinine  for  emaciation,  impairment  of  the  general  health  and  a  small  chronic 
abscess  of  the  right  cheek.  He  was  discharged  from  the  service  June  2;i  on  account  of  deafness.] — Second  Dhigion, 
Sixth  Coiyn  HoHpita},  Army  of  Potomac. 

C.\SE  49. — Private  Henry  ('.  Tibb,  Co.  H,  1st  Me.,  muscular  and  of  sounil  constitution,  was  admitted  .Ian.  7, 
1<()5,  at  H  V.  M.,  having  been  taken  during  the  previous  night  with  a  sevi-re  chill  which  had  not  entirely  left  him  at 
die  time  of  admission.  Ho  had  intense  ))aiu  in  the  head  and  back,  his  legs  dragged  in  the  itVort  to  walk  and  he  was 
so  giddy  that  he  could  scarcely  see:  pulse  lOH,  (|uick  and  full;  tongue  dry  and  brown;  counteiianee  livid;  eyi'S  suf- 
fused; pupils  normal;  petechia'  were  scattered  over  the  trunk,  and  on  the  lower  extremities  numerous  dark-brown 
ecchymosed  spots  varying  from  the  size  of  a  small  pea  to  that  of  a  ten-cent  piece  an<l  coalescing  in  many  places.  A 
cathartic  of  castor  oil  and  turpentine  was  given,  bottles  of  hot  water  were  ajiplied  to  the  feet  and  stimulating 
liniments  to  the  surface.  At  5  f.  >l.  he  was  unconscious,  restless  ami  moaning  constantly.  He  died  at  I!  a.  .m.,  thirty 
hours  after  the  attack,  in  convulsions,  without  l)uiging  or  vomiting.  The  surface  of  the  back,  lower  |)art  of  the 
abdomen  and  the  lower  extremities,  excej)!  a  small  ])art  of  the  anterior  aspect  of  the  thighs,  were  almost  black. — 
SecomI  Oivisioii,  Sixth  Corps  Honpital,  Jrmy  of  I'otomur. 

C.vSK  50. — Private  Henry  McDowell,  Co.  C,  2l8t  Pa.,  complained  of  headache  at  I  v.  M.  Feb.  lt>,  ISti.").  jind  at  1 1 
I".  M.  had  a  severe  chill,  after  which  dark  l)lotches  apjieared  on  the  face  ami  extremities,  lb'  was  admitted  at  11  .\.  M. 
next  day  almost  pulseless,  tongue  slightly  furred,  face  somewhat  jauudiceil,  skin  of  iiatuial  tcm))eraturc  but  cov- 
ered with  irregular  purple  lilotches:  his  miinl  was  dull  but  ho  was  able  to  answer  (|uestious  correctly;  he  was  very 
restless  although  unable  to  sit  up  or  even  turn  himself  in  bed.  Ten  grains  of  i|niiiine  were  given  every  four  hours 
and  an  ounce  of  whiskey  every  half  hour;  warmth  was  ai)i)lied  to  the  feet  and  sinapisms  to  the  s]iine;  carbonate  of 
ammonia  was  also  employed.  Coma  came  on  w  ith  increasing  yellown<'ss  of  the  skin  and  profuse  pers)iiration  :  he 
died  at  7  P.  .M.  of  the  18th. — Second  Division,  Sixth  Corps  Hospital,  Armij  of  J'otomuc. 

C.VSK  51. — Martin  Gray,  unassigned:  age  2G;  was  admitted  March  IG,  lX(i5,  with  delirium,  dilated  pupils,  invol- 
untary passages,  dysphagia,  stertorous  breathing,  opisthotonos,  i)artial  paralysis  of  the  lower  extremities,  acute  pain 
along  the  spine,  a  small  wiry  ]iulse,  110,  and  nuiist  skin.  Fifteen  grains  of  blue  mass  were  given  at  once  ami  a  half 
<lrachm  of  hyphosnlphite  of  soda  every  three  hours.  As  his  ciuidition  was  unchaugeil  lu'xt  day,  a  tly-blister  was 
applie<l  over  the  sjiine  and  a  purgative  of  croton  oil  administered.  On  the  18th  the  delirium  abated  and  the  dyspha- 
gia was  relieved;  the  pupils  were  dilated  but  not  in.sensible,  and  although  the  stools  were  passed  involuntarily  the 
bladder  acted  naturally.  Next  day  his  ajipetite  returned ;  jmlse  90 ;  skiu  moist ;  there  was  no  paralysis  or  invohin- 
tary  evacuation.  The  record  is  defective  after  this  date,  giving  only  notes  of  treatment,  thus:  21st.  Uave  two  ounces 
of  castor  oil  as  an  enema.  23d.  Gave  ten  grains  of  blue  mass,  2t)th.  Gave  compound  cathartic  pills.  28th.  Gave 
one  grain  of  calomel  and  one-tifth  of  a  grain  of  opium  every  two  hours.  29th.  Gave  two  drops  of  fluid  extract  of 
aconite  every  two  honra.  31st.  Died. — Hospital,  I'ort  Stromj,  («. 
Mfjj.  Hist.   Ft.  Ill— 72 


'-'"O  insEASKs  Ai.LTi;n  to  on  associatkii  wnn 

Cask  rt2. — Toamster  Paviil  Caiter.  cdloii'd:  Co.  F,  Ait'y  Kesi'ivc  :  a<lmittfil  ,Iaii.  W.  ixfi.").  Diagnosis — tvjilioid 
ft'vev.  J)ii'(l  L'l'd.  ro.-<l-iii<iiiiiii  fxainiiiatiiiii :  The  pia  iiiatiT  was  iiijiHtcil,  ilio  aracluioid  ilik-kcncd  and  tli4Ti' wnc 
yellow  patches  dveilyiii;:  several  jiarts  »['  the  luain.  the  laij;est  jiatcli  at  the  base:  the  vi'iiti-ieles  eontained  loin-  oi- 
five  (iiiiiees  ot'  seium.  The  liiiii;s  and  heart  were  healthy:  llie  left  veiitriele  eontained  a  larfje  Jilirinons  clot.  The 
liver,  spleen,  kidneys,  dnodennin  and  Jejnnuni  were  healthy.  Tlie  solitary  j;Iands  in  the  greater  part  uf  the  ileum 
Were  injeeted.  as  also  were  two  of  I'eyer's  |iatelies. — I'Uhl  Hu^iiilul,  I'iftli  Corps.  Armij  af  I'otiimtic. 

Ill  tlio  gcncnil  hospitals  clinical  and  j)o«f-inu/ictti  iiutes  were  made,  some  of  wliicli  are 
lierewith  submitted: 

Cases  III  llw  Xiitliiii((I  Ilosjiital.  BaUiinon.  MdnjlaiiiJ. 

In  some  of  his  cases  at  this  hos])ital  Ass't  .Surgeon  IiEokge  M.  McGii.l,  U.  S.  Army,  seemed  to  doubt  whether 
he  had  typhus  fever  or  the  so-ealled  spotted  fever  under  eousiderati(ui.  Thus,  eases  5(1  ami  57  were  indexed  in  his 
note-hook  Spotted  fever'  T>/phi(-i  fera-f.  and  1)3  Typhus':',  while  some  were  reeorded  in  aeeordanco  with  post-mortem 
ol>servation.s  as  Conyestion  of  the  hriiin.  httKjs.  etc.  Jloreover,  the  suggestion  of  a  contagious  quality  is  made.  Auutng 
his  notes  tlie  following  occurs:  It  is  my  painful  duty  to  say  a  word  in  memory  of  Mr.  Caulk,  a  young  gentleman  of 
high  promise,  a  student  of  medicine  at  the  I'ni  versity  of  Maryland,  who.  after  assisting  us  in  our  examination  of  the 
bodies  of  so-called  "  spotted  fever"  cases  at  the  National  hospital,  himself  contracted  the  disease  and  died  of  it. 

Cask  53. — Spoilt d  firer. — Private  Isaac  York,  Co.  A,  13th  Ind.,  was  admitted  Jan.  li.  1805.  The  patient  had 
walked  to  the  hospital  from  the  provost  marshal's  otlice,  and,  although  his  expression  was  dull,  ho  gave  his  name  and 
reginu-nt  and  told  how  the  former  was  spelled.  About  noon  he  became  restless  and  crazy,  rolling  and  tossing  in  bed. 
attemiiting  to  get  up  and  requiring  two  men  to  restrain  him.  Ilis  eyes  were  somewhat  injected;  his  pupils  rather 
dilated  but  responsive  to  light :  pulse  frequent  and  full  but  soft.  He  did  not  speak,  but  api)eared  to  suffer  pain  in 
the  abdomen  and  shrank  from  pressure,  esijecially  over  the  right  iliac  fossa.  The  lungs  could  not  bo  satisfactorily 
examined  on  account  of  his  extreme  restlessness,  but  no  marked  abnormal  sounds  were  heard.  Counter-irritation  was 
applied  to  the  back  of  the  neck  and  a  turpentine  enema  administered.  His  condition  remained  unchanged  during 
the  night :  occasionally  he  was  quiet  for  a  few  minutes,  but  most  of  the  time  he  rolled  from  side  to  side  and  made  vio- 
lent efforts  to  get  up.  to  restrain  which  a  sheet  was  tied  across  his  body  to  the  sides  of  the  bed.  IV'ext  morning  he 
was  more  (|uiet  and  appeared  partially  to  understand,  answering  questi(uis  with  a  nod:  his  tongue  was  covered  with 
sordes.  pulse  softer  and  weaker,  pupils  natural  or  a  little  contracted.  .Some  ecchymoses  on  his  arms,  chest  and  abdo- 
men were  ascribed  to  friction  against  the  restraining  sheet :  three  pints  of  urine,  natural  in  appearance,  were  drawn 
off:  deglutition  was  difficult,  but  he  occasionally  took  small  (luantities  of  liquid.  Towards  evening  ho  liecame  heavy 
and  comatose,  the  evacuations  involuntary.  t)n  the  morning  of  the  Kith  the  breathing  was  stertorous:  a  number  of 
dark  blotches  of  difi'erent  sizes  and  some  small  pink  spots  were  found  on  the  chest  and  abdomen.  During  the  day 
some  contraction  of  the  tiexors  of  the  right  side  was  followed  by  paralysis  of  that  side;  he  frequently  movedthe  left 
arm  and  leg  but  never  the  right.  He  died  at  3  a.  m.  of  the  18th.  I'ost-iiiortcm  examination  :  The  dura  mater  adhered  to  the 
summit  of  the  cerebrum  and  was  somewhat  injected:  the  pia  mater  was  finely  injected  and  its  larger  veins  full  of 
Idood:  the  arachnoid  was  opaque;  the  substance  of  tlie  brain  was  congested  and  of  a  pink  color;  the  lateral  ventricles 
■contained  liquid  and  tlieir  serous  lining  was  clouded:  the  veins  of  the  choroid  plexus  were  distended:  a  li(iuid  looking 
liki-  jius  was  found  about  the  right  hippocampus  major:  the  lining  membrane  of  the  ))Osterior  born  of  the  right  side 
■was  congested  and  had  its  veins  enlarged:  the  third  ventricle  contained  serum  :  the  fourth  ventricle  was  covered  with 
what  was  considered  to  be  plastic  exudation  and  showed  small  ([uantitiesof  puruloid  li(|uid;  the  pineal  body  ap])eared 
gelatinous  and  was  three  times  larger  than  usiuil.  The  lower  lobe  of  the  left  lung  was  intensely  congested. — a  por- 
tion, one  and  a  half  inches  sijuare,  sank  readily  in  water;  the  lower  lobe  of  the  right  lungshowed  lohitlar  solidifica- 
tion.    The  heart  contained  white  clots  in  both  ventricles.     The  liver,  spleen  and  kidneys  were  congested. 

Case  54. — Congettion  of  the  hruiii  :  Spotted  f ever. — Private  Orlando  Jones,  Co.  C,  81st  Pa.;  admitted  Feb.  16, 1805. 
Died  next  day.  He  was  partially  comatose  and  could  give  no  account  of  his  previous  history;  but  after  counter-irrita- 
tion to  the  back  of  the  neck  he  became  able  to  speak  and  stated  that  he  had  been  sick  only  a  few  days.  The  pupils 
Avere  dilated:  there  was  great  jiallor  of  countenance,  with  dulness  and  rhonchus  over  the  lower  iiart  of  both  lungs, 
retention  of  urine  and  tenderness  on  pressure  in  the  right  iliac  fossa.  The  urine  was  removed  by  catheter.  I'ost-mortem 
examination:  Body  well  develoi)edaud  in  good  condition  ;  blood  liquid  throughout  the  vessels.  The  veinsofthe  pia 
mater  were  quite  full ;  the  Pacchionian  bodies  were  ntimerous  on  the  summit  of  the  hemispheres  and  resembled  recently 
tlirown  out  fibrin  ;  the  brain  was  firm  and  somewhat  full  of  blood;  the  ventricles  contained  small  quantities  of  serum 
and  the  floor  of  the  fourth  ventricle  was  reddened.  The  lungs  were  black  from  melanic  deposit;  the  posterior  part 
of  the  lower  lobe  of  the  left  Inng  was  congested  by  hypostasis,  and  when  cut  into  showed  si)ots  of  intense  congestion 
along  the  tracts  of  the  bronchial  tubes  of  one-eighth  inch  calil)re.  The  liver  was  dark  in  color,  firmer  than  usual,  and 
marked  with  fibrinous  lines  along  the  course  of  its  vessels ;  the  gall-bladder  contained  black  bile;  the  spleen  and 
pancreas  were  apparently  normal.  The  jejunum  and  ileum  were  somewhat  reddened.  The  kidneys  were  full  of  blood  : 
the  urine  healthy:  the  suprarenal  capsules  enlarged  and  firm. 

Case  m.— Spotted  fever. — Private  William  Doty,  Co.  D,  91st  X.  Y.;  age  27:  temperate,  but  subject  to  epilepsy: 
was  admitted  March  2,  1865,  having  had  a  convulsive  attack  on  the  previous  day.  On  admission  no  sign  of  disease 
was  discovered,  but  ou  the  4th  he  had  pyrexia,  severe  i)ain  in  the  left  side  and  a  faint  friction-sound  over  the  lower 
l>ait  of  the  teft  lung.  A  blister  was  applied  and  a  large  dose  of  Dover's  powder  given.  He  complained  but  little 
next  day  and  seenu-d  to  be  doing  well,  but  at  night  became  <lelirions.  On  the  6th  he  was  restless,  tossing  about  in 
bed,  and  in  the  absence  of  restraint  getting  up  and  wandering  about  the  ward  ;  pulse  rapid  and  feeble;  pupils  natural 


THE    PAROXYSMAL    AND    CONTINTED    FFA'ERS.  571 

but  insensible:  bead  tbrown  back  by  spasm  of  the  mnscles.  He  died  early  on  the  8tli.  J'nsf-mortfm  examination 
seven  Iionrs  after  death :  Heneath  the  visceral  layer  of  the  arachnoid,  which  «as  clear  and  smooth,  was  a  white  tibrin- 
like  snlistance,  most  abundant  along  the  course  of  the  larj;er  vessels:  a  snnill  (juantity  of  sernni  escajied  on  openinj;; 
the  lateral  ventricles,  the  lininj;  mendiranes  of  which  were  arborescent  from  contrestion  and  s])otted  with  small 
ecchymoses  jiosteriorly  and  interiorly,  especially  on  the  left  side:  the  cornua  contained  also  about  three  drachms  of 
ims-like  li(|nid:  in  tin'  uiii>er  part  of  the  left  lobe  <if  the  ceri'lielhim.  one  inch  within  its  ]posti'rior  semicircular  bonier, 
was  a  small  clot  from  wbiidi  bloodvessels  radiated  irrei;uhirly;  in  synnneti  ii'al  position  im  tin' other  siile  was  a  siniil.'ir 
clot :  a  third  clot,  thin  and  small,  was  found  on  the  ri^ht  sidi'  of  the  valley  <d"  the  cereliellnm  :  the  lloor  of  the  fourth 
ventricle  was  covered  with  a  bluish,  tenacious,  pus-like  substance  overlying  hue  irregular  .•irbiuescent  conj;estions:  a 
red  sjxit  was  found  in  the  centre  of  the  cross  .section  of  the  medulla  ohliuifjata.  The  hiwer  jiart  of  the  ])<Mis,  the  per- 
forate<l  s])aces  and  their  vicinity,  especially  along  the  tracts  of  the  vessels,  were  coated  with  a  bluish  filirinoid  sub- 
stance. The  cerebral  and  cerebellar  tissues  were  congested.  The  posterior  surface  of  tlie  right  lung  was  uneven  and 
occhymosed  and  portions  of  its  upper  lobe  sank  in  water:  there  were  inti'rlobar  and  saccular  adhesions  of  the  left 
lung  with  subplcnral  ecchymoses,  and  at  one  point  intense  congestion.  The  heart  contained  black  and  wliite  clots. 
The  liver  was  large,  dark-colored  and  full  of  blood:  the  gall-bladder  contained  black  bile.  The  siileen,  weighing 
twelve  ounces,  was  light-colored  ami  easily  broken  up:  the  kidneys  and  iiancreas  were  congested.  There  were  regions 
of  intense  congestion  in  the  stonnich,  duodenum  and  jejunum  :  the  large  intestine  was  slightly  reddened.  The  Idooil 
in  the  vessels  was  Huid.  The  urine  was  highly  albuminous.  The  spinal  cord  was  exauniu'd  thiily  three  hours  after 
death  :  About  a  drachm  of  serous  liquid  mixed  with  lymidi-tlakes  escajied  on  opining  the  tlu'<a  :  bluish  Hakes  of  librin 
were  found  enveloi)ing  the  spinal  nuirrow,  especially  iiosteriorly;  a  cross  section  in  the  dorsal  region  re\ealed  nuich 
softening,  but  no  other  similarly  affected  spot  was  discovered. 

Case  56. — Spotted  ffvrrf  Ti/phiisf — Culbcrt  Whitcoinb,  (iovernment  emi)loye,  was  adinilled  March  H,  ISIm.  with 
well-iTiarked  symptoms  of  typhoid  pneumonia.  Cups  followed  by  blisters  were  freely  applied  ovi-r  the  surface  of  the 
chest.  On  the  14th  the  breathing  was  easy,  cough  slight,  expi'ctoration  natural, and  a  cli'ar  souml  was  heard  over 
all  parts  of  the  chest :  but  on  the  IGth  the  patient  was  seized  with  delirium  anil  diarrhcea  and  his  tongue  lieiame  dry 
and  cracked.  He  died  on  the  18th.  i'dsf-mo/'/cm  examination  :  Hody  not  much  emaciated.  The  veins  of  the  ])ia 
mater  were  so  engorged,  especially  on  the  posterior  as|iei't  of  the  cerebr;il  hemisjdieres,  as  to  present  tlii'  ap|>earance  of 
a  su]>erticial  clot:  the  cerebrum  was  congested;  the  lateral  ventricles  contained  a  cousideralile  (|Uanlity  of  si'rum 
which,  in  the  ])osterior  horn  of  the  left  side,  was  tinged  with  blood;  the  Ihjor  of  the  fourth  ventricle  was  discoloied 
at  its  extremities  and  crossed  above  the  origin  of  the  auditory  nerve  by  a  while  zone  ])resentiug  four  lines  of  marked 
congestion:  the  substance  of  the  cerebellum  was  a))i)arently  softer  than  that  of  the  cerebruni.  The  right  lung  was 
congested  posteriorly  and  seemed  ecchymosed  in  its  substance  and  superticially  undir  the  phuia:  lln'  lilt  was  car- 
nihed  ]iosterior!y.  The  right  cavities  of  the  heart  contaiiu'd  whili'  inelastic  clots;  the  cardiac  walls  were  flaccid 
and  of  a  dark -rid  color,  looking  as  if  tlu'V  had  been  bruised  ;  the  lining  mi'mbrane  of  the  aorta  was  of  a  dark-siarh't 
C(dor.  The  liver  was  dark-colored  ami  friable;  the  bile  very  black;  the  spleen  snuill,  tough  and  dark-c(dori'd ;  the 
kidneys  llaci-id,  tinted  red  and  not  distinctly  marked  on  section  into  tubular  and  cortical  ixirtions:  the  sac  of  the 
right  sujirarenal  capsule  was  distendid  with  a  granular  bloo<ly  li(|nid;  the  pancreas  was  ri'ildeneil.  The  stom.'ich 
jiresented  a  large  submiu'ous  ecchymosis  at  the  fundus;  the  small  intestine  was  intinsely  ciingestcd,  with  I'l'yi'r's 
patches  well  developed  ami  the  siditary  glamls  enlarged:  the  large  intestine  was  similarly  congested  and  presi'iiied  a 
few  rouiul  and  irregularly  oval  ulcers.     No  albumen  was  found  in  the  urine.     The  blooil  generally  was  lii|uid. 

Case  ol.— Spotted  fcrer?  Tiiphun?—Cor]t'l  Frederick  liossardo.C'o.  I,  21th  Mich.;  age  20;  was  admit  tid  March  II. 
180.">.  in  a  state  of  jiartial  coma  with  tremor.  He  could  he  aroused  to  take  nouiishmenl  and  stimulants,  but  iiuickly 
relapsed  into  stupor.  He  had  Involuntary  evactiations  and  iit  tiims  viideut  spasms  of  the  extensor  muscles.  Deep 
presMurein  the  right  iliac  fo.ssa  appeared  to  cause  i>ain.  Tin' stujior  and  spasms  ccuitinued  until  death  on  the  ITth.  /'«»/- 
mortem  examination  :  Body  greatly  emaciated.  The  racdi Ionian  bodies  were  well  developed  :  the  arachnoid  contained 
limpid  serum;  the  substance  of  the  brain  was  firm;  the  lateral  ventricles  contained  a  small  (inantity  of  seiiiiu  and  their 
lining  membrane  was  oi>a<]Ue:  the  floor  of  the  fourth  ventricle  was  white  but  marki'd  by  arborescent  congestions  above 
the  origin  of  the  auditory  nerves;  thesubstauceof  the  cerebellum  was  softer  than  that  of  I  he  cerebrum.  The  right  lung, 
twenty-eight  onnces,  was  full  of  blood,  and  under  the  pleura  on  the  posterior  portion  of  its  lower  lobe  were  two  ecchy- 
mosed spots  ;  the  left  lung,  twenty-six  ounces,  was  partially  solidilicd  posteriorly  and  had  an  ecchymosed  appear- 
ance. Hoth  ventricles  contained  clots,  white  in  the  left  but  mixed  in  the  right.  The  liver  was  light-colored,  friable 
and  odorous;  the  spleen  enlarged  to  twelve  ounces,  dark-colored  and  easily  broken  down;  the  ]iancreas  reddened; 
the  kidneys  congested;  the  siii>rarenal  cajisules  healthy.  The  stomach  was  enlarged  and  mottled  internally;  the 
jejunum  yellow  and  ecchymosed;  the  small  intestine  thinned  generally  and  I'eyer's  patches  c(mspicuoiis;  the  large 
intestine  discolored  and  the  colic  glands  enlarged  and  blackened. 

Case  58. — Spotted  f ever. — Private  Aaron  James  Brown,  Co.  I,  ■")2il  Ohio:  age  32;  admitted  March  11,  18()r>.  The 
body  of  the  patient  exhaled  an  aimuoniacal  odor:  its  surface  wasof  theordinary  temperature  but  very  dry  and  covered 
witli  dark  mulberry-colored  spots  irregularly  circular  in  form,  aiiout  the  size  of  a  split-])ea,  but  not  elevated  and  not 
disapiiearing  entirely  on  ])ressiiie;  the  tongue  was  still' and,  like  the  teeth,  coated  with  dark  incrustations:  thei)u])ils 
were  at  lirst  resiionsivc  ,o  light  but  afterwards  became  insensible.  He  had  delirium,  which  increased  and  wasaccom- 
l)aiiied  with  muscnlar  spasms,  drawing  the  head  strongly  backward.  He  died  on  the  21st.  I'ont-mortem  examination  : 
Body  not  much  emaciated;  skin  measled  with  dark-coloreil  and  apparently  fading  spots.  There  was  no  serum  in  the 
sac  of  the  arachnoid,  but  the  veins  of  the  pia  mater  were  full,  and  this  meiubrane  was  detached  with  dilliculty  from 
the  convolntions;  there  were  numerous  puncta  on  the  cut  surface  of  the  brain,  which  also  was  scmiewhat  reddened; 


572 


■Dr.^KAsF.S    AT.LIFli    TO    OK    AssOCTATKl^    WITH 


bloody  serum  was  foiiiul  in  the  posterior  horn  of  the  left  lateral  ventriele — but  very  little  in  the  anterior  horn  :  tho 
tioor  of  tlio  fourth  ventriele  was  opaijue  anil  the  routs  of  the  auditory  nerves  indistinct ;  the  medulla  obloMLjata  was 
somewhat  congested.  The  right  lung  was  adherent  on  its  posterior  aspect ;  its  lower  lobi-  presented  several  snbplenral 
apojilectie  sjiots  posteriorly;  some  mottling  was  observed  over  the  exterior  face  of  the  whole  lung;  though  full  of 
blood  the  organ  was  not  thought  to  be  congested.  The  left  lung  was  also  full  of  blood  but  not  congested  except  in  the 
posterior  part  of  the  lower  lobe,  where  the  oiitlines  of  the  lobules  were  well  defined  and  their  substance  on  section 
presented  light-red  polyhedral  spots  in  a  nuitnx  of  eti'used  blood:  a  portion  of  this  tissue  sank  in  water,  and  when 
broken  up  by  the  finger  yielded  a  bloody  pulp.  The  heart  was  free  from  clots.  The  liver  presented  oval  diseolora- 
tions  on  its  upper  surface;  its  substance  was  finely  congested.  es])eeially  in  the  regions  indicated  by  the  congested 
superficial  patches  ;  the  upper  surface  also  showe<l  irregular  light-colored  niottlings,  which  were  shown  by  section 
to  extend  into  the  subjacent  tissue:  the  gall-bladder  contained  black  bile.  The  sjileen  was  normal;  the  kidneys 
slightly  congested  ;  the  suprarenal  capsules  reddened  :  the  pancreas  enlarged,  light  colored  and  friable.  Dark  ecchy- 
mosed  spots  were  found  under  the  mucous  membrane  of  the  stomach.  The  up])er  part  of  the  jejunum  was  reddened^ 
congestion  in  thesnuiU  intestine  seemed  to  have  a  tendency  to  determine  itself  in  spots  of  irregular  form,  with  a  diam- 
eter not  generally  larger  than  one-fourth  of  an  inch  ;  I'eyer's  patches  apjieared  healthly.  The  lower  part  of  the  large 
intestine  was  congested.    Albumen  was  found  in  large  (juautity  in  the  urine.     The  blood  was  generally  fluid. 

Case  59. — i'onflcflion  of  the  hrain  and  lungs. — Corp'l  Jacob  Crow,  Co.  I.  20th  Ohio;  age  32;  was  admitted  March 
11,  1865,  with  symptoms  of  incipient  typhoid  fever.  NYhile  apparently  improving,  on  April  1,  he  was  seized  with 
erysipelas  of  the  face.  On  the  subsidence  of  the  iutlammation  he  became  delirious  and  was  restrained  with  difficulty; 
opisthotonos  came  on,  and  he  died  on  the  10th.  I'ost-niortvm  examination:  Lateral  ventricles  each  containing  an  ounce 
of  serum  :  pia  nuiter.  fourth  ventricle,  pons  and  medulla  congested.  Lungs  congested,  with  some  solidification  and 
empliysema  of  the  lobules:  bronchial  tubes  congested  and  containing  purulent  fluid.  Heart  tilled  with  mixed  clots. 
Sj)leeu  large  and  pulpy:  kidneys  congested.     Ileum  hyper.emic  and  presenting  the  shaven-beard  appearance. 

C.\SE  60. — Congestion  of  lung}  and  brain. — Corp'l  Jacob  Brubaker,  Co.  B,  12th  U.  S.  Inf.;  age  21 ;  admitted  March 

17,  1865,  after  three  or  four  weeks  sickness.  On  admission  there  was  fever  with  a  coated,  dry  and  tremulous  tongue, 
twitching  of  the  mouth  and  some  hesitation  in  articulation;  slight  cough  was  also  present,  with  resonance  and 
sibilant  and  sonorous  riiles  over  the  ])osterior  aspect  of  the  chest.  The  nervous  symptoms  became  more  marked,  the 
l)atient  rolling  restlessly  from  side  to  side,  and  a  slight  purpuric  rash  was  observed  over  the  abdomen  and  chest,  not 
elevated  and  not  disappearing  under  pressure.  He  died  comatose  April  7.  I'ont-morlem  examination:  Pia  mater 
injected:  arachnoid  opaque;  ventricles  containing  serum.  Lungs  generally  congested,  with  lobular  consolidation 
and  emphysema  in  the  posterior  portions:  bronchial  tabes  reddened  and  containing  mnch  tenacious  bloody  mucus. 
Spleen  large.     Intestine  hypera-mic  ;  Peyer's  patches  conspicuous  and  marked  with  black  points. 

Case  61. — Cerebro-sjyinal  mcningilis. — Private  Robert  Minchion,  Co.  D,  2d  Mass.;   age  18;   was  admitted  March 

18,  1865,  with  symptoms  of  nervous  disturbance,  and  on  the  lower  extremities  from  the  hips  downward  a  ])eculiar 
eruption,  consisting  of  a  red  areola  varying  from  the  size  of  a  five-cent  piece  to  that  of  a  half-dollar,  enclosing  a  dark 
centre  in  a  state  of  incipient  sloughing.  The  tongue  was  dry  and  coated  with  a  dark-yellow  crust ;  the  abdomen  but 
slightly  tender:  the  evacuations  regular.  The  patient  complained  much  of  the  fatigue  of  travel  an<l  of  hardships 
endured  on  Galloupe's  Island,  Boston  Harbor,  stating  that  inferior  food  and  scarcity  of  water  were  the  causes  of  his 
present  conditiou  of  prostration  and  filth.  He  was  rational  but  slightly  deaf.  About  a  week  after  admission  an 
eruption  resembling  that  produced  by  eroton  oil  appeared  on  the  left  cheek  and  neck,  and  as  this  i:i  the  course  of 
two  days  became  somewhat  umbilicated  the  patient  was  isolated.  The  central  portions  of  the  spots  on  the  legs  had 
in  the  meantime  gradually  sloughed,  and  incoherence,  delirium,  dimness  of  vision,  contraction  of  the  pupils,  suffusion 
of  the  conjunctivif,  with  increasing  opisthotonos  and  nltimately  jmrtial  coma  had  supervened.  The  comatose  con- 
dition lasted  until  twenty-four  hours  before  death,  when  he  became  wild  and  almost  uncontrollable;  this  was  fol- 
lowed by  great  muscular  prostration  from  which  he  did  not  rally.  Death  took  place  April  12.  I'osi-mortim  exauiina- 
tion:  Body  emaciated,  rigid  and  nuirked  by  ulcerations,  especially  on  the  lower  extremities  and  left  side  of  the  face 
and  neck.  The  sac  of  the  arachnoid  contained  a  small  quantity  of  liquid  in  which,  especially  on  the  right  side,  flakes 
of  lymph  were  floating:  lymph-flakes  were  also  loosely  or  closely  attached  to  the  perforated  spaces,  ojitic  commis- 
sure, left  fissure  of  Sylvius,  anterior  portion  of  the  pons  and  to  the  arachnoid  stretching  over  the  valley  of  the  cere- 
bellum: the  pia  mater  was  finely  congested:  puncta  were  nnmerous  on  the  cut  surface  of  the  cerebrum;  tho  right 
lateral  ventricle,  the  lining  membrane  of  which  was  highly  congested,  contained  half  an  ounce  of  amber-colored 
tloccnlent  liquid,  with  flakes  of  lymph  in  the  cornua  and  on  tlie  choroid  jilexus;  the  left  ventricle  presented  less 
liquid,  nu)re  flocculi  and  more  intense  congestion  of  its  lining;  the  third  ventricle  was  filled  with  a  similar  li(juid,  the 
tlocculi  of  which  had  lodged  chiefly  in  the  infundibulum :  the  pineal  body  was  large;  the  fornix  an<l  lower  part  of 
the  corpus  callosum  were  greatly  softetied,  the  former  being  of  the  consistence  of  thick  cream ;  the  floor  of  the  fourth 
ventricle  was  discolored  getierally  and  presented  small  blood-spots,  seven  on  the  left  side  and  two  on  the  right  in  the 
situation  of  the  linea-  transversa'.  The  sac  of  the  spinal  arachnoid  contained  serum,  and  a  mass  of  lymph  was  attached 
to  its  visceral  surfiice;  the  pia  mater  was  congested;  the  cord  was  softened  and  broken  in  the  middle  of  the  dorsal 
region.— the  break  nuiy  have  been  fuade  by  accident  in  opetiing  the  canal,  but  the  softening  was  observed  opposite 
the  first  lumbar  vertebra.  The  bronchial  tulies  in  both  lungs  were  congested;  the  left  lung  was  collapsed  in  some 
parts  but  was  otherwise  normal;  the  right  was  hepatized,  red  in  its  posterior  and  upper  part  and  gray  iu  its  poste- 
rior anil  lower  part.  The  heart  contained  fibrinous  clots  in  all  its  cavities.  The  liver  was  normal;  the  spleen  large 
and  firm:  the  i)aucreas,  kidneys  and  suprarenal  capsules  normal.  The  stomach  was  congested;  the  ileum  thinned; 
Peyer's  i)atches  well  marked  but  not  hypera;mic;  the  large  intestine  congested  in  parts. 


THE   PAROXYSMAL    AND    COXTIXUED    FEVERS.  573 

Case  62. — Spolhd  fcrcrf — Lt.  Col.  Giistavus  Helmricli.  40tli  Mo.:  a  paiolod  iirisoner:  age  4K;  stout  and  iiius- 
cnlar;  was  admitted  March  24,  1865,  with  nervous  syiiiptonis,  chietiy  manifested  liy  twitching  of  the  corners  of  the 
month,  jerking  of  tlie  limbs,  especially  when  tou<'hed,  tremor  of  the  tongue  and  imperfect  speech,  lli'  seemed  to 
understand  questions  partially,  especially  when  put  in  German,  l>ut  his  answers  were  incoherent.  He  tried  to  write 
his  name  hut  his  hand  was  too  tremulous ;  when  half  through  an  attempt  to  s]>ell  it  he  lost  the  connection  and  turned 
impatiently  awny.  His  pulse  was  soft  and  feeble:  conjunctiva'  injected  and  ])upils  contracted.  There  was  a  ilift'nscd 
purpuric  rash  on  the  chest,  abdomen  and  arms.  He  shrank  from  pressure  over  the  ei)igastrium  and  over  the  abdo- 
men generally.  He  stated  that  he  had  vomited  and  that  his  bowels  had  not  been  moved  for  three  days.  The  respir- 
atory nnirmur  was  slightly  diminished  over  the  posterior  parts  of  the  chest  and  the  breathing  was  somewhat  bronchial 
under  tlie  left  scapula.  Coma  supervened  during  the  night  following  admission,  and  he  died  at  6  .v.  M.  next  day. 
J'u-il-iiwrtim  examination :  liody  well  developed.  The  jiia  mater  adhered  to  tlie  cerebral  convolutions  and  at  the  base 
of  the  brain  was  linely  and  generally  congested;  a  large  ipiantity  of  serum  was  found  under  tlie  visceral  arachnoid, 
and  two  ounces  tinged  with  blood  were  taken  from  under  the  tentorium  afti'r  the  rcnmval  of  the  brain.  The  cere- 
bral substance  was  tirm  and  showed  many  puncta  on  section;  the  lateral  ventricles  contained  a  small  (juautity  of 
serum;  the  large  veins  of  the  corpora  striata  near  the  foramen  of  Monro  and  those  of  the  velnm  interpositnm  were 
covered  with  an  opaque  translucent  membrane;  the  fornix  had  many  puncta  at  its  union  with  the  corpus  callosum 
posteriorly;  the  third  ventricle  contained  serum;  the  pia  mater  covering  the  valve  of  Vieussens  was  intensely  but 
delicately  congested;  the  floor  of  the  fourth  ventricle  was  generally  reddened,  with  arborescences  in  the  njiperpart, 
a  scarlet  jioint  of  extravasation  on  each  side  above  the  linea'  transversa'  and  more  discoloration  tlnm  usual  near  the 
point  of  the  calamus:  the  perns  Varolii  was  congested.  The  right  lung  was  engorged;  the  lower  lobe  of  the  left  lung, 
on  section,  exuded  a  bloody  liquid  and  had  adhesions  on  its  outer  face  and  some  subpleural  dark  spots  on  its  posterior 
aspect.  The  right  ventricle  of  the  heart  contained  a  small  white  clot :  the  right  auricle  and  left  ventricle  had  I'ach 
a  soft  mixed  clot.  The  liver  was  firm,  heavy,  smooth  on  section,  reddish-brown,  with  indistinct  acini :  a  small  calca- 
reous mass,  surrounded  by  a  star-shaped  contraction  of  the  capsule,  was  found  in  the  mi<ldle  of  the  upper  part  of  the 
right  lobe;  the  bile  was  thick,  black  and  granulated.  The  spleen,  eighteen  ounces,  was  much  engorged  and  di'cidedly 
softened,  its  capsule  thickened.  The  kidneys  were  somewhat  large  and  congeste<l  in  their  tubular  portions;  the  ))an- 
creas,  enlarged  and  congested,  contained  a  large  calcareous  mass.  The  mucous  membrane  of  the  stomach  was  not 
apparently  softened,  but  was  of  a  dark  ash-red  color  generally  and  <'lierry-red  at  the  fundus:  the  small  intestine 
presented  in  certain  regions  a  somewhat  ironed  appearance;  the  upper  part  of  the  jejunum  was  darkly  discolored; 
Peyer's  patches  were  distinct,  hard  to  the  feel  and  black  ]>ointed;  the  mucous  folds  of  the  ileum  were  blackened. 
The  ciecuin  and  colon  were  liy])eraiiiic  and  their  mucous  coats  blackeneil. 

Case  6H. — Tiiphiin.' — Private. John  Hramon,  Co.  1),  16tli  Iowa;  age  12  :  was  admitted  Nov.  2S,  1H6I,  as  ih'bilitated 
by  recurrences  of  intermittent  fever.  Abmit  a  week  after  admission  the  fever  iiianilested  itself,  returning  at  regular 
intervals  until  subdued  by  <iuinia  and  alteratives.  The  patient  so  far  recovered  as  to  be  aide  to  do  light  duty  and 
enjoyed  apparently  good  health  until  April  1,  IHd'i,  when  he  was  seized  with  fever  and  cough  with  light  rust-colored 
expectoration.  Under  treatment  the  pneumonia  disappeared,  the  patient  became  able  to  sit  up  and  his  aiijietite 
returned;  but  on  the  10th  he  was  seized  with  great  lassitude,  anorexia  and  sleeplessness;  the  excretions  became 
scanty,  the  tongue  dry  and  dark  and  the  abdomen  somewhat  teinh'r.  Next  day  a  ditfused  retldish  papular  eruption 
appeared  over  the  entire  body.  The  patient  continued  rational,  complaining  only  of  excessive  weakness  until  the 
14th,  when  it  was  found  ditticiilt  to  obtain  reiilics  from  him:  .a  peculiar  odor  emanated  from  the  body;  the  urine  con- 
tained no  albumen;  the  bowels  had  been  oiiened  by  cathartics  and  enemata.  (tii  the  l.Mli  the  surface  was  mottled 
and  cold:  the  face  dusky;  eyes  sulfused;  pupils  contracted  and  feel)ly  res|poiisive  to  light;  tongue  covered  with  soft 
dark  soides  and  protruded  with  ditiieulty ;  impulse  of  the  heart  weak.  There  was  no  opislliotmios  throughout  the 
ease.  He  died  on  the  16tli.  I'ont-niorlim  examination :  Body  rigiil :  its  surface  marked  by  a  continence  of  discolored 
spots  of  ditt'erent  sizes.  The  sac  of  the  arachnoid  contained  aliout  an  ounce  of  serum :  the  jiia  mater  was  linely  injected. 
On  the  vertex  of  each  hemisphere  was  an  eccliymosed  spot  about  the  size  of  a  cent;  the  cerelnal  siilistance  was  gen- 
erally but  slightly  congested;  the  lateral  ventricles  contained  a  small  quantity  of  serum;  a  single  central  line  of 
congestion  was  found  on  the  floor  of  the  fourth  ventricle  above  the  region  of  the  auditory  nerves.  Jioth  lungs  were 
adherent,  collapsed,  flaccid,  but  so  injected  posteriorly  as  to  seem  ecchymosed.  The  heart  contained  clots.  The  liver 
was  congested  and  of  high  specific  gravity;  the  bile  dark-brown;  the  spleen  eleven  ounces,  softened;  the  pancreas 
and  kidneys  normal.  The  mucous  membrane  of  the  Btomach  was  congested  at  the  fundus  and  along  the  lower  curva- 
ture. The  duodenum  was  congested  and  had  the  ironed-out  apiiearance;  the  adjoining  parts  of  the  jejunum  and 
ileum  were  stained  with  bile:  the  ileum  was  congested  in  parts;  Peyer's  patches  were  conspicuously  marked  with 
black  spots.     The  ascending  colon  was  hypera'iiiic. 

Case  64. — Spotted  ferei: — Private  Samuel  I.  Hargrave,  Co.  K.  I.''i2d  Ind.;  age  lil;  was  admitted  delirious  Aug.  11, 
186.").  His  previous  history  was  unknown,  but  it  was  understood  that  he  had  been  sick  about  ten  days.  His  pulse 
■was  rapid  and  thready,  tongue  dry  and  brown,  pupils  slightly  contracted,  bowels  constipated,  bladder  distended, 
right  iliac  region  tender.  The  head  was  extremely  extended  and  there  were  marks  of  recent  vesication  on  the  back 
of  the  neck.  Xo  eruption  was  observed  on  any  part  of  the  body.  The  bladder  was  relieved  by  catheter  and  the  bowels 
by  enemata;  a  half-grain  of  morphia  procured  several  hours  of  quiet  sh'cp  ;  live  grains  each  of  <iuinine  and  chlorate 
of  potash  were  given  every  four  or  six  hours,  with  beef-essence,  eggs  and  milk-punch;  cold  was  applitnl  to  the  head 
and  blisters  between  the  shoulders.  I'he  patient,  when  not  under  the  iutlnence  of  anodynes,  was  extremely  restless, 
tossing  about  in  bed  and  getting  up  when  not  clo.sely  watched:  occasionally  he  seemed  rational,  but  rejilied  inco- 
herently when  addressed.  The  opisthotonos  continued  until  death.  T'lie  urine,  drawn  off  twice  daily,  was  freijuently 
tested  and  found  to  be  normal.     Uu  the  Itlth  his  tongue  became  swollen  and  deglutition  difficult.     He  died  on  the  2l8t. 


574  I'lsKA^Es  .\r.i.i!:p  TO  on  assOitatkd  witu 

PO'ft-moiii  lit  ("xaiiiiiialidii :  Ilcidy  much  eiuaciatod  and  sliixlitly  viijid,  I'ndov  tlir  araidiiidid,  cdvoriiii;  tlic  \  alloy  of  the 
t'erebtdliim.  thr  cMUa  ccrolKdli.  in'itorati'd  s]iaci's.  tissnrcs  iit'  Sylvius  and  uppiT  sui'lace  of  thi'  ('cii'linnii  were  thicK 
deposits  of  lynqdi :  t  hi'  jiia  luati-i  was  iiitcnx'ly  and  universally  eoniiested;  a  sac  about  the  size  of  a  l>ea,  eontainiuf; 
lymph  anil  pus,  was  founit  in  the  iij;ht  |dexns  of  the  third  ventricle,  tlakes  of  lymph  in  the  uiiddle  horn  of  the  loft 
lateral  ventricle  and  tine  reil  arhorcscences  on  the  lloor  of  the  fourth  ventricle:  the  substance  of  the  brain  presented 
nnnierons  i)uucta  but  was  not  apparently  altered  in  consist<'uce.  A  f;rayisli  licinid  tlowed  from  the  sae  of  the  sjiinal 
arachnoid  w  hen  it  was  accidentally  cut  in  the  hiiubar  region  :  a  larj;e  ([uantity  of  lymph,  one  to  three  lines  in  thick- 
ness, was  found  under  the  visceral  layer,  especially  at  the  lower  part  of  the  eord;  the  jiia  mater  was  intensely  con- 
gested: the  substance  of  the  cord  was  not  softened.  The  lunfis  were  congested  and  ecchymosed  iiosterioily.  The 
heart  was  firm  and  of  a  deep-red  color. — a  large  yellowish  clot  on  each  side.  The  liver  was  dark-colored,  mottled 
snperiorly  with  yellowish-white,  tinn,  full  of  blood  and  strongly  odorons :  the  gall-bladder  contained  black  tluid  bile ; 
the  spleen  was  normal :  the  kidneys  small  and  somewhat  yellow,  congested  in  their  dependent  jmrtions.  The  stomach, 
near  the  jiylorns,  was  congested.  The  small  intestine  was  hypera'mic,  dark-red  at  the  lower  end  :  the  solitary  glands 
were  enlarged  and  I'eyers  jiatehes  well  develojH'd.     The  colon  was  somewhat  injected. 

Ccisis  at  the  Ilotipitah  of  Ahxiindria.  Va. 

Cask,  ("i, — Private  (n-orge  Kice.  Co.  li.  10th  Vt.:  age  SO:  admitted  Jan.  12,  lydl.  Diagnosis — acute  rhcuuni- 
tisni.  On  the  Mill  he  was  seized  w  itli  oiiisthotonos.  Counter-irritants  along  the  spine  gave  lint  little  relief.  ITo 
died  on  the  17th.  rdxi-miirtiiii  examination:  The  pia  mater  was  congested  and  there  was  exudation  of  lymph  along 
the  spinal  cord.     The  lungs  were  congested. 

Case  Oti. — Private  AVilliam  llitchen,  Co.  P).  1st  X.  .1.  Cav.:  age  2.5:  was  admitted  .Jan.  20,  18l)4,  as  a  case  of 
iinotidian  inti'tiuittent.  The  fever  was  arrested  by  ([uinine,  but  on  the  29th  the  i)atient  was  seized  with  jiain  in  the 
limbs,  headache,  some  delirium  and  paralysis  of  the  right  arm  and  leg,  while  his  tongue  became  dry  and  his  pulse 
freiiuent.  Cups  and  blisters  w  ere  applied  to  the  back  of  the  neck,  after  which  he  became  quieter  and  ultimately  coma- 
tose, in  which  condition  he  remained  until  death,  February  1.  Post-mortem  examination :  The  brain  was  congested  ;  pus 
was  found  ou  the  cerebro-splual  membranes.     The  lungs  were  congested  and  part  of  the  left  lung  hepatized. 

Cask  iu. — Private  John  K.  Jones.  1st  Me.  Cav.:  age  lt< :  was  admitted  March  8,  1864,  with  what  was  supi)osed 
to  be  congestive  intermittent  fever,  but  in  a  few  days  symptoms  of  cerebro-spinal  meningitis  were  manifesteil.  The 
patient  died  comatose  on  the  13th.  He  was  treated  with  calonu'l.  saliiu^  cathartics,  (luinine  freely  administered  and 
enemata  of  eolocyuth.  l'u!<t-iiiorti:iii  examination:  Extensive  intlammation  of  the  membranes  of  the  brain  and  spinal 
cord,  extending  as  far  as  the  middle-of  the  dorsal  region:  large  lymph-deposits  on  the  arachnoid:  the  ventricles  of 
the  brain  were  unusually  dry. 

Cask  (is. — Private  C.  R.  Sjiencer,  Co,  B,  107th  X.  Y.:  age  2S :  admitted  Xov.  2,  18tU.  Died  5th,  rost-morfcm 
examination  :  X'o  emaciation  :  marked  rigor  mortis  :  extensive  suggiUation  ])osteriorly  and  on  abdomen.  The  arach- 
noidal surfaces  along  the  longituilinaltissnre  w  ere  adherent :  tlie  pia  mater  was  congested :  there  were  purulent  deposits 
by  the  sides  of  the  large  veins  in  the  subarachnoid  space  and  at  the  base  of  the  brain,  covering  and  in  some  phfces 
fluctuating  on  the  under  surface  of  the  pons,  cerebellum  and  medulla  oblongata,  the  roots  of  the  cerebral  nerves 
and  the  spinal  cord.  The  lungs  were  healthy.  The  heart  was  distended  with  dark  unclotted  blood.  The  spleen 
was  enlarged  and  the  intestines  somewhat  meteorized,  but  otherwise  the  abdominal  viscera  were  healthy. 

Case  69.— Private  Marshall  Stowell,  Co.  E,  189th  X.  Y,:  age  16;  was  admitted  Nov,  30, 1864,  with  typhoid  fever. 
He  was  restless  and  noisy,  his  face  flushed,  eyes  suft'used,  tongue  dry,  swollen  and  with  the  jiapilhe  much  enlarged 
in  the  middle  an<l  at  the  base,  mouth  and  throat  dry  and  sore,  Jeeth  and  lips  covered  with  sordes,  pulse  frequent  and 
irregular,  skin  hot  and  dry:  but  there  was  no  diarrhcea.  He  was  treated  with  cold  to  the  head,  sinapisms  to  the  feet 
and  abdomen,  hyosciamus.  brandy -punch,  beef-tea  ami  a  few  doses  of  turpentine  and  chlorate  of  potash.  On  December 
10,  having  been  alternately  restless  and  quiet  in  the  meantime,  he  was  seized  with  pain  in  the  head,  much  abdominal 
tenderness  and  vomiting,  morning  and  evening,  of  a  thick  brownish  liiiuid.  The  tenderness  increased  and  the  patient 
became  very  irritable — [pulse  130 — until  the  13tli,  when  there  was  less  pain,  some  appetite  and  a  better  pulse,  100, 
But  on  the  16th  he  became  somewhat  comatose.  As  there  had  been  no  stool  for  a  week  oil  of  turpentine  was  given 
with  theeBect  of  producing  a  full  natural  evacuation;  but  the  coma  gradually  increased  with  quickened  and  labored 
breathing,  and  hedied  December  20.  I'ost-viortem  examination:  Hody  emaciated;  face  pale;  surface  showing  a  little 
stasis  but  no  petechia'  or  spots.  The  surface  of  the  brain  was  congested  and  covered  with  patches  of  oi)a(iue  green 
lymph:  the  lateral,  middle  and  fourth  ventricles  were  filled  with  serum  and  sticky  pus:  the  substance  of  the  brain 
was  not  softened.  The  posterior  and  lower  j)ortiou  of  the  right  lung  was  mostly  crepitant  but  of  a  dark-red  color, 
and  its  smaller  tubes  contained  muco-pus:  the  posterior  and  upper  part  of  the  left  lung  was  dark-red  and  softened 
but  crepitant.  The  right  side  of  the  heart  was  distended  with  a  tirm  wliite  clot  and  with  thick  but  fluid  black  blood. 
The  liver  was  pale  and  had  yellowish  spots  extending  from  its  surface  into  its  substance:  the  spleen,  about  the  size 
of  the  fist,  was  firm  and  of  a  light  red-brown  color.  The  kidneys  were  fatty  and  granular:  the  bladder  disteinled, 
reaching  to  within  three  inches  of  the  umbilicus.  The  mesenteric  glands  were  enlarged.  The  ileum  was  congested 
on  its  mesenteric  side  but  not  ulcerated.  The  colon  contained  a  moderate  quantity  of  fteces  of  normal  appearance 
and  presented  oval  dark  spots  of  a  bluish  tinge  on  the  mucous  membrane  from  the  transver.so  colon  to  the  rectum. 
ISpciimin  520,  Med,  Sect.,  Army  Medical  Mu.seuin,  show  s  part  of  the  left  lateral  ventricle,  the  choroid  plexus,  rough- 
ened by  pseudo-membrane,  with  shreds  of  lymph  hanging  from  various  jiarts  of  the  ventricular  lining.] 

Case  70.— Private  Sylvester  Slow,  Co.  K,  20tli  Mass.;  age  24;  was  admitted  Dec,  28,  1864,  having  walked  from 
the  Washington  street  prison.  He  complained  of  pain  in  the  joints  and  insisted  that  there  was  nothing  else  the 
matter  with  him;  his  tongue  was  somewhat  brown  in  the  centre,  but  the  edges  were  clean  and  moist;  skin  dry  and 


THE    PAROXYSMAL    AXP    COXTIXrKP    FKVKn^.  ■)  i  O 

<'(iol:  eyes  iiatiinil :  liowcls  moved  (liuiiiL;  tlic  jn'cviiius  nifiht :  broatliiiii;  siiiMouliat  liiinii'il:  slif^lit  (luliiess  over  Imili 
Imigs;  iiobeailiK'lie.  Diiriii<itlie  iiifjlit  be  hail  a  lit  last  in  jj  Lint  a  slioit  time,  after  wliicli  lie  lieeame  deli  lions,  miilterinf; 
iiicolieieutly,  and  afteetcd  at  the  same  time  with  a  short  harassing  eoiii;Ii  aeoomiianicd  with  I'rotliy,  Moody  exjieeto- 
ratioii.  ]Ie  die<l  at  11  a.  M.  of  the  iiltli.  rost-mtn-tim  examination:  Yellow  exudation  at  the  base  of  the  brain  and 
between  the  cerebrum  and  cerebellnin:  some  slightly  turbid  serum  in  the  lateral  ventricles:  a  |)i.!rnii'nt  deposit  the 
size  of  a  ]iea  in  the  lower  part  of  the  riv;ht  optie  thalamus,  presumed  to  be  the  result  of  a  formi'r  extravasation  of 
blood;  sbjilit  harileniui;  of  the  braiu-sniistanee.  Some  lobular  ]iiieumoiiia:  cirrhosis  of  the  liver:  enlartjeuient  of 
the  spleen:  iutlammation  of  the  solitary  follicles  of  the  ileum  ami  ca'ciim. 

Case  71. — Private  John  Fitzjiatrick,  Co.  (;,  28111  Mieli.;  a^eST;  admitted  Jan.  '2Ct,  18ti.">.  ])ia^'iiosis — acute  bmn- 
chitis.  Died  February  2.  7'«.v;-iHor(<Hi  examination :  No  emaciation:  marked  rii;or  mortis:  niiich  siififrillation  ]ios- 
tcriorly.  The  longitudinal  sinus  was  tilled  with  dark  clotted  blood  :  the  dura  mater  was  niuinal  but  the  jiia  mater 
was  covered  with  unorganized  lynijih:  the  brain  w.-is  healthy,  with  two  dra(dims  of  serum  in  its  ventricles;  the 
spinal  cord  was  iu>t  examined.  The  mucous  inemluane  of  the  trachea  and  bromdii  were  iullamc'd.  thickiMied  and 
roughened  ;  the  bronchial  glands  enlarged  iind  very  dark.  The  lungs  were  somewhat  emphysematous  in  their  u|)]ier 
aud  congested  i.i  their  lower  lobes.  The  heart  was  enlarged  and  showed  large  numbers  of  fal-globules  under  the 
microscope;  the  ])ericardium  was  normal.  Theomentiim  was  congested:  the  li\  erenlargecl  and  very  ])ale:  the  intes- 
tines normal  except  for  a  softening  of  the  uuicoiis  niemliraiie  of  the  ileum  :  the  mesenteric  glands  enlarged  and  ilark  ; 
the  remaining  abdoiuinal  viscera  normal. 

Case  72. — Private  William  E.  Tappan,  Co.  II,  2Sth  Mich.;  age  17;  admitted  ,Ian.  :U,  ISiTi.  Skin  hot  aud  <lry: 
tongue  dry  and  somewhat  fissured,  red  at  the  edges  and  coated  dark  yellow  in  the  middle-:  pulse  (|iiick  and  feeble; 
bowels  rather  loose;  urine  scanty  and  high-colored;  res]iiration  somewhat  hurried:  lu^  was  rational  and  complained 
of  pain  in  the  back  of  the  head  and  neck.  lie  did  not  rest  well  during  the  follow  ing  night,  and  next  day,  although 
his  tongue  was  less  dry,  his  pulse  was  fuller  aud  the  pain  mor<'  intense,  extending  from  the  head  down  the  s]iine  aud 
over  the  body  generally;  lie  was  peevish,  fretful  and  slightly  delirious  at  times,  though  he  answered  (luestions  cor- 
rectly. A  blister  was  applied  to  the  back  of  the  neck  and  alteratives  administered.  On  February  2  delirium  was 
constant;  the  patient  muttered,  tried  to  get  up,  and  had  occasional  attaeksofo|)isthotonos  which  increased  in  violence, 
but  there  was  no  paralysis;  ho  refused  all  food.  Wet  cujis  were  apjilied  along  llw  s)iine.  Next  ilay  opisthotonos 
was  less  marked,  but  delirium  continued  with  dilat<'<l  pupils:  tlie  catheter  was  re<niin'd  to  relieve  llic  bladder.  Ou 
the  4th  the  pulse  became  weak  and  intermitting;  tlu'  respiration  labored  and  accoiiipanied  with  a  rattling  in  the 
throat;  he  wassemi-com.atose  but  easily  aroused:  the  tetanic  convulsions  ri'tiirued  with  violence,  :iud  heilied  at  11  !".M. 
I'osl-mortciii  exam  i  nation:  ISody  not  emaciated.  The  veins  of  the  cere  lira  1  membranes  were  distended  with  black  blood: 
the  brain  was  firm  aud  slightly  injected;  its  lateral  ventricles  <'ontaiued  tliick  jius  and  Ihi'ir  veins  wen-  black  aud 
engorged;  the  vi'lnui  interjiosi  turn,  valve  of  Vieu.ssens  and  the  membranes  ficuii  the  optic  I'omiiiissiire  ilow  n  the  medulla 
as  far  as  could  be  seen  were  covered  with  lymph  and  )ius;  the  gray  matter  of  thi'  ceieliellum  was  so  pale  as  to  be 
scarcely  distinguishable  from  the  white  matter:  the  cerebellum  and  spinal  cord  wire  sol'iined.  Tbe  upper  and  lower 
lobes  of  the  right  lung  were  somewhat  congested  and  showed  dark-imrple  or  l)lackish  iialilics  of  soil  cued  tissue  :  the 
middle  lobe  was  (edematous,  of  a  gray  color  tinged  with  pink,  and  presented  at  its  iiiaigin  ii  jiatch  of  shrunken  Hver- 
red  tissue  full  of  enlarged  bronchial  tubes  containing  ]nis  ;  the  left  lung  w  as  similarly  alVccted  but  in  a  less  degree. 
The  heart  was  normal.  The  liver  was  somewhat  enlarged,  yellow  aud  granular:  the  spleen  small,  its  trabecuhe 
and  Malpigbian  bodies  enlarged,  dry  and  bloodless;  the  intestines  ami  kidneys  normal ;  tin-  bbulder  largely  distended 
and  the  overlying  recti  muscles  of  a  bright-red  color. 

Ca.'ik  73. — Private  Nicholas  V.  Sharp,  Co.  A,  25thWis.;  age  'M'>;  admitted  Feb.!),  18t!5,  from  Washington  street 
])risoii.  Diagnosis — typhoid  fever.  The  only  syniptoms  on  the  record  are:  Dark-pnrple  spots  covering  the  body; 
tongue  slightly  coated;  pulse  130,  weak;  some  frontal  headache;  bowels  loose,  lie  died  during  the  day.  I'o»t-morlini 
examination:  Lymph  was  cti'iised  at  the  base  of  the  brain  and  between  the  cerebrum  and  cercliidlum;  there  was  also 
engorgement  of  the  cerebral  veins  and  serous etl'usion  in  tbe  ventricles.  Tlie  ))ericardial  sai'  contained  etVusi'd  serum. 
Part  of  the  upper  lobe  of  the  left  lung  was  intlamed  aud  softened.  The  liver  was  large,  fatty, soft  and  granular:  the 
spleen  large,  soft  aud  discolored;  the  small  intestine  normal;  the  colon  slightly  intlamed. 

Case  71. — ^Private  Jacob  Evans,  Co.  E,  Ist  Del.,  was  admitted  Feb.  II,  1K(>."),  unconscious  and  in  a  condition  of 
low  delirium.  In  a  few  days  opisthotonos  came  on,  and  he  died  on  the  21th.  .Stimulating  liniments  and  sinapisms 
were  applied  to  tbe  spine  and  extremities,  while  the  head  was  kept  cool.  Punt-mortcm  examination  :  Tbe  membranes 
of  the  brain  were  injected;  lymph  and  pus  were  deposited  from  the  medulla  upwanls  to  near  the  ojitic  oimmissure; 
the  brain-substance  was  cream-colored  aud  softened;  the  lateral  ventricles  were  tilled  with  pus  aud  si'ruui.  tbe  choroid 
plexus  of  each  opacjue  and  pale  and  the  wall  of  the  posterior  cornu  .softened;  the  third  ventricle  was  disteudeil  with 
serum,  the  fourth  with  serum  aud  pus.  The  spinal  uiembranes  were  unaft'ccted.  The  lower  Udie  of  the  right  lung 
was  dark-brown,  soft,  non-crepitant  and  heavier  than  water;  the  left  lung  w  as  softened,  its  bronchial  tubes  injected. 
There  was  a  slight  effusion  in  the  pericardial  sac.  The  walls  of  the  stomach  were  soft  and  wliite;  the  liver  light- 
colored  aud  cirrhosed;  the  spleen  an;cmic;  the  portal  veiiis  full;  the  colon  distended  with  flatus. 

Case  7."). — Private  James  O'Learv,  V.  S.  Inf..  unattached  ;  admitted  Feb.  23, 18().j,  from  Washington  street  prison 
so  nearly  moribund  that  no  history  could  be  obtained  from  hiui.  His  eyes  were  fixed  au<l  vacant,  skiu  cold,  dry  aud 
livid.  He  died  soon  after  admission.  I'ost-morlem  examinatiou :  The  meningeal  vessels  w  ere  pale  and  watery,  as  were 
those  of  the  vascular  processes  in  the  lateral  ventricles;  serum  was  effused  beneath  the  arachnoid  and  lymph  at  the 
vertex  and  over  the  base  of  the  brain;  the  cerebral  substance  w  as  pale,  soft  aud  ana'inic,  aud  the  ventricles  contained 


0(b  DISEASKS    AI.LIKD    TO    OR    AS^SOCIATED    ^V1T^ 

seruiii  with  sour-  lymiih.     Tlie  spinal  oonl  was  soft,    Tlie  plaiuls  at  tlio  root  of  eacli  lung  eontaiiieil  calcaii'ous  deposits. 
The  liver  was  large:  the  siiloen  soft  ami  l>"lliy:  the  bhuUler  largely  disteiuleil. 

Cask  70. — Serg't  William  R.  Brock.  Co.  F.  Cith  Teun.;  age  34  ;  was  admitted  Feb.  17,  18G5,  with  pneumonia.  lie 
improved  steadily  until  March  6.  when  he  was  attacked  with  cerebro-spinal  meningitis,  for  which  he  was  blistered 
ou  the  neck  and  spine  and  treated  with  veratrum  viride  and  saline  cathartics.  lie  died  on  the  8th.  I'ost-morti  m 
examination:  The  pia  mater  was  congested;  there  was  a  large  quantity  of  purulent  liiiuid  beneath  the  arachnoid, 
one  ounce  of  yellowish  serum  in  the  ventricles  and  two  ounces  at  the  base  of  the  brain:  the  cerebral  substance  was 
nonnal  but  the  cerebellum  was  softened.  The  membranes  of  the  spinal  cord  were  thickened  and  the  subarachnoid 
space  tilled  with  inirulent  liquid.     The  middle  part  of  each  lung  was  hepatized. 

Case  77. — Private  John  McClure.  lid  I'.  S.  Cav. ,  was  admitted  April  8, 1805,  in  an  unconscious  state.  He  writhed 
incessantly:  his  pulse  was  slow  and  labored:  his  eyes  tixed  and  staring  and  his  pupils  dilated.  He  had  no  convul- 
sions, but  died  conuitose  on  the  lltli.  rust-moricm  examination:  Serum  and  yellow  lymph  were  found  beneath  the 
arachnoid,  especially  on  the  right  side,  and  also  between  the  optic  tracts  and  crura  cerebri;  the  substance  of  the 
brain  was  noruuil,  but  the  choroid  plexus  on  each  side  was  darkly  congested  and  somewhat  thickened  or  opaciue  on 
its  anterior  margin.  The  right  lung  was  pale,  bloodless  and  soliditied  in  the  ]>osterior  ])arts  of  its  u]>pei'  and  middle 
lobes  and  deeply  congested  in  its  lower  lobe;  the  left  lung  was  congested.  The  heart  was  large  and  slightly  fatty; 
some  old  opacities  were  found  on  the  anterior  surface  of  the  right  vent  ride.  The  liver  was  pale,  the  spleen  small  and 
hard:   the  lower  ileum  natural. 

Caxi'K  at  i-arioiis  Gciicyal  Uuspituls. 

Cask  78. — Lieut.  K.  I>.  Edwards  (rebel)  was  admitted  Feb.  1,  1804,  in  a  condition  of  low  delirium  from  whicli 
he  could  be  aroused  to  answer  ciuestions  rationally:  Thirst:  constipation:  pvilse  strong.  115;  deafness:  eyelids  pnrple 
and  swollen  and  pupils  sluggish:  severe  pain  in  the  forehead  and  left  side  of  the  face;  pain  and  stififness  of  the 
muscles  of  the  back  of  the  neck  and  back,  with  tenderness  over  the  last  cervical  and  tirst  dorsal  vertelirie;  sensation 
somewhat  lessened  and  motion  greatly  impaired  in  the  left  arm  and  leg.  The  delirium  increased  and  with  it  the 
paralysis,  which  extended  to  the  other  side.  For  four  days  before  death  he  was  in  an  ahuost  helpless  condition,  drowsy 
and  stupid,  eoihplaining  only  when  moved.  He  died  on  the  7th,  I'ost-iiioytem  examination:  Eigor  not  well  marked: 
considerable  suggiUation  posteriorly;  some  reddish  spots  on  the  limbs.  An  ounce  of  reddish  serum  was  found 
at  the  base  of  the  brain  and  a  (juantity  of  exudation,  diffluent  and  pus-like,  around  the  left  lobe  of  the  cerebelhnu 
and  adhering  to  the  tentorium;  the  veins  of  the  pia  mater  were  tilled  with  blood:  the  membranes  were  easily 
detached  from  the  convolutions,  and  a  thin  semitranspareiit  exudation  covered  the  surface  of  both  hemispheres;  the 
puncta  vasculosa  were  ntimerous  aud  the  lateral  ventricles  tilled  with  liquid,  but  the  vessels  of  the  choroid  plexus 
were  not  injected;  the  pineal  gland  was  broken  down  into  a  thin  yellowisli  licjuid  adhering  to  the  velum  interpositum, 
anil  there  was  some  exudation  about  the  optic  commissure.  lUoody  serum,  amounting  to  five  and  a  half  ounces,  was 
found  in  the  spinal  canal,  with  some  blood-clot  aud  an  exudation  of  a  membranous  form  extending  from  the  last  cervical 
to  the  tenth  dorsal  vertebra:  the  cord,  which  was  bathe<l  in  a  yellowish  creamy  fluid,  was  soft  and  semifluid  at  the 
points  where  the  false  membrane  terminated;  the  graj-  substance  was  scarcely  distinguishable  from  the  white.  Both 
ventricles  of  the  heart  contained  fibrinous  clots:  blood,  partly  coagulated,  flowed  from  the  great  vessels.  The  lower 
lobe  of  the  right  lung  sank  in  water  and  the  upper  lobe  was  saturated  with  reddish  serum;  the  lower  lobe  of  the  left 
lung  was  dark-blue  posteriorly  and  condensed  in  patches.  The  liver  was  soft,  greasy  and  of  the  nutuu'g  appearance; 
the  gall-ldadder  contained  half  an  ounce  of  reddish-brown  bile:  the  spleen,  five  ounces  and  a  half,  was  bluish-green 
anteriorly,  reddish  posteriorly,  its  sulistance  diffluent  and  the  Malpighian  bodies  enlarged  and  distinct;  the  kidneys 
were  healthy.  The  mucous  membrane  of  the  stonuich  was  softened  in  several  places,  especially  about  the  cardiac 
orifice.  The  intestinal  walls  were  thin  :  the  ileum  in  part  colored  blue,  its  epithelial  layer  softened  in  ql>long  patches 
and  its  solitary  follicles  visible.  The  large  intestine  was  healthy  but  the  open  mouths  of  the  solitary  glands  ajipearcd 
quite  distinct. — Ass't  Sunj.  Eoheris  Bartholow,  U.  i>.  A.,  IlosjnttiJ,  Chattanooga,  Tenn* 

Cask  70. — -Andrew  Galesjiy,  Government  employe,  admitted  Fell.  1,  1804,  Diaguosi-s — pneumonia.  Died  4th, 
roit-mortim  examination :  The  vessels  of  the  l>rain  were  much  engorged  ;  serum  was  effused  under  the  arachnoid  and 
lymph  around  the  choroid  vessels  and  at  the  base  of  the  brain  over  the  ojitic  connnissure;  the  lateral  ventricles  con- 
tained each  two  drachms  of  serum.  The  lungs  were  much  congested.  The  lieart  contained  large  buft'-colored  clots. 
The  liver  and  kidneys  were  fatty;  the  stomach,  spleen  and  intestines  healthy, — Hospital  A'o.  1,  KaahviUe,  Ten». 

Case  80, — Private  James  Draper,  9th  Ohio  Ilatfy,  was  admitted  Feb,  10, 1804,  with  laryngitis.  He  had  regained 
his  strength  and  was  about  to  rejoin  his  conunand  when  he  was  suddenly  attacked  with  active  delirium,  during  which 
bis  pulse  was  100,  tongue  dry  and  red  aud  eyes  sulfused.  These  symptoms  histed  forty-eight  hours,  after  which  he 
became  comatose,  and  died  March  21,  I'lmt-mortDii  examination :  The  Pacchionian  bodies  were  enlarged  and  appeared 
to  be  ulcerated;  the  cerebro-s])inal  membranes,  as  far  as  the  fifth  cervical  vertebra,  were  congested  and  contained 
four  ounces  of  clear  serum;  the  cerebral  vessels  were  injected,  the  convolutions  covered  with  lymph  and  the  floor 
of  the  ventricles  with  fibrinous  deposits,     No  other  organs  were  examined, — Hospitat,  TuUahoma,  Tenn. 

Case  81, — Private  Robert  Carr,  Co.  G,  1st  Mo.  Eng'rs;  age  15;  was  admitted  March  2,  1804,  with  meningitis. 
He  died  on  the  Oth.  ront-moriem  examination:  There  were  heavy  de])Osit8  of  lymph  on  the  surface  of  the  brain  but 
its  substance  was  healthy.  The  lower  lobe  of  the  left  lung  was  hepatized.  The  right  cavities  of  the  heart  contained 
large  yellowish  clots  and  there  were  smaller  clots  in  the  left  side ;  the  endocardium  in  the  left  auricle  was  roughened. 
The  abdominal  viscera  were  healthy. — Hospital  Xo.  1,  SashviUe,  Tenn. 


*I>r.  B.vitTHoLuw  i>ub!i>ln'd  t'li.-*  lax'  in  tli'^  <  'utri,ninH  Liui'-^l  iwt  iMmi'nir,  ,JuI\ .  lSO-1. 


THE   PAROXYSMAL    AXP    COXTINUED    FEVKRS.  57 


Case  82. Private  tieove  W.  Bassiiisfi'  Co.  F.  12th  Mo.  Cav..  was  ailiiiitteil  Marcli  19,  IXlU.  liaviiij;  liad  a  eliill 

on  the  jirevioiis  day.  He  coinplained  of  pain  between  the  shoulders,  which  inorcased  in  severity  until  the  21st, 
when  he  was  taken  with  a  congestive  chill  or  collapse  and  became  insensible.  The  muscles  of  the  back  and  neck 
contracted  spasmodically;  the  surface  was  cold,  the  pulse  small,  freijuent  and  threa<l-like,  digestion  ditlicnlt  and  the 
discharges  involuntary.  After  three  days  the  pulse  V)ecame  fuller  and  slower,  the  surface  warm  and  consciousness 
returned,  the  i]atient  complaining  of  pain  in  the  head  and  l>ack  and  of  extreme  sensitiveness  of  the  surface.  From 
this  time  he  had  fever  of  a  tyiilio-malarial  tyi)c.  which  lasted  three  weeks  without  any  material  change  except  a 
gradual  improvement.  On  the  date  of  the  report,  A]iril  20,  he  was  considered  convalescent.  He  hail  weakn(■^s  ol 
the  back  and  symptoms  of  paralysis  of  the  lower  extremities,  but  not  such  as  to  pri'vciit  him  from  walking  abmit 
the  wards. — Siu-r/con  Ira  Itussdl,  Z'.  S.  Voh.,  Binton  Harracks,  Mo." 

Case  8.3. — Private  Alfred  Lock  wood,  41st  Ohio,  w.is  admitted  from  the  military  luisou  March  2.">,  INil,  in  a  semi- 
comatose condition,  with  the  head  drawn  back,  rigidity  of  the  muscles  of  the  neck  and  temlerness  on  jiressure  over 
the  cervical  vertebr.T,  The  eyes  were  injected,  i)upils  dilated  and  fixed,  pulse  iW.  soft  and  full,  tongue  furred  yel- 
lowish-white and  abdomen  slightly  tympanitic.  When  roused  and  questioned  lie  always  gave  the  sanu-  answer,  and 
when  placed  upon  his  feet  he  staggered  like  a  drunken  man.  Six  cups  were  used  <ui  the  temples  and  nape  of  the  neck 
for  the  extraction  of  eight  ounces  of  blood  and  cold  cloths  thereafter  apjilied  to  the  head  ;  at  the  sauu'  time  crotonoil 
was  administered,  which  operated  feebly.  After  this  the  j>atient  seemed  imjiroved:  he  had  bi'tler  conuuand  of  his 
faculties  when  his  attention  was  fixed,  but  when  left  to  himself  he  fell  into  a  wandering  slate  of  mind,  talking  and 
making  frequent  comiilaints  of  pain  in  his  head  wliile  tossing  himself  continually  I'lom  side  to  side  in  bi'il.  <  In 
the  third  day  dark  livid  spots  appeared,  scattered  sparsely  over  I  he  whole  surface  but  in  greater  numbers  <in  the 
lower  extremities  and  particularly  around  the  Joints;  restlessness  and  dilirium  became  aggravated  and  were  ;iccom- 
panied  with  decided  o])isthotonos;  the  face  was  dark-hued,  es]iecially  on  the  lips  and  ahe  nasi;  the  jiujiils  con- 
tracted; the  pulse  t'O and  rather  weak.  As  the  case  progre.s.sed  the  pul.se  rose  to  Ulli-lHO,  while  the  dark  moist  coaling 
of  the  tongue  elianged  into  a  dry  black  crust,  and  sordes  appeared  on  the  teeth  and  lips.  On  the  fifth  (hiy  the  patient 
lay  on  his  back  with  the  thighs  and  legs  partially  Hexed,  the  toes  eontra<'ted  on  the  soles  and  the  thumbs  drawn 
into  the  palms.  Subsequently  the  countenancB  became  Iniggard,  the  eyelids  half  closed,  the  eyeballs  fixed  and  the 
■cornea'  glazed,  the  extremities  cold  and  the  surface  covered  with  a  clammy  sweat,  the  i)ulse  hardly  iierceptiMe,  the 
abdomen  excessively  tympanitic  and  the  resjiiratory  movenu'iils  short  and  rapid,  llealli  occurred  .\])ril  1.  On  the 
second  and  third  days  small  doses  of  tartar  emetic  and  nitrate  of  polasli  wen'  given  every  two  hours  wilh  crolon  oil 
to  the  si)ine:  on  the  fourth  day  these  were  replaced  by  eight  grains  of  iodidi'  of  potassium  I'very  four  hours:  lastly 
carbonate  of  ammonia  and  wine  were  given.  I'oKl-iiiiirtciii  cxamiuat  ion  :  .Several  rcceul  adhesions  wi're  fonml  bel  ween 
the  dura  nuiter  and  the  visceral  arachnoid,  with  thickening  of  I  he  latter  and  a  puiuIiMil  mass  between  It  and  the  pia 
m.ater,  the  vessels  of  which  were  enormously  distended  with  blaik  tluid  blood.  I'lie  spinal  arachnoid  was  intlamed 
throughout:  in  the  region  of  the  third  or  fourth  dorsal  vertebra  half  an  ounci'  of  pus  was  found  wilh  sid'tening  of 
the  substance  of  the  cord.— -Jc(,  Ann't  Siinj.  F.  C.  Leber.  CUtii  llosjiitnl.  I.diiinrilli .  h'l/J 

Case  81. — Private  John  L.  Smith,  Co.  K,  71th  Ohio,  was  admitted  Mar<li  2.">,  ISlJl,  with  menial  derangemi'Ut 
vrbich  soon  passed  into  delirium.  He  pointed  to  his  forehead  and  temples  as  thi'  seal  of  violent  pain,  while  at  the 
same  time  his  face  was  Hushed  and  dusky,  eyes  injected  au<l  jiupils  lixed.  A  while  fur  on  thi'  tongue  ipiickly  changed 
to  a  dry  brown  crust:  the  pulse  was  I'M),  full  but  not  hard,  and  the  respiration  c|uiekened.  He  w;is  v<'ry  restless, 
made  freciuent  attemiits  to  get  out  of  bed  and  when  on  his  feel  reeled  like,  a  drnnken  man.  His  di-liriuiu  was  of  a 
liumorous  character.  The  treatment  consisted  of  cold  a]q)lications  to  th<'  shaved  scalp,  abstraction  of  blood  by  cups 
on  the  temples  and  nape  of  the  neck  and  the  administration  of  a  purgative  dose  of  Kpsom  salt  with  one  grain  of  tartar 
emetic,  followed  by  smaller  doses  of  the  latter.  During  the  night  he  was  restless  and  did  not  sleep,  but  next  day  the 
pulse  fell  to  120  and  the  pain  in  the  head  abated  somewhat,  although  there  renuiined  great  lieat  of  skin  and  dryness 
«f  tongue.  He  talked  continually  and  still  attemjited  to  get  out  of  bed.  He  diil  not  seem  to  snIVer  from  thirst,  yet 
he  drank  whatever  was  offered  him,  such  as  milk,  lemonade  or  water,  without  a)>paii'ntly  noticing  whiit  he  was 
faking.  On  the  27th  the  pulse  was  reduced  in  volunu'  but  not  in  frequency;  the  face  |iale;  eyes  dull  and  heavy; 
teethand  lips  covered  with  sordes;  efforts  to  talk  were  made  but  the  jialient  couhl  not  aitieulate:  bis  head  wastirmly 
retracted  and  there  ap])earedon  the  surface,  particularly  on  the  neck  and  upper  jiart  of  the  I'liest,  dark-coloreil  pa i dies 
liaving  the  appearance  of  blood  extravasated  umler  the  cuticle.  Dry  cu))S  were  applied  to  the  b;ick  of  the  neck, 
croton  oil  along  the  sjiine  and  a  blister  to  the  scalp.  Stupor  develo]ied  on  the  2K|h,  s)icedily  dee))ening  into  coma 
and  death.  l'u«l-iiiorttm  examination:  The  arachnoid  was  thickened:  lym])h  was  accumulated  in  Ihe  cerebral  sulci 
and  covered  the  entire  base  of  the  brain;  the  lateral  ventricles  were  not  distended  with  li(iuid,  but  the  right  jioste- 
rior  cornu  contained  a  small  quantity  of  pus  and  lymph.  Numerous  black  sjiots  were  ob.served  in  the  substance  of 
Hie  cerebrum,  which  appeared  otherwise  healthy.  The  spinal  arachnoid  was  thickened  and  presented  underlying 
exudation.  The  blood  in  all  the  vessels  remained  fluid.  The  thoracic  and  abdominal  viscera  were  not  examineil. — 
Ad.  .-Iss't  iiiirij.  11.  Wirth,  Cluy  Hospital,  LouisrilU;  Ki/.i 

Case  85. — Private  Henry  Clynier,  Co.  K,  128th  Ind.:  age  10;  was  admittecl  comatose  April  .">.  iMil,  and  died  next 
•lay.  I'oift-morlem  examination:  Body  muscular;  rigor  mortis  fairly  marked ;  face,  head  and  shoulders  bronzed.  The 
veins  of  the  cerebral  membranes  were  distended :  a  layer  of  soft  lymph  covered  the  surface  of  the  brain  and  a  similar 
/ayer  was  found  between  the  membranes;  thebraiu  was  softened,  particularly  in  its  middle  lobes;  the  medulla  oblongata 
and  pons  were  also  somewhat  softened;   the  gray  substance  was  pale  in  color  and  few  puncta  were  visible,  but 


*  Surgeon  Rcsseli's  cases  were  publiiihed  in  the  UfiMmt  Mfd'u'id  fuul  Stirijii-nl  Jmtninl,  May  \9.  1804, 

t  Surgeiin  ALEX.  T.  W.vTsox,  V.  S.  Vuls,,  in  cliM'ge  uf  tlie  liospital,  |iulilinheil  this  case  in  the  Ammcau  Mtdical  Time$,  May  7, 1864, 

Med.  Hist.,  pt.  Ill— 73. 


578  BliEASKS    ALLIED    TO    OR    ASSOCIATED    -WITH 

tho  vascular  processes  in  the  interior  of  the  brain  were  congestecL  The  Iiuiks,  which  weighed  fifty-six  onnces,  were- 
congestetl  posteriorly  and  presented  collapsed  and  (edematous  patches  of  a  dark-blue  color.  The  heart  was  well  sup- 
plied with  fat :  the  walls  of  the  right  ventricle  were  thinned,  those  of  the  left  ventricle  were  three-quarters  of  an  inch 
thick,  but  their  substance  was  easily  torn  :  the  right  cavities  contained  a  snudl  fibrinous  clot.  The  liver,  seventy-nine 
oiuices,  presented  the  nutmeg  appearance,  and  bile  tlowed  from  it  on  section;  tho  gall-bladder  was  distended;  the 
spleen  measured  nine  by  six  inches  and  was  unusually  firm,  bluish-gray  externally,  purplish-brown  internally,  the 
Malpighian  bodies  very  distinct:  the  kidneys  were  externally  of  a  bluish-purple  color,  the  centre  reddish-brown  and 
the  pyramids  purple,  streaked  and  patched  with  yellow.  The  omentum  and  mesentery  were  loaded  with  fat.  The 
mucous  membrane  of  the  stomach,  yellowish-gray  in  color,  presented  many  small  but  highly  congested  points.  The 
solitary  glands  of  the  small  intestine  were  prominent, especially  those  near  the  ileo-ca'cal  valve,  where  also  were  many 
small  ulcers  each  about  two  lines  in  diauu-ter.  The  mucous  membrane  of  the  c;ecum  was  bluish-gray,  its  follicles  dis- 
tended and  pigmented;  in  the  upper  part  of  the  rectum  were  several  large  dark-blue  and  brown  patches,  where  the 
raucous  membrane  was  softened  and  eifsily  detached. — llusjiitol  Xu.  1,  Xiiitln-iUc,  Teiiii. 

Case  8(i. — William  S.  Kay.  a  civilian,  but  formerly  a  confederate  soldier,  was  admitted  April  6,  1864,  com- 
plaining of  pain  in  his  head,  neck  and  l)ack  and  in  his  bones  generally;  his  eyes  were  injected  and  face  flushed,  l)ut 
he  was  perfectly  rational  and  aide  to  walk  up  a  llight  of  stairs — half  an  hour  afterwards,  however,  he  was  delirious. 
He  seenied  to  be  in  great  distress,  moving  about  in  bod,  raising  himself  uj)  and  falling  back  again  ;  pulse  rapid  but 
not  strong;  no  increase  of  temiierature  was  perceptible  about  the  head.  Five  cathartic  pills  were  given;  cups  were 
applied  along  the  spine  and  croton  oil  and  sinapisms  to  the  lower  extremities  ;  cold  apjilications  to  the  head  distressed 
him.  During  the  afternoon  the  patient  was  ini-lined  to  sleep:  for  some  minutes  he  would  lie  (juiet  and  then  start  up 
as  if  frightened.  He  took  no  nourishment  and  was  iuditferent  to  drink.  The  skin  had  become  so  insensitive  that 
mustard  applied  for  hours  made  no  impression.  During  the  night  he  was  very  restless.  Xcxt  morning  dark-red  spots, 
varying  in  size  and  form,  were  found  on  his  neck,  breast  and  legs;  he  continued  delirious,  talking  and  moving  con- 
stantly: his  head  became  firmly  drawn  back  and  coma  speedily  supervened.  He  died  thirty  hours  after  admission. 
Xo  pOKt-mortciii  examination  was  made. — Act.  Asu't  Siinj.  II.  JVirtli,  Cluij  Hospital,  LouinviUe,  Jxy." 

C.\SE  87. — John  13.  iluzzey.  a  recruit :  age  35;  was  admitted  comatose  April  7,  18G4,  havingbeen  taken  two  days 
before  with  severe  chills  and  pain  in  tho  head  and  back.  His  body  was  covered  with  iiurplish-red  spots  of  various 
sizes,  one  of  which  appeared  on  the  right  sclerotic:  his  eyes  were  closed,  head  somewhat  thrown  back,  muscles  niod- 
•  erately  rigid,  res]>iration  24  and  labored,  ]>ulse  tit!,  full  and  slow:  he  was  nijablo  to  protrude  his  tongue.  A  hot  bath 
restored  his  consciousness  and  he  inquired — "Where  all  this  water  came  from?''  On  removal  to  bed  he  was  rubbed 
briskly  with  tincture  of  capsicum,  after  which  he  broke  into  a  profuse  perspiration.  Four  grains  of  quinine  were 
given  every  two  hours,  with  whiskey  at  the  rate  of  ten  ounces  daily  and  beef-tea  and  milk  ad  libitum.  In  the  evening 
he  was  stupid  and  unable  to  articulate:  pulse  84.  .Six  ounces  of  blood  were  taken  from  the  neck  and  a  cathartic  of 
calomel  administered.  \ext  morning  the  skin  was  moist  and  the  patient,  with  some  support,  sat  up  in  bed,  talked 
rationally  and  said  he  felt  better:  pulse  84,  resi>iration  ;-!2  and  tongue  coated  with  a  creamy  fur.  Tho  (juantity  of 
stimulant  and  (luinine  was  diminished.  On  the  iHh  there  was  an  inclination  to  sleep;  pulse  90,  full  and  hard;  skin  hot 
and  dry:  tongue  dry  and  brown.  In  the  course  of  this  day  subsultus  tendinum,  alidomiual  respiration  and  involun- 
tary evacuations  were  noted.  Cupping  the  nape  of  the  nock  was  again  resorted  to,  followed  by  blisters  to  the  neck 
and  extremities.  Next  day,  however,  he  was  completely  comatose  ;  pulse  117,  full  and  hard ;  respiration  44,  sighing; 
pupils  insensible:  toes  of  the  left  foot  strongly  flexed:  the  spots  had  nearly  disai)peared.  He  died  April  11  at  3  a.  m. 
Foxt-mortem  examination:  A  few  spots  were  seen  on  the  extremities.  The  vessels  of  the  dura  mater  were  turgid  with 
blood  aud  a  layer  of  coagulable  lymph  one-sixteenth  of  an  inch  thick  covered  the  whole  of  the  arachnoid  and  pia 
mater :  the  lateral  ventricles  were  tilled  with  bloody  serum  and  two  ounces  of  a  similar  liquid  were  found  at  the  base 
of  the  brain  :  the  choroid  vessels  were  injected.  The  medullary  portion  of  the  spinal  cord  was  normal,  but  the  mem- 
branes were  deeply  injected  and  the  pia  mater  exhibited  along  the  posterior  aspect  of  the  cord  a  layer  of  lymph-like 
exudation  which  was  found  to  consist  wholly  of  pyoid  colls.— 7V»«'c(  Stn'H  Hospital,  I'hUaddpMa,  I'a.] 

Case  88.— Wni.  H.  Allen.  Co.  B,  12th  Mo.  Cav.:  age  18;  of  small  stature  aud  delicate  constitution,  was  admit- 
ted April  11,  1864,  having  been  sick  for  two  days  in  quarters,  during  most  of  which  time  he  had  been  delirious.  On 
the  day  before  he  was  taken  sick  he  had  eaten  heartily  of  trash  bought  from  a  sutler  and  had  drunk  six  bottles  of 
ginger  pop.  On  admission  ho  complained  of  pain  in  his  head,  back,  neck  and  throat;  his  expression  was  wild,  and 
although  at  first  rational,  in  a  few  hours  he  became  delirious,  talkative  and  restless,  rising  from  bed  and  walking 
across  the  ward  with  a  wild  vacant  stare.  Constant  attention  was  reijuired  to  keep  him  in  bed.  Kestlessness  and 
delirium  continued  with  little  intermission  until  within  a  few  hours  of  his  death  on  the  20th.  When  roused  he  gavo 
rational  answers  but  immediately  relapsed  into  delirium;  his  discharges  were  i)assod  involuntarily;  he  comjilained 
of  pain  in  his  legs :  the  muscles  of  his  back  and  neck  wore  contracted ;  on  the  day  before  death  his  i)ulse  was  160  aud 
resjiiration  CO;  he  took  but  little  nourishment  and  ground  his  teeth  constantly.  I'o.st-mortem  examination:  The  mem- 
branes of  the  brain  and  spinal  cord  were  highly  injected ;  the  cavity  of  the  arachnoid  contained  an  ounce  and  a  half 
of  serum ;  pus  and  lymph  were  deposited  on  the  medulla  oblongata,  jmns  Varolii  and  spinal  cord  except  in  the  cervical 
region,  in  which,  however,  the  membranes  were  much  injected ;  the  lateral  ventricles  each  contained  half  an  ounce  of 
sero-purulent  fluid;  the  substance  of  the  brain  was  congested  and  softened.  The  lungs  were  considerably  congested. 
The  mucous  membrane  of  the  stomach  was  (piite  dark  in  color  aud  .softened.  No  other  morbid  appearance  was 
recorded. — Suyf/ton  Ira  Hussell,  V.  S.  V.,  Benton  Ilai-railn,  .Mo.t 

*  Soo  noto  to  case  84. 

t Act.  Ass't  Surgeon  .\.  Dougla.-!  Hali.  communicatoil  tliisiiiso  t..  tin-  fDinuiittcc  c.ii  ".Siiottcil  Fever,  su-called,"'  of  tlie  Anieri.iui  Jledical  Associa- 
tion.    See  Al.lJ.,-nrlix  to  the  Rcjiurt  of  that  Coniniittee,  p.  iW,  Vol.  XVII  of  the  Transaction..-.  .  t  See  note  to  cajse  82. 


THE  PAROXY.^MAI.  A>'D  CONTINUED  FEVEKS.  579 

Case  80.— Private  Jas.  F.  Johnson.  Co.  H.  13tli  III.  Cav.:  age  about  !.'>:  Kniall  and  delioale.  wa.s  admitted  April 
13,  1861.  On  the  10th  he  had  eaten  a  huge  quantity  of  canned  .stiawhenics.  apples  and  sardines.  Next  evening  he 
had  spasms  and  vomited  freely,  bringing  ii]i  with  the  ingesta  live  large  lnniliricoi<l  worms,  lie  licoame  delirious  and 
had  contraction  of  the  muscles  of  the  hack  and  neck.  Death  occurred  on  the  ITtli.  I'ust-iiiorUm  examination:  The 
dura  mater  was  injected:  lymph  and  pus  followed  the  course  of  the  large  cerebral  veins  and  sulci  and  covered  the 
medulla  ol)longata.  pons  and  cerebellum:  the  brain  was  congested  and  softened  and  its  ventricles  contained  sero- 
purulent  tin  id.  A  large  quant  ity  of  ]ius  was  found  on  the  lower  part  of  the  cord  and  cauda  e<|uina.  Moth  lungs  were 
somewhat  congested.  Nineteen  lumbricoid  norms  were  found  in  llie  stomach  and  intestines. — Siiryioii  Ira  HhkikII, 
V.  S.  I'..  Benlun  Bttrraclcs,  ilo.  * 

C.\SE  90. — Private  William  Hurd.Co.  C,81st  N.  Y.:  age  17:  robust :  was  admit  ted  .\prir.'7.  l)<(;i.  having  suffered 
for  several  days  from  severe  jiain  in  the  head  with  nausea  and  vomiting.  iSliortly  after  admissi<ui  he  becamedelirious 
and  had  well-marked  opisthotonos:  pulse  81,  full  but  not  hard:  tongue  dry:  teeth  covered  with  sordes.  Next 
morning  a  few  indistinct  dark  spots  were  discovered  on  the  loins.  Two  days  lati'r  a  eireumscrihed  red  spot,  an  inch 
in  diameter  and  of  inllamuuitory  character.  ai)peared  upon  the  pahnar  aspect  of  the  right  forearm  near  the  wrist, 
and  from  that  time  the  arm  was  jiartially  jiaraly/ed.  Dt'liritim  continued  till  within  a  few  hours  of  diMth:  it  was 
active  but  not  violent,  the  i)atient  being  easily  restrained  and  ea]>able  of  giving  a  rational  answer  when  aroused. 
The  tetanic  spasm  involved  only  the  muscles  of  the  neck.  There  was  no  sutfusion  of  the  face  or  of  the  eyes.  The 
bowels  were  inclined  to  be  loose  and  the  stools  dark.  The  urine  was  passed  freely  and  contained  no  alluinuMi.  A  few- 
hours  before  death  the  pulse  became  more  frequent  and  feeble,  the  muscular  spasm  relaxed,  the  pupils  dilated  and 
the  patient  unconscious,  lie  died  May  I.  I'lmt-morlcm  examination:  Some  hypostatic  congestion:  no  spots  visible 
except  that  on  the  arm,  under  which  was  some  serous  and  libriniuis  etVnsion.  The  brain  was  of  full  size,  its  veins 
distended.  There  was  a  moderate  serous  etfusion  under  the  arachnoid,  and  also  a  gn'cnish  uu'mliranous  exudation, 
one  to  two  lines  in  thickness,  dejiosited  in  large  patclu^s  ovi'r  the  ceri'brum  an<l  along  llu'  course  of  the  vessels 
extending  into  the  fissures  of  Sylvius:  this  deposit  was  more  almudant  on  the  vertex  than  on  the  sidi'S,  on  the  left 
side  than  on  the  right  aiul  on  the  bas<'  than  on  the  u]i]ii'r  surface;  an  cxicusive  patch,  two  or  more  lines  in  thick- 
ness, lined  the  tissures  of  the  cerebellum  and  covered  the  crura  ci-reliri.  pons  Varolii  and  nu'dulla  oblongata; 
the  brain  was  very  vascular  but  not  softened,  and  there  was  but  lillle  si'rous  ell'usion  in  llw  ventricles.  The 
spinal  cord  was  not  softened,  but  was  invested  under  the  arachnoid  in  its  whole  length  by  a  uniform  jdastic 
layer  about  two  lines  thick ;  a  section  of  the  cord,  in  its  lower  pari,  gave  ixit  to  a  ilislinci  ly  greenish  liquid.  The 
lungs  and  jileura'  wore  healthy.  The  heart,  lirmly  contracted,  contained  a  small  fibrinous  deposit  near  ils  ajiex.  The 
liver  showed  generally  a  moderate  amount  of  fatty  degeueralion  w  ilh  <pccasioiial  patches  of  complelely  degeueraled 
tissue;  the  spleen  was  healthy;  the  jiaiicreas  vasiuhu  ;  lume  of  the  solid  viscera  were  soflcncd.  Tlicie  wcii'  a  few 
ecchymoscs  on  the  mucous  membrane  of  the  stonmcli.  Tlic  intestines  were  tynipanil  ic:  t  be- Jejuniini  was  normal; 
the  ileum  contained  a  suuill  i|nantily  of  greenish  I'm-ccs;  I'lyi'r's  jpalclics  were  distinct  but  not  diseased  ;  \hv  vessels 
of  the  colon  were  much  ccuigesled,  esjiecially  al  ilscomuunicmenl,  and  this  condition  lessened  in  proportion  to  the  dis- 
tance from  that  point:  In  the  lower  ileum  and  ca'cum  the  mucous  membrane  was  moderalidy  softened,  uniformly 
reddeneil  and  ecchymoscd  in  many  sp<ils;  the  solitary  glands  were  prominent  and  distinct  as  in  cholera,  each  aliont 
the  size  of  a  millet-seed,  but  there  was  no  uleeralion.  The  mi's<Mileric  glands  were  nnalleiled.  Ihc'  semilunar 
ganglion  and  sidar  Jilexus  showed  lui  vascularity,  sid'tcning  or  oilier  indication  of  diseasi'.  T'lk'  blood  In  the  vessels 
was  generally  tluid. — Cnitral  J'aik  IJunpital,  yur  lor/,-  I'ih/. 

Case  91. — Private  .John  Miuisherger,  Co.  1,  90tli  Pa.:  age  10:  convalescing  satisfactorily  I'rom  a  resection  of 
the  left  elbow  ,j<iint,  rose  on  the  morning  of  .July  2H,  IKlil,  in  his  usual  good  hi^allh,  dressed  himself  and  wi'iit  out 
to  the  jiump  for  a  drink  as  was  his  daily  habit.  About  li  A.  M.  he  was  suddenly  seized  with  a  si'vcri'  [lain  between 
the  shoulder-blades,  the  feeling  being  as  if  some  one  was  luessiiig  a  bar  of  hot  iron  into  his  back  bone.  A  mustard 
l)laster  gave  speedy  relief,  anil  after  the  attack  was  over  he  got  up  and  walked  about  the  ward.  An  hour  later  the 
]iain  returned,  but  was  relieved  In  ten  or  fifteen  minutes  by  a  reapplication  of  the  mustard,  lb'  appe;ired  to  l)e  sick 
at  stomach  and  tried  to  vomit :  he  declined  food  lint  had  no  thirsl.  His  strength  ajipeared  goo<l.  bul  alu-r  the  attack 
he  fell  into  a  profuse  perspiraticm  audslejit  an  hour  or  two.  At  10  a.  m.  the  pain  returneil  w  ilh  such  iucreasi'd  severity 
that  he  cried  out  in  anguish:  it  also  lasted  longer.  At  11  a.  M.,on  raising  him  uj)  in  bed  for  the  applicaliou  of  ciijis, 
he  was  seized  with  a  fourth  paroxysm,  and  exclaiming  "Oh!  such  jiain!"  fell  overoiithe  shoulderof  an  altendant  and 
immediately  became  unconscious  as  if  in  syncope,  his  face  deathly  pale,  eyes  lixeil,  muscular  system  relaxed,  radial 
pulse  fluttering  and  breathing  interrupted  l)y  long  intervals.  In  a  few  minutes  the  pallor  of  the  face  and  li|is  gave 
jdace  to  the  lividity  of  asphyxia;  the  eyes  were  open,  fixed  and  glassy,  the  left  pupil  contracted,  the  right  dilated; 
the  muscles  completely  relaxed  and  the  pulse  imiii'tceptilde  at  the  wrist.  He  took  afterwards  only  threeor  four  long 
sighing  inspirations,  with  long  intervals  between  them,  altliough  ammonia  was  ajiplied  to  the  nostrils  and  Marshall 
Hall's  method  of  artificial  respiration  was  faithfnily  tried.  He  died  at  11.30  a.  .M.  There  was  no  thirst  or  any  unnatural 
warmth  of  skin  during  the  five  and  a  half  hours  his  sickiu'ss  lasted;  nor  were  petei-hial  or  any  other  kiiul  of  sjiots 
visible  on  the  surface.  Posf-woc/cw  examination  :  On  leinoviug  the  skull-cap  four  ounces  of  blood  and  serum  e.scai)ed; 
the  veins  and  sinuses  of  the  brain  were  congested  with  fiuid  blood  ;  there  was  a  moderate  quantity  of  subarachnoid 
effusion  over  the  hemisphere.'!  anrl  the  ventricles  contained  about  an  ounce  of  serum.  The  spinal  cord  and  its  mem- 
branes appeared  healthy.  The  hiugs  were  intensely  congested  with  venous  blood;  the  pleural  cavities  containei 
eight  ounces  of  serum  and  the  pericardial  sac  two  ounces;  the  valves  of  the  heart  were  sufficient.  All  the  abdominal 
viscera  were  healthy  except  the  kidneys,  which  were  congested  of  a  bright  maroon  color;  the  urine  obtained  at  the 


*  See  uuti.'  tti  c-Mi'  S-J 


580  DISEASES    ALLIED    TO    OE    ASSOCIATED    WITH 

autopsy  was  allmniinous.  The  blood  reraaiued  fluid  evevywliero;  it  was  dark  in  color  and  flowed  freely  wherever 
an  incision  was  made  in  the  body. — At^s't  Sury.  Geo.  A.  .Wiirskk,  f.  ^.  T'.,  Stuiitoii  Hospital,  ll'anhington,  D.  C* 

Case  92. — Private  John  Davis,  Co.  E,  8tli  Vt.:  age  28:  was  admitted  July  2li,  18(11,  with  ([uotidiau  intermittent 
of  moderate  severity.  This  was  immediately  checked  by  (luinine,  and  the  patient  seemed  in  a  fair  way  to  recovery 
when,  on  the  morning  of  the  31st,  he  remained  in  bod  feeling  weak  and  without  ajipetite.  The  tongue  was  clean; 
there  was  no  heat  of  skin  or  heart  disturbance,  but  the  countenance  expressed  a  good  deal  of  anxiety.  Ho  said  tliat 
about  midnight  he  had  been  seized  with  groat  restlessness  which  lasted  twenty  minutes,  but  he  had  not  slept  until 
towards  morning.  He  did  well  during  the  day  until  5.30  P.  M.,  when  he  was  again  attacked  with  restlessness  and 
convulsive  movements  resembling  those  presented  by  certain  oases  of  hysteria.  He  became  delirious,  tossing  him- 
self about  in  bed  and  uttering  shrill  screams:  his  ptipils  were  dilated;  respiration  14;  pulse  100  and  full.  Ice  was 
applied  to  the  head  and  spine  and  mustard  to  the  epigastrium:  a  turpentine  enema  was  given.  No  medicine  was 
lirescribed  by  the  mouth  us  the  ability  to  swallow  ajipeared  to  be  lost.  Coma  gradually  supervened,  and  the  patient 
died  at  midnight. twenty-four  hours  after  the  onset  of  the  attack  and  six  and  a  half  hours  after  the  full  development  of 
its  character.  Toward  the  last  he  was  bathed  in  perspiration.  /'u.vNwyi'/cni  examination:  Body  welldeveloi)ed  ;  surface 
of  back  of  neck  and  shoulders  showing  twenty-fl  ve  or  thirty  dark-pur))Ie  spots  from  the  size  of  a  nnistard-seed  to  that 
of  a  pea.  circular,  somewhat  elevated,  with  well-detined  margins,  and  consisting  of  an  infiltration  of  dark-colored 
blood  in  all  the  layers  of  the  skin  and  to  some  extent  in  the  subcutaneous  connective.  During  the  removal  of  the 
skull-oap  about  six  ounces  of  serum  colored  with  blood  flowed  away;  the  Pacchionian  bodies  were  unusually  numer- 
ous, large  and  adherent  for  a  subject  of  28  years:  the  arachnoid  was  opa(|ue,  especially  over  the  vortex,  and  some 
limpid  serum  lay  beneath  it  :  the  ventricles  contained  a  moderate  <iuantity  of  serum;  the  choroid  plexus  in  the  fourth 
ventricle  was  thickened  and  looked  like  a  lamina  of  jiale  flabby  granulations,  but  the  vessels  in  the  other  ventricles 
pr,?sented  no  abnormity:  the  substance  of  the  cerebrum,  cereliellum,  pons  and  medulla  oblongata  was  moderately 
congested  throughout.  The  theca  vertebralis  was  well  tilled  with  serum,  notwithstanding  the  large  quantity  which 
had  escaped  during  the  examination  of  the  brain,  and  the  cerebro-spinal  tlnid  contained  flocculi  in  the  lumbar  region: 
the  arachnoid  was  opaque  and  the  vessels  beneath  it  intensely  congested  ;  the  substance  of  the  cord  seemed  healthy. 
The  lungs  were  engorged  and  the  middle  lobe  of  the  right  lirng  contained  an  apoplectic  extravasation  as  large  as  a 
walnut.  The  heart-clots  were  small.  The  blood  was  much  more  fluid  than  natural.  The  liver  and  intestines  were 
healthy:  the  kidneys  congested;  the  urine  highly  albuminous. — Stanton  HoHpital,  Washington,  V.  C* 

Case  93. — Private  Simeon  Bond,  37th  Co.  2d  Batt.  V.  R.  Corps:  age  2."):  a  member  of  the  hospital  guard,  was 
admitted  from  (inarters  on  the  evening  of  August  14,  18ti4.  Ho  had  complained  of  debility  and  loss  of  appetite  for 
several  days,  and  the  orderly  sergeant  thought  him  slightly  out  of  his  head.  On  admission  he  was  weak,  feverish, 
thirsty  and  sick  at  stomach,  but  did  not  vomit;  pulse  90:  he  had  headache  lint  no  other  pain.  Neutral  mixture 
and  aconite  were  prescribed.  He  was  restless  and  slept  but  little  during  the  night,  and  next  morning  he  did  not  seem 
to  realize  where  he  was.  He  wanted  to  get  up  and  steal  away,  but  was  quiet  withal.  His  head  was  hot,  eyes  some- 
what injected,  tongue  furred,  pulse  95  and  stronger.  The  ice-bag,  a  brisk  purgative  and  acetate  of  ammonia  with 
antimonial  wine  and  nitric  ether  were  prescribed.  Morphia  was  administered  in  the  evening  and  he  passed  a  better 
night.  On  the  16th  he  was  mildly  delirious,  sinking  into  stupor  when  left  undisturbed;  pupils  somewhat  dilated, 
symmetrical;  eyes  more  injected;  pulse  80  and  full:  respiration  deep  and  regular  but  slower  than  natural.  He  had 
no  spasm  of  anj-  kind.  A  blister  was  applied  to  the  nape  of  the  neck  and  sinapisms  to  the  epigastrium  and  inside 
of  the  thighs:  quinine  was  given  in  full  doses.  His  bowels  had  been  freely  moved.  No  improvement  followed, — 
the  stupor  grew  more  profound,  and  he  died  comatose  about  11  v.  M.,  a  little  over  forty-eight  hours  after  his  admis- 
sion.— Stanton  Huspitui,  Washwylon.  D.  C* 

Case  94. — Sergeant  Frederic  H.  Reed,  Co.  I!,  IT-'ttli  Ohio,  was  admitted  Oct.  16,  1864,  complaining  of  severe 
frontal  ])aiu  and  slight  fever:  the  latter  came  on  daily  in  the  evening  and  ended  in  a  few  hours  without  sweating. 
Castor  oil  with  laudanum  was  administered,  and  next  day  he  felt  bettor.  On  the  18th  there  was  slight  delirium, 
with  increased  pain  in  the  head.  A  six-grain  dose  of  calomel  was  given:  but  as  he  raved  incessantly,  during  the 
following  night  ice  was  applied  to  the  shaven  scalp  and  a  blister  to  the  najie  of  the  neck,  while  two  grains  of  tartar 
emetic  with  twenty-five  drops"  of  laudanum  were  given  every  two  hours.  On  the  20th  the  delirium  continued  but 
with  a  tendency  to  stupor,  which  ultimately  ended  in  coma  and  death  on  the  morning  of  the  21tli.  J'oxt-mortem  exam- 
ination :  Pus  was  layered  over  the  surface  of  the  arachnoid  and  the  meningeal  vessels  were  injected;  the  ventricles 
of  the  brain  were  dry.     The  thoracic  and  abdominal  viscera  were  normal. — Hospital  Xo,  8,  Xashvillc,  Tinn. 

Case  95. — Private  Jesse  Briner,  Co.  B,  50th  Ind.;  age  24;  was  admitted  Oct.  20,  1864,  in  a  comatose  condition 
attended  with  cqiisthotonos :  ]inlse  60.  tongue  moist  and  white,  skin  moist,  pupils  dilated  and  turned  upward  ;  he  had 
been  api)arently  in  good  health  until  the  day  before  his  admission.  Blisters  were  applied  to  the  back  of  the  neck, 
the  bowels  were  moved  by  repeated  enemata  and  a  quart  of  high-colored  urine  was  drawn  off  by  catheter.  He  died 
on  the  21st.  Post-mortem  examination:  Body  large,  well-formed,  fleshy  and  without  external  marks  of  injury.  The 
dura  mater  was  congested  and  the  surface  ot  the  arachnoid  covered  with  a  fibrinous  deposit ;  the  brain  was  congested 
and  there  were  deposits  of  fibrin  in  the  ventricles,  at  the  ba.'^e  and  over  the  cerebellum.  The  lungs  were  somewhat 
congested  posteriorly  and  contained  tubercles,  chiefly  aggregated  in  the  lower  lobes.  The  heart  and  the  abdominal 
viscera  were  normal. — Hospital  No.  8,  NashvUle,  I'onn. 

Case  96. — William  B.  Poer,  a  citizen  of  Missouri,  died  Dec.  3,  1861.  I'ost-mortvM  examination :  Body  not  emaci- 
ated.    The  posterior  part  of  the  cerebrum,  the  pons  and  the  lower  portion  of  the  cerebellum  were  covered  with  a  thin 


^  J'liiN  A.  LiDF.LL.  L'.  S.  v.,  published  this  case  in  an  article  on  Buidemic  Cifrthro-spiiuU  Meitinijitis  in  the  Aitterk-au  Join;  Mtil,  St-ietices,  June,  ISC'). 


TH1-:    I'AIKIXVSMAI.    AM>    ('■(iXTlNTKIi    KKVKi;>;.  581 

laytT  of  Jialo  iiurulcut  matter  overlaid  by  tlio  iiillaiiifil  nii-inliraiics:  the  ineilullary  jiorlioii  of  tlie  rerelinim  was 
softened  and  presented  many  inineta:  tlie  ventricles  contained  only  lialf  a  drachm  of  Kcriini:  the  cerebellinii  was 
almost  iiulpy;  the  thoracic  and  abdominal  viscera  were  normal. — Acl.  Ask'I  Siirij.  J.  JC.  Ih-oohf.  Hock  Inlimd  llmpilal,  III. 

Cask  97.— Randolph  ifoxley.  a  citizen  of  Missonri.  admitted  Dec.  W.  1X04;  died  I'Tth.  roKl-iiiorlim  examina- 
tion: About  one  drachm  of  pns  escaped  on  reinovinjr  the  iliua  mater:  thecerelirnm  an<l  cerebellum  were  covered  with 
pus;  the  lateral  ventricles  contained  two  ounces  of  Inrbid  serum.  The  left  lunjr  «as  eouKested  and  adhere<l  to  the 
(tiaphnijrm,  where  it  conmiunicated  with  a  cavity  iu  the  spleen  containing  four  or  five  ounces  of  thick  pus  and  ;i  white 
ealeareons  dejiosit.  The  sj)leen  was  jjjreatly  enlarjied,  softened  and  disorfrani/ed  as  stated:  the  liver  and  mesenteric 
Inlands  were  enlar^'ed:  the  colon  ami  rectum  were  highly  eouj;ested:  the  kidneys  were  normal  in  size  but  aiiiieared 
somewhat  softened. — .lei.  .l«.s'(  Siiy;/.  J.  E.  Brooke,  lUicI:  I.ilund  Hospital,  III. 

C.v.sK  98. — Private  H.  P.  Sersing.  6'2d  X.  ('.  Meuini,'itis.  Admitted  and  died  Jan.  19, 18tri.  /'<).v/-;,i,<Wim  ex.imina- 
tion:  The  surface  of  the  brain  was  covered  witli  ])us.  its  substance  softened  and  its  nuMubranes  inllauu'd.  The  bladder 
was  distended  with  urine. — Act,  .Isn't  Siiry.  If.  C.  Xcukirk,  Hock  hhitiil  Ilonpildl,  111. 

Cask  99.— Private  Robert  Redick,  Co.  F,  1st  N-  Y.  I.i^'ht  Arfy;  age  liL':  was  admitted  Jan.  :!1.  lS(),"i,  at  X  i".  M. 
This  man  was  taken  suddenly  ill  on  the  previous  day  with  high  fever  anil  delirium:  pulse  13iK  eyes  injected,  skin 
dry,  tongue  dry  and  coated,  teeth  covered  with  sordes,  respiration  slow,sto(ds  involuntary  ami  llu>  lower  extremities 
and  back  covered  with  dark-purple  spots  in  size  varying  from  a  jiinhcad  to  a  large  pea.  On  admission  lie  was  snli'er- 
ing  from  nervous  prostration;  the  radial  pulse  was  almost  imperceptible:  there  was  intense  dyspno'a,  a  dull  heavy 
feeling  about  the  liead  and  a  dull  pain  between  the  shoulder-hiaoes;  the  face  was  livid,  the  lii)s  purple  and  the 
extremities  cold.  He  died  two  hours  after  admission.  Post-mortciu  examination:  Itody  of  full  habit  and  lleshy.  exhib- 
iting spots  of  eccliynioses  from  one-fourth  to  th  lee-fourths  of  an  inch  in  diameter  over  the  wlude  surface  ami  hypostatic 
congestion  in  the  depending  )iortions.  'J'lie  hloodvessids  of  the  brain  were  very  much  engorged;  an  onnci'  of  serum 
was  found  in  the  cavity  of  the  arachnoid,  a  similar  iiuantity  in  each  vcMitrich'  and  about  two  oumcs  at  the  base  of 
the  brain:  the  Pacchionian  bodies  were  largi'ly  develoiied;  the  substance  of  the  brain  normal.  The  spinal  cord  and 
its  nieuihranes  were  healthy.  The  he;irt  was  normal;  a  libriiious  dot  was  found  iu  its  right  ventricli'.  l!<illi  lungs 
were  highly  congested,  considerably  collai)seil  and  contained  a  few  small  aiiojihctic  blood-clots:  the  bronchial  tubes 
were  tilled  with  serum  and  frothy  minus.  I  he  liver  was  noriu.il ;  the  gall-blailder  distended  with  ilark  \  iscid  bile; 
th«'  spleen  congested.  'I'lie  stomach  and  bowels  weri'  distended  wilh  tinliis.  'i'he  kidneys  were  normal;  the  urine 
slightly  albuminous.     The  blood  generally  was  rcniarkably  lliiid. — ^Iniitnu  lloxjulol,  IVonhiiiijIon.  I).  ('.' 

Cask  KIO. — Private  .Iidin  F.  K'islcy.  Co.  li,  ."idtli  Ohio;  age  '2\:  was  adiultteil  Feb.  I!,  l-(i.">,  having  been  sick  for 
five  days.  The  disease  comnienced  with  a  chill  which  lasted  an  lioiir  and  was  followed  hy  seven'  lumbar  pain.  On 
admission  ho  had  no  headache,  but  pain  in  the  loins  was  very  distressing;  he  was  restless  and  had  a  wihl  expri'S- 
sion,  a  moist  and  eoateil  tongue,  full  and  rapid  jmlse,  eoryza,  cough  ami  some  oppression  of  tin'  chest :  a  dark  rash, 
which  disappeared  on  pressure,  was  noticed  on  the  surface.  Roehelle  salt  and  morphia  were  administered  and  dry 
eiijis  applied,  but  111  the  evi'iiiiig  he  was  no  better.  lie  was  restless  during  the  night.  Next  day  the  dark  rash  covered 
the  whole  of  the  body:  the  ]iati<'nt  was  drowsy,  his  puiills  contracted;  alidomen  tympanltii':  ri's)iiiatioii  dillicult, 

111!  died  I latose  before  inidday.      I'oxt-inorlcm  examination:  ( 'best ,  abdomen   and   posleilor  aspect   of  extremities 

I'oveieil  with  a  dark-iiurple  rash  and  petechial  spots;  face  presenting  |iui']Mirie  ]iatehes  but  no  l>eteehia'.  The  blood 
throngliout  the  body  was  thin.  The  veins  of  the  cerebral  and  siiiiial  membranes  were  engorged  and  (here  was  serum 
beneath  the  arachnoid;  but  the  substance  of  the  brain  and  cord  was  healthy.  Kcchyniosed  spots  wen^  found  on 
the  parietal  pleura  and  serum  tinged  with  hlood  in  each  pleural  sac,  lint  the  lungs  were  healthy.  The  )>eriloneiiin, 
mesentery,  stomach  and  intestines  were  covered  with  scarlet  and  dark-red  petechial  spots.  The  liver  weiy;lied  one 
hundred  and  sixteen  ounces;  the  gall-bladder  was  large  and  full.  The  ii;;lit  kidney  weighed  eleven  oiiinis,  the  left 
ten  ounces ;  their  capsules  and  the  surrounding  connect  ive  t  Issue  wire  ecchy  mosed. — DotKjIdn  llosjiitiil,  U'dHliiiii/lon,  1).  C. 

Case  101. — Private  Klisha  Cotton,  Co.  I,  Slilli  Ohio;  age  L':t;  was  admltti'd  Feb.  IH.  isii.".,  with  severe  jiain 
In  the  head.  lie  was  rational;  his  appetite  good:  bowels  constipated  :  juilse  IK.  Castor  oil  wilh  oil  of  tiirpeiitine 
was  given  and  repeated.  Next  day  four  cui>s  were  aiiplied  to  the  nape  of  the  neck,  fioiii  which  sliglit  relief  was 
derived;  pulse  46.     The  pain  continued  and  on  the  L'lst  delirium  set  iu.  which,  on  liiel'lld,  bee:iiiie  violent  and  aeconi- 


*Thi«  CISC"  vns  (■olnnmniratwl  l)y  Dr.  I>.  W.  I'ukxtiss  Id  IIm'  r<iiiimitt>v  mi  "SiiLtl  .1  I'rnT,  rm-ciiII.-iI.  '  ,,l'  lln'  Aiiirricm  Mnliiul  A.— "■  iaiii'ii,  ami 
jiulilislipil,  ]i.  :!.V),  Vol.  XVIInf  tliu  TriinmrliiM.  At  the  Siuiic  tinii'  llr.  I'llKNTlss  snlniirtli-il  iis  ii  ni-i'  ..f  i.|.iill,.|l  f,.vir  Hi.'  I'hIImm  in;;.  «lii,li  :i|.|.i'ju's  on  tin- 
rcctirilri  of  ttio  Iiosi)ital  ins  ono  of  cercbml  aj'ol'N'Xy:  Privilti-  .lann-.-*  K.  IlaV'-;*,  C-i.  «'.  tntli  \.  I!.  Corps,  was  tnlniillMil  .Ian.  7,  Isli.',.  villi  hcaila-'hi..  HftNunii'iI 
to  lie  the  rcsnlt  of  a  dL-l'iuu-h.  Next  ilay  jH-rsisli'iit  conui  rarnc  on,  antt  In-  ilifil  on  tin-  liMli.  ivW-jMorfcan-xaniiinitioii :  llijrorniorri.s  well  inarlxcO.  Thori' 
wa.sa  quantity,  aljont  figlit  oimci-s,  of  clTtisc'l  l»lo4"I  I«'tMccn  tin'  in'inln-aii'-s  of  llio  I  train  ali-l  a  lar;ri'  <-lot  on  tin-  citli-  of  lln^  ri;;Iit  ln-nu>]tlitTo;  tin*  hnli- 
staucc  of  tlif  brail]  was  healthy.  Tlnn- wrrt'  ohl  lolhi-sions  of  tin-  hin^rs.  atnl,  in  tho  In'art,  Hliy:ht  intliinitioll  of  the  aorlir  valvi'.;.  Tlif  ollirr  or;;ans  Hcn> 
not  examined.— .SV.oiMi  /;..»/. i/.i/,  tl'ci.-;,;„,;/.,i/,  h.  ('.  The  e.ui-nlation  of  lli.'  Moo.1  is  imonsislenl  Milh  the  theory  nf  rerehrii-s|.ilial  fevi'r  in  this  ease,  m 
in  tlic  following,  which  was  ajiliarently  the  result  of  vioK-nee:  I'rivate  .lolin  lliltehinson,  nnassie;neit  reernit  ;  ii;;e  IS  ;  while  wrestline;  Feb.  -I,  tstl-l,  was 
irii'iH-.lami  fell  heavily,  striking;  his  l.aek,hnt  heditl  not  runiplain  of  injury  ami  was  |.reseiil  at  roll-eall  in  the  even  in;.'.  NfXl  day.  liowever.  he  reniaincd 
ill  his  tent,  wliere,  in  the  eveiiinjr,  lie  was  found  ^roaniiifr.  (.In  admission  to  ho^l,ilaI  at  this  time  ho  was  very  restless  and  delirious,  uniihle  to  reply 
intelligiiily  and  laiising  into  drowsiuesst  (K'ca.--ionally  for  a  few  ininiites  at  a  time ;  his  extremities  wen;  cold  hut  the  Hurface  elsewhere  was  natural ;  thn 
odor  of  alrohol  was  deteetedaliout  liis  person.  Iluriiiff  tho  night  he  had  two  loose  Htools  ;  his  tongue  lieraiue  red  and  dry  and  sordes  a pin-a nil  on  his  teeth. 
On  the  tlth  the  delirium  was  more  aetive :  lie  trieil  to  get  out  of  hed — moved  in  every  ilireetion.  rose  ,in  his  knees  and  was  restrained  only  liy  fori-e  •,  Iiis 
pulse  was  rapid  and  weak,  1:^0;  alHloincn  not  tender.  He  refusiil  to  swallow  meilieine;  two  small  doses  of  iiuinine  and  opium  were  given  jwr  reetuni. 
Towards  iniiluij^dit  ho  heiaiue  eonmtose  and  died.  /'fW-iner/eiit  examination  :  IJody  well  developed  and  showing  no  marks  of  violence.  The  niemhraiiesof 
the  hrain  were  much  congestiil ;  the  snhstanee  of  the  hniiii  healthy.  Tho  nienihranes  of  the  spinal  cord  were  congested,  and  external  to  the  dura  mater 
tliere  was  some  clotteil  Mood  which  decreased  in  (luamity  from  ahov.'  downwards.  The  liiiii's,  Ii\er,  spleen  and  kidneys  were  congested  ;  in  one  of  tlie 
kidneys  was  n  clot  of  hloi«l  tlii'  size  of  a  is'a  hetween  the  capsule  and  parenchyma.  The  liliid.ler  was  disteuded  with  slightly  alhumiunns  uviiie.  IVyer's 
patches  and  the  small  intestine  generally  wen-  slightly  congested.— y'ener's  i.oir  7f..«jii(.i;.  /Vof.e/. /y./,;.i.  ;'„. 


5S2  DISKASKS    ALI.IKD    T()    0\l    ASSOCI ATKI  i    Willi 

jiauied  with  acfi'liMated  pnlsr.  li)i>.  On  Marcli  1  ihoro  was  maikcil  prosiration,  with  iimtti'iiiig  deliriniii:  |nilse  Vli). 
He  (lied  on  the  Sd.  I'oft-inorti  in  exaiiiiiiatioii :  Tlie  j>ia  mater  was  injected:  lyiinili  was  deposited  at  the  fiNSiiie  of 
Sylvius,  aiomid  the  sella  tnicica.  on  the  snrt'aee  of  \h.'  cereliellniM  and  (ions  Varolii  and  on  the  roots  of  the  optic  ami 
pueumogastnc  nerves:  the  ]mns  and  cereliellnni  were  injecteil  and  s.iftened:  the  siil)slanee  of  the  brain  was  con- 
gested and  its  ventricles  eontaini'd  serum  and  liluinous  deposits. — i'miihi  rhiiid  llifpiltil,  Mil. 

t'A.SK.  11)2. — Private  W.  <;.  Hicks,  to.  L.  1st  X.  11.  Heavy  .\n'y:  :i  teni]ierate  man  of  full  haliit :  eomiilainccl  from 
March  1.  ISll.").  of  pain  between  the  shoulders,  but  was  otherwise  ai)i)areiitly  well.  On  the  22d  he  was  seized  with  a 
severe  chill  and  headache,  for  which  a  mercurial  pniije  was  taken  :  at  10  p.  m.  the  j)aiii  extended  aloiif;  the  s|iine  ami 
was  attended  with  vomitini;  and  some  febrile  action;  ]nilse  100.  Three  cathartic  pills  were  jriven,  with  cold  appli- 
cations to  the  head  and  mustard  to  the  back  of  tlie  neck.  He  vomited  the  medicine,  passed  a  restless  nijiht,  and  in 
the  early  morning  went  out  ami  walked  half  a  mile,  when  he  was  found  nearly  insensible.  On  admission  to  hospital 
on  the  23d  lio  was  partly  cimscious  but  unable  to  speak :  his  face  was  llushed,  skin  hot  and  dry,  pulse  100  and  feeble : 
his  eyes  opened  when  he  was  addressed,  his  rijrlit  hand  moviufr  incessantly  toward  his  liead,  which  was  thrown  back 
by  tetanic  spasm;  liis  lower  extremities  were  also  in  constant  motion:  he  moaned  at  short  intervals  and  resisted 
efforts  to  open  his  nuiuth  for  the  administration  of  food  and  medicine.  Six  wet  cups  were  ajijdied  to  the  back  of  the 
neck  and  were  followed  by  a  cantharidal  blister:  mustanl  was  used  aloui;  the  sjdne  and  on  the  feet  and  calves  of 
the  lei;s:  two  drops  of  crotoii  oil  were  given  ami  ten  grains  of  the  sulphate  of  iiuinine.  At  noon  the  bowels  were 
moved  freely,  but  the  patient  was  iinconseions  and  the  opisthotonos  aggravated.  At  i'  r.  m.  there  was  no  change, 
although  the  blister  had  drawn  well.  Ice  was  apjilied  to  the  head  and  beef-essence  given  freely.  He  jiassed  a  restless 
night,  bis  lower  extremities  in  constant  motion  and  his  breathing  labored.  He  died  at  7  r.  >i.  in  an  attack  of  severe 
tetanic  spasm,  rosf-morttm  examination:  Body  robust.  The  ]iia  nuiter  covering  the  cerebrum,  cerebellum  and  cord 
was  much  congested.  The  brain  was  not  examiued.  Beneath  the  sjiinal  arachnoid  was  a  large  collection  of  pus, 
which  seemed  mixed  with  a  small  quantity  of  oil:  the  substance  of  the  cord  appeared  healthy.  The  right  ventricle 
of  the  heart  was  nearly  tilled  with  a  tirm  coaguluiu.     The  lungs  were  healthy. — IlosiiitaJ,  Fort  licno,  JJ.  C. 

C.\SE  103. — Private  Benjamin  Lond,  Co.  K.  2d  JIass.  C'av.:  age  10;  was  admitted  April  4,  1865,  complaining  of 
aching  in  all  the  joints.  His  knees  were  slightly  swollen;  pulse  100,  weak:  tongue  large  and  red,  with  prominent 
papilhe  and  a  dirty-w  lute  fur.  He  remained  in  this  condition,  his  appetite  good,  until  the  10th,  when  he  was  seized 
with  pain  in  the  hack  of  the  head  and  neck  and  opisthotonos.  He  gra<lually  grew  worse,  his  countenance  becoming 
anxious,  pulse  130,  mind  confused,  tetanic  spasms  more  violent,  pupils  dilated  and  deglutition  difhcult.  He  died  on 
the  27th.  I\)i<t-iiiortiiii  examination:  The  nunnbraiu-s  of  the  brain  were  congested  and  its  sinuses  turgid  with  blood: 
lytuph  was  deposited  around  the  optic  nerves,  the  pituitary  gland  and  along  the  auti'rior  surface  of  the  medulla;  the 
substance  of  the  brain  was  softened,  its  ventricles  tilled  with  serum  and  the  choroid  plexus  of  each  congested  and 
thickened.  The  membranes  of  the  spinal  cord  were  intlamed.  The  lungs  and  jdeura  were  healthy.  The  pericardium 
was  congested  and  contained  an  ounce  and  a  half  of  sero-jius:  the  mitral  valves  were  thickened.  The  abdominal 
viscera  were  normal. — (.'uiiibtrliunl  llmj'itii}.  J/i/. 

C.vSK  104. — P'-ivate  (Jeorge  W.  Ferguson.  Co.  U.  8tli  Tenn.  Cav.;  age  IS:  was  admitte<l  Pec.  2, 1H64.  with  chronic 
diarrlicea,  from  which  he  recovered  and  was  placed  on  light  duty.  < 'u  April  10,  186.5,  he  had  vertigo  and  his  eyes 
were  inflamed.  On  the  IPth  a  slight  chill  was  followed  by  high  fever,  the  patient's  face  being  flushed  and  swollen, 
eyes  suffused.  respirati(m  hurried,  skin  hot  and  dry,  tongue  heavily  coated  with  whitish  fur.  bowels  loose,  pulse  120 
and  full,  limbs  weak  and  sore.  At  4  r.  M.  he  had  a  copious  perspiration,  lasting  an  hour,  and  followed  by  a  recur- 
rence and  aggravation  of  his  former  symiitoins,  which  continued  during  the  night.  On  the  20th  he  was  delirious:  at 
11  A.  >i.  comato.se,  pupils  dilated,  evacuations  freiiueut  and  involuntary,  thiu,  very  oft'ensive  and  of  an  ochre  color: 
at  3  r.  M.  opisthotonos  and  tri.smiis  supervened,  pulse  120,  full  and  strong,  respiration  30,  loud,  abdomen  tympanitic: 
at  8  r.  -M.  he  had  several  severe  convulsions  followed  by  increased  opisthotonos  and  trismus,  which  continued  until 
death  at  11  A.  M.  of  the  21st.  He  was  treated  with  veratrum  viride  and  ipecacuanha,  with  nitrate  of  ))otash,  turpen- 
tine enemata,  mustard  to  the  abdomen  and  extremities  and  ice  to  the  head,  I'ost- mortem  examination:  The  mem- 
branes of  the  brain  were  congested  and  the  sinuses  filled  with  dark  blood:  the  brain  weighed  sixty  ounces;  its  sub- 
stance was  softened,  especially  in  the  corpus  callosum,  optic  thalami  and  pons:  the  lateral  ventricles  contained  two 
drachms  of  bloody  sennn  and  the  choroid  plexus  in  each  was  highly  congested ;  the  medulla  oblongata  was  softened. 
The  lungs  were  engorgeil.  The  heart,  stomach  and  large  intestine  were  healthy,  hut  the  lower  part  of  the  ileum  was 
congested  and  the  mesenteric  glands  much  enlarged.  The  liver  and  kidneys  were  congested;  the  gall-ldadder  much 
distended;  the  spleen  larger  than  normal. — Hospital,  Madison,  Ind. 

Case  105. — Private  .lames  Wesley  Turner.  Co.  D,  126th  Ohio;  age  30;  was  admitted  at  2  r.  M.  June  27,  1865, 
from  his  regimen'i,  which  was  en  route  home.  He  was  insensible:  his  eyes  much  injected  and  watery;  pupils  con- 
tracted and  fixed:  I'.ps  covered  with  sordes;  heail  hot:  general  surface  of  natural  temperature  but  covered  thickly, 
especially  on  the  legs,  anus,  back  and  face,  with  dark-purple  spots,  some  of  which  were  elevated,  having  a  diameter 
of  from  one-eighth  to  three-eighths  of  an  inch.  He  lay  <m  his  back  with  his  knees  drawn  up  and  head  thrown  hack, 
hut  he  was  withal  very  restle.ss;  there  was  tenderness  on  pressure  over  the  occiput  and  spine.  As  the  bladder  was 
much  distended  the  catheter  was  used  and  fifty  ounces  of  high-colored  and  strongly  ammoniacal  urine  were  removed 
with  decided  relief  to  the  restlessness.  At  3  P.  M.,  on  the  manifestation  of  some  tetanic  spasm,  bromide  of  ])otassium 
was  ordered  in  fifteen-grain  do.ses  hourly  until  !1  P.  M.  and  thereafter  every  two  liouis.  At  6  P.  M.  the  ])atient  was 
quiet.  After  the  withdrawal  of  forty  ounces  of  uriiu'  by  catheter  at  10  P.  M.  the  tetanic  condition  disappeared,  the 
eyes  became  less  suffused,  the  pu)iils  <lilated  son\ewliat  and  res])onded  to  light  and  the  macuhe  seemed  of  a  brighter 
color;  respiration  was  natural.     He  slept  well  for  three  hours  during  the  night,  but  towanls  morning  became  a  little 


THK    PAROXYSMA],    AN1>    CUNTIXrKU    KKVKKS.  583 

restless;  Iie<lrank  water  and  was  alile  to  lidlil  the  en  p  in  hisliands.  At  S  a.  M.  thirty-six  ounces  of  urine  were  removed, 
the  patient  evincinj;  ^reat  dislike  for  the  ojieiation.  A  teaspoonful  of  a  solution  of  onejrrain  of  sul])hate  of  strvehuia 
in  four  ounces  of  camphor- water  was  directed  to  be  ^iven  every  two  hours,  alternatiui;  with  the  hromide,  the  spine  to 
be  rubbed  with  a  liniment  of  annnonia.olive  oil.  chloroform  and  tur]ieiitine.  In  the  even  in  j;  he  was  i|uite  conscious: 
he  fiave  his  nanu',  said  he  was  married  aiul  that  his  home  was  in  Lawrenci\  Ohio.  At  this  time  the  strvchnia  was 
omitted  and  the  bromide  reduced  to  ten  i;rains  every  four  honrs.  lie  was  comfortable  durini;  the  nij;ht,  urinated 
voluntarily  and  had  two  stools  towards  morniujr.  On  the  29tli  a  teaspoonful  of  a  solution  of  sixteen  fjrains  of  sul- 
phaie  of  quinia  and  one  grain  of  sulphate  of  morphia  in  three  ounces  of  water  was  ordered  to  be  taken  mcry  four 
liours;  a  tablespoon fnl  of  brandy  with  milk  was  also  given.  At  11  A.  M.,  after  the  second  dosu  of  (|uinia  an<l  nior|diia 
had  been  taken,  he  became  unconscious  but  without  tetanic  symptoms;  eyes  injected:  ]ui)>ils  contracted:  liead  hot  ami 
perspiring  juofasely:  general  temperature  elevated  :  ]mls<'  180:  impulse  of  heart  strong  and  respiration  hurried.  The 
(|uinia-nH)ri)hine  solution  was  omitted  and  the  liroinide  renewed  every  two  hours;  tini'ture  of  veratrum  viride  in 
three-drop  doses  was  also  ordered  to  be  taken  every  two  hours,  but  as  it  made  no  impression  it  was  discontinmil. 
H<^  grew  steadily  worse,  passing  urine  and  fa-ces  involuntarily.  At  1  A.  M.  of  the  HOtli  he  had  a  severe  chill  which 
lasted  an  hour  and  was  followed  by  high  fever,  after  which  his  ]iniiils  gradually  ililati'il  and  <'onui  supervened,  ending 
in  death  at  5  r.  >f.  Ponl-mortem  examination:  The  skin  was  of  a  decided  yellow  color.  The  nunubraues  of  the  brain 
were  nuicli  injected;  the  anterior,  superior  and  posterior  surfaces  of  the  cerebral  lu'mis|)lieres,  the  ocrebelluiu  and 
medulla  ol)longata  were  covered  with  patclies  of  yellowish  matter  which  were  thickest  along  the  median  lino  and  in 
the  sulci;  there  were  about  two  ounces  of  bloody  serum  at  the  base  of  the  brain;  the  brain-substance  was  normal  ■ 
the  pineal  gland  congested.  The  membranes  of  the  spinal  cord  were  deeply  congested  and  tilled  with  bloody  serum. 
The  i)ericardium  contained  three  ounces  of  blood-tinged  serum;  the  coronary  vessels  were  lurgiil;  the  walls  of  tin- 
heart  softened;  the  aorta  reddened.  The  right  luug  was  slightly  congesli'd ;  the  left  nnich  congested  )iosteriorly. 
partially  hepatized  and  softened.  The  omentum  was  congested  in  patches;  a  portion  of  the  lower  ileum,  about  two 
feet  in  length,  was  congested.  The  blood  was  dark  and  uucoagul.iled  excipt  a  slight  clotting  in  the  right  ventricle 
of  the  heart. — Cumberland  Jluspitiil,  Md. 

Dr.  Calvin  G.  Page  lias  publislird'''  tlu'  clinical  records  of  uinctecu  cases  dF  cerebro- 
spinal meningitis  that  occurred  among  recruits  at  (lalloupe's  Tsbind,  llnston  llarlior,  Afass., 
from  September,  ]  8Gi,  to  May,  1865.  Aledical  Inspector  ( }.  J 1 .  Lym  a  n,  U.  S.  Army,  referred, 
March  20,  1865,  the  causation  of  these  cases  to  overcrowding  iind  defective  ventilation. 
Measles  prevailed  among  the  recruits  at  the  s;ime  time. 

The  post  was  organized  for  the  reception  of  recruits  and  drafted  men  from  this  state,  ami  as  a  depot  for  lho.s<> 
in  transit  from  the  rendezvous  in  Maine  and  >iew  ilam|ishire.  There  are  twenty  liarracks  in  all;  lour  are  occupied 
by  tile  |iernuinent  garrison,  the  remaining  sixteen,  lOOx'JOx  1(1  feet  and  furnished  with  two  tiers  of  bunks,  were  each 
intended  for  one  hundred  recruits,  giving  two  hundred  and  eighty  feet  of  air-space  lier  unin.  These  (|uarti'rs  have 
been  suthcient  for  the  post  until  this  winter,  when  they  l)eeauu'  overirowded,  owing  to  the  diliicully  of  olit.iiniug 
transportation.  Eaeji  barrack  has  bei'U  oeeujiied  by  an  average  of  from  one  hundred  and  fifty  to  two  liniidreil  mi'ii. 
The  conseciuence  has  been  an  increased  amount  of  sickness  and  the  developniiiil  of  a  few  easi's  of  cerebrospinal  men- 
ingitis.    To  add  to  the  difficulty  an  epidemic  of  measles  occurred,  but  this  is  now  declining. 

The  following  excellent  report  of  fulminant  cases  among  recruits  id,  Concord,  N.  11.. 
was  filed  March  1,  1865,  by  Act.  Ass't  Burgeon  Al.r.KliT  II.  Cuoshy.  ( )verci'owding  had 
apparently  little  to  do  with  these  developments,  as  none  of  those  aflected  had  been  at  the 
rendezvous  for  more  than  a  few  days.  The  evidence  ])oinls  ratlu'r  to  an  infection  in  the  locality 
whence  the  young  men  were  derived. 

I  have  the  honor  to  report  the  details  of  eight  cases  of  epidemic  cerebro-si)inal  meningitis,  live  of  which  occurred 
in  camp  under  my  personal  observation.  Of  the  latter  four  died,  and  as  the  disea.se  seems  now  to  be  attractin.g 
attention,  owing  to  its  appearance  in  other  places,  I  have  thought  that  a  record  of  these  might  be  of  value. 

Case  1. — Gilman  McAlpin,  recruit,  ISthX.  II.;  age  20  years:  in  camp  six  <lays:  well  develojied.  with  light  hair 
and  eyes  and  lymphatic  temperament,  came  into  hospital  .lanuary  -iO,  saying  he  had  had  a  lit.  As  he  came  from  the 
barracks  and  had  no  bunk  mate  I  could  not  obtain  a  reliable  account  of  this  lit  or  of  his  conilition  during  the  ))revious 
night.  At  this  time,  8  a.  m.,  he  was  somewhat  feverish  and  intensely  thirsty;  he  was  inclined  to  vomit  and  had 
frefinent  dark-colored  and  fetid  watery  discharges  from  the  bowels:  his  pnl.se  was  small,  thread-like  and  rapid  and 
his  extremities  cold;  tongue  covered  with  a  brownish  coat;  skin  dry  and  harsh,  but  subseiiuently  bathed  in  a  clammy 
persjiiratiou.  He  was  immediately  jilaced  in  bed:  hot  stinnilating drinks  were  administered,  with  powders  of  (|uinine 
and  caiisicum.  Four  hours  afterwards  he  became  very  restless,  throwing  himself  about  in  bed,  groaning  and  pressing 
his  head  with  his  hands,  his  eyes  somewhat  injected  and  watery  and  the  pupils  dilated.  At  2  i'.  >I.  he  ceased  to  answer 
questions,  but  the  jactitation  increased  and  the  groans  changeil  to  screams,  the  patient  bi'ing  ajiiuirently  in  great 
pain,  w  liich  seemed  general  and  not  confined  to  the  head.  At  3  v.  M.  nian.v  )ieteehia'  were  discovered  below  the  knees 
and  on  the  forearm  and  hands, — small  and  of  a  bright-red  color,  not  cdianging  or  disaiipei'.rir.g  un<ler  iiressurc.     About 


*  lu  the  Voslml  Mnl.  mi,l  Siinj.  J.inr.  I..\XI1I.,  ISUi'i,  imgf  lUil  cl  snj. 


584  DISEASKS    AI.LIKP    TO    OR    ASSOCTATKD    WITH 

till'  saiui'  time  the  licad  Avas  ihau  n  backward  updii  tlio  neck,  aiul  this  ]Hisilion  was  not  alti-reil  even  in  his  iiKist  restless 
monieiits.  The  treatiiunt  was  stiiiuilatinir,  with  Iieat  to  the  extremities  and  general  friction.  The  watery  (tiseliarges 
from  the  howel.s  eontinued,  becominj;  involuntary  during;  the  nij;ht:  there  was  also  oeeasional  vomitinj;.  At  !•  r.  M., 
I  called  Surgeon  J.  Smith  Ross.  V.  S.  N.,  in  charge  of  the  Depot  hospital,  to  see  the  case.  lie  suggested  cerehro-spinal 
meningitis  and  advised  a  continuance  of  the  treatment,  with  inunediate  vesication  of  the  sjiine  from  the  occiput  to 
the  dorsal  vertelira'  and  the  free  use  oi  turpentine  inteiiially  liy  enema  and  externally  hy  friction.  This  was  aectjrd- 
ingly  done.  The  symptoms  remained  as  dcserihed  for  tive  days,  when  the  patient  began  to  grow  more  (juiet  and  to 
notice  what  was  said  to  him.  It  was  then  discovered  that  he  was  totally  deaf  and  that  the  sight  of  the  right  eye 
was  wanting.  He  was  able  to  read  (juestions  writtin  upon  a  slate  and  to  make  intelligent  rcjjlies.  On  the  eighth 
day  after  his  seizure  he  began  to  complain  of  excruciating  pain  in  the  knees,  both  of  which  were  found  to  be  sn(dleii 
and  tender.  -A  wash  containing  acetate  of  lead  and  opium  soon  gave  relief,  and  from  tliis  time  convalese<'nce  w  a.s 
rapid.     To-day.  March  1.  he  is  able  to  Ije  out  of  doors,  slightly  deaf  and  with  sonu-  dimness  of  vision. 

C.vsK  2. — February  2.  at  11  A.  M..  I  was  called  to  see  a  recruit  for  the  ISth  regiment,  Henry  H.  Hook,  aged  19 
years,  -who  had  been  four  days  in  camp.  He  was  an  unconnuonly  stout,  well-built  young  man,  and  obviously  of 
great  muscular  strength.  I  found  him  lying  in  the  bunk  next  to  that  which  had  been  occupied  by  McAIpin,  and  my 
attention  was  at  once  attracted  to  certain  very  dark-purplish  spots  upon  his  cheeks  and  neck.  In  fact,  his  whole 
body  and  limbs  were  covered  with  them,  from  the  size  of  a  half-dime  to  that  of  a  Spanish  dollar.  He  complained 
of  nothing  but  a  slight  pain  in  his  head  and  intense  thirst :  sai<l  he  had  vomited  once  and  had  one  thin  discharge 
from  the  bowels.  At  this  time  it  was  impossible  to  detect  any  radial  pulse,  and  the  action  of  the  heart  was  well 
described  by  the  hospital  steward  as  a  jcrl'  and  a  tlittltr;  respiration  thirteen  i)er  minute  and  quite  loud;  extremities 
cold.  He  was  at  once  removed  to  hospital  and  an  actively  stimulating  treatment  counueneed.  Whiskey  and  quinine 
were  freely  administered:  sponges  saturated  in  alcohol  placed  in  the  axilhe:  alcohol,  hot  water  and  turpentine  itseil 
freely  upon  the  body  and  limbs,  and  constant  friction  maintained  by  two  "reliefs''  of  four  men  each.  Professor  D. 
CliOSHV,  of  Dartnu)uth,  happening  to  be  in  town,  was  called  in,  but  declined  to  give  an  opinion  as  to  the  disease. 
Dr.  Ross.  U.  S.  N.,  also  saw  him.  ]!oth  concurred  in  a  fatal  prognosis.  After  two  hours  of  incessant  lalior  the  radial 
pulse  could  just  be  felt  but  could  not  be  counted.  At  this  time  the  patient  said  ho  felt  better  and  was  confident  he 
would  recover.  The  spots  on  the  surface  became  darker  and  more  numerous  and  the  eyes  injected  and  watery,  but 
the  pupils  continued  nearly  normal.  Toward  evening  respiration  became  more  hurried  and  the  patient  vomited 
several  limes,  the  ejected  matters  consisting  merely  of  the  lluids  he  had  taken  during  the  afternoon.  His  mental 
f;iculties  were  entirely  uuobscured  until  two  hours  before  his  death,  when  he  became  comatose.  He  expired  at  S*  P.  Ji., 
just  ten  hours  after  he  entered  the  hospital.  He  was  proI>ably  sick  about  thirteen  liours,  for  it  was  found  that  ho 
was  up  and  dres.sed  early  that  morning  and  that  he  partook  of  breakfast  at  7.;W  A.  jr.  It  was  also  learned  that 
during  the  previous  day  he  had  been  eating  canned  lobster,  and  that  during  the  evening  he  had  been  in  unusually 
good  spirits,  having  kept  his  comrades  from  sleeping  by  his  jokes  and  fun  until  11  o'clock.  As  the  body  was  removed 
at  once  it  was  impossible  to  make  a  put^t-iiiortim  examination. 

From  February  2  until  the  1.5th  we  had  no  other  case  of  the  kind  and  were  hopeful  that  we  had  seen  the  last 
of  the  disease,  but  upon  the  morning  of  this  day  occurred  Cask  o.— .Vlbert  P..  Goldsmith,  recruit  18th  X.  H.,  age  18, 
who  had  been  six  days  in  camp,  ami  was  a  stout,  hearty,  fine-looking  fellow.  He  was  admitted  to  hospital  at  10 
.V.  jr.  suifering  with  headache,  rigors,  intense  thirst  and  vomiting;  pulse  126  to  130,  small  and  thread-like;  tongue 
covered  with  light-brown  fur:  extremities  cold  and  skin  moist  and  clammj-.  He  was  at  once  put  under  treatment 
similar  to  that  applied  to  the  last  case, — this  by  the  advice  of  all  the  iihysicians  who  saw  him.  For  some  hours  his 
system  responded  and  we  seemed  in  a  fair  way  to  get  reaction  established,  when,  at  9  r.  .M.,  the  fatal  plague-spots 
made  their  appearance  on  the  leg,  thence  spreading  over  the  whole  body,  but  much  less  numerous  than  in  Hook's 
ease;  the  color,  however,  was  the  same,  dark  purple-like  ecchymosis.  Respiration  now  became  hurried,  rising  from 
12  to  20  per  minute,  and  a  rattling  sound  was  heard  in  the  trachea.  He  complained  of  no  pain  and  talked  freely 
about  an  expected  furlough.  Three  hours  later  he  becaiue  utterly  unconscious  and  expired  at  2  o'clock,  fourteen 
hours  after  entering  the  hospital  and  five  hours  after  the  appearance  of  the  spots. 

The  disease  had  now  become  so  serious  that  I  requested  the  commanding  officer  of  the  rendezvous  to  convene 
a  board  of  medical  and  military  officers  to  investigate  it  and  make  a  thorough  sanitary  insiicction  of  the  camp.  Such 
a  board  was  in  fact  ordered,  but  owing  to  pressing  official  duties  Surgeon  Ross  of  the  Depot  hospital  was  not  able 
to  attend,  and  only  a  partial  autopsy  was  made  in  the  case  with  the  assistance  of  Dr.  A.  H.  Roiirxsox  of  this  city: 
Rigor  mortis  slight;  body  more  mottled  than  before  death;  on  retlecting  the  scalp  we  found  a  largo  (juantity  of  lluid 
blood  opposite  the  occipital  protuberance;  this  flowed  freely  and  ran  in  a  stream  to  the  floor.  Upon  removing  the 
calvaria  there  was  a,  slight  escape  of  serum  with  some  Idood  intermixed;  the  membranes  of  the  Iirain  seemed  to  have 
lost  their  clear  silver-like  transparency  and  were  dark-colored;  the  superficial  veins  were  distended  with  dark  blood 
and  were  considerably  increascil  in  size,  many  of  them  l)eing  as  large  as  a  conmion  quill ;  the  sinuses  were  also  enlarged 
and  distended  with  uucoagulated  Ijlood.  The  substance  of  the  brain  was  apparently  healthy;  the  ventricles  cou- 
taincd  a  moderate  quantity  of  .seium,  and  the  choroid  jilexus  was  natural  save  in  color,  which  was  lighter  tliaii 
usual.  The  tentorium  was  darker  and  more  opaque  than  the  dura  mater  and  araolinoid  and  seemed  distended  with 
lluid;  on  puncturing  it  slightly  there  was  an  immediate  and  rapid  flow  of  greenish-yellow  syrupy  li(]uid, — in 
quantity  about  five  ounces;  the  veins  of  the  cerebellum  were  distended  and  the  surface  dark  in  color,  Xothing 
unusual  was  observed  in  the  medulla  or  the  upper  i)ortion  of  the  cord.  The  spots  on  the  skin  were  founil  to  consist 
of  dark  blood  effused  into  all  the  tissues  ilown  to  the  subcutaneous  cellular;  on  dissesfiug  off  a  portion  the  color 
was  perfectly  retained  by  covering  the  cut  edges  with  guiM-pai)er.    As  it  was  nece.ssai-y  to  send  the  body  home  for 


THK    PAROXYSMAL    AND    CONTINUED    FF;VEES.  585 

interment  by  an  early  train  I  was  oliligeil  to  stop  the  exaniinatiou  at  this  point;  but  it  was  continucil  by  sonic  med- 
ical gentlemen  after  the  body  reached  home,  and  I  am  in(h'lited  to  Dr.  T.  V.  Buowx,  of  Chester,  for  the  report  of  the 
autop.sy  of  the  trunk  and  contained  organs,  made  about  forty-two  hours  after  death  by  Drs.  Buowx,  Eastman'  and 
Clauk  :  The  integument  on  the  neck  and  breast  was  of  a  scarlet  hue,  with  spots  of  extravasated  blood  throughout 
the  greater  part  of  the  remainder  of  the  body.  The  iuterual  organs  were  engorged  with  bluish-black  blood,  the 
veins  of  the  chest  in  particular  being  tilled  with  lilood  almost  blue  in  color.  The  liver  was  generally  darker  than 
natural  and  the  thinner  portions  of  its  lobes  presented  a  marbled  blue  ai)peaiaiice,  'I'lie  mucous  coat  of  the  stomach 
was  intact,  but  the  others  were  congested,  the  inllamiiiatory  condition  of  the  middle  and  submucous  showing  in 
irregular  light-red  spots  tlirough  the  mucous  lining;  some  of  these  were  mere  points,  others  extensive  patches.  The 
intestines  were  normal.     The  lungs  appeared  natural.     The  other  organs  were  not  examined. 

Four  days  more  elapsed  when  we  liad  Cask  4.— John  C.  T.  Webster,  recruit,  18tli  N.  II.;  age  Ut  years;  live  days 
in  camp  ;  came  into  the  dispensary  and  asked  me  to  look  at  his  arms  to  decide  if  certain  s|>ots  he  liad  discovered 
were  li'ke  those  upon  Goldsmith.  To  be  sure  they  were, — the  same  dark-iuirple  spots,  only  few  in  number  and  small 
in  size.  He  complained  of  nothing  but  thirst,  and  tho  only  other  obvious  symptom  was  the  injected  and  watery 
appearance  of  the  eyes;  pulse  1V2,  soft  and  small.  Tho  treatment  was  tlie  same  as  in  Hook's  case. — stimulation  by 
every  known  method  within  reach  and  every  effort  to  restore  the  skin  to  its  natural  condition.  He  complained  of 
no  pain  at  any  time,  and  was  only  troubled  by  excessive  nausea  and  ficciuent  vomiting.  Tliiee  bonis  after  taking 
to  bed  he  became  entirely  comatose  and  remained  in  this  condition  eight  hours.  During  this  period  our  etlorts  to 
induce  reaction  were  unremitting,  and  at  9  r.  M.  nature  rewarded  our  labor,  for  the  iiatieut  openeil  his  eyi's,  tho 
pupils  of  which  were  slightly  dilated,  and  recogui/ed  me,  calling  me  by  name  and  expressing  a  desire  to  jiass  water, 
which  he  accomplished  with  ease.  }le  drank  a  glass  of  whiskey-iiunch,  holding  the  tumbler  himself,  and  saiil  ho 
felt  perfectly  well.  Tho  stimulating  treatment  was  continued  during  the  night  and  lie  api>arently  grew  no  worse; 
answered  when  spoken  to  and  changed  his  position  in  bed  freiiiiently.  His  extremities  were  warm  and  the  skin 
natural,  with  no  new  spots.  In  fact  1  could  not  but  believe  that  he  w.as  in  a  fair  way  to  recovery.  This  continued 
until  6  A.  M,,  when  he  called  for  water;  the  attendant  stepjied  to  the  table  to  ]ire)iare  him  a  jmiicli.  Immediately  a 
gurgling  sound  was  heard,  and  when  the  nurse  turned  he  found  tho  patient's  head  thrown  back  on  the  pillow,  tho 
spots  on  his  face  darker  in  color  and  the  breathing  slow  and  laboreil,  I'.verylhing  that  was  jiossible  was  done  to 
arouse  him,  but  he  sank  rapidly,  and  expired  at  (i.l.'i  A.  M.,  twenty  hours  after  the  attack.  Tiie  jionl  iiiviirm  examina- 
tion ill  this  case  also  was  liiii  ried;  but  the  following  was  developed  :  lira  in  heallliy  save  in  the  distention  of  its  veins 
with  lluid  bloo<l ;  niemlnaiies  dark  and  with  a  consideialde  e  tins  ion  of  light -red  Ivmph  about  the  e<'rel)i'llum.  J.uiigs 
and  liver  engorged  but  lu'althy.  Stomach  covered  in  places  with  light  veriiiilicin  spots  which  sliowe<l  through  the 
intact  mucous  coat  and  also  througli  the  peritoneal  covering;  the  miiseular  coat  was  engorged  with  blood, — in  fact, 
by  holding  a  freshly-cut  jiicce  edgi'wise  the  divisicui  between  the  three  layers  was  perfectly  distinct,  the  muscular 
portion  seeming  inoi<'  than  ouc-sixtli  of  an  incli  in  tliiikiiess. 

C'a.se  ;":. — George  D.  Mocue,  recruit,  IMh  N.  II.;  a  line  looking,  hciillhy  young  man;  age  21;  twelve  days  in 
camp;  came  into  the  dis|ieiisary  I'l'bruary  'Jit,  and  after  leaning  against  tli<^  eonnler  inviteil  my  attention  by  tho 
in(iuiry  if  1  thought  \w  had  ilir  ditciiKi:  He  complained  of  thirst  ami  gieat  pain  in  the  head;  his  eyes  were  injected 
and  overllowing;  ]mlse  small  and  rajiid;  respiration  hurried,  lb' was  at  onco  iilaced  in  the  ward  ami  an  active 
course  of  internal  and  external  stimulation  comineiiced.  'I'nrpcntine,  was  given  ratlu^r  moie  freely  than  in  the  other 
cases,  and  was  used  generally  aliout  the  body.  At  this  Jiiiicturo  Capt.  Silvey,  Assistant  I'rovost  Marshal  Gincral  for 
the  State  and  ex  ojjicio  at  the  hea'd  of  the  recruiting  service,  re<iuested  me  lo  telegraph  to  Hanover  for  Professor  Dixi 
Ciiosnv.  This  was  done;  he  and  some  other  medical  gentlemeii  were  sniuni<nicd,  but  unfortunately  did  not  arrive  in 
time.  This  patient  said  he  had  felt  unwell  in  the  night  iind  bci  n  very  thirsty  for  hours,  but  pain  in  the  head  had  not 
cmne  on  until  after  daylight.  He  was  put  under  tieatiiient  at  «  o(  lock,  I'nder  the  inlluence  of  a  drink  compo.sed  of 
whiskey,  ginger  and  capsicum  ho  rallie<l  somewhat  and  his  pnlso  gained  in  strength  but  did  not  increase  in  fre- 
■luency.  About  10  A.  >I.  one  spot  made  its  appearance  on  his  leg,  followed  in  two  hours  by  a  few  others  siiarsely 
distributed  over  the  body.  The  purple  spots  weri'  less  marked  in  this  case  than  in  any  of  the  others.  About  noon 
he  became  comatose  and  his  respiration  slow  and  very  peculiar;  he  would  draw  in  the  air  with  a  prolongi'd  ell'ort, 
and  after  a  second  or  two  suddenly  exjicl  it  with  great  force,— rcpi-ating  this  eleven  times  jier  minute,  liet'ore 
becoming  completely  unconscious  he  would  snap  with  his  teeth  at  the  glass  contaiiiitig  his  ilrink  or  mi'dicine  and 
was  api>arently  in  some  pain,  although  he  could  not  be  induced  to  answer  finestions.  At  2.t.".  r.  m.  ho  threw  bis  nead 
back  violently  upon  tlie  pillow;  his  breathing  became  shorter  and  was  accompanied  by  a  rattling  in  the  trachea. 
He  died  at  3  v.  M.,  seven  hours  after  his  admission.  roHt-iiiortnii  examination  seventeen  hours  after  death,  in  presence 
of  Drs.  D.  and  H,  B,  Cro.shy,  Dartmouth  College,  and  Dr,  l\  H,  .STii.WKi.r.,  V.  S.  A..  Kigor  mortis  well  established; 
considerable  discoloration  about  the  neck  and  heli.x  of  the  ear,— in  fact  this  has  been  observed  in  all  the  fatal  cases. 
On  cutting  through  the  scalp  blood  of  a  dark  color  tlowed  readily;  the  membranes  of  the  brain  were  nearly  or  <inite 
natural  and  the  veins  and  sinuses  but  little  enlarged.  All  present,  however,  were  struck  with  the  very  great  ditl'er- 
ence  existing  in  the  size  of  the  hemispheres,  tho  right  being  less  than  two-thirds  the  size  of  the  left,  and  the  dividing 
line,  instead  of  running  exactly  in  the  centre,  ran  directly  under  the  right  parietal  protuberance.  There  was  a  very 
slight  effusion  into  the  vi'iitricles.  and  the  substance  of  the  brain  was  apiiarently  healthy.  Upon  removing  the  cere- 
bellum entire,  small  points  of  calcareous  matter  were  discovered  at  the  base,  on  the  surface  and  under  the  investing 
membrane.  There  was  no  efi'usion  into  the  ventricles  and  the  cerebro-spiual  fluid  was  normal  in  iniantity.  The  lungs 
were  somewhat  engorged,  blood  flowing  freely  after  the  scalpel;  and  the  same  was  true  of  the  liver,  although  the 
color  of  the  latter  was  nearly  natural.  The  stomach  was  filled  with  an  amber-colored  liiiuid,  probably  consisting  of 
Mki),  Hist,,  I't.  111—71 


586  DISKASKS    ALl.IKD    TO    OR    ASsOCIATKI>    WirU. 

the  medk-ines  mihI  drink  adiiiinisreiiMl,  and  in  llic  iuti'iior.  near  tin'  lar^i'  curvatnri',  wiTc  soattoied  hriiilit  vi'iinilion- 
culored  spots  arranged  in  jHiints  and  patilios.  ^ 

It  slionld  lie  stated  that  all  these  young  men  eanie  from  Chester  and  irs  vicinity.  In  fact  these  and  three 
other  cases  which  occurred  at  homo  dnrinj;  the  last  week  of  I'ebrnary.  came  from  ur  resided  within  a  radius  of  ten 
miles  from  that  village.  lam  indehted  to  Dr.  Biuiwx.  of  Chester,  for  ,i  r.'port  of  the  c.iso  of  a  young  man  who  died 
within  a  few  rods  of  tioldsmith's  residence: 

C.\SE  ().— II.  M.,  a  young  farnu-r,  19  years  of  age,  of  strictly  temperate  hahits,  who  had  not  been  from  luuue  for 
several  nu>nths,  complained  of  a  feeling  of  uneasiness  during  tlie  forenoon  of  February  17,  but  continued  about  his 
business  until  I  r.  M..  when  he  gave  nji  his  work  on  account  of  liejdaehe.  and  thinking  he  had  caught  cold  took  some 
domestic  stimulanls  to  overcome  the  feeling  of  chilliness  which  oppressed  him.  lie  liad  a  burning  thirst,  which  was 
allayed  by  copious  draughts.  Severe  rigors  were  experienced  during  the  night,  and  ho  had  several  dark-colored  dis- 
charges from  the  bowels:  the  urine  was  free  and  apparently  natural.  This  was  gathered  from  the  attendant,  as  I  was 
not  called  until  8  o'clock  next  day,  at  which  time  the  respiration  was  hurried  and  the  pulso  at  the  wrist  almost  imper- 
ceptible, though  the  heart  Could  be  heard,  its  first  sound  being  a  kind  of  snap,  the  second  only  a  quiver  or  tremor. 
The  left  side  of  the  face  wa.s  swollen,  the  eyes  congested,  the  skin  beginning  to  show  the  peculiar  spotted  appearance 
of  extra  vasatod  blood,  dark-red  and  generally  distributed  over  the  surface  :  one  spot  was  large,  three  or  four  lines  in 
its  longest  diameter.  His  ears  were  bluish,  especially  at  the  helix.  The  respiratiiui  continued  rapid  and  the  heart 
beat  with  less  force  until  midnight,  when  he  died.  During  the  whole  time  the  intellect  remained  clear:  the  patient 
said  he  sjift'ered  no  pain,  yet  his  countenance  wore  an  indescribable  locd^  of  anguisli  and  despair,  although  he  had 
not  been  informed  of  the  terrible  nature  of  the  disease.     So  po^t-m^irleiii  examination  was  obtained. 

Cask  7. — A  furloughed  soldier  from  the  IStli  X.  11.  died  at  his  houu'  February  27,  in  Londonderry,  after  an 
illness  of  eleven  hours,  with  symptoms  like  those  of  Hook.     Xo  report  of  his  case  could  be  obtained. 

Case  8.— A  young  woman  em]doyod  in  one  of  the  factories  at  Manchester  died  F'ebruary  28.  She  was  appa- 
rently well  the  evening  before,  but  woke  up  in  the  night  complaining  of  violent  pain  in  the  head  and  intense  thirst, 
soon  followed  by  chills.  She  was  treated  by  a  Thompsonian  with  the  usual  red  pepper  and  hot  bath.  These  at  first 
relieved  her,  and  the  spots  did  not  make  their  appearance  until  0  a.  m.  They  were  of  a  dark  color  and  very  numer- 
ous. Other  physicians  were  called,  who  persisted  in  a  stimulating  course  of  treatment,  but  she  becanu'  comatose 
and  at  2  r.  M.  died,  thirteen  hours  after  she  tirst  complained. 

It  will  be  seen  that  in  all  the  fatal  cases  the  spots  were  of  a  dark-rod  or  jiurplo  hue,  while  in  the  tirst  case, 
which  recovered,  they  were  bright-red  and  suurll  in  size :  all  had  rigors,  the  chill  being  usually  the  first  symptom ;  all 
complained  of  thirst  and  all  but  one  of  pain  in  the  head:  in  all  there  was  an  injected  and  watery  condition  of  the 
eyes:  in  all  the  intellect  was  clear  until  the  supervention  of  coma  :  all  were  under  twenty  years  of  ago  and  of  remark- 
ably good  habits,  sons  of  farmers  in  the  same  neighborhood:  all  liad  been  in  camp  only  a  few  days;  none  of  the 
]ienuanent  garrison  or  recruits  from  other  places  were  attacked.  It  is  worthy  of  notice  that  the  liistory  of  six  of 
these  cases  shows  that  on  the  day  preceding  their  seizure  the  patients  were  in  uncommonly  good  spirits.  This  was 
so  marked  in  the  cases  of  Hook,  Goldsmith  and  Webster  tliat  it  was  observed  at  the  time  by  their  comrades,  and  I  am 
informed  that  the  same  was  true  of  the  young  woman  who  died  at  Manchester.  Only  two  points  of  uniform  resem- 
blance are  observed  in  the  poat-mortvm  appearances:  1st.  The  unusual  tluidity  of  the  blood,  and  2d,  the  peculiar  spots 
upon  the  inner  coaf  of  the  stomach.  The  appearance  of  the  brain  and  its  surroundings  diftered  in  every  case,  and  in 
no  case  was  there  true  intlammation.  Great  uniformity  will  be  observed  in  the  manner  of  death. ).  e..  rapid  asthenia. 
:rll  Seeming  to  have  been  ))rostrated  at  once  by  the  shock  of  the  invasion  acting  upon  the  nervous  centres.  In  con- 
clusion I  would  state  that  I  adopted  every  means  in  my  power  to  prevent  the  spread  of  the  disease.  The  cases  were 
put  in  a  sojiarate  ward;  the  recruits  themselves  were  isolated.  The  whole  hospital  and  barracks  were  thoroughly 
purified  and  ventilated:  free  use  was  made  of  the  disinfectant  agents  furnished  by  Government.  Peruussion  to 
furlough  the  men  from  the  particular  locality  whence  all  these  cases  were  derived  was  refused  by  the  Secretary  of 
War  on  the  ground  that  this  measure  might  tend  more  to  the  propagation  than  the  suppression  of  the  epidemic. 

Among  the  Colored  Troop.s,  ticcorJinfj  to  Bur<reon  Ira  Ru.'^sell.  U.  S.  Yol.s..  tlie  clis- 
ease  pre-sented  essentially  the  same  feature.s  as  in  tlie  cases  of  white  men.  This  officer  when 
on  <Inty  at  Benton  Barracks,  St.  Louis,  Mo.,  oliserved  an  tpiJemic  in  .lanuarv,  ISG-i,  amonir 
the  colored  troops  at  tliat  rendezvous..  The  men,  who  were  mostly  escaped  or  emancipated 
slaves,  had  endured  many  hardships  hefore  their  arrival.  They  were  crowded  together  in 
imperfectly  heated  Cjuarters  and  had  an  insuthcient  supply  of  clothing  for  the  very  cold 
weather  of  that  season. 

Forty-two  oases  were  reported,  many  of  them  genuine  cases  of  cerebro-spinal  meningitis, — post-mortem  exami- 
nation showing  exudation  of  lymph  or  pus  on  the  arachnoid  of  thi^  brain  and  spinal  cord,  with  the  superficial 
cerebral  vessels  highly  congested  and  the  arachnoidal  and  ventricular  cavities  filled  with  serum.  The  early  symp- 
toms were  much  like  those  of  pneumonia:  The  patient  had  a  slight  chill,  white  tongue,  sumll  rapid  pulse,  dull 
headache  and  pain  in  the  back  and  limbs.  These  symptoms  continued  several  days,  when  a  severe  chill  ensued. 
attended  at  first  with  violent  delirium  and  afterwards  with  coma,  the  surface  all  the  while  cold,  the  pulse  small  or 


latt-r-rulur  Jniwini^  uf  tliese  liglit-rctl  !i|),»ts  (,('  Mibriiu,(ni>  ,-\trinasjitiun  \\u^  Hlfl  with  I»r.  <'itn,;nY's  repnrt. 


TIIK    PAKOXYSMAL    AND    a)NTINrKI)    I'KVKRS!.  5S7 

imperceptililf,  the  musclt's  of  tlio  liaek  retract  in,;;  the  liead  spasmodically  ami  tljosc  of  the  lej;8  and  arms  more  or  h-ss 
rigid,  deglutition  imperfect  or  impossible,  and  death  as  the  usual  result.  Occasionally,  however,  after  from  one  to 
four  days,  reaction  took  ]dace,  wainith  returned  to  the  surface,  the  sjiasms  relaxed,  <'oma  wa.s  di.ssipated,  and  fc\  er  of 
a  typhoid  type  set  in  which  ran  a  longer  or  shorter  jieriod  with  variable  results,  t^uinia  was  giv<n  freely  in  the 
early  stages  to  exerci.se  a  contiolliiig  inliuence  over  the  disc;i.s<-.  1  luring  tin'  I'ohl  and  comatose  stages  siiiajiisms  to  the 
surface  and  cups  to  the  s])ine  were  employed,  with  (luinia.  capsicum  an<l  alc(diollc  stimulants  internally. 

iVi'Iiaps  llio  opiJfiiiic  aiiioii^^r  llie  negro  lalionTs  al  the  cavalrv  dcpni  aM  licsl.iirn'  I'lunl. 
Ml].,  was  an  outbreak  dt' tliis  (.lisrase,  luit  the  roeoi-tls  tlo  iidt  ideiililV  it.  The  re(|iiest  ..I'thc 
superintendent  i'ur  assistance,  dateil  Xov.  2").  lS6o,  states  that  ■'culoivd  nien^ierteetlv  ht  alihv 
at  niulit  ai'e  found  dead  in  the  morning  and  nianv  of  tlie  cniplovevs  are  heconiin'j;  jianic- 
f^tricken."  A  board  ol'  medical  otlioers  appointed  on  the  I'uHowing  dav  to  enquire  into  the 
causes  of  the  epidemic  did  not  extend  its  research.es  beyond  the  ollieial  requirement.  The 
opinion  was  submitted  that  the  preponderating  causes  of  the  epidemic  existed  prior  to  the 
admission  of  tlie  negroes  into  the  camp,  there  liaving  lieeii  exposures  ami  laek  of  suitable 
food  and  clothing,  and  that  the  development  of  the  disease  hail  been  coiistmimat'd  bv  the 
continued  operation  of  these  causes,  together  with  sleeping  on  damp  iiav  in  Sibh'v  tents 
without  floors  or  ventilation.  The  report  states  tliat  the  epidemic  alTeeted  eiiieflv  those  who 
had  come  from  the  eastern  shore  of  Alarvland  and  \'irgiiiia,  and  that  among  live  hundred 
men  from  these  Irrealities  tliere  had  been  twenty-eight  fatal  cases.  lUit  nothing  is  said  of 
the  disease  in  its  clinical  or  pathological  asju-cts. 

Among  tiik  Conkkiieratk  Ti^xm's. — A  single  case  from  the  records  of  the  I'etti'jrew 
hospital,  Raleigh,  X.  C,  signed  liv  Iv  lU'UKK  IFayWooii,  ('.  S.  A.,  appears  among  the  papi-rs 
on  iile  in  tliis  oifice.  The  case  was  regarded  as  one  ot' t\'[iho;il  lever,  but  opisthoinnle  i-ii^iiiit  v 
and  paralysis  sufficiently  indicated  the  imphealion  of  the  cerebi-o-spinal  s\-stem. 

Private  Joliii  Snyder,  a  coii.script  from  Xortli  (Jaroliiia  ;  age  Hit :  nniNciilaraiid  strong;  wan  admit  led  Manh  !•,  IHCil. 
lie  coniidained  of  being  chilly  and  had  some  fever.  Four  grains  of  Dover's  powder  were  administeied  every  three 
lionrs.  In  the  evening  the  wkin  was  moist  though  there  was  hIIU  Nome  fever.  Kpistaxis  occurred  during  the  night, 
and  next  morning  the  jnilsi'  was  S.'i  to  ill)  and  moderately  full  and  tlie  tongue  coateil  with  a  while  t'ur.  .Swcct  spirit 
of  uitre  in  teaspoonful  doses  \\;is  oidcred  every  two  hours.  Soon  afl<'rwjird.s  lu^  con)]ilained  ot"  nansc.i  and  vomited 
80nio  blood  with  bile  and  curdled  milk.  .\  sinapism  was  aiiidii'd  over  the  e|iigasti  iiim,  alti'r  which  the  vomiting 
ceased.  In  the  evening  he  had  some  jiain  iu  the  ba<k  and  aching  in  Ihi'  legs;  as  his  bowels  had  not  been  opened  for 
several  days  a  ]iill  of  blue  ma.ss,  rhnl)arb  and  aloes  wa.'*  administeicd.  At  7  .\.  M.  of  the  llth  liis  jinlse  was  .'ibout 
itO,  less  full  and  more  compresHible;  the  tongue  when  jirojei-ted  was  s<imi'what  )>ointcil  and  still  furred;  he  comjilained 
of  aching  in  the  neck,  shonlders  and  legs,  and  of  jiaiu  in  th(<  small  of  the  liack;  he  was  rather  dull  in  answering 
(jnestions.  His  bowids  being  still  icintincd,  he  was  given  a  talilesjKxinfnl  of  castor  oil.  which  ([uickly  piodnccd  two 
good  stools,  A  sinapism  was  ajiplied  over  the  Inmliar  region,  'J  he  disease  a]>pearing  to  be  typhoid  fever,  oil  of  tur- 
pentine, five  drops,  with  sulphate  of  quinine,  one  grain,  and  sweet  spirit  of  nitre,  a  drachm,  were  given  every 
three  hours.  In  the  afternoon  he  was  reported  worse  and  was  found  scratching  continnotiHly  against  the  wall  of 
tlie  room  with  his  right  hand,  his  brow  corrugated,  pupils  dilated  and  expression  wild;  he  was  also  speechless: 
pulse  about  90;  temperature  raised;  muscles  of  the  extremities  and  back  rigidly  contracted.  Sixteen  ounces  of  blooil 
were  drawn.  An  hour  afterwards  there  was  no  change  in  the  symjitoms.  Various  measures  were  tried, — hot  foot- 
bath,s,  sinapisms  to  the  back  of  the  neck  and  down  the  s]>ine,  bandages  dipped  iu  hot  turpentine  w  ia]iped  armind 
the  legs  and  allowed  to  remain  until  in  some  places  blisters  appeared, — but  the  |>aticnt  grew  worse;  the  )iupils  con- 
tracted almost  to  the  size  of  a  pin's  point;  the  eyes  becaum  much  congesteil ;  the  breathing  stertorous  and  sns|)endcd 
at  intervals  for  fifteen  to  twenty  seconds;  he  strangled  when  lii|nids  were  ])laced  in  his  mouth.  He  died  at  i.'M)  next 
morning.     From  the  beginning  of  the  attack  to  the  end  his  right  arm  was  active  but  the  left  leg  was  motionless. 

The  Confederate  States  2IedicaJ  (IikI  Surrncal  Jmirnal,  jmblished  under  tlie  auspices 
of  the  Surgeon  General's  Office,  C.  S.  .\...  contains  two  articles  on  eereljro-spinal  meninu'itis. 

In  the  first.  Surgeon  G.  A.  Moses,  of  Mobile,  Ala.,  called  attention  to  the  di.sease  as  he  oliserved  it  among  the 
negroes.  He  was  jiarticularly  struck  by  the  suddenness  of  its  declaration,  its  rapid  <leveIo])nicnt  and  termination. 
The  subjects,  generally  young  and  robust,  were  to  all  apiiearances  in  good  health,  when  a  chill  or  pain  in  the  head 
attracted  attention.  This  pain  was  concentrated  about  the  base;  the  neck  became  stitt'and  pains  were  felt  in  the 
extremities  or  in  the  abdomen;  opisthotonic  convulsions  occurred,  every  movement  attended  Avith  intense  jiain. 
Meanwhile  the  patient  became  stupid  and  ultimately  comatose,  the  pupils  dilated  or  inactive.  The  tongue,  at  first 
moist  and  normal  or  covered  witli  a  whitish  fur,  became  dry,  hard  and  swollen;  the  bowels  constipated:  the  pulse 


588  PISKASF.S    AI.LTEll    TO    OR    ASSOCTATKn    WITH 

sniull  and  .slow  and  tin-  vtspiratiuii  laliored,  -vvith  profuse  diaiiUoresis  ln't'ore  death.  Siiuietinies  tii(!  severe  sytiiptoins 
intermitted  for  twelve  or  t  wentv-1'our  hours,  suggest iuf;  the  lio|)e  i)f  a  favorable  issue,  but  suddenly  a  relapse  oceurred 
wliicli  ended  in  death.  The  tirst  syiuptoni  whieli  attraeted  attention  appeared  to  indicate  not  tlie  commeneeuient  of 
the  disease  lint  its  maturity.  In  cases  that  ended  fatally  in  from  ten  to  lifteen  hours  lymph  was  effused  larjiely  in  the 
pia  nuiter.  Dr.  S.  V.  Yot'Xi;,  P. A.l'.S.,  was  cited  as  haviiis;  known  of  tu)  recovery  in  thirty-live  eases  that  came 
under  his  observation  when  the  disease  prevailed  in  lirenada,  Miss.,  in  the  winter  of  18t)li-til.  None  of  Dr.  Moses's 
eases  lived  thron^h  the  fifth  ilay.  He  does  not  state  their  number,  but  ^ives  notes  of  four  as  typical  of  the  others. 
These  are  abstracted  as  follows: 

1.  Alec,  a  slave :  age  2") ;  was  admitted  March  24, 18tU,  at  10  .\.  M.,  having;  felt  somewhat  unwell  on  the  previous 
day.  There  was  some  congestion  of  the  left  lung  and  rigidity  of  tlie  posterior  cervical  muscles.  A  purgative  of 
calomel  aiul  jalap  was  prescribed,  but  he  refused  to  take  it:  wet  cups  were  applied  to  the  chest  and  the  cold  douche 
to  the  head,  the  latter  used  continuously  for  half  an  hour  at  a.  time  every  alternate  half  hour ;  one  drachm  of  whiskey 
was  given  every  half  hour.  At  1  r.  M.  he  became  noisily  delirious  and  was  restrained  in  bed  with  diflicnlty.  At  5 
r.  Jt.  the  pupils  were  largely  dilated  and  inactive:  the  iiatient  jiassed  his  urine  involuntarily  and  cried  as  if  suffer- 
ing: pulse 80,  irregular, soft  and  ijuick  :  respiration  28.  Next  day  he  was  comatose:  pupils  contracted  ;  skin  perspiring; 
pulse  110,  fuller  and  softer:  respiration  somewhat  quicker.  He  died  at  0.30  .v.  M.  of  the  2lith.  Post-iiiiirtDii  examina- 
t  ion :  The  vessel.s  of  the  cerebral  meninges  were  nuieh  congested,  very  tortuous  and  surrounded  with  exuded  lymph ; 
the  base  of  the  brain  was  coated  with  lymph  and  pus  and  the  ventricles  contained  turbid  sernnt:  the  spinal  cord 
posteriorly  was  covered  with  exudation. 

2.  Henry,  a  slave;  age  2."i;  was  admitted  at  0  p.  M.,  March  0,  18tU,  having  had  a  chill  before  entering.  Until 
1  r.  M.  of  the  r_'th  jiain  in  the  head  was  so  intense  that  the  patient  had  to  be  removed  to  a  detached  room  on  account 
of  his  groans  and  outcries.  As  coma  supervened  the  pupils  became  dilated  and  almost  inactive.  Death  occurred 
at  4  A.M. of  the  lltli.  He  was  treated  with  five  grains  of  iodide  of  potassium  every  hour,  and  towards  the  end  the 
scalp  was  blistered  and  stimulants  admiuistered.  I'ofit-morUii)  examiiuition:  Pacchionian  bodies  enlarged;  deposits 
of  lymph  between  the  arachnoid  and  pia  mater:  lymph  and  pus  at  the  base  of  the  brain:  substance  of  the  cerebel- 
lum reddened  and  slightly  softened  superficially. 

0.  John,  a  slave;  age  28:  was  sick  for  two  days  with  a  profuse  and  freiiuent  diarrhoea  before  admission  at  .5 
r.  M.,  March  19,  18(54,  when  his  bowels  were  quiet,  tongue  dry  and  covered  in  the  centre  with  a  wliite  fur;  skin 
natural:  pulse  148,  suuiU  and  soft:  pupils  contracted  and  motionless;  he  complained  of  x)ain  in  the  head,  neck  and 
extremities,  particularly  in  the  arms.  Half  an  ounce  of  whiskey  every  liour  constituted  the  only  treatment.  He  died 
twenty-four  hours  after  admission,  roal-niortim  examination  :  The  dura  mater  in  several  places  near  the  Pacchionian 
bodies  adhered  to  the  visceral  arachnoid:  lymph  was  found  in  the  course  of  the  meningeal  vessels  and  posterior  to 
the  optic  ciimniissure;  the  spinal  cord  was  healthy. 

4.  The  patient  was  admitted  Feb.  24,  ISlil,  with  symptoms  of  pneiunonia,  but  in  twenty-four  hours  indications 
of  meningitis  were  developed  and  death  occurred  on  the  tifth  day.  The  peculiarity  of  this  case  consisted  of  the 
enlargement  of  the  contiacted  pupils  on  exposure  to  light.     The  usual  ^)os(-)»or/()ji  appearances  were  discovered. 

The  article  written  by  Dr.  ilosKS  led  Surgeon  P.  (Iervais  Robixsox,  P.  A,  C.  S.,  to  publish  an  account  of  four 
cases  whieli  occurred  in  the  22d  X.  C.  in  the  winter  of  18(i2-t>3,  while  encamped  on  the  Kappahannock  near  Fredericks- 
burg. \a.  The  soldiers  attacked  were  members  of  the  same  company;  three  were  conscrijits  and  had  been  in  camp 
but  little  more  than  a  month:  the  fourth  was  a  veteran.  Of  the  conscripts  two  were  brothers  and  the  third  their 
brother-iu-law.     The  veteran  only  recovered: 

1.  The  ]iatieut  complained  at  tirst  of  a  persistent  ilull  headache,  the  only  other  symptom  being  a  constipated 
condition  of  the  bowels.  On  the  fifth  day  he  became  profoundly  comatose  and  died.  Croton  oil  overcame  the  con- 
stipation; blisters  over  the  spine  and  cold  applications  to  the  head  had  no  evident  influence  on  the  course  of  the 
disease.  Posl-moytmi  examination  :  The  surface  of  the  braiu  was  much  and  generally  injected,  and  there  was  an  exten- 
sive eti'usion  beneath  the  arachnoid  with  occasionally  coagulated  patches  of  a  yellow  color,  particularly  along  the 
longitudinal  sinus,  at  the  base  of  the  brain  and  the  commencement  of  the  cord,  Xo  effusion  was  found  in  the  ven- 
tricles, nor  did  the  substance  of  the  brain  presint  any  sign  of  having  i)arlicipated  in  the  inllamniation, 

2.  On  the  day  the  first  soldier  died  his  brother  eomidained  of  dull  headache  and  in  the  evening  became 
violently  and  suddenly  delirious,  reqturing  the  aid  of  several  men  to  restrain  him.  The  more  violent  paroxysms  were 
controlled  by  the  cold  douche  to  the  head,  and  by  the  continued  application  of  cold  cloths  delirium  subsided  and 
reason  was  restored.  The  bowels  were  moved  by  croton  oil  and  blisters  were  applied  to  the  spine.  During  this 
period  of  intermission  the  patient  was  tramiuil,  partaking  of  such  light  nourishment  as  could  be  piocured  in  camp; 
the  pulse,  tongue  and  skin  were  normal,  and  perhaps  the  only  appreciable  signs  of  a  braiu  lesion  were  exhibited  in 
paralysis  of  the  sensory  roots  of  the  fifth  pair  and  an  unnatural  aeuteness  of  hearing.  Towards  the  end  of  the  fifth 
day  the  pupils  became  dilated  and  the  patient  comatose  until  death  occurred,  a1>out  the  seventh  day.  Post-morion 
examination:  The  lymphy  exudations  were  more  extensive  than  in  the  first  case  and  the  injection  of  the  meningeal 
vessels  greater;  the  lateral  ventricles  were  distended  with  liquid, 

3.  The  case  of  the  brother  in-law  followed  closely  on  the  second.  In  this  headache  was  succeeded  by  maniacal 
delirium,  after  which  there  was  a  period  of  deceptive  intermission.  Deafness  was  observed  on  the  third  day;  ccdlap.se 
and  couui  supervened  about  the  sixth  ;  death  oceurred  on  the  ninth,  .'^mall  doses  of  calonu'l  were  given  until  a  gentle 
I)tyalism  was  developed:  stimulants  were  administered  during  the  intermission  and  stimulating  enemata  in  the  last 
stage,  but  without  apparent  benefit.     The  jw^'-i/ioi/'iH  ajtpearances  were  similar  to  those  in  the  second  case, 

1.  Hefoie  the  termination  of  the  third  case  the  veteran  was  taken  with  headache  succeeded  by  delirium  less 
violent  than  in  the  two  cases  immediately  precetling.     This  subsided  in  the  cour.se  of  thirty-six  hours,  and  althiJU"-li 


THK    TAEOXYSMAL    AND    CONTINL'KL)    FKVKR;;.  589 

tlip  pain  ill  tlie  head  coiitinueil  for  some  days  the  patient  gradually  inipidViMl  until  about  the  .sixth  <ir  seventli  day, 
when  convalescence  was  fairly  established. 

J  )r.  Joseph  Joxes  lias  publiilKAl  two  reports  from  tlie  files  of  tiie  iSurgeon  Geiiei-iil's  OHiee, 
C;  S.  A.,  wliicli,  with  two  cases  reconleJ  liy  himself  and  the  papers  already  jiresented,  consti- 
tute tlic  main  portion  of  the  frai;-mentarv  records  of  cereliru-sjnnal  i'fv^v  ]>ivsi'rved  hy  the 
medical  officers  of  the  Confederacy. 

W.  I).  MncilKl.r,,  Senior  Sid-j/eon.  lUioiUs'  Brhjudi.  }-\h.  1,1803. — The  following  case  is  one  of  six  fatal  cases  which 
have  occurred  in  my  regiment,  all  similar  in  the  symptoms,  with  a  few  tritling  and  nniiiiiiortant  variations.  It  is 
well  to  remark  that  in  every  instance  the  subjects  have  been  robust,  lieallliy  men  and  in  the  prime  of  life: 

Sergeant  A.  (jemeany,  3d  Ala.;  age  28  years,  tall  and  robust;  was  taken  on  the  morning  of  the  ."ith  of  .laiiiiary 
with  a  severe  chill  attended  with  vomiting  and  pains  in  the  abdomen  ;  the  bowels  were  const  ipatc<l ;  he  siilVered  dur- 
ing the  day  with  severe  headache  and  pains  in  the  hack  and  neck;  the  feeling  of  (diilliness  eontiiiiu'd;  ln'  was  jierfeetly 
sensible  during  the  day,  talked  to  his  friends  in  a  natural  manner  and  jiartook  of  food  in  the  shape  of  soup  at  the 
dinner  house;  he  continued  in  this  ccuidition  until  about  10  i'.  Ji.,  when  a  convulsion  caused  his  inessinates  to  call 
lue  to  see  him;  they  had  up  to  this  time  considered  his  ease  as  one  of  chill  and  fever  and  paid  but  little  attention  to  the 
matter;  this  convulsion,  whicli  they  described  as  exceedingly  violent  and  of  nearly  a  half-liour's  duration,  was  the 
first  symptom  to  excite  their  fears.  On  arriving  at  his  teut  I  found  him  in  a  condition  resembling  the  collapse  of 
cholera  Asiatica  (could  bo  aroused  when  spoken  to  in  a  loud  voici>  or  when  shaken,  but  his  answers  were  not  very 
intelligible),  surface  of  liody  cold  and  covered  with  bluish-red  patches  sinh  as  aro  seen  in  hemorrhagica  (lurpura. 
There  was  not  at  this  time  any  symptimi  of  either  paralysis  or  tetaiins;  the  pulse  was  full  but  very  slow,  the  ])upils 
contracted  but  responding  readily  to  the  action  of  light ;  res])iration  was  laboreil,  and  there  was  a  constant  llow  fr<uii 
the  nostrils  of  a  yellowish  slightly  fetid  lluid.  This  condition  continued  without  the  a|i|)earance  of  other  symptoms 
until  about  1  a.  m.,  when  a  species  of  reaction  ensued,  severe  and  entirely  unciMilrollable.  (Kxpecting  this  from  the 
condition  of  the  pulse  upon  my  fust  examination,  1  had  iiiado  tlie  alteni]it,  notwithstanding  the  apiiearance  of  col- 
lapse, thinking  tliat  the  condition  of  the  pulse  warranted  me  in  this,  to  h'ssen  the  (juantity  of  blood  by  opening  the 
temporal  artery,  but  the  blood  refused  to  tlow,  as  it  did  also  from  the  arm.)  Convulsion,  or,  more  ]>ro)>erly,  spasm 
after  spasm  in  ra)>id  succession  ensued.  Theefforts  at  respiration  became  painful  to  the  beholder;  niiitlering<leliriuiu 
followed  after  about  two  hours'  duration  of  this  condition  ;  the  intestines  liad  remained  cold  during  the  whole  of  this 
time;  respiration  became  less  laliored;  the  ]uilse  was  now  fast  and  thready.  At  8  o'clock  next  morning  I  found  the 
patient  fast  sinking:  the  niuttcrings  had  ceased,  resjiiratlon  was  slow  but  not  luhored,  the  jinlse  very  fast  hut  scarcely 
perceptible,  the  pujiils  ])reternaturally  dilated  and  not  responding  to  the  a<'tioii  of  light,  the  sphincters  relaxed,  the 
entire  surface  of  the  body  cold  and  the  spots  before  spoken  of  very  much  increased.  With  thesi'  symptoms  gradually 
increasing,  the  patient  died  at  !'  .\.  m. 

Dr.  IMiTi'iiELL  was  inclined  tn  consider  his  cases  related  to  tvphns.     The  other  report 
is  hy  Burgeon  .1.  T.  liAXKs,  loth  (ra.,  Fredericksburg,  Va.,  ^larcli  2S,  ]sr)3. 

Dr.  Ii\NK.s  docs  not  state  tlieiiuniber  of  his  eases,  but  giv<>s  tlii'  particulars  of  his  (Ifth  ease  as  illuslrativecpf  the 
whole.  All,  he  says,  were  stout,  healthy  soldiers;  three  or  four  of  them  c:ireless  of  protection,  I'ontidenl  in  their 
jihysical  endurance  and  all  inured  to  camp  life;  ages  from  lit  to  27  years. 

Thompson,  of  Co.  E;  age  21 :  felt  well  and  ate  a  full  supper  on  March  13,  isr>3.  but  comjilained  of  feeling  badly 
at  bedtime.  During  the  night  he  liail  a  chill  and  vomited  his  «ii)i))er.  At  1  A.  M.  tin'  chill  passed  olV;  imlse  liMl.  I:irge, 
soft,  compressible;  skin  warm;  face  Hushed,  with  a  sliglit  purjile  tinge;  eyes  injected  and  watery;  iiu]iils  normal; 
expression  dull  and  dejected;  tongue  coated  white  and  moist ;  liead  easy;  mind  clear;  respiration  of  a  moaning  char 
acter,  but  without  cough,  and  full  and  easy  when  engaged  in  conversation,  lie  complained  of  intense  and  unbearablo 
pain  in  his  legs  and  begged  for  something  to  relieve  it.  Three  grains  each  of  calomel  ami  ipecacuanha,  with  half  a 
grain  of  opium,  were  given,  and  at  6  A.  M.,  his  condition  being  unchanged,  two  ounces  of  blood  were  drawn  by  enps 
from  the  nape  of  the  neck.  An  emetic  of  ipecacuanha  and  warm  water  given  at  this  time  brought  u|)  nothing  but  .a 
little  glairy  luucus.  An  hour  later  the  pur]ile  tinge  in  his  face  was  deepened  and  the  circulation  dejiressed.  Mustard 
was  applied  along  the  spine  and  (luiniue,  four  grains,  caiuidior  and  caiisicum,  of  each  six  grains,  and  calomel,  three 
grains,  were  prescribed  for  administration  hourly.  At  noon  there  was  no  jmlsation  at  the  wrist;  nevertheless  the 
patient  was  able  to  rise  fnun  his  bed  and  walk  aViout.  aided  by  two  comrades.  Morjdiia  was  addc<l  to  the  treatment, 
but  the  pain  continued  unrelieved.  Towards  evening  the  extremities  became  cold  and  tlu!  Hush  on  the  face  changed 
to  a  mottled  jmrplo  hue.  lie  died  at  11  v.  M.,  his  mind  clear  to  tln^  last.  I'linl-morlim  examination:  Body  in  good 
condition;  skin  discolored  by  extravasation  of  blood.  The  arachnoid  was  somewhat  cloudy  and  had  three  small, 
well-delined,  opaque  spots  over  the  iijiper  part  of  the  left  cereliral  liemisi>liere.  The  veins  were  engorged,  but  there 
wa»iio  eflusion  in  the  ventricles  and  the  brain-matter  was  of  natural  color  and  consistence.  The  condition  of  the 
spinal  cord  is  not  stated.  The  only  notable  appearances  in  the  abdomen  cousisted  of  slight  injection  of  the  small 
intestine,  enlargement  of  the  spleen  to  double  its  usual  size  and  great  distention  of  the  gall-bladder  by  yellow  healthy- 
looking  bile.  The  lower  half  of  the  right  lung  was  engorged  and  its  lower  bord<'r  coated  with  plastic  lymph;  its 
ujiper  half  and  the  left  lung  were  healthy.  The  pericardium  was  normal;  the  heart  contained  firm  fibrinous  clots 
in  all  its  cavities  closely  interwoven  with  the  valves;  the  veins  emptying  into  the  heart  were  full  of  Ihiid  blood. 

Although  at  the  time  the  !.M'ound  was  covered  with  snow  Dr.  Banks  was  inclined  to 


590  MSKA^^ES    A].LIKn    TO    OK    AsSOCTATKn    AVITU 

con>iJer  liis  cases  concestivo  malarial  fevers,  as  reniittonts  ami  iutonaittents  hail  been  eoin- 
inon  in  liis  re^-inrent  all  llie  winter,  lie  ili.l  not  reLi'arJ  the  meningeal  lesion  suffieient  t(> 
account  for  Jeath,  while  the  course  of  the  disease  negatived  the  idea  of  typhus. 

Dr.  JoXKs's  cases  were  two  of  six  which  occurred  at  Augusta,  Ga.,  early  in  1865,  in 
the  3d  Ga.  This  regiment  was  encaniiied  in  a  valley;  regiments  occu[»ying  the  neiglilooring 
hills  were  unaffected.  All  tlu^  cases  ended  fatally.  The  symptoms  were  nausea,  vomiting, 
diarrhoea  and  convulsions  followed  liy  severe  pain  in  the  head,  extending  along  the  spine, 
alternate  contraction  ami  dilatation  of  the  pupils,  low  uuittering,  spasms,  delirium  and  coma. 

Case  1. — I'lh  ate  Goosliy  was  taken.  Feliruary  12,  with  soreness  in  tlie  cliest  and  congli,  pain  in  t  lie  head  and  back, 
nausea  and  sli^jlit  diairlupa.  As  the  liver  was  enlarged  and  tender,  a  1)lister  was  applied  to  relieve  tlic  engorgement. 
On  the  llth  delirium  set  in  with  uucontrollal>le  restlessness  and  loud  cries.  In  lucid  intervals  the  patient  complained 
of  violent  pain  in  the  head.  A  blister  was  applied  to  the  hack  of  the  head  and  neck,  ten  ounces  of  blood  were 
abstracted  and  quinine  freely  administered  at  intervals,  but  the  disease  progressed  steadily,  the  prominent  symptoms 
being  muttering  delirium,  contraction  of  the  pupils,  deafness,  rigidity  of  the  muscles  of  the  neck  and  spine,  slow 
pulse,  impeded  respiration  and  torpid  bowels.  Death  occurred  on  the  25th.  rost-mortcm  examination  eight  hours 
after  death:  Dura  mater  normal  :  arachnoid  opalescent  over  the  sulci;  pia  mater  congested  and  the  larger  veins  and 
many  of  the  arteries  distended  with  dark-colored  blood.  The  parts  at  the  base  of  the  brain  and  the  spinal  cord 
were  coated  with  a  firm,  light,  greenish-yellow,  wax-like  fibrinous  exudation  of  considerable  thickuess.  Large  tracts 
of  the  cerebrum,  cerebellum,  the  cauda  equina  and  most  of  the  roots  of  the  spinal  nerves  were  also  coated,  but  the 
deposit  on  these  parts  was  thinner  and  less  consistent  than  at  the  base  of  the  brain  or  on  the  cord,  and  in  many  places 
it  required  close  inspection  of  the  pia  mater  for  its  discovery.  The  third  and  lateral  ventricles  were  distended  with  a 
light  greenish-yellow,  semi-fluid,  pus-like  matter,  and  their  walls  were  coated  with  a  layer  of  semi-organize<l  plastic 
lymph.  Under  the  microscope  the  layers  of  exudation  resembled  the  lymph  thrown  out  in  mechanical  injuries  and 
acute  inflammations ;  the  liquid  exudation  of  the  ventricles  consisted  of  a  serous  fluid  containing  numerous  exudation 
cells  similar  to  those  of  ordinary  inflannuatory  processes,  together  with  free  nuclei  and  granules  in  considerable  num- 
bers. Xo  exudation  was  observed  on  the  free  surface  of  the  arachnoid.  The  right  lobe  of  the  liver  was  congested  and 
dark-e(dored,  its  under  surface  slate-colored:  the  spleen  was  somewhat  larger  and  softer  than  usuiil.  The  mucous 
membrane  of  the  stonutch  was  congested  and  ecehymosed  in  spots;  that  of  the  intestinal  canal,  parlieularly  of  the 
lower  part  of  the  ileum,  was  also  somewhat  congested,  but  the  glands  were  apparently  normal. 

Case  2. private  H.  Powell :  age  20:  was  brought  to  hospital  at  uoou  March  12,  having  been  taken  sick  during 

the  previous  night.  His  head  was  thrown  back  and  he  cried  out  in  agony  when  disturbed  from  this  imsition  :  pulse 
'JO,  small  and  quick;  eyes  slightly  crossed;  pupils  dilated  but  mobile;  hearing  impaired;  mind  stupefied,  but  he  put 
out  his  tongue  when  desired  to  do  so.  On  the  IGth  he  became  very  deaf  and  was  unable  to  articulate.  Death  on  the 
17th  was  preceded  by  labored  breathing  and  profuse  perspiration,  rost-mortcm  examination:  The  cerebro-spinal 
membranes  were  congested,  their  veins  distended  with  black  blood,  the  cavity  of  the  arachnoid  filled  with  serum. 
The  base  of  the  brain  was  covered  with  lymph  and  the  ventricles  contained  li(iuid  effusion.  The  cord  was  coated 
with  lymph  nearly  one-fourth  of  an  inch  tliick  on  the  posterior  aspect  but  thinner  in  front. 

Amo.xo  Till-;  PiusoxKi:.-^. — The  records  present  nothing  definite  with  regard  to  the  occur- 
rence of  cend.ro-spinal  i'ev<T  among  the  prisoners  on  either  side.  I'ruhahly  the  disease  was 
relatively  more  frequent  among  them  than  among  the  troops  on  service.  The  patients  in 
several  of  the  cases  given  above  were  received  from  the  guarddiouse  or  prison.  Unfortunately 
the  ])risou  repiorts  do  not  intimate  the  existence  of  cerebro-spinal  f'ver  or  uieningitis;  they 
show,  however,  a  lar<rer  death-rate  from  hypertemic  conditions  ot  the  cerebro-spinal  system 
than  those  of  tlie  white  troups  generally:  In  the  nine  ].rison  depots  already  desci'ibed  there 
were  IGO  deaths  reported  as  from  inflammation  of  the  brain,  of  its  membranes  and  of  the 
spinal  cord.  This  is  ef|ual  to  an  annual  death-rate  of  1.06  per  1,000  men;  Init  flu;  corres- 
ponding rate  among  our  white  troops  was  only  .93  per  1,000. 

n.— SYMPTOMATOLOGY  AKD  PATHOLOGICAL  ANATOMY. 

The  clinical  liistories  of  the  one  hundred  and  live  cases  preserved  by  our  medical  ofHcers 
necessarily  present  some  variety,  as  their  course  exteiide.l  from  five  and  a  lialf  hours  to  more 
than  that  number  of  wodcs.  A  better  understanding  of  the  character  of  these  cases  may 
be  obtained  by  disregarding  for  the  moment  the  extreme  cases  while  studying  those  of  mean 


THK    iWEOXYSMAI.    AM)    COXTIXl"  KD    FKVKRS.  591 

or  average  i.luratioii.  Tlie  plienomena  of  the  simple  forms  of  these  consisted  of  a  chill  fol- 
lowed by  more  or  less  reaction,  during  which  intense  headache  and  restlessness  eventuated 
in  delirium.  com;i  and  death,  the  process  occupying  from  tliive  to  ten  days.  To  these  svmp- 
toms  in  tlic  more  fi)in}ilicated  cases  were  added  pain  in  some  part  of  the  spine,  extending 
thence  occasionally  to  the  extremities,  tetanic  spasms  and  {laralys'is;  and  tliese  jjhenomeiia 
were  associated  or  n')t  witli  the  aj^pearance  of  petechiie  or  [nu'puric  spots  or  blotches  im  tli<:> 
general  surface. 

The  fir.st-iiieiitiiiiicd  sci  ics  incliuli-s  oasc,^  43.  45,  4(5  ami  1(10.  with  tlieii-  lii-iiionliaiiic  lilotclu'.-ij 
Ami  oases  ">,  21,  211,  31,  33  and  .")4,  in  wliicli  no  spots  weiv  recorded. 

The  second  series  comprises  cases  '.K  12,  53.  »<3,  81,  XT,  00  and  105,  ■vvhicli  were  variously  simtteil. 
And  cases  l(i,  30,  34,  3.S.  55,  57,  (55,  CO,  (iT,  72.  74.  77.  80  and  103.  wliicli  were  free  from  sjiots  so  far  as  appears 
from  the  record. 

The  initiatory  chill  in  these  tliirty-two  cases  was  usuallv  disiincllv  marked,  although 
in  1(5  it  is  said  to  have  been  slight,  while  in  a  few  cases  the  record  does  not  mention  its 
occurrence,  the  attack  having  commenced  aj)jiarentlv  with  lieadaclie,  nausea  and  vomiting. 
In  67  the  severity  of  the  chill  led  the  case  to  be  regarded  as  one  of  congestive  interraittcnt 
fever.  The  reaction  in  this  instance  was  imperfect,  for  it  is  stated  that  a  low  form  of  cerebro- 
spinal meningitis  was  developed;  usually,  however,  the  reaction  was  cif  some  intensitv, 
the  face  becomiiiii;  flushed,  the  eves  injected  and  waterv,  thr'  skin  iiot  and  di'v  and  the 
secretions  diminisheil.  Nausea  and  vomiting,  generallv  of  gi'een  liiliarv  matter,  as  in  43, 
45  and  90,  were  sometimes  noted;  in  the  iii'st  of  these  cases  the  \(imiting  was  persistent. 
Exceptionally,  as  in  89,  the  ojecta  cuiilained  luiubricoid  worms,  manv  otliers  of  wlueli  were 
afterwards  found  in  tlie  stomach  and  intestines.  Intense  pain  was  developed,  usually  in  the 
occiput  and  back  of  the  neck,  Init  sometimes,  as  in  84,  in  tia'  foi'eliead  and  temples;  in  105 
the  pain  extende'd  down  the  spine  and  in  72  over  the  body  generally.  On  the  other  liand, 
in  loo  there  was  iio  heailache,  the  distressing  pain  being  con(ine(l  to  the  lumbar  region. 
The  pulse  was  freipKMitlv  (piiclv  and  full;  in  a  i'l.'W  instances  it  was  characterized  as  hard; 
in  a  few  also  it  was  rajiid  and  alnujst  imjierreptible. 

As  rciiction  was  established  the  tongue  fi'om  lieing  moist  and  clean,  or  more  or  less 
furred,  was  observed  in  9,  83,  81,  105  and  others  to  become  dry,  red  and  al'lerwards  dark- 
colored,  while  sordes  appeared  on  the  teeth  and  gums.  The  increasing  pain  was  generally 
associated  with  delirious  restlessness,  moaning,  outcries  or  incoherent  talk,  tlie  patient  tossing 
himself  from  side  to  side  of  the  bed  or  so  persistently  endeavoring  to  get  up  that  men  had 
to  be  constantly  on  guai'd  to  restrain  him.  In  one  case,  84,  the  delirium  is  said  to  have 
been  of  a  humorous  character.  The  pupils  Avere  natural  or  contracted.  Boinetimes  also 
retention  of  urine  added  to  the  distress  of  the  patient  at  this  stage;  in  lUo  delirium  and 
restlessness  were  certainly  in  part  due  to  the  sufTering  from  this  cause.  Jactitation  was  in 
many  cases  modified  bv  tonic  spasms,  generally  of  the  extensors  of  the  head,  the  patient  lying 
on  his  back  with  his  knees  drawn  up,  his  head  thrown  back  and  the  cervical  muscles  rigid; 
in  case  12  the  facial  muscles  were  involved  and  the  patient  scjuinted;  in  53  contraction  of 
the  flexors  of  the  right  side  was  followed  by  their  paralysis;  in  06,  also,  the  right  side  was 
paralyzed;  in  83  and  84  the  jiatients  reeled  and  staggered  when  roused  from  their  delirium 
and  placed  upon  their  feet;  and  in  30  this  staggering  gait  was  followed  by  paraplegia. 
Sometimes,  as  in  43,  there  was  hypenesthesia  of  the  general  surface. 

Delirium  continued  for  an  uneertain  period,  but  ultimately  the  patient  became  less  vio- 
lent, noisy  or  restless,  and  was  aroused  to  consciousness  with  increased  difficulty.      In  some, 


592  Ii|>K.\-i:>     Al.r.IKlt    Ti»    OK     AfSueiATr.li     WITH 

us  72,  tlic  trtanic  spasms  |ifi-si>l<il  nolwitlistandinu-  tin;'  JffpouiiiLi-  cuina.  Ian  giaicrally  those 
subsided  as  the  pu|vils  became  elihited,  the  pulse  solUa-,  fuller  aiul  weaker,  the  slciii  cool  ami 
covered  with  rnoistur(\  tlie  breathing  labored  and  the  stupor  profound:  iuN'oluntary  passages 
"were  common  during  this  period. 

The  presence  or  absence  of  ]nu-purie  .spots  appeared  to  exercise  no  iniluenee  on  the 
progress  of  the  disease.  These  generally  appeared  during  the  stage  of  delirium.  They  con- 
sisted of  purplish-red  spots  of  various  sizes,  usually  from  one-eighth  to  three-eighths  ot  an 
inch  in  diameter,  although  sometimes  larger  originallv  or  by  coalescence.  They  persisted 
under  pressure  and  were  in  some  instances  slightly  elevated.  Certain  regions  of  the  surface 
were  speciallvaftected  in  individual  cases  but  not  in  the  aggregate.  A  few  indistinct  spots 
were  observed  on  the  loins  in  case  90.  Usually,  however,  they  were  scattered  over  the  sur- 
face, sparselv  as  in  83,  but  generally  closely  set  and  more  numerous  on  some  parts  than  others, 
as  on  the  limbs  in  9;  on  the  lower  extremities  and  especiallv  in  the  vicinity  of  the  joints  in 
83;  on  the  chest  and  abdomen  in  45.  In  100,  besides  the  petechial  spots,  a  dark  rash,  dis- 
ajipearing  underpressure,  is  said  to  have  been  present,  and  in  53  some  pink  spots  were  noted 
in  addition  to  the  dark-colored  blotches. 

The  post-7norfcm  appearances  of  the  cerebro-spinal  axis  were  very  similar  in  all  these  cases. 
A  hv])er£emic  condition  of  the  pia  mater  constituted  the  anatonrical  or  local  essential,  and 
on  this  depended  certain  secondary  changes  in  the  subarachnoid  spaces  and  ventricles.  The 
vessels  underlviny  the  visceral  arachnoid  were  engorcjedwith  black  fluid  blood.  Serum  was 
sometimes  noted,  as  in  105,  at  the  base  of  the  brain  and  in  the  membranes  of  tlie  cord,  but 
the  characteristic  lesion  appeared  to  be  the  exudation  of  a  yellowish  or  greenisli  lymph  or 
pus  beneatb  the  arachnoid,  apparently  thickening  that  membrane  and  destroying  its  trans- 
parencv  throughout  more  or  less  of  its  extent.  The  parts  most  frequently  and  extensively 
affected  bv  the  deposit  were  the  base  of  the  brain,  the  pons  Varolii,  cerebellum,  medulla 
oblongata,  tlie  spinal  cord  and  tlie  sulci  between  the  convolutions  of  the  cerebral  hemispheres. 
The  de2")0sit  was  tough,  fibrinous  and  oftentimes  two  or  three  lines  in  thickness,  or  it  was  soft 
and  senii-purulent.  With  the  exception  of  cases  57  and  100,  which  will  bo  referred  to  par- 
ticularlv  hereafter,  and  12,  whieji  was  not  examined  after  death,  it  was  ])resent  in  all  the 
above-mentioned  cases,  always  at  tlie'  base  ot  the  brain,  frec|ueutly  in  the  sulci  and  some- 
times over  the  surface  of  the  convolutions.  In  some  instances  the  condition  of  the  pia  mater 
of  the  cord  is  not  stated,  probably  because  it  was  not  examined.  In  others  the  cord  is  said 
to  have  been  coated  with  this  plastic  or  seiui-jiumlent  deposit,  sometimes  uniformly,  as  in 
90,  at  other  times  chieilv  on  its  posterior  aspect,  as  in  oo  and  87;  while  in  some  cases.  a> 
45,  the  membranes  are  said  to  have  been  infiltrated  with  pus.  But  in  certain  cases,  as  34, 
it  is  definitelv  stated  that  although  the  membranes  of  the  cord  were  congested  there  was  no 
exudation  on  its  surface,  and  in  74  there  appears  ti>  have  been  not  even  congestion.  The 
serous  surface  of  the  arachnoid  was  unailected  except  in  two  cases — 43,  in  which  the  cavity 
contained  effusion,  and  83,  which  i:)resented  some  recent  adhesions  between  the  visceral  and 
parietal  layers.  The  ventricles  usually  contained  a  turbid'  effusion  or  serum  with  a  semi- 
purulent  deposit,  while  their  walls  were  coated  with  vellowish  lymph.  In  some  of  the  sjiotted 
cases,  as  in  43,  4o,  87  and  105.  the  effused  serum  was  tinged  with  blood,  but  in  others  it 
was  turbid  or  purulent,  as  in  the  unspotted  cases,  and  while  in  46,  a  spotted  case,  there  was 
no  serum  in  the  ventricles,  in  67,  an  unspotted  case,  these  cavities  were  unusually  diy. 
The  exceptional  cases,  57  nnd  lOf),  presented  no  positive  sitni  of  intlammatiriu  of  tin.'  mem- 


THE    PAi;OXY,-MAL    AND    CONTINrKD    FEVERS.  59S 

branes,  altliougli  more  or  less  cuiige^tiouwas  present.  Tlie  I'uniier  was  eharacterized  by  stupor 
and  spasiris,  and  typlius  ur  fuhninant  typlioid,  as  in  58,  59  and  60,  to  Ite  instaneed  hereafter, 
was  not  wholly  t'xcludcil  in  tlie  diagnosis.  Tlie  symptoms  in  the  latter  pointed  to  a  spinal 
meningitis;  Imt  althnugh  the  2'ia  inater  was  engorged  and  serum  effused  into  the  subarach- 
noid space  no  mention  is  made  of  the  characteristic  deposits  of  lymph  and  pus;  the  bk)od, 
which  was  liquid  and  dark-colored,  formed  ecchymosed  spots  on  the  viscera  of  the  thorax 
and  abdomen,  as  in  case  28,  to  be  mentioned  hereafter. 

The  substance  of  the  bram  was  not  uniformly  afiected.  In  some  its  condition  was  not 
stated,  in  others  it  was  recorded  healthy.  In  84  it  presented  dark-colored  jjuncta;  in  5i  and 
55  it  was  congested;  in  45,  46,  89  and  103  congested  and  softened.'  In  34  tlie  cerebellum 
was  considered  pultaceous;  in  72  it  was  soft  and  its  gray  matter  almost  as  pale  as  its  white 
substance ;  in  tlie  former  case  the  cord  was  congested,  in  the  latter  softened.  The  cord  was 
also  soft  in  83  and  90,  a  section  of  its  lower  part  in  the  last-mentioned  case  having  given 
issue  to  a  greenish  liquid. 

The  anatomical  appearances  of  the  thoracic  and  abdominal  viscera  were  inconstant,  and 
hence  more  or  less  accidental.  They  are  omitted  at  this  time  to  permit  of  the  uninterrupted 
study  of  the  symptoms  and  meningeal  lesions  of  the  remainder  of  the  one  hundred  and  five 
cases  presented  as  cerebro-spinal  fever. 

Twenty  of  these  cases  ran  a  more  rapid  course,  ending  fatally  in  a,  lew  hours  or  in  a  day 
or  two  after  the  development  of  the  disease. 

Ten  of  tliein  were  nuienlated,  13,  14,  27,  28,  49,  50,  t)2,  Xl!,  i"2  and  !«•; 

The  leinaiiKler,  4,  H,  24,  47,  SO,  91,  93,  95,  102  and  104,  so  far  ai*  appeaiH  from  tlio  reeords,  worn  frcp  from  H]>otH. 

Neither  the  symptoms  nor  tlio  post-mortem  appearances  of  these  cases  presented  the 
unitbrmity  observed  in  the  cases  already  discussed.  Rome,  however,  were  characterized  by 
a  sequence  of  symptoms  similar  to  that  noted  in  the  cases  of  longer  diu-ation.  In  cases  8, 
13,  24,  27,  47,  80,  92,  95  and  102  the  short  history  of  th.j  fatal  attack  embraced  chills, 
fever,  headache,  delirium  and  coma,  with  or  without  spasms  or  paralysis,  or  the  defective  record 
shows  only  the  sudden  development  of  fatal  coma  with  or  without  convulsive  seizures;  and 
ill  all  these  cases  the  characteristic  deposits  of  lymph  or  pus  wci'e  observed  under  the  arach- 
noid. In  102  the  purulent  deposits  were  confined  to  the  spinal  cord,  the  cerebral  pia  mater 
having  been  congested  merely. 

But  in  the  two  cases,  24  and  92,  the  exudation  appears  only  to  have  clouded  tla;  mem- 
brane, and  instead  of  a  purulent  infiltration  of  the  pia  mater  and  subarachnoid  tissue  the 
cerebro-spinal  fluid  was  generally  clear,  being  turbid  only  in  the  lower  part  of  the  cord.  These 
cases,  anatomically  considered,  form  the  only  links  of  connection  between  the  few  cases  that 
presented  simple  engorgement  of  the  vessels  with  perhaps  serous  effusion  and  the  many  that 
were  characterized  by  well-defined  inflammatory  products.  In  4,  91,  99  and  104  the  men- 
ingeal vessels  and  sinuses  were  filled  with  dark-colored  fluid  blood,  lait  no  deposits  of  lymph 
or  pus  were  present.  These  may  be  regarded  either  as  cases  of  malarial  congestion  or  of 
cerebro-spinal  fever  in  which  death  anticipated  the  development  of  the  local  lesion,  as  in  typhoid 
fever  it  may  anticipate  the  ulceration  of  the  glands  or  even  in  fulminant  cases  their  enlarge- 
ment. In  Ola  healthy  man  was  seized  with  an  agonizing  pain  between  the  shoulder  blades 
and,  after  j>aroxysmal  recurrences  of  the  pain,  died  sudilenly  five  and  a  half  hours  after  the 
first  attack.  In  4  a  sequence  of  headache,  chill  mid  ])erspiration  was  followed  by  coma,  trismus 
and  death  witliiu  thirty  hours  of  the  seizure.  In  i)9  death  took  place  from  collapse  after 
Mku.  Hist.,  Pt.  Ill— 75 


594  DI.'^EASE:^    ALLIED    TO    OR    ASSOriATE]!    WITH 

twenty-four  hours  of  fever,  delirium,  headache,  maculas  and  nervous  prostration.  In  104 
chill,  fever  and  ])erspiration  were  followed  by  a  recurrence  of  the  chill  and  fever  with  delirium, 
opisthotonos,  trismus  and  coma. 

It  is  perhaps  as  impossible  to  discriminate  between  these  cases  and  cases  of  pernicious 
malarial  fever  as  it  is  to  determine  the  etiology  from  the  symptoms  alone  in  cases  49,  50,  86 
and  93,  which  were  not  examined  after  death.  A  diagnosis  of  cerebro-spinal  fever  or  malarial 
congestion,  in  cases  where  only  meningeal  congestion  is  present,  involves  a  determination  of 
the  cause,  if  there  be,  indeed,  two  separate  and  distinct  diseases  manifesting  themselves  by 
this  condition  of  the  corebro-spinal  membranes.  In  50  and  86  analogy  would  anticipate  the 
presence  of  inflammatory  products  in  the  pia  mater;  the  symptoms  in  the  former  were  head- 
ache, chill,  irregular  blotches,  dulness  of  mind,  coma,  profuse  perspiration  and  death  in  about 
fifty-one  hours;  in  the  latter,  pain  in  the  head  and  neck,  restless  delirium,  petecliise,  an 
ansesthetized  condition  of  the  skin,  contraction  of  the  posterior  cervical  muscles  and  coma, 
with  death  at  the  end  of  two  days.  Case  49  was  probably  congestive;  it  was  characterized 
by  a  severe  and  long-continued  chill,  petechite-and  coalescing  purpuric  spots  with  coma  follow- 
ing, and  death  within  thirty  hours.  The  record  of  93  is,  on  the  other  hand,  suggestive  of 
typhoid  fever  in  its  virulent  form:  Debility  and  slight  mental  aberration,  fever  and  headache 
lasting  for  several  days,  ultimately  mild  delirium,  stupor  and  death  forty-eight  hours  after 
admission  to  hospital  but  an  uncertain  number  of  days  after  seizure. 

Three  cases  still  remain  for  remark — 14,  28  and  62.  The  nervous  symptoms  in  the  last 
are  notably  unlike  those  associated  with  undoubted  cerebro-spinal  inflammation  ;  and  typhoid 
fever  is  by  no  means  contraindicated  by  the  post-mortein  observations, — the  membranes  of 
the  brain  finely  congested  and  the  patches  of  Peyer  distmct,  hard  to  the  feel  and  black- 
pointed.  Case  14  is  of  interest,  inasmuch  as  it  occurred  in  an  epidemic  of  spotted  fever  attended 
with  the  exudation  of  products  of  inflammation  within  the  cranium  and  spinal  canal,  and  was 
regarded  by  the  attending  medical  officers  as  a  case  of  the  prevailing  disease.  Nevertheless  it 
presented  but  little  congestion  of  the  cerebro-spinal  membranes,  although  the  arachnoid  was 
slightly  opaque;  it  ended  in  collapse,  not  in  coma,  and  the  fatal  lesion  was  developed  in  the 
serous  lining  of  the  pericardium  instead  of  in  the  membranes  of  the  nervous  centres.  The 
pericardium  contained  six  or  eight  ounces  of  sero-i>urulent  liquid  with  large  masses  of  floccu- 
lent  lymph,  and  its  surface  was  covered  with  a  layer  of  lymph  membranous  in  tenacity  and 
thickness.  The  connection  of  pericarditis  with  a  diseased  condition  of  the  blood,  as  in  rheu- 
matic fever,  albuminuria,  etc.,  and  its  infrequency  as  a  spontaneous  idiopathic  affection,  argue 
that  in  the  present  instance  it  was  due  to  a  blood-poison,  and  in  view  of  the  nature  of  the 
cases  then  prevailing  at  New  Berne,  where  it  occurred,  to  the  same  blood-poison  that  in  other 
instances  educed  inflammatory  results  in  the  cerebro-spinal  membranes. 

The  following  case  illustrates  the  association  of  pericarditic  lesions  with  a  clinical  his- 
tory suggestive  of  cerebro-spinal  meningitis: 

Private  John  Buchanan,  Co.  L,15th  N.  Y.  Cav.,  was  admitted  Feb.  12,  1864,  with  headache,  severe  pain  in  tlie 
back,  nausea  and  slight  iuflaniniation  of  tlie  fauces.  He  was  sent  to  a  tent  where  eruptive  diseases  were  treated. 
The  tongue  became  heavily  coated  and  the  fever  and  headache  increased ;  low  delirium  followed  in  a  day  or  two,  with 
an  intense  rigidity  of  the  muscles  of  the  neck,  tympanitic  abdomen  and  strangury.  Ho  died  at  midnight  of  the 
15th.  He  was  treated  with  blue-pill,  Dover's  powder,  sweet  spirit  of  nitre,  ice  to  the  head,  catheterism,  wine-whey 
and  milk-punch,  rost-mortem  examination:  The  anterior  and  lower  part  of  the  right  lung  was  congested.  The  peri- 
cardium contained  an  ounce  of  sero-purulent  liquid  and  a  small  deposit  of  fibrin  on  the  surface  of  the  heart.  The 
peritoneum  was  slightly  congested;  the  intestines  distended  with  gas;  the  gall-bladder  large;  the  urinary  bladder 
^Utended  and  its  mucous  surface  congested. — Jet.  Ass't  Surg.  John  Goldshorough,  Hospital,  Frederick,  Md. 


THE    I'AKOXYSMAL    AND    CONTINL'KH    FEVERS. 


595 


Case  2S  is  uf  equal  interest,  but  from  another  point  of  view.  Agonizing  pain  in  the  back 
was  associated  witli  purple  spots  on  the  skin,  an  oozing  of  blood  into  the  mouth,  giving  a 
sweetish  taste  to  everything,  and  a  blood-color  in  the  urine.  These  symptoms  were  followed 
by  high  fever,  violent  delirium,  coma  and  death.  At  the  post-mortem  examination  the  brain 
was  found  to  be  healthy.  The  spinal  cord  unfortunately  does  not  appear  to  have  been  exam- 
ined. All  tlie  otlier  organs  of  the  body  were  covered  with  ecchymosed  spots.  On  account 
of  the  uncertainty  as  to  the  condition  of  tlie  spinal  cord  the  presence  of  a  spinal  fever  or 
meningitis,  as  anatomically  distinct  from  the  hypersemia  of  a  congestive  case  ot  malarial 
disease,  cannot  be  determined.  The  coma  and  death  in  this  case  must  be  ascribed  to  the  high 
febrile  condition  brought  about  by  a  deterioration  of  the  blood  analogous  to  that  present  in 
malarial  hsematuria  or  hemorrhagic  malarial  fever.*  Case  100,  already  described,  was  of  a 
similar  character. 

In  the  following  case,  submitted  in  this  connection,  the  dissolution  of  the  blood  and 
its  appearance  in  all  the  organs  and  secretions  led  to  the  diagnosis  of  ])urpura  hemorrhagica. 
The  mercurials  which  the  patient  had  taken,  although  the  cause  of  sonic  ol'  the  symptoms 
enumerated,  cannot  be  held  responsible  for  the  purpuric  colorations,  delirium  and  death. f 

Corporal  Joseph  B.  Grow,  Co   E,  3<1  Vt.  Art'y:  age  25;  innsc-nlar;  was  admittod  Jan.  Iti,  IHt!.".,  having  Ix-en 
attacked  four  days  before  with  a  severe  cliill,  general  pains,  nnicli  thirst,  nausea,  vomiting  and  diarrlnea.     On  adniis- 
Bion  the  vomiting  and  diarrhroa  were  reported  as  having  aliated;  tlie  |i;itient  had  lu'adache  lint  no  delirinm:  his  eyes 
were  darkly  sntFused  and  their  lids  o-dematons;  tongue  moist,  slightly  coated,  protruded  with  ditiicully  ;  gums  sore 
and  exsanguine;  fauces  swollen  and  inflamed;  flow  of  saliva  excessive;  snbnnixillary  and  cerviial  glands  enlargi'd 
and  painful :  he  had  also  a  profnsi^  coryz.a,  pain  in  the  chest  and  cough  with  Idoody  sjiuta;  his  face,  neck  and  breast 
were  of  a  bright  red  e<dor,  as  if  covered  wHh  a  scarlatinal  rash,  which  also  a]>peared  in  patches  on  the  lower  jiart  of 
the  trunk  and  limlis;  this  coloration  disappeared  nn(h>r  pressure.     Another  eruption,  scattered  over  the  entire  surface, 
and  consisting  of  briglit-red  spots  varying  from  the  si/e  of  a  jiiuhead  to  that  of  a  three-cent  i)iece,  persisted  under 
pressure.     The  patient  had  been  suffering  for  five  months  from  syjihilis,  for  which  he  hail  taken  mercury.     A  saline 
cathartic  was  given  and  Dover's  po\v<ler  at  night.      He  vomited  the  cathartic,  i)assed  a  restless  night,  and  next 
morning  was  found  with  all   his  symptoms  aggravated,— thirst,  glandular  sw.dling  and   conjunctival  congestion 
increased,  scarlet  etllorescence  spreading  and  persisting,  sjiots  more  numerous  and  larger:  he  had  also  severe  ]>aiu  in 
the  heail  and  loins;  his  stomach  was  irritable  and  his  bowels  unmoved.     On  the  IMtli  the  skin  was  of  a  dark-))urplo 
color,  un,ittecle<l  by  pressure  save  in  a  few  places;  blood  oo/ed  from  the  gums  ami  fau<'es  and  was  niinghMl  with 
the  expectoration,  saliva  and  tears ;  the  nrino  was  dark-colored  from  venous  blood ;  the  patient  was  delirious  ;  pulse 
100  and  soft.     Tincture  of  iron  and  whiskey  were  given  at  intervals  during  the  day;  in  the  evening  a  natural-looking 
stool  was  obtainl^d  by  an  enema  of  <'astor  oil  and  turpentine  ;  chlorale  au<l  permanganate  of  potash  were  also  added 
to  the  tre.itmeut.     The  delirium  increased,  the  |)ulse,  bccauui  ra|)id  and  \v<aU  and  the  secretions  continued,  mixed 
with  blood,  until  death  took  place  on  the  evening  of  the  liUh.     rn^l-mortrm  examinalioii  :  Rigor  mortis  well  marked; 
surface  covered  with  a  coalescence  of  puri)uric  spots  which,  on  the  thighs,  had  Ix^come  greenishblaek  in  color  and 
were  roughly  elevated,  the  lachrymal  sacs  were  tilled  with  dark  lluiil  blood  ;   the,  conjunctival  membranes  were  con- 
gested and  projected  between  the  half-open  lids.     The  mucous  covering  of  the  mouth,  tongue,  gums,  fauces  and 
(psophagns  was  pale  except  where  spotted  with  purpuric  extravasations.     The  pericardium  showed  on  its  anterior 
surface  a  semitransparent,  gelatinous  mass  the  size  of  a  lemon;  the  heart  was  covered  with  purpuric  spots;  both 
ventricles  contained  well-washed  clots.     Th<!  lungs  were  congested  and  spotted,  as  were  the  costal  pleura';  the  bron- 
chial tubes  were  filled  with  bloody  froth.     The  stomach  contained  eight  ounces  of  dark  cotfee-colored  Hquid;  its 
submucous  tissue  w  as  colored  with  coalescing  ecchymoses.  The  intestines  were  in  the  same  comlition  as  the  o'sophagus 
and  the  peritoneum  was  similarly  spotted.     The  omentum  was  contract<Ml  and  of  a  deep  straw-color  and  the  mesen- 
teric glands  distended  with  dark  venous  blood,  which  flowed  freely  on  incision.     The  liver,  weighing  six  pounds  and 
a  half,  was  covered  with  large  purpuric  spots,  and  presented  on  its  under  surface  several  ash-colored  patches  about 
an  inch  S(iuare,  which  extended  a  quarter  of  an  inch  into  the  substance  of  the  organ  ;  tlui  gall-bladder  was  distended 
and  contiguous  organs  were  tinged  with  a  dark-green  color;  the  spleen  was  spotted  externally  and  congested.     The 
connective  tissue  around  the  kidneys  was  filled  with  blood;  the  pelves  and  tubuli  were  distended  with  coagulated 


*  See  mipyn^  iwiffc  V2<I. 

t  W.  S.  .\ltMSTRi'M;,  Mol)ilf,  Alil.,  in  (tL'srriliiiig  iiii  cpiilftnic  i>f  cerfbro-spinal  linMuiif;itis  which  ()c<-iirn*«l  in  that  city. — Athuilit  Mt'dind I  tinr<jit\d 

Jnw-tinl  .lutu'  ISCfi, — gives  tlic  <-iise  of  a  soldier  Kiiffering  from  mercurial  ptyalisin,  which  in  in  stronj?  contrast  witli  that  snlnnittcd  in  tlie  text.  On  Feb. 
;i  ISC',  wlien  llie  piitient  was  ailmittcii,  Ilia  skin  was  yellow  and  lie  had  vomited  liile  several  times  ;  his  tongue  was  swollen  and  nicerated  and  he  sulTered 
from  [will  in  the  forehead  and  teni|iles.  On  the  Tth  he  had  severe  pni"  in  ttic  head  and  his  mind  wandered.  Next  daj  the  pain  was  more  intense  anrl 
extended  along  the  spine,  which  was  tender  on  pressure  ;  he  complained  of  pain  in  the  neck  when  his  liead  was  moved.  Delirium  continued,  the  pupil- 
l>eca'iie  sliiggi>li,  the  pulse  weaker  ;  the  patient  refused  nourishment  and  picked  at  the  hedchitlies.  He  dietl  on  the  11th.  No  poft-mortem  exaniinatio:i 
was  held.    Neilhei  petechia)  uor  purpuric  extravasations  are  mentioned  as  having  been  otjaerved  during  this  epidemic. 


596  DTSEAPES    ALLIED    TO    OR    ASSOCTATKD    WITH 

blood;  the  ureters  showed  purpuric  spots  on  their  nnicous  surfaces;  the  bladder,  wliich  was  tilleil  with  bloody  urine, 
had  its  mucous  coat  covered  with  small  scarlet  spots,  those  around  the  neck  of  the  organ  being  arranged  in  a  stellate 
form. — Hospital,  Second  Division,  Sixth  Army  Corps. 

In  the  h-eries  of  one  liuiidred  and  five  recorded  cases  tweuty-eiglit  of  tliuso  wliic.li  liad  a 
fatal  issue  were  protracted  in  their  duration  from  ten  days  to  tlu'ee  months. 

Only  seven  of  these  were  maculated,  7,  15,  25,  41,  58,  60  and  (i;!,  and  in  none  were  the  spots  so  profuse  as  in  the 
more  rapidly  fatal  cases. 

The  others,  2,  3,  6,  11,  18,  20,  35,  36,  37,  39,  42,  44,  51,  52,  59,  61,  61,  7S,  W,  91  aiul  lol,  were  unspotted  so  far  as 
is  shown  by  the  records. 

The  characteristic  symptoms  of  an  impHeation  of  tlic  cerebro-sj^Inal  membranes  were 
present  in  many  of  these.  In  eleven,  viz:  7,  35,  36,  41,  42,  44,  64,  78,  88,  94  and  101, 
the  delayed  issue  was  due  to  a  jn-olongation  of  the  febrile  or  delirious  period,  but  in  2,  18 
and  25  the  increased  duration  of  the  attack  was  the  result  of  a  temporary  amelioration  of 
the  symptoms.  In  2  the  improvement  continued  for  three  weeks,  the  excitement  abating 
and  the  patient  becoming  able  to  sit  up  and  give  generally  rational  answers;  but  at  the  end 
of  this  time  he  grew  worse  suddenly  and  died.  In  18  the  delirium  and  rigidity  of  the  pos- 
terior cervical  muscles  following  the  initiatory  chilliness  subsided  at  the  end  of  two  weeks, 
but  ten  days  later  the  spasms  returned  gradually  and  continued  until  death.  In  25  chill, 
fever  and  delirium  were  followed  by  unconsciousness,  wliich  by  the  eighth  day  had  passed 
off,  leaving  the  patient  perfectly  rational;  the  improvement  lasted  for  two  Aveeks,  when 
continued  fever  of  an  adynamic  type  was  developed;  low  delirium,  floccitatio,  bedsores, 
unconsciousness  and  stupor  were  successively  manifested;  pain  in  the  back  of  the  neck 
characterized  the  early  period  of  this  relapse,  and  a  persistent  backward  tilting  of  the  head 
its  later  period ;  an  eruption  appeared  on  the  face  and  abdomen  on  the  thirteenth  day  of  the 
second  seizure,  and  death  occurred  two  days  later.  In  all  these  cases  post-mortem  observa- 
tion revealed  the  presence  of  meningeal  congestion  and  of  deposits  of  lymph  and  pus  such  as 
were  found  in  the  majority  of  the  more  speedily  fatal  cases. 

No  examination  was  made  after  death  in  cases  11,  20  and  51,  but  the  clinical  records 
favor  the  supposition  that  cerebro-spinal  meningitis  was  present. 

Identical  inflammatory  lesions  were  found  also  in  cases  6, 15,  37,  39,  52  and  61,  which, 
in  their  clinical  aspects,  differed  considerably  from  the  average  or  typical  case  of  the  ilisease. 
These  cases  in  fact  suggest  that  the  cerebro-spinal  inflammation  originated  in  the  deteriorated 
condition  of  the  blood  consequent  on  congestive  malarial,  typhoid  or  the  eruptive  fevers 
instead  of  on  that  due  to  a  special  and  peculiar  febrile  |»oison.  Heventeen  days  elapsed  in 
case  6  Ijetween  thi."  occurrence  of  a  congestive  chill  and  tlie.  supervention  of  severe  headaclie, 
febrile  delirium  and  convergent  strabismus,  wliich  ended  in  deatli  five  days  atterwards.  The 
only  clinical  statement  in  52  is  the  diagnosis  of  typhoid  fever,  whicli,  however,  cannot  be 
considered  substantiated  by  the  intestinal  lesion, — the  injection  of  two  of  the  patches  of 
Peyer.  But  in  15  chill,  headache,  pain  in  the  back  and  limbs,  recurring  cpistaxis  with 
febrile  movement,  cough,  sibilant  rales,  sordes,  diarrhoea,  gurgling  in  the  riglit  iliac  fossa, 
violent  and  afterwards  muttering  delirium,  and  the  appearance  of  sevei'al  undescribed  spots 
on  the  eleventh  day,  with  coma  on  the  twelfth  and  death  on  tlie  fourteenth,  constitute  a 
secjuence  of  symptoms  indicating  a  possibility  of  typhoid  fever,  whicli  is  by  no  means  neg- 
atived by  the  enlargement  of  the  solitary  glands  and  the  thickening  and  ulceration  of  the 
patches  of  Peyer,  noted  in  ilia  post-mortem  YecovA;  occipital  pain  and  the  extended  position 
of  the  head  were  the  only  symptoms  pointing  to  the  implication  of  the  cerebral  membranes. 


THE   PAROXYSMAL   AND    CONTINUKD    FEVERS,  597 

The  following  report  brings  prominently  into  view  the  occurrence  of  cerebral  cases  in 
an  epidemic  of  typhoid  fever: 

Ad.  Jss't  SKrffcon  J.  P.  T)F,  Bkulkr,  Aiigunt  30,  lSti2. — Tyi)hoi(l  fever  has  been  very  prevalent  iu  the  ho.s])itaIs  of 
Evansville,  Iiid.,  and  in  many  cases  entirely  nnniaiiageable.  Inllannuations  of  the  brain  an<l  its  membranes  prevaileij, 
it  seemed  to  me,  to  an  nniisual  extent.  Tenderness  and  gurgling  in  (he  right  iliae  region  and  diarrlio'a  occurred  in  a 
large  majority  of  tlie  cases.  Tlie  ro.se-colored  eruption  was  distinctly  marked  in  over  two-thinls  of  tliose  ali'ected. 
Petechite  were  oliserved  in  a  number  of  cases;  the  tendency  to  ])ur|)ura  was  so  nuirked  that  the  slightest  friction, 
as  of  scratching,  would  be  followed  by  ecchynioses.  I  may  hero  add  thiit  scorbutic  symi)toms  were  common  in  all 
diseases  associat<'d  with  debility.  In  mild  cases  the  treatment  consisted  of  genth^  diai)horetics  and  cooling  refriger- 
ants, with  a]ierients,  ojiiates  or  astringents,  as  seemed  to  he  indicated,  and  a  diet  of  barley-water,  animal  broths  and 
boiled  or  thickened  iriilk.  When  the  bowels  were  i)rominently  atb-cted  tur])entine  emulsion  was  very  generally  relied 
on,  with  turpentine  applications  to  the  abdominal  surface;  numy  other  reme<lies  were  tried,  but  on  the  whole  this 
seemed  the  most  satisfactory.  In  another  class  of  cases  evidences  of  imi)erfect  oxygenation  of  the  blood  were 
prominent:  The  skin  was  dark-red  or  livid  all  over  the  body,  especially  about  the  lips,  gums  and  ears;  pressure 
readily  produced  a  white  spot,  but  when  the  finger  was  removed  the  color  was  restored  very  slowly, — in  a  word,  the 
capillary  circulation  w  as  sluggish  and  the  vessels  engorged.  The  surface  was  often  cool  and  the  pulse  freiiuent  and 
feeble.  In  these  cases  stinnilants  were  early  resorted  to  and  the  results  were  often  very  satisfactory:  i>ortcr,  ale, 
wine  and  brandy  were  freely  given.  Indeed,  I  think  that  brandy  given  in  large  and  frciiuently  reiii^atcd  doses  was 
the  means  of  saving  a  number  of  lives.  Another  remedy  much  valued  in  this  variety  of  the  disease  was  chlorate  of 
potash — given  in  eight  or  ten-grain  doses  every  four  or  five  hours.  We  understand  but  littleof  its  modus  operandi, 
but  it  seems  nn([uestionahle  that  it  does  in  some  way  assist  in  oxygenating  the  lilood.  In  cases  accom]>anied  with 
inflammation  of  the  brain  there  was  often  forced  respiration.  This  was  promi)tly  and  )iermanent]y  relieved  in  so 
many  cases  by  blistering  the  nape  of  the  neck  that  something  more  than  a  coincidence  is  suggested. 

Fourteen  posl-mortcm  examinations  were  made  in  fever  cases.  In  nine  there  was  well-marked  ulceration  of 
Peyer's  glands,  often  extensive  and  in  one  ])erforating, — there  was  ])robaldy  perforation  in  another  case  not  exam- 
ined;— in  two  the  glands  were  enlarged  and  unusually  distinct;  and  in  three  the  ihuim  was  unatlected*  but  in  two 
of  these  the  disease  seemed  to  have  spent  its  force  u|)on  the  brain,  having  prove<l  fatal  in  a  cora|>aratively  short 
time,  and  in  the  third  the  immediate  cause  of  death  was  an  acute  inllauiuiallou  of  the  lungs. 

Similar  cerebral  complications  were  developed  in  tlu>  progress  of  measles  in  ciises  ,'^7 
and  39;  while  Ass't  Burgeon  MoGill,  U.  S.  Army,  regarded  61  as  originally  a  case  of  mod- 
ified variola,  in  the  course  of  which,  "under  the  cerebral  type  of  disease  ]>revailing,  general 
cerebro-spinal  meningitis  supervened."  Nevertheless,  as  this  patient  contracted  his  disease 
at  Galloupe's  Island,  Boston  Harbor,  where  measles  and  the  so-called  spotted  fever  were  pre- 
vailing, the  sloughing  spots  on  the  lower  extremities  are  probably  to  be  attributed  to  tbo 
same  deteriorated  condition  of  the  blood  that  produced  them  in  some  of  tin;  cases  recorded 
by  Dr.  Calvin  G.  Vauv.  at  the  station  mentioned.''' 

In  the  remaining  five  of  the  protracted  cases  a  fever  was  present  which  cannot  ])e  identi- 
fied as  cerebro-spinal  by  the  lesions  found  after  deatli.  In  H  and  60  fever,  delirium  and  a 
typhoid  condition  were  associated  with  some  injection  of  the  membranes  and  cloudiness  of 
the  arachnoid,  apparently  not  inconsistent  with  the  presence  of  a  continued  malarial  fever, 
as  the  spleen  in  both  was  large  and  the  patches  of  Peyer  conspicuous,  marked  with  lilack 
points  in  one  and  slightly  ulcerated  in  the  other.  The  difficulty  of  discriminating  betweiMi 
malarial  and  cerebro-spinal  fever  was,  as  may  be  seen  by  these  instances,  not  confined  to  the 
congestive  cases  of  the  former.  The  following  case  of  remittent  fever  would  prohablv  have 
been  considered  an  example  of  cerebro-spinal  fever  had  it  occurre<l  dui'ing  the  ejiidemic  ]»rev- 
alence  of  that  disease: 

Private  .losepli  IJarnes,  12th  111.;  age  2.5;  was  admitted  Nov.  22, 18(U,  crying  aloud  from  intense  pain  In  the  head 
and  back.  The  pain  continued  unabated  for  several  days,  notwithstanding  trealiuent  by  opiates,  sinaiiisins  to  the 
back  and  feet,  cups  ti>  the  back  and  free  ntovement  of  the  bowels  liy  (^astor  oil.  <Jm  the  2!Hh  it  became  less  severe, 
but  the  tongue  was  dry  and  tissured,  the  eyes  sutfused  and  the  mind  wanderiug.  A  blister  ajiplied  on  the  30th  to 
the  back  of  the  neck  partially  restored  consciousness,  Imt  the  delirium  returned,  the  patient  at  tinu's  attempting  to 
leave  his  bed  and  at  other  tiiues  being  inclined  to  muttering  delirium  and  stupor.  He  died  comatose  on  Decembi'rS. 
Poal-miirtiiii  examination  :  The  skull-ca]i  was  remarkably  thin.  The  membranes  of  the  brain  were  somewhat  congeste<l 
and  nioister  than  usual.     There  was  no  evidence  of  intlammation  about  the  hase  of  the  brain  and  the  brain-substance 


•See  mtpya,  page  5»y. 


59S  diseases:    allied   TO   OR   ASSOCIATED    WITH 

appeared  liealtliy:  but  the  lateral  ventricles  were  distended  witli  bloody  Heriuii  and  the  floor  of  eaeh  was  coated  with 
white  cciaf;ulated  libvin  which  extended  into  tlie  eornua  :  a  similar  exudation  was  t'ouud  in  tlu-  otlicr  ventricles.  The 
other  orj;ans  were  not  examined. — Act.  Asx't  Siiry.  IT.  ('.  May,  Hospital  Xo.  8,  Xinflirille,  Ti mi. 

The  three  eases,  58,  59  and  63,  occurred  at  the  Xational  hospital,  iKdtimore,  Md..  where, 
as  already  stated,  the  occasional  presence  of  true  ty|)hus  was  suspected.  In  58  a  tvphous 
condition,  with  muscular  spasms  drawing  the  head  strongly  backward,  presented  some  con- 
gestion of  the  brain  and  its  membranes,  some  opacity  of  the  floor  of  tlie  fourth  ventricle  and 
bloody  serum  in  the  eornua  of  the  lateral  ventricles.  In  63  the  patient,  who  was  subject  to 
intermittent  fever,  and  had  just  recovered  from  pneumonia  contractet  while  in-  hospital,  sud- 
denly developed  typhous  symptoms  wliicli  prove<l  fatal  in  six  days  without  the  occurrence 
of  convulsions;  slight  injection  of  tln^  brain  and  its  membranes  witli  two  small  e.xtravasa- 
tions  of  blood  on  the  convexitv  of  tlu-  hemisplieres  were  observed  in  this  case,  with  some 
congestion  and  ecchymosis  of  the  mucous  membrane  of  the  alimentary  canal  and  pigmenta- 
tion of  the  patches  of  I'ever.  The  dinic'al  history  of  59  shows  delirium  and  (>[iistli(jioiios, 
while  the  post-morte/ii  record  reveals  onlv  congestion  of  the  pia  mater  and  lungs,  cidarge- 
ment  of  the  spleen  and  pigmentation  of  the  agminated  glands. 

lu  eighteen  of  the  cue  hundred  and  five  cases  there  is  no  clinical  record,  or  the  symptoms  mentioned  are  insuf- 
ficient to  identify  the  disease.  These  are  cases  10,  IH,  22,  40,  r>ti,  (W-Tl,  7H,  7"),  7(i,  79,  81,  sr.  and  iHl-ilS;  in  only  one  of 
these  cases,  73,  is  the  existence  of  sjiots  indicated. 

A  few  of  these  were  recorded  as  ty]ihoid  fever;  but  this  view  of  their  nature  was  not 
sustained  hy post-mortem  observation  except  perhaps  in  l')(),  in  which  engorgement  of  tlu^  pia 
mater,  contjestion  and  ecchymosis  of  the  mucous  membranes,  enlaro;emeut  of  the  s(dibirv  and 
agiuinated  glands  and  ulceratiim  of  the  large  intestine  might  be  sup[ii)Si'd  to  indicate  a  ty]>ho- 
malarial  fever  fatal  in  its  carlv  stage.  In  all  the  otlici'  cases  tlie  chai'acteristie  lesions  of 
cerebro-sjiinal  meningitis  were  discovered  after  death. 

Four  of  the  recoveries,  1,17,  23  and  26,  were  reported  during  tlie  New  Berne  epi- 
demic, one,  32,  from  Chattanooga,  Tenn.,  one,  48,  from  the  Army  of  the  Potomac,  and 
one,  82,  from  Benton  Barracks,  Mo.;  and  in  all  the  accuracy  of  the  diagnosis  appears  to  have 
been  fairlv  establi.^hfd.  The  patient  in  2<)  was  returned  to  duty  on  the  seventeentli  day, 
and  the  only  recorded  symptoms  were  headache  and  pain  in  the  back  of  the  neck;  in  23 
the  patient  was  returned  to  duty  at  the  end  of  a  month,  having  rallied  from  his  stupor 
on  the  third  day  of  the  attack  on  the  establishment  of  profuse  salivation.  In  neither  of 
these  were  the  characteristic  symptoms  present,  but  the  type  of  disease  then  and  there  |n-e- 
vailing  warrants  tlieir  acceptance  as  cases  of  cerebro-spinal  fever  in  the  alwence  of  po.nt- 
mortem  testimony  to  the  contrary.  Petechial  spots  were  observed  in  48  and  a  wheal  of 
large  size  on  the  anterior  aspect  of  the  trunk  in  32 ;  but  case  1  is  the  only  instance  of  recovery 
which  was  characterized  by  the  early  development  of  purpuric  blotches, — they  appeared  on 
the  arms  and  legs  during  the  reaction  from  tlie  chill ;  the  patient  was  unconscious,  but  neither 
coma  nor  convulsions  were  developed;  improvement  was  manifested  by  the  return  of  con- 
sciousness on  the  fifth  day;  the  spots  sloughed  instead  of  fading,  and  the  cornea  appears  to 
have  become  opaque  and  greenish.*  Case  17,  although  unspotted,  was  somewhat  similar  in  its 
course;  in  both  instances  the  men  were  discliarged  between  three  and  four  months  after  the 
attack.  In  32  the  onset  was  by  chill,  fever  and  headache,  but  the  pain  was  most  severe  in 
the  spinal  cord  and  along  the  thighs;  delirium  and  paralysis  continued  for  two  weeks,  after 

♦Case  11  of  th'*  Kcriffi  reprirtH.l  frum  Galliinpe'ri  Island,  Bustuii  Harbur. — pee  i)age  .58:1,— was  of  a  riiiuilar  iliarafti-r.  TluTt-  was  neither  opistliiitomis 
n.ir  cerebnil  disturbaucc,  hut  tin*  spots  un  tlu'  arms  slouglieil  auil  a  tliscbargt:  exmleil  from  Ijeneatli  the  erust.s  that  lurmeil  on  the  legs;  iuiproveuieht 
>l;it.-«l  fruni  the  sloiighiiij;,  hut  vision  was  greatly  inijiaireil. 


THE   PAROXYSMAL   AND   CONTINUED    FEVERS.  599 

which  recovery  was  gradually  effected.  In  48  headache,  stupor,  vomiting,  involuntary  pas- 
sages, opisthotonos,  hyperesthesia  of  the  surface,  petechia^  delirious  moaning  and  complete 
deafness  continued  for  about  three  weeks,  and  terminated  in  a  gradual  improvement;  but 
deafness  persisted  and  necessitated  the  discharge  of  the  patient  at  the  end  of  six  months.  In 
82  a  chill  was  followed  by  pain  between  the  shoulders;  two  days  later  a  congestive  chill  was 
experienced;  reaction -was  not  fully  established  until  three  days  had  elapsed;  after  which 
pain  in  the  head  and  back,  extreme  sensitiveness  of  the  surface,  indications  of  paralysis  of 
the  lower  extremities  and  fever  of  a  typho-malarial  type  continued  for  three  weeks  before 
the  occurrence  of  convalescence.  A  malarial  element  appeai-s  to  have  been  recognized  in 
this  instance,  as  in  17,  in  which  a  chill  at  noon  of  one  day  was  followed  by  violent  delirium 
at  the  same  hour  of  the  following  day. 

Of  the  one  hundred  and  five  cases  submitted,  seven  recovered  and  in  eight  no  posf- 
mortem  examination  was  held.  Of  the  ninety  cases  remaining  seventy-five  were  identified 
as  cerebro-spinal  meningitis  by  the  post-mortem,  appearances,  while  fifteen  were  characterized 
by  more  or  less  congestion  of  the  cerebro-spinal  membranes.  Most  of  the  seventy-five  cases 
presented  a  certain  sequence  of  symptoms  of  sudden  development  aild  comparatively  rapid 
progress;  but  in  a  few  cases,  as  6,  15,  37,  39,  52  and  61,  the  disease  supervened  on  a  con- 
tinued fever  of  malarial,  typhoid  or  typhous  origin  or  on  an  eruptive  fever.  Two  cases,  24 
and  92,  appear  as  connecting  links  between  the  inflammatory  and  congestive  cases.  An 
uncertainty  attaches  to  the  fifteen  cases  in  which  positive  evidence  of  inflammation  was  not 
observed:  In  some  congestive  or  continued  malarial  fever,  in  some  ty|ihoid  and  in  some 
typhus  is  suggesttjd  as  a  jjrobability,  instead  of  a  specific  febrile  poison  manifesting  its  jtres- 
ence  in  the  system  by  cerebro-spinal  congestion.  One  of  these,  62,  was  pioliably  a  case 
of  typhoid  fever;  one,  14,  was  a  distinct  pericarditis  anatomically;  four,  57,  58,  59  and  63, 
may  have  been  typhus  or  fulminant  typhoid;  one,  56,  typho-malarial;  two,  3  and  60,  con- 
tiimed  malarial  fever;  two,  28  and  100,  hemorrhagic  malarial  fever,  and  four,  4,  49,  99  and 
104,  congestive  malarial  fever. 

SUMMARY  OF  THE  POST-MORTKM  APrEARANCES  IN  THE  RECORDED  CASES. 

'I'lie  LUNds  ^ve^n  more  fiv(|iieiitly  the  seat  of  morbid  cbanges  than  any  other  organ  or  tissne  excepting  the 
cerebral  membranes.  Kefereneo  is  made  to  their  condition  in  seventy-four  of  the  ninety  fatal  cases  the  records  of 
which  have  lieeu  preserved.  In  twenty  of  these  they  were  healthy;  in  tifty-fonr  altered.  Generally,  as  in  5,  7,  35, 
30,  39,  40,  54,  73,  SI  .and  97,  one  lung  only  was  aft'ected,  bnt  more  freqnently  both  were  implicated  in  the  congestions, 
extravasations  and  intlammatory  changes  that  constituted  the  morbid  condition.  Congestion  cliaraeterized  the  ra])- 
idly  fatal  cases;  pneiimonitic  processes  were  more  frequent  in  those  that  ran  a  protracted  course. 

The  condition  of  the  pleural  niembraue  is  indicated  in  twenty-eight  cases,  in  ten  of  which  it  was  uoruuil;  it 
was  probably  normal  also  in  nine  other  cases  in  which  the  lungs  are  said  to  have  been  healthy,  the  serous  membrane 
remaining  unmentioned.  Of  the  eighteen  cases  presenting  morbid  changes  there  were  adhesions  in  40,  43,03,  (iS  and 
97;  in  some  of  these  the  adhesions  were  old  and  unconnected  with  the  fatal  illness,  but  in  the  last-mentioned  case 
connnunication  was  established  with  an  abscess  in  the  spleen.  In  39  and  91  there  was  eftusiou  of  serum;  in  33,  35  and 
36  exudation  of  lymph,  and  in  28,  55-58,  62,  tU  and  100  eccliymoses. 

The  HEART  was  normal  in  twenty-three  cases,  and  in  twenty  others  in  which  its  contents  are  stated  its  con- 
dition did  not  appear  to  call  for  remark.  Morbid  changes  are  mentioned  in  thirteen  cases  :  In  4,  39,  85  and  105  the 
heart  was  softened,  iu  40  tlabby,  in  50  llaccid,  in  71  and  77  fatty,  in  64  tirm  and  dark-red,  in  28  ecchymosed,  in  45 
ana'mic  and  horny,  in  43  dense  and  cartilaginous  and  in  103  thickened  iu  its  mitral  valve.  In  thirty-four  cases  the 
cardiac  contents  are  mentioned  :  In  58  the  heart  is  said  to  have  been  free  from  clots,  in  4, 9j  35,  m  and  105  to  have  con- 
tained dark  fluid  blood,  in  63  and  92  clots,  in  55  and  59  mixed  clots  and  in  79  and  90  fibrinous  coagula.  Fibrinous 
deposits  were  observed  in  both  sides  in  8,  10,  13,  14,  27,  45,  53,  61,  64,  78  aud  81 ;  in  the  right  side  in  25,  38,  56,  62,  69, 
85,  99  and  102,  aud  iu  two  of  these,  38  and  62,  the  contents  of  the  left  side  are  respectively  specified  as  uncoagulated 
blood  and  mixed  clots:  in  the  left  side  in  46,  52  and  57,  the  right  side  in  the  first  containing  coagulated  blood  and  in 
the  last  mixed  coagula. 

The  PEKiCARDiusi  is  said  to  liave  been  normal  in  two  of  seventeen  cases  in  which  its  condition  was  noted.  The 
Bae  contained  an  unstated  i[uantity  of  serum  in  46,  73  and  74,  two  ounces  in  91,  three  in  5  aud  40,  four  in  39  and 


600  DTSEASKS    AI.I.rF.n    TO    OK    ASSOCIATKD    WFTH 

eight  in  35;  in  105  the  effused  liquiil  was  tinned  with  blood,  and  in  St,  14,  3X,  13  and  103  there  were  definite  indications 
of  pericarditis:  in  2X  tlie  serous  uieuibrane  was  eccliyuu)st.'d. 

The  STOMACH  was  the  subject  of  report  in  forty-two  cases,  in  twenty-three  of  which  it  was  uornuil.  Congestion 
was  noted  in  5,  55,  (il-()4  and  85;  ecchymoses  in  28,  5t),  58,  ilO  and  100;  mottling  in  57;  softening  iu  74,  78  and  88: 
Innibricoid  worms  iu  8Sl,  and  indation  or  distention  iu  3t)  and  itit. 

The  condition  of  the  small  intestine,  iu  whole  or  iu  part,  is  noted  in  sixty-eight  cases,  in  twenty-seven  of 
which  it  was  normal  and  in  one,  99,  distended  merely.  In  five  cases,  3,  5,  9,  15  and  25,  the  condition  of  the  intes- 
tinal glands  only  is  stated.  The  bowel  as  a  whole  is  reported  more  or  less  conge.sted  in  28,  33,  35,  36,  39,  40,  >5G,  58, 
60  and  64 :  iu  58  the  congestion  tended  to  form  small  irregular  spots  :  iu  35  there  was  also  ulceration  of  the  ileum  and 
in  30  and  39  intussusception.  Ecchymoses  were  present  in  43,  46  and  100  and  Inmbricoid  worms  in  89.  The  duodenum 
was  congested  and  of  an  ironed-out  ajipearauee  in  63,  and  the  duodenum  and  jejunum  iu  55  were  siiuilarly  affected. 
Abnormal  conditions  in  38,  42,  54  and  62  were  couftued  to  the  jejunum  and  ileum — in  the  first-mentioned  case  the 
jejunum  was  congested  and  the  ileum  contracted:  in  the  second  a  Inmbricoid  worm  iu  the  jejunum  was  noted,  with  a 
thinned  and  congested  state  of  the  ileum  ;  in  54  both  <livisions  were  reddened,  and  in  62  the  upper  was  colored  dark- 
red  and  the  mucous  folds  of  the  lower  thiuued  and  blackened:  iu  a  fifth  case,  57,  the  jejuunm  is  said  to  have  been 
yellowish  and  the  ileum  thinned,  its  aggregated  glands  tumid.  The  ileum  alone  is  mentioned  in  fourteen  cases:  In 
45  contracted;  in  31,  59,  69,  104  and  105  congested,  59  presenting  the  shaven-beard  appearance;  in  78  softened,  pig- 
mented and  the  solitary  glands  enlarged ;  in  4  and  85  ulcerated,  the  solitary  glands  prominent  iu  the  latter:  iu  .52  the 
agminated  and  solitary  glands  were  injected  and  in  70  the  crypts  were  inflamed;  in  61  the  mucous  folds  were  thin  and 
ironed-out,  in  71  softened,  and  in  90  reddened,  ecchymosed  and  softened. 

The  LARGE  INTESTINE  is  referred  to  iu  fifty-seven  cases;  in  thirty-two  no  notable  change  was  reported;  in 
fifteea  of  the  remaining  twenty-five  cases  the  intestine  as  a  whole  is  described :  It  was  injected  or  congested  iu  36,  39, 
40,  55,  60  and  61,  discolored  in  57,  ecchymosed  in  28,  43,  46  and  100,  ulcerated  in  33  and  56;  its  solitary  follicles  were 
inflamed  in  70  and  in  89  it  contained  Inmbricoid  worms.  In  ten  cases  morbid  appearances  are  noted  only  in  connec- 
tion with  one  or  two  of  the  anatomical  divisions  of  the  bowel :  The  solitary  follicles  of  the  ca'cuni  were  prominent  in 
78;  the  colon  was  congested  in  63,  64  and  73  and  pigmented  in  t)9 ;  the  ca'cuui  ami  colon  congested  in  62  and  90,  ])ig- 
mented  in  the  former,  ecchymosed  and  with  proiuinent  follicles  in  the  latter;  the  colon  and  rectum  congested  in  97: 
the  lower  part  of  the  intestine  congested  in  58;  the  solitary  follicles  of  the  ca'cum  prominent  aud  the  mucous  mem- 
brane of  the  rectum  softened  and  pigmented  in  85. 

Besides  the  abnormity  of  the  iwtches  ok  peyek  aud  solitary  i-ollicles  in  specified  portions  of  the  intestinal 
tract  already  noted  iu  eases  52,  57,  70,  78,  85  and  90,  the  agminated  glands  were  conspicuous  or  tliickeued  in  twelve 
cases,  in  four  of  which,  5,  56,  61  and  64,  there  was  no  other  alteration,  in  one,  28,  ecchymosis,  in  three,  3,  9  and  15, 
slight  ulceration,  and  in  four,  25,  60,  62  and  63,  pigmentation  ;  the  solitary  follicles  were  enlarged  in  15,  28, 56  and  64, 

The  condition  of  the  livek  was  reported  in  sixty-nine  of  the  examinations.  It  was  normal  in  twenty-seven 
and  altered  in  forty-two  cases :  It  was  large  in  eight,  34,  35,  38,  40,  41.  75.  97  aud  100:  pale  in  two,  69  aud  77;  large 
aud  pale  in  three,  28,  71  and 72  ;  fatty  in  five,  29,  78,  79,  85  and  90 ;  large  and  fatty  in  two,  4  and  73;  engorged  in  two, 
42  and  55:  congested  in  six,  7,  43,  53,  58,  63  and  104  :  large  and  congested  in  four,  3.  13,  27  and  39;  large  and  mottled 
in  two,  36  and  37;  light,  friable  and  odorous  in  57  ;  dark  superficially  in  44;  dark,  firm  and  odorous  in  64;  cirrhosed 
in  the  two  cases  70  and  74,  and  dark  and  firm  in  the  three  cases  54,  56  aud  62. 

The  gall-bladdeu  was  distended  in  eleven  cases,  25,  35,  38,  41,  42,  45,  46,  85,  99,  100  and  104;  empty  in  36,  37, 
39  and  40,  The  bile,  when  specified,  was  generally  dark-colored  and  freiiuently  viscid,  as  in  25,  ,54,  55,  .56,  .58,  62,  63, 
64,  78  and  99. 

The  state  of  the  spleen  is  reported  in  sixty-eight  cases,  in  thirty-three  of  which  it  was  healthy.  Morbid  changes 
are  recorded  in  thirty-five  cases:  Theorgan  was  congested  in  four, 4,  8,  53  and  99;  large  and  congested  iu  three,  3,  13 
and  27:  large  and  soft  in  six,  9,  59,  62,  63,  73  and  97,  with  an  aliscess  in  tlie  last-mentioned  case.  Enlargement  is  the 
only  change  recorded  in  the  nine  cases  35,  38,  41,  43,  45,  60,  68,  70  and  104;  softening  in  two,  75  and  78,  The  spleen 
was  large  and  firm  in  three,  28,  61  and  85 ;  large,  light  -colored  aud  friable  iu  55  and  large,  dark-colored  and  frialile  iu 
57.  It  was  ana'inic  in  74  and  small  in  the  five  cases  7,  46,  56,  72  and  77,  light-colored  in  tlie  first  mentioned,  hard  iu 
the  last  and  dark  and  tough  in  56. 

The  kidneys  were  normal  in  thirty-nine  cases,  abnormal  in  twenty-three.  They  were  enlarged  in  4  aud  39; 
ecchymosed  in  28  aud  100,  each  kidney  weighing  ten  or  eleven  ounces:  fatty  iu  29.  47,  69,  79  aud  85:  soft  or  Haccid 
in  56  and  97,  and  congested  in  37,  53-.55,  57-59,  62,  64,  91,  92  and  104. 

The  stJPKAREN'.\L  capsules  were  reported  normal  in  57  aud  61,  enlarged  and  firm  in  51,  reddened  in  58;  the 
right  capsule  in  56  was  distended  with  a  bloody  granular  liiinid.  • 

The  urinary  bladder  was  reported  abnormal  in  two  cases  only,  45  and  28, — in  the  former  infiaraed,  discolored 
aiul  distended  with  decomposing  urine,  and  iu  the  latter  ecchymosed;  it  was  empty  iu  35  and  distended  in  38,  69,  72, 
75  and  98,     The  CRISE  was  reported  albuminous  in  29,  .55,  58,  91,  92  and  99,  healthy  in  54  aud  not  albuminous  iu  56. 

The  PANCREAS  is  said  to  have  been  normal  in  15,  54,  61  and  63,  jiale  in  28,  reddened  in  56,  57  aud  90,  congested 
in  55,  friable  and  light-colored  iu  58,  and  large,  congested  and  containing  a  calcareous  di'posit  in  62. 

The  PERITONEUM  was  ecchymosed  iu  28  aud  100  aud  inflamed  in  31  aud  11 ;  the  omentum  was  congested  in  71 
aud  1(15  and  tlie  serous  sac  contained  some  ertiision  in  40  and  46. 

The  MESENTERIC  GLANUS  Were  enlarged  in  3().  37.  45,  l(i,  57,  Oil,  71,  97  aud  104,  and  in  two  of  tliese,  57  and  71, 
they  were  dark-colored. 


THK    PAROXYSMAL    AND    COXTIXT-KD    FEVERS.  601 

The  m.ooi),  besides  liaving  Ijeeu  (Lnk  and  fluid  in  the  heart-cavities  in  4,  9,  35,  38,  68  and  69,  was  said  to  have 
been  fluid  generally  in  54,  55,  56,58,90,  91,  92,  99, 100  and  105.  It  was  dark,  thin  or  fluid  in  four  of  the  twenty  rapid 
eases,  4, 19,  92  and  99;  in  seven  of  the  thirty-two  eases  of  medium  duration.  9,  38,  .54,  55.  90,  100  and  105:  in  two,  35  and 
58,  of  tlie  twenty-eight  jirotracted  cases,  and  in  three  of  those  in  whieh  the  elinioal  record  was  insullicient  to  identify 
tlie  disease,  .56,  68  and  69.  A  similar  condition  was  noted  in  seven  of  the  twenty-nine  8i)otted  cases,  9,  58,  90,  92,  99, 
100  and  105,  and  in  eases  4,  35,  38,  54,  55  and  91  of  the  fifty -one  unspotted  cases. 

Pathology. — The  disease  under  consideration  was  sometimes  spoken  of  as  spotted  fever 
and  sometimes  as  epidemic  cerehro-spnnal  meningitis/  but  neither  title  was  ajipHcable  to  all 
tlie  cases  that  Avere  aggregated  under  it.  Some  were  free  from  macultB  and  others,  whetlier 
maculated  or  not,  presented  no  evidence  of  inflammation  of  the  membranes  of  the  brain  and 
spinal  cord.  Of  course,  if  the  inflammatory  products  that  were  found  in  the  subarachnoid 
spaces  of  a  majority  of  the  cases  be  assumed  to  have  been  characteristic  of  the  disease,  all 
cases  failing  to  present  these  appearances  must  be  referred  to  congestive  malarial  fever,  ful- 
minant typhus,  typhoid  or  other  pernicious  febrile  cause,  no  matter  how  closely  in  their  clin- 
ical aspects  and  etiological  associations  they  may  have  resembled  the  accepted  cases  of 
so-called  cerebro-spinal  meningitis.*  But  there  was  no  warrant  for  setting  up  an  anatomical 
standard  of  this  kind.  Cases  must  be  considered  as  they  occurred,  whether  agreeing  or 
failing  to  agree  with  preconceptions  and  arbitrary  assumjitions.  Case  14  was  as  truly  one 
of  the  disease  then  prevalent'at  New  Berne,  N.  C,  as  any  of  the  twenty-six  other  recorded 
cases;  and  yet  there  were  no  inflammatory  products  under  the  arachnoid,  although  such 
products  were  found  in  connection  with  the  serous  envelope  of  the  heart.  This  case  alone 
demonstrates  that  the  disease  was  certainly  not  in  its  essence  a  cerebro-sjiinal  meningitis  nor 
even  in  all  cases  a  cerebro-spinal  fever.  So  also  cases  28  and  100,  in  which  the  dark-colored 
and  fluid  blood  escaped  from  the  vessels,  forming  ecchymosed  patches  on  the  cutaneous, 
mucous  and  serous  surfaces,  must  be  regarded  as  true  cases  of  spotted  fever,  although  there 
was  no  evidence  of  the  presence  of  cerebro-spinal  meningitis.  Some  of  the  cases  at  Galloupe's 
Island  were  of  a  similar  character,  as  Xo.  11  of  Dr.  Page's  record,f  in  which  the  cutaneous 
blotches  sloughed;  and  although  in  this  case  there  was  no  opisthotonos  or  cerebral  dis- 
turbance, its  connection  with  a  true  cereloro-spinal  meningitis  is  proved  by  case  61,  from  that 
station,  which  terminated  fatally  at  the  National  hospital,  Baltimore,  Md.  Dr.  Crosby's 
cases  at  Concord,  N.  IT.,  were  also  specimens  of  tlie  disease  ik)W  under  consideration,  although 
his  fifth  case  presented  no  post-mortem  evidence  of  an  inflammation  of  the  cerebro-spinal 
membranes. 

Two  of  the  writers  who  have  discussed  the  spotted-fever  cases  of  the  war  concluded 
that  their  essential  was  an  inflammation  of  the  membranes  of  the  lirain  and  spinal  cord. J 
Of  course,  in  the  army  as  in  civil  life,  there  no  doubt  occurred  cases  ot'  idiopathic  cerebro- 
spinal meningitis;  cases  unconnected  with  any  primary  blood-disorder, — in  fact,  Bartholow 
regarded  32  and  78,  already  submitted,  as  of  this  character;  but  .Iones  and  Hunt  have 
thrown  the  whole  of  the  spotted-fever  cases  into  the  idiopathic  plilegmasi;e.  They  con- 
sidered that  the  post-mortem  examination  of  a  typical  case,  that  of  Private  Goosby,  3d 
Georgia  militia,§  did  not  develop  a  single  fact  to  justify  the  classification  of  this  disease  with 
the  pyrexiae.     Both  regarded  the  disorganization  of  the  blood  as  a  secondary  result  of  derange- 

*  Thus,  Sanford  B.  Hunt,  page  39H  of  tht-  Medical  Memoirs,  V.  S,  Sanilarii  (\>mviisxion,  says  uf  tin-  cas*"  given  ^lipra  ji.s  case  4,  tltat  jKmf-morlem  exani- 
inatiou  revealed  no  eviileiiee  of  eerebro-siiinal  meningitis  ;  anil  Bince  he  regarded  the  disease  known  as  spotted  fever,  typhus  syueu{ialis,  etr.,  as  a  common 
plileKHiiisia  of  the  eeretiro-spinal  nienihranes,  this  ease  was  therefore  to  him  not  a  rase  <»f  the  disease  whidi  prevailed  at  the  time  of  its  occurrence  at 
New  Berne. 

f  See  mpra,  page  r>8.t. 

{See  Jones's  Medical  iiiul  l^iirgieal  Mrmoiis,  pp.  411  rl  »ei/.,  also  Ceiehn-^iiiutil  Meiiimjil,-.  Iiy  S.vNKokn  1!    Hi  NT,  V.  S.  Suu.  Cum.  Memuira. 

gSee  .«iijon,  puRe  r.lKI. 

Med.  Hist.,  Pt.  111—76 


602  r»lsE.\Si;s    AT.I.TF.P    TO    OR    ASSOCIATED    WITH 

merit  of  the  circulation  and  ivspiratiou  induced  by  the  disturbance  and  jM'rversion  of  the 
cerebro-spinal  functions, — and  the  discoloration  of  the  skin  was  referred  to  irregular  capillary 
action  and  congestion  dependent  on  deranged  nervous  action  and  circulation. 

It  is  unnecessary,  perhaps,  to  point  out  to  those  who  have  examined  the  submitted 
cases,  that  the  disorganization  of  the  blood  was  not  proportioned  to  the  continuance  of  the 
inflammation  or  the  amovmt  of  the  inflammatory  products,  but  rather  to  the  rapidity  of  the 
progress  of  the  cases;  and  that  in  several  instances  in  which  the  presence  of  inflannnation 
was  not  satisfactorily  established  the  blood  was  as  fluid  and  as  dark  as  in  those  that,  having 
persisted  for  a  longer  time,  exhibited  well-defined  evidences  of  inflammation.  It  is  equally 
manifest  that  the  purpuric  spots  were  not  dependent  on  deranged  nervous  action,  for  they 
sometimes  appeared  during  the  initial  diill  and  before  symptoms  of  an  infiainmation  of 
the  membranes  were  recognized.  Tliey  wei'e  more  profuse,  as  a  rule,  in  the  rapid  cases 
than  in  those  of  slower  progress,  although  the  latter  presented  a  greater  accumulation  of 
the  products  of  inflammation  on  the  cerebro-spinal  surfaces  to  derange  the  nervous  system. 
Indeed,  an  investigation  of  the  cases  that  have  been  submitted  demonstrates  that  the  danger 
was  proportioneil  to  the  deterioration  of  the  blood  as  shown  by  tlie  presence  of  purpuric 
spots,  for  of  twenty  rapidly  fatal  cases  one-half  were  maculated;  of  thirty-two  cases  fatal  in 
from  three  to  ten  days  three-eighths  were  maculated;  of  twenty-eight  jirotracted  fatal  cases 
one-fourth  were  maculated,  and  of  seven  cases  that  did  not  terminate  fatally  two  only  were 
spotted.  l^Ioreoyer,  while  the  spots  in  the  rapid  cases  presented  frequently  the  characters  of 
ecchymotic  blotches  coalescing  and  covering  the  whole  of  the  surface  of  the  body,  in  the  pro- 
tracted cases  they  were  more  often  minute  and  sparsely  scattered  over  some  particular  region. 

But  if  these  spots  were  due  to  disordered  capillary  action  resulting  from  meningeal  inflam- 
mation they  should  be  found  in  inflammationsof  traumatic  origin.  The  symptoms  of  traumatic 
spinal  meningitis  are  pain  <and  tenderness  in  the  afl'ected  part,  often  extending  into  the  extremi- 
ties, pyrexia,  restlessness,  cutaneous  liypertesthesia  and  paralytic  tendencies;  the  posterior, 
cervical  and  dorsal  muscles  become  rigid  and  the  patient's  head  is  curved  backward;  when 
the  cerebral  membranes  are  involved  intense  headache,  restlessness  and  delirium  are  followed 
by  coma  and  death,  although  occasionally  death  may  be  the  result  of  the  sevei'ity  of  the  tetanic 
spasms.  The  anatomical  conditions  associated  with  these  symptoms  are  identical  with  those 
found  in  the  majority  of  the  s])otted  fever  cases, — plastic  lymph  on  the  surface  of  the  brain  and 
spinal  cord,  with  accumulations  of  pyoid  serum  in  the  subarachnoid  spaces.  The  identity  of 
the  symptoms  in  idiopathic  and  traumatic  meningitis  indicates  that  their  inflammatorv  pro- 
ducts exert  a  similar  influence  on  the  econoni}';  but  as  the  products  of  traumatic  origin  are 
not  as.sociated  with  ecchymotic  blotches,  the  macula}  in  the  idiopathic  cases  must  be  due  to 
some  other  cause  than  the  inflammatory  derangement  of  the  nervous  system. 

On  the  other  hand,  where  the  blood  is  in  a  degenerated  condition,  whether  slowly  pro- 
duced by  defective  alimentation,  as  in  scurvy,  more  rapidly  by  the  primary  influence  of  a 
blood-poison,. abetted  by  the  retention  of  the  products  of  febi'ile  waste,  as  in  typhoid,  typlio- 
malarial  and  continued  malarial  fevers,  or  immediately  by  the  pernicious  influence  of  a 
virulent  miasm,  as  in  congestive  malarial  fevers  and  some  cases  of  typhus,  these  ecchymoses 
appear  not  only  on  the  cutaneous  surface  but  on  the  mucous  and  serous  surfaces. 

The  cases  submitted  in  this  chapter  must  therefore  be  regarded  as  due  to  a  powerful 
fever-cause  acting  primarily  on  the  blood*  like  those  of  typhoid,  typhus,  the  malarial  and 

*.\  committee  i)f  the  Alueririiu  M»tiu-al  AsscK-iatioli  reported  on  this  jioiiit  as  follows  ;  "In  every  easf  ttie  itlomi  was  fluid,  even  when  death  took  plare 
in  four  liours  was  tJiis  tlie  case,     .V  s|ieciuien  of  lilood  talieu  fnini  a  s|iotte,l-fi-v.T  |iali'-iit  and  exuniilted  l),v  ttie  roinniittee  presented  tile  following'  appear 


THK    PAROXYSMAL   AND   CONTINUED    FEVKRS.  603 

eruptive  fevers,  producing  pui'purir  or  ecchymosed  spots  as  these  do,  and  like  thein  having 
a  tendency  to  the  development  of  internal  congestions  and  inflammations.  The  ecchymoses 
which  suggested  its  popular  title  of  spotted  fever  are  certainly  not  peculiar  to  it;  and  the 
determination  to  the  membranes  of  the  brain  and  spinal  cord,  which  obtained  for  it  the  name 
of  epidemic  cerebro-spinal  meningitis,  is  often  associated  with  congestive  and  inflammatorv 
actions  in  other  organs,  and  is  sometimes  absent,  as  in  case  14  and  others  already  instanced.* 

In  fact  this  fever-cause  acts  on  the  economy  like  other  specific  febrile  causes;  and  as  it 
is  apparently  always  associated  with  one  or  other  of  them  in  the  connnunity,  and  sometimes 
even  in  the  individual,  their  relations  are  intimate. 

Occurring  as  a  comjilication  in  the  progress  of  well-developed  measles,  as  in  cases  37 
and  39,  the  disease  would  present  no  ditficulty  clinically  in  its  recognition;  but  if  the  impli- 
cation of  the  cerebro-spinal  system  took  jilace  prior  to  the  manifestation  of  the  characteristic 
symptoms  of  the  specific  eruptive  fever  it  would  b(^  extreinclv  ditlicult,  ind(>t'(l  impossible, 
to  discriminate  between  the  fever  and  the  complication.  In  olhcrwords,  the  ddiM'ioration  of 
the  blood  produced  by  the  virus  of  the  ei'uptivc  fever  would  (iriginate  a  case  of  cerebro-spinal 
fever  with  inflammatory  lesions,  ecchymoses  and  death  befoi'e  the  real  nature  of  the  morbific 
cause  was  declared.  In  individual  cases  of  the  eru]>tive  fevers  tlit;  symptoms  and  posf- 
mortem  lesions  of  cerebro-spinal  meningitis  appan^ntly  originate  in  the  deteriorated  condition 
of  the  blood  produced  by  the  cause  of  the  jniniai'v  fever.  There  is  at  least  no  necessity  for 
calling  in  the  aid  of  a  special  cause  to  account  for  iilienomena  which  are  sufliciently  explained 
by  causes  known  to  be  already  present.  It  becomes  a  (piestion,  tliert;fon>,  whether  in  epi- 
demics of  th(^  eruptive  fevers  the  prevailing  miasm  may  iKit  develop  cases  not  oidy  indis- 
tinguishable from  but  idtMitical  with  those  assumed  to  lie  caused  by  the  sjH'cific  miasm  of  an  . 
epidemic  cereljro-spinal  meningitis. 

The  poison  of  typhus  fever  affects  tli(>  blood  in  the  first  instance,  and  in  consequence  of 
its  deterioration  a  perversion  of  nutrition  and  general  disonler  of  the  functions  are  developed, 
together  with  a  further  degeneration  of  the  blood  by  the  accumulation  of  tissue-waste.  The 
alimentary  mucous  membrane,  the  pulmonary  tissue  and  bi-onchial  lining  are  the  sites  of 
extravasation  and  other  hypersemic  processes;  the  spleen  and  kidneys  are  engorg(>d,  the 
liver  altered,  tht;  skin  maculated.  All  these  organs  are  usually  nion.-  or  less  aflfected,  but 
sometimes  the  diseased  action  is  greater  in  one  organ  than  in  another,  and  some  epidemics  are 
characterized  by  the  special  im]jlication  of  a  particular  oi'gan.  The  brain  and  its  mem- 
branes are  seldom  affected,  notwithstanding  the  severity  of  the  cerebral  symjitoms  which  are 
attributed  to  the  circulation  of  a  degenerated  blood;  neverthel(>ss  cases  do  occur  in  which 
there  is  a  true  meningitis,  and  these  are  more  conunon  in  some  e})idemics  than  in  others. 
i^or  must  it  be  forgotten  that  prior  to  the  separation  of  this  cerebro-spinal  fever  from  typhus 
at  Geneva  in  1805,  epidemics  of  typhus  with  cerebro-spinal  complications  were  not  infre- 
quent. The  history  of  many  of  these  has  been  investigated,  and  they  are  now  cited  by  most 
writers  as  epidemics  of  cerebro-spinal  meningitis.      But  some  medical  observers  do  not  concur 

ancep :  The  red  corpuscles  were  shrivelled,  crenated,  not  in  rouleaux,  aud  numerous  white  corpuscles  were  noticed  in  the  field.  *  *  It  will  be  remem- 
liered  that  the  only  rtmslunt  liathological  condition  i:s  an  altered  state  of  the  hlood, — one  in  which  it  fails  to  coagulate  after  death  and  in  which  the  corpuscles 
have  undergone  certain  marked  physical  changes  indicative  of  a  diminished  vitality." — TrunMctii'ita,  IStiil,  p.  32'J. 

*  In  the  report  of  the  discussion  on  Spotted  Fever  at  the  New  York  Academy  of  Medicine,  April  2l>,  1804,  in  the  Anterkan  Meflical  Timen,  Vol.  VIII, 
J).  237.  Dr.  Clark  is  representi-d  as  stating  that  in  some  cases  the  hrain  and  sjiinal  cord  were  itivolved  in  the  intlainniation,  and  so  far  the  term  cerehru- 
spinal  meningitis  w  as  correct  enough  ;  hut  in  other  cases  the  inflammation  was  limited  to  the  hruin,  while  in  still  other  cases  the  hrain  and  cord  es4'a|H-d 
altogether  and  the  intlammation  spent  its  force  upon  ttie  pericanlinni,  tlie  pleune  and  even  upon  the  lungs.  That  heing  the  case  the  disease,  in  his 
opinitju,  was  due  tt>  a  condition  of  the  system  in  which  tliere  is  a  tendency  to  inflanimatiofi,  whii  h  inthinuu.ition  might  show  itself  in  one  ..r  anotlur 
part  of  the  body  dei^'Udent  mum  circumstances  which  we  cannot  as  yet  appreciate. 


604  DISEA^;KS    ALLIED    TO    OR    ASSOCIATED    WITH 

in  tlie  propriety  of  separating  this  disease  I'roni  tyi->lius.  Boi'DlN  endeavored  to  prove  their 
identity.*  MUECIIISON,  after  reviewing  tlieir  points  of  similarity  and  diil^erence,  concluded 
that  before  attempting  to  estahlish  a  new  specific  disease  it  was  necessary  to  keep  in  view 
the  many  modifications  which  those  already  known  to  us  may  undergo,  and  more  particu- 
larly to  study  their  etiological  relations  and  the  circumstances  under  which  they  arise  and 
are  propagated. f  Buchanan  considered  that  in  some  at  least  of  the  epidemics  of  cerebro- 
spinal fever  the  primarv  fever  was  akin  to  typhus,  if  not  actually  identical  with  it. J  In  this 
country  several  observers  and  writers  have  held  similar  views:  Upham  considered  the  dis- 
ease to  partake  of  the  nature  of  typhus  in  a  severe  and  malignant  form;  Wkp.her§  and 
Baltzell||  concluded  that  epidemic  cerebro-spinal  meningitis  is  only  epidemic  ty|)hus  wherein 
from  some  cause  the  cerebro-spinal  system  is  the  principal  seat  of  attack.  D.  W.  Draper 
argued  in  like  manner:  The  causes  from  which  cerebro-spinal  meningitis  originates  are  sim- 
ilar to  those  of  typhus;  the  symptoms  are  many  of  them  identical  and  all  of  them  referable 
to  the  same  essential  dyscrasia,  and  the  lesions,  though  presenting  some  striking  peculiari- 
ties, have  all  of  them  been  described  as  belonging  to  typhus.^ 

The  symptoms  of  typhus  are  usually  slow  in  their  development  as  compared  with  those 
of  cerebro-spinal  fever.  Delirium  in  typhus  does  not  occur  until  the  end  of  the  first  or  the 
beginning  of  the  second  week.  It  is  due  to  the  infiuence  of  the  deteriorated  and  progres- 
sively deteriorating  blood,  and  appears  to  Ije  independent  of  the  passive  congestions  of  tlie 
meningeal  vessels  and  the  subarachnoidal  serum  which  are  often  present.  On  the  other 
hand,  in  cerebro-spinal  fever  the  delirium  is  frequently  developed  in  a  few  hours,  and  is  due 
in  most  cases  to  the  inflammatory  processes  in  the  |)ia  mater.  The  eruption  of  typhus 
appears  on  the  third  or  fourth  day  of  the  disease ;  the  spots  of  cerebro-spinal  fever  oftentimes 
in  as  many  hours.  But  if  the  infiuence  exercised  by  the  typhous  miasm  is  more  than 
usually  virulent,  constituting  that  \'ariety  of  the  disease  called  typlma  sidera^is,  the  symptoms 
maybe  intensified  and  the  fever  reach  its  fatal  ending  in  a  few  days  or  even  hours  from  the 
beginning  of  the  attack.  Case  388  of  the  post-7)io7ie'm  records  of  the  continued  fevers  pre- 
sents the  appearances  observed  in  a  colored  soldier  said  to  have  died  of  typhus, — the  brain 
and  its  membranes  were  coated  with  purulent  matter  as  in  cerebro-spinal  meningitis.  In 
such  cases,  especially  when  accompanied  with  opisthotonos,  it  may  be  impossible  to  discrimi- 
nate clinically  between  the  two  diseases,  and  it  may  be  equally  impossible  to  decide  after 
post-mortevi  observation ;  for  if  meningeal  inflammation  be  present  it  may  be  regarded  either 
as  a  result  of  the  cerebro-spinal  febrile  cause  or  as  a  meningeal  complication  of  typhus,  while, 
if  the  inflammation  be  not  present,  the  disease  will  probably  be  regarded  as  typhus;  but  a 
doubt  will  remain  on  account  of  the  possibility  of  death  in  cerebro-spinal  fever  before  the 
development  of  the  local  lesion. 

Thus  in  typhus,  as  in  the  eruptive  fevers,  the  individual  case  may  be  complicated  by 
cerebro-spinal  symptoms  and  lesions  which  may  consistently  be  referred  to  the  primary  dis- 
order of  the  blood,  while  in  its  epidemic  prevalence  occasional  cases  of  cerebro-spinal  men- 
ingitis may  appear  to  raise  tlie  question  whether  a  cerebro-spinal  fever,  originating  under 
conditions  which  in  other  instances  give  origin  to  typhus,  should  be  regarded  as  a  manifesta- 
tion of  the  tyjihus  miasm,  which  is  amply  sufficient  to  explain  its  peculiarities,  or  as  a  disease 
due  to  a  miasm  distinct  from  that  of  typhus  and  all  other  febrile  diseases. 

*  Hisiuu-e  Jh   TyjihuH  ('f'n'hn'-sjniml  on  Ji-  hi  tii'iliiiU*^  impruprfnient  ai>pfl''i'  Mi-'niuyUe  t\'rebro-spiiittle  Epidimiquf,  l«ir  J.-Ch.-M.  BouuiN,  PurU,  1854. 
f  Oh  the  Ct^rfhru-Apimd  HinupU-vi*  ami  Lesimts  of  Typhm. — Lawft^  18»J5,  ji.  418.  %  Typhus  Ffn-r,  iu  /iV;/;(f»/«r.s  Syxtem  of  MetUcho-,  Vol.  I,  p.  550. 

^  Cerel-ro-xpinal  Mt'iiin,jUi^.—B'>yUtiyu  Prize  Es-siy,  l;*6t'),-  B..sturi.  M;t<<..  Isr.i',.  |t  Auwr.  J,„u.  Me>lical  ikouut-^,  October,  laiVI. 

^  See  his  paper  iu  the  Bulletin  of  tfte  Xeic  York  Academy  vf  Mvdkiw,  Vul.  Jl,  page -^45  e^  s*--/. 


THE    PAROXYf^MAL    AND    CONTINUED    FEVERS.  605 

Similarly  the  supervention  of  cerebrospinal  syinptonis,  due  to  inflammatory  changes  in 
the  pia  matei-,  is  regarded  as  an  uncommon  result  ot  the  typhoid  fever-poison.  The  history 
of  medical  progress  in  the  studv  of  fever  is  I'l'sponsible  for  this  belief.  At  the  beginning  of 
the  present  century  typhus,  t  vplioid  and  rrrebro-spinal  level's  Were  confounded.  Tlie  cerebro- 
spinal cases  were  first  separated  from  the  others;  afterwards  typlioid  was  distinguished  fium 
typhus  fever.  Bince  typhoid  fever  has  attained  recognition  as  a  distinct  disease,  cerebro- 
spinal cases  occurring  during  its  epidemics  liave  been  considered  only  in  other  connections. 
Nevertheless  a  few  cases  of  true  meningitis  supervening  on  typhoid  fever  suffice  to  show 
the  intimate  relationship  of  the  two  diseases.  Ordinarily  delirium  is  slowly  develo[ied  in 
typhoid,  and  is  due  to  the  gradual  deterioration  of  the  blood  by  the  accunudation  of  the 
j)roducts  of  metabolic  change;  but  in  fulminant  cases,  wdiere  death  occurs  in  a  few  days, 
delirium  and  coma  are  early  sjniiptoms  due  to  the  primary  influence  of  the  miasm  in  tlie 
blood.  Ecchymotic  blotches  or  petechise  are  infrequent,  but  they  do  aj^pear  in  certain 
virulent  cases,  which,  if  speedily  fatal,  mav  j)resent  the  patches  of  Peyer  conspicuous,  con- 
gested, black-pointed  or  tumefied  l)ut  not  ulcerated.  Of  the  few  cases  of  ajiparently  pure 
typhoid  fever,  submitted  in  a  previous  chapter,  in  which  the  in-ain  and  its  membranes  were 
found  to  have  been  aflfected,  there  was  congestion  with  more  or  less  effusion  of  serum  into 
the  ventricles  and  subarachnoid  space  ;*  but  these  cases  were  selected  as  presenting  no  anoma- 
lies suggestive  of  a  niodificatiou  liy  anv  complicaling  influence.  In  the  classical  cases  of 
Ch.  a.  Louis,  congestion  of  the  cerebral  mendjranes,  with  elTusion  of  serum,  was  a  frequent 
observation,  but  rarely  was  the  serum  turbid  from  floccidi  ;  some  opacity  of  the  arachnoid, 
which  apparently  antedated  the  typhoid  attack,  was  found  in  four  cases,  and  in  two  cases 
albuminous  particles  adhered  to  the  visceral  or  jiarietal  layer  of  this  membranc.f  These 
cases  also  were  selected  to  illustrate  the  ordinarv  course,  ])iH)gress  and  lesions  of  the  newly 
discovered  typhoid  aflfection.  Among  i\\e pos(-murtc7ii  records  of  the  continued  fevers  already 
sidjmitted  are  to  be  found  two  cases,  80  and  257,  in  wdiich  lymph  was  deposited  on  the 
surface  of  the  brain.  In  the  former,  which  was  regardt'd  as  a  case  of  typho-inalarial 
fever,  no  cerebral  symptoms  were  noted,  but  the  hemispheres  were  coated  with  coagulable 
lymph,  the  ventricles  contained  turbid  serum  and  the  intestinal  nuicous  membrane  was  exten- 
sively diseased.  In  the  latter,  regarded  as  a  case  of  typhoid  fever  characterized  by  delirium 
and  coma,  the  base  of  the  brain  was  coated  with  a  thin  layer  of  lymph,  the  ventricular  liquid 
was  turbid  and,  although  the  wdiole  of  the  intestinal  mucous  membrane  was  congested,  the 
agminated  and  solitary  glands  were  unafl'ected.  Both  of  these  cases,  from  the  post-mortem 
stand-point,  might  have  been  regarded  as  cerebro-sjnnal  fever.  Again,  if  the  cases  reported 
as  cerebro-spinal  or  spotted  fever  be  examined  it  will  be  found  that  in  some  the  disease 
apparently  supervened  on  or  was  coincident  with  a  ty})hoid  attack  and  while  typhoid  fever 
was  prevalent  in  the  locality.  When  the  fever  ran  a  regular  typhoid  course,  as  in  case  15 
of  the  series  presented  in  this  chapter,  the  cerebro-spinal  inflammation  nuist.  be  regarded, 
like  pneumonia  under  similar  circumstances,  as  a  complication  or  secondary  result  produced 
by  the  perversion  of  nutrition  consequent  on  the  circulation  of  a  vitiated  blood.  But  in  ful- 
minant cases  speedily  fatal  by  coma  after  aggravated  cerebral  symptoms  and  convulsive 
seizures,  the  diagnosis  becomes  obscure  and  the  uncertainty  may  not  be  dissipated  even  by 
a  view  of  the  -post-mortem  lesions,  for  the  absence  of  typhoid  ulceration  of  the  patches  of 
Peyer  is,  in  such  violent  cases,  no  evidence  of  the  absence  of  tlie  tvphoid  miasm,  and  the 


*S«e  analysis,  m^a,  page  431.  f  See  his  Recherche^,  etc.,  t.  I,  Paris,  l8-2'J,  jiage  ;JT^, — also  wijjra,  [laye  4;jl. 


606  DJ.SKA.^ES    ALLIKL)    To    Oti   ASm  ii '1 A  ri:i)    WITH 

absence  of  lympli  or  pus  in  tlie  nervous  centres  niiglit  lie  considered  ns  no  evidence  of  tlie 
absence  of  tlie  virulent  cerebro-spinal  miasm,  while  the  })resence  of  these  inliannnatory  pro- 
ducts might  be  regarded  either  as  a  secondary  result  of  the  typhoid  influence  or  the  immediate 
consequence  of  a  special  cerebro-spinal  febrile  cause.  Again  the  question  arises,  as  in  similar 
cases  occurring  in  ejiidemics  of  typhus  and  the  eruptive  fevers;  and  again  the  reply  is  sug- 
gested, that  it  is  as  unnecessary  to  assume  the  existence  of  a  special  miasm  acting  on  the 
cerebro-spinal  system  as  to  assume  the  existence  of  one  acting  under  similar  circumstances 
on  the  pulmonary  tissue;  since,  in  the  individual,  cerebro-spinal  symptoms  and  lesions  may 
be  referred  for  causation  to  the  tv[)hoid  poison,  cerebro-spinal  cases  occurring  in  typhoid 
epidemics  may  likewise  be  so  referred. 

But  the  cases  that  have  been  submitted  from  the  medical  records  of  the  war  appear  to 
connect  cerebro-spinal  fever  more  extensively,  if  not  more  closely,  with  malarial  diseases  than 
with  typhus,  typihoid  or  the  eruptive  fe\-ers.  Congestive  intermittents  leave  the  blood  fluid, 
the  skin  maculated  and  the  interior  organs  congested  and  ecchymosed  after  death  by  coma, 
sometimes  associated  with  convulsions.  Jackson's  cases  of  so-called  spotted  lever*  were  dis- 
tinctly congestive.  Their  recovery  under  specific  treatment  demonstrated  their  malarial 
character.  In  the  fatal  cases  the  membranes  of  the  brain  showed  no  trace  of  inflammation, 
only  passing  engorgement.  So  long  as  the  vessels  of  the  pia  mater  remained  in  this  congested 
condition  a  complete  and  speedy  recovery  was  possible  by  appropriate  treatment.  Even  if 
the  congested  vessels  became  relieved  l>y  efluslou  of  serum  into  the  subarachnoid  space  and 
ventricles,  a  speedy  return  to  health  was  ec^ually  possible.  Sometimes  the  lungs,  the  kidneys 
or  the  intestinal  lining  were  the  site  of  the  congestion  and,  as  in  the  case  of  the  cerebral 
membranes,  recovery  was  readily  efTected  if  the  congestion  was  passive  and  did  not  terminate 
in  inflammatory  exudation.  The  hypentmic  processes  are  continuous  one  with  the  other; 
the  boundary  line  between  them  can  be  discovered  only  with  the  microscope ;  yet  the  passage 
of  this  line  was  generally  of  vital  importance  to  the  patient,  as  its  consequences  were  the 
establishment  of  a  pneumonia,  a  nephritis,  a  dysentery  or  a  cerebro-spinal  meningitis,  accord- 
ing to  the  locality  of  the  hypertemic  tissues.  Dr.  Jackson  did  not  observe  any  case  pass 
beyond  the  stage  of  congestion;  but  some  of  ]\[krritt",s  cases  of  pernicious  feverf  at  Beau- 
fort, S.  C,  in  May,  i860,  presented  symptoms  of  spinal  meningitis.  Kneeland  recognized 
at  New  Berne,  N.  C,  the  occurrence  at  the  same  time  and  place  of  congestive  malarial  cases 
and  cerebro-spinal  febrile  cases,  and  considered  them  due  to  different  causes  of  the  same  generic 
nature.  But  it  seems  wholly  unnecessary  to  call  in  another  cause  when  influences  already 
recognized  as  in  operation  suffice  to  ex])lain  the  phenomena. 

Undoubtedly  the  clinical  diflferences  between  congestion  of  the  brain  from  malarial  }iois(Mi 
and  cerebro-spinal  meningitis  are  very  great.  Kecovery  is  eflfected  under  proper  treatment 
as  if  by  magic  in  the  one  instance,  while  in  the  otlier  the  result,  notwithstanding  all  treatment, 
is  death  or  a  protracted  illness,  differing  wholly  from  the  usual  course  of  malarial  congestion 
and  too  often  disabling  the  patient  by  a  permanent  impairment  of  sight,  hearing  and  muscular 
power.  Quinine  is  an  efficient  remedy  in  the  one  instance  and  is  valueless  in  the  other. 
These  important  dissimilarities,  seeming  to  indicate  a  radical  diilerence  in  the  cause,  have 
obscured  the  fact  that  anatomically  the  difTerence  between  the  two  conditions  is  small  and 
}>athologically  even  smaller.  The  prevalence  in  a  malarious  locality  of  the  congestive  and 
inflammatory  forms  of  a  spotted  fever,  in  which  the  cerebro-spinal  membranes  are  implicated, 

*  See  lufra,  (wges  128  aud  141.  t  See  mip™,  l«Bu  112. 


THE    PAROXVSxMAL    AXP    COMINl'KD    KKVERS.  607 

forms  a  strong  argument  in  favor  of  a  similar  origin  for  both,  and  as  the  malarial  poison  lias 
been  identified  with  the  causation  of  the  one  it  may  well  be  regarded  as  the  essential  of  the 
other.  The  impotence  of  quinine  as  a  remedial  agent  in  cases  of  cerebro-spinal  fever  does 
not  antagonize  tlie  theory  of  its  malarial  origin.  When  malarial  congestion  of  the  intestinal 
mucous  membrane  has  been  followed  In'  the  ulcerations  of  dysentery,  or  when  pulmonary 
congestion  of  similar  origin  has  developed  into  pneumonia,  the  secondary  inflammatory  result 
is  uninfluenced  by  the  specific  for  the  primary  disease;  so  when  congestion  of  the  cerebro- 
spinal membranes  is  followed  by  the  extrusion  of  the  products  of  the  secondary  inflamma- 
tion relief  may  not  be  expected  from  quinine.  But  if  the  disease  had  in  these  instances  been 
due  to  malaria,  quinine  ought  to  have  proved  in  some  measure  prophylactic.  Unt'ortunately 
there  is  no  evidence  on  this  point.  The  attention  of  our  medical  officers  does  not  a])pear  to 
have  been  directed  to  it.  Dr.  Kneeland  was  apparently  the  only  officer  who  tried  tt)  protect 
his  men  in  this  manner.  His  experience,  so  far  as  it  goes,  is  interesting.  Only  four  cases 
occurred  in  his  regiment  after  the  death  of  the  first  case  led  him  to  use  (juinine  as  a  pre- 
ventive. Not  all  of  the  men  were  so  protected,  but  only  those  ordered  on  duty  necessitating 
exposure  during  the  night;  meanwhile  the  two  neighboring  regiments  continued  to  furnish 
cases  for  the  New  Berne  hospitals. 

It  has  already  been  shown  that  in  continued  malarial  (v.vvr  congestion  of  the  membranes 
of  the  brain  with  effusion  was  a  common  p(»it-morl<iii  observation ;  m  case  287  of  the  pn.st- 
mortem  records  of  the  continued  fevers  there  wei'e  in  addition  ecchymost's  of  the  surface  of 
the  cerebrum  and  on  the  floor  of  the  fourth  ventricle;  but  in  80  and  L*")7  distinct  evidences 
of  inflammation  were  presented.  In  the  first  of  these;  cases  the  ])atches  of  I'eyer  were  promi- 
nent and  speckled  with  blood;  in  the  second  the  ileum  was  gangrenous;  in  the  last  the 
agminated  glands  were  report eil  as  normal. 

Similar  conditions  of  congestion  of  the  brani  and  its  membranes  wei'(^  fouii<l  in  the  tvpho- 
malarial  and  mixed  or  uncertain  cases;  but  in  111  the  exanunation  revealed  thickening  and 
opacity  of  the  arachnoid  over  the  interpeduncular  space;  in  )>79  exudation  on  the  arachnoid, 
engorgement  of  the  brain-substance  and  distention  of  the  ventricles  with  blood-stained  serum, 
and  in  303  injection  of  the  membranes,  turbid  eiVusion  in  the  ventricles  ami  extruded  lymph 
at  the  base  of  the  brain.  In  the  first *of  these  the  patches  of  Peyer  were  enlarged;  in  the 
second  their  condition  was  not  stated;  in  the  last  ulcerated. 

Some  of  these  cases  indicate  the  existence  of  cerebro-spinal  lesions  complicating  con- 
tinued malarial  and  typho-malarial  fevers,  and  since  these  lesions  may  oceur  in  the  individual 
case  as  a  result  of  the  malarial  poison,  there  is  every  reason  for  referring  to  the  same  jwison 
those  cerebro-spinal  cases  or  spotted  cases  without  cerebro-spinal  symptoms  that  occurred  in 
localities  where  malarial  fevers  were  prevailing.  It  may  lie  olijected,  however,  that  the 
season  of  prevalence  of  epidemic  cerebro-spinal  meningitis  was  not  that  of  the  malarial  fevers. 
The  former  was  distinctly  a  winter  phenomenon.  None  of  the  105  cases  submitted  occurred 
in  the  month  of  May,  3  in  June,  2  each  in  July  and  August,  1  in  September  and  2  in  Octo- 
ber. Oases  were  rare  in  the  months  when  the  malarial  tide  was  high,  but  on  its  subsidence 
they  became  more  numerous, — in  November  3,  in  Decendjer  8,  in  Jamiary  3i,  in  February 
25,  in  March  18  and  in  April  10.  No  reliance  can  be  placed  on  these  figures  as  indicating 
monthly  prevalence,  but  they  may  be  accepted  as  sustaining  the  statement  of  many  of  our 
officers  that  spotted  fever  was  seen  chiefly  during  the  colder  months  of  the  year.  But  this 
argument  would  exclude  hemorrhagic  malarial  fever  from  the  list  of  malarial  diseases,  and 


608  DISEASES    ALLIED    TO    OR   ASSOCIATED    WITH 

also  tlie  many  cases  of  undoubled  congestive  chills  that  occurred,  as  in  Jaokson's  command, 
during  the  winter  months.  It  may  be,  as  already  suggested  in  treating  of  malarial  hsema- 
turia,  that  in  these  virulent  cases  the  malarial  miasm  effected  an  entrance  into  the  system 
in  a  concentrated  state  by  means  of  the  water-supply. 

Lastly,  the  occurrence  of  cerebro-spinal  or  spotted  fever  may  be  referred  to  the  fulmi- 
nant operation  of  that  miasm  which  produced  pneumonia  under  ordinary  conditions.  Viewing 
pneumonia  as  a  specific  constitutional  disease,  with  a  local  lesion  in  the  lungs,*  it  becomes 
connected  causatively  with  cerebro-spinal  meningitis  by  the  arguments  that  have  served  to 
eflfect  a  similar  connection  between  tvpthoid  fever  and  the  cerebral  manifestations.  This 
connection  will  be  found  to  be  no  mere  theoretical  idea,  for  in  the  instances  in  which  the 
medical  records  of  the  war  show  an  epidemic  prevalence  of  pneumonia  with  a  corresponding 
intensity  of  the  febrile  poison,  the  so-called  cerebro-spinal  meningitis  was  present  at  the 
same  time.  Surgeon  Ira  Russell,  who  reported  fifty  cases  of  cerebro-spinal  fever  among 
the  colored  troops  at  Benton  Barracks,  Mo.,  in  January  and  February,  1864, t  reported  also 
the  great  prevalence  and  fatalitv  of  pneumonia,  784  cases,  of  which  156  proved  fatal,  havmg 
been  received  into  hospital  during  the  four  months,  January  1  to  April  30. J  In  another 
instance  the  report  of  Surgeon  D.  Porte  Smythe,  19th  Texas  Inf.,§  shows  that  the  epidemic 
pneumonia  which  aflPected  his  regiment  and  others  of  the  same  division  gave  him  in  one 
month,  in  a  strength  of  900  men,  200  cases  of  pneumonia,  ten  per  cent,  of  which  were  of  cere- 
bral or  erysipelatous  tvpes.  The  cerebral  cases,  which  were  at  first  regarded  as  meningitis, 
were  characterized  by  rigors  and  headache;  there  was  little  pulmonary  disturbance,  but  death 
ensued  in  from  twelve  to  twenty-four  hours  with  convulsions  and  delirium. || 

From  the  constant  change  in  the  blood,  the  frequent  ecchymotic  blotches  and  the  occur- 
rence of  cases  unattended  by  cerebro-spinal  inflammation,  it  is  evident  that  in  the  disease 
under  consideration  there  was  more  than  a  cerebro-spinal  meningitis  due  to  those  general 
atmospheric  conditions,  such  as  cold,  exposure  and  bad  ventilation,  that  provoke  the  com- 
mon phlegmasiae  of  fibrous  and  serous  membranes.  A  febrile  poison  must  be  assumed  in  its- 
causation.  The  natural  history  of  this  febrile  cause  is  extremely  obscure,  or  as  Chauffard 
expresses  it,  the  etiology  of  the  disease  is  envelop4e  d' ombres  irapen^trahles.^  This  is  chiefly 
owing  to  the  apparently  contradictory  observations  that  have  been  made  and  recorded.  But 
if  the  causation  be  referred  to  the  occasional  operation  of  any  of  the  miasmatic  influences 
which  destroy  the  integrity  of  the  blood  and  develop  hypersemic  conditions  of  the  various 
organs  these  contradictory  observations  become  reconciled. 

The  cause,  for  instance,  judging  from  the  intensity  of  the  disease  in  the  individual  case, 
is  one  of  great  virulence;  but  in  its  operation  on  the  community  this  virulence  is  not  corre- 
spondingly evidenced.  The  cases  of  an  epidemic  are  comparatively  few  and  scattered,  and 
there  is  no  explanation  of  the  protection  of  the  many  analagous  to  that  which  holds  good  in 
other  febrile  diseases,  as  scarlet  fever  or  measles;  but  if  they  be  regarded  as  the  cerebro- 
spinal or  spotted  manifestations  of  a  prevailing  febrile  cause,  the  virulent  scattered  cases 
become  bound  together  by  others  of  less  malignancy.** 

%l _^ _^ _^ ^_ 

*  See  iit/ni,  pftRP  8' 4.  f  Sfe  atipra,  page  586.  J  Sop  infra^  pafjp  75S.  g  Jnfrn,  page  758. 

I  JuEROENjiEN  refers  to  the  frequency  of  the  asstx-iation  of  an  epidemic  meningitis  with  pneumonia,  and  cites  Immermann  and  HRLreR  aa  having 
recently  called  the  attention  of  phyHicians  to  thie  point.  Out  of  thirty  autnpHies  in  cawps  of  pneumonia  they  ftniiid  nitip  in  which  meningitis  was  also 
preiient.  It  was  at-certained  beyuiid  queBtion  that  an  epidemic  of  cerebro-spinal  meningitis  waH  prevailing  at  tlie  same  time. — Zieinuen  $  ('ychpetUtt, 
American  Ed.,  Vol.  V,  p.  115,  ^  Quoted  hy  Zikmskfn. 

**Tlie  Tommittre  "On  Spotted  Fever,  so-called,"  in  its  report  to  the  American  Medical  AsstM-iaticfn,  drew  attention  to  this,— see  page  ^Z1  of  the 
TranBactions,  1866 :  "When  the  attention  of  the  proieseion  in  Philadelphia  waa  called  to  the  exintenre  of  spotted  fever  there  was  prevailing  in  that  city 
a  Berere  and  wide-spread  epidemic  of  injiuenza  or  epidemic  catarrhal  fever.     *    *    •    Several  medical  mea  la  active  practice  were  at  once  struck  with  the 


THE    PAROXVftMAL    AND    CONTINUED    FEVERS.  609 

On  tills  view  the  different  statements  witli  regard  to  tlie  climatic  and  other  conditions 
associated  with  its  epidemics  may  also  be  understood.  Dr.  Upham  continued  Lis  study  of 
the  disease  after  tlie  war  and  furnished  an  able  report  to  the  Massacliusetts  Board  of  Health 
on  the  epidemic  of  1873,  based  upon  communications  from  two  hundred  phvsicians  trans- 
mitting- the  facts  in  five  hundred  and  seventeen  cases. '^'  From  these  he  found  that  all  aiies, 
occupations  and  nationalities  were  susceptible  of  the  di.sease.  The  cases  were  distributed 
arnonii  all  classes  and  grades  of  societv. — "the  hiu'h  and  the  low,  the  rich  and  the  iioor,  loca- 
tion.s  imexcei^tionable  for  situation,  open  to  abundant  light  arid  air,  and  the  pcnt-uj>  hovels 
of  the  lowly  and  wretched  have  all  contributed  to  the  material  of  the  epidemic."  STiLLEf 
says  that  localities  of  every  sort,  high  and  low,  dry  and  moist,  those  saturated  with  marsh 
miasmata  and  those  favored  by  the  pure  breezes  of  mountain  districts  have  been  alike 
invaded;  the  disease  has  passed  by  large  cities  reeking  with  the  corruptions  of  a  soil  satu- 
rated with  ordure  and  a  population  grimed  with  filth  to  devastate  clean  and  airy  villages  and 
the  families  of  substantial  farmers  inhabiting  isolated  spots.  I^s  greater  prevalence  in  the 
winter  months  appears  to  be  one  of  the  few  features  which  remain  unaltered  in  the  investi- 
gation of  many  epidemics;  but  even  this  is  unconnected  with  low  temj>erature,  for  while 
Yagee  represents  the  beginning  of  the  Chillicothe  eiiidemic  as  having  coincided  with  a  snow- 
storm following  dense  fogs  and  chilly  east  winds,  "Ware  reports  the  outbreak  at  New  Berne 
as  having  been  preceded  bv  a  period  of  dr}-  warm  weather.  In  the  former  instance  measles 
prevailed;   in  the  latter  typhoid  fever  and  malarial  diseases. 

In  many  cases  the  disease  occurred  suddenly  and  unexpectedly  in  the  strongest  and 
apparentlv  the  soundest  men  of  the  command:  but  in  this  it  did  not  difl'er  iVoni  congestive 
malarial  fever.  In  the  trreater  number,  however,  the  sufferers  were  liroken  duwn  bv  con- 
tinned  hardships,  fatigues  and  exposures.  This  was  specially  noted  by  Kussell  in  his 
account  of  the  epidemic  among  the  escaped  and  emancipated  slaves.  The  disease  frequently 
selected  its  victims  from  the  guard-house  or  prisons,  and  the  inmates  of  these  Ijefore  their 
commitment  had  usually  undergone  many  hardshijis,  among  which  may  be  particularly  noted 
exposures  at  night  in  malarious  localities,  with  insufficient  food,  shelter  and  clothing.  Even 
after  their  commitment  they  were  often  insuflficiently  provided  with  clothing  and  blankets. 
A  large  number  of  victims  was  also  drawn  from  detachments  of  recruits  who  had  frequently 
to  endure  unnecessary  suffering  on  account  of  their  ignorance  and  that  of  their  officers,  while 
they  were  at  the  same  time  peculiarly  liable  to  those  scourges  of  new  regiments,  typhoid 
fever  and  measles.  Overcrowding  is  frcquentlv  referred  to  as  a  proljable  cause;  but  it  seems 
that  this  operated  as  a  predisposing  cause  of  cerebro-spinal  fever  only  when  the  diseases  just 
mentioned  were  present  and  aggravated  by  deficient  air-space  and  defective  ventilation.  In 
the  presence  of  other  and  essential  elements  of  causation,  overcrowding  no  doubt  exercised 
a  pernicious  influence,  but  of  itself  it  was  as  incompetent  to  exp^lain  the  presence  of  cerebro- 
spinal fever  as  to  account  for  the  large  death-rate  among  Confederate  prisoners,  when  their 
Union  guard,  who  were  similarly  crowded,  had  a  comparatively  small  rate. J 


reseinblanco  of  many  of  the  symptoms  of  thp  two  diseases,  and  wore  led  to  inquire  if  influenza  niiglit  not  lie  but  a  mild  manifestation  of  that  ejiidemic 
influence  which  in  its  intensity  linnluced  sjiotted  fever.  Xor,  it  will  be  S4'en,  wen- tlu-ir  synii»tonis  very  dissimilar  save  in  de^rei'.  *  *  *  The  Com* 
mittec  do  not  propose  to  reopen  this  suhject  more  than  to  call  the  attention  of  tlie  Assoeiation  to  the  interesting:  fact  of  the  almost  uniform  coincident 
prevalence  of  spotted  and  of  catarrhal  fevers," 

*  Altlion>;h  the  year  1873  was  considered  an  epidemic  year  it  does  not  follow  that  the  disi'ase  was  absent  in  other  years.  During  the  ten  years, 
1S7.V82,  2,053  deaths  occurred  in  Massachusetts  from  cerebro-spinal  meningitis,  tlf  these  74"  occurred  in  1873  and  an  average  of  130  iu  each  of  the  nine 
other  years. 

f  iLpUinuw  ^reain'jiti-i. — AlfukI' Stii.lk.  Philadeljihia,  I'a.,  lsr,7,  \>.  *.'5. 

(See  snjii-ijj  ]«,!.-,■  IW*.. 

Med.  Hist.,  Pt.  111—77 


610  PISKASES    ALLIED    TO    OR    ASSOCIATED    WITH 

Dr.  Gaillaed,  ill  an  article  on  the  disease  in  tlie  civil  ponulation,  noted  what  ho  con- 
sidereJ  a  remarkable  feature  of  its  prevalence  in  the  Southern  States.  Contrary  to  its 
recorded  history  elsewhere,  as  manv  adults  as  children  were  the  subjects  of  its  attack/''  The 
greater  prevalence  of  malarial  disease,  affecting  young  and  old  alike  in  the  South,  wouLl 
account  for  this  want  of  consistency  with  returns  from  localities  where  susceptibility  to  typlioi(l 
and  tlie  eruptive  fevers  constituted  an  important  factor  in  the  prevalence  of  cerebro-spinal 
fever. 

By  some  observers,  especially  in  Europe,  the  disease  has  been  regarded  as  contagious. 
A  suggestion  of  contagion  appears  in  the  records  of  the  National  hospital,  Baltimore,  Md., 
where  typhus  fever  was  prolialdy  present. f  and  perhaps  in  Page's  recorded  case  13,  from 
Galloupe's  Island,  where  ir.easles  prevailed  extensively  in  a  virulent  form, J  but  in  other 
instances  no  mention  is  made  of  contagion  unless  to  deny  its  existence.  Wake,  in  his  account 
of  the  disease  in  the  malarious  region  around  Xew  Berne,  states  that  there  was  no  evidence 
of  contagiousness,  §  and  it  is  well  known  to  the  writer  that  the  disease  did  not  spread  in  the 
division  field  hospitals  of  the  Army  of  the  Potomac,  although  no  attempt  was  made  to  isolate 
the  occasional  cases  that  were  received  from  the  regimental  camps. 

In  conclusion  it  is  submitted  that  as  the  so-called  typhoid  condition  may  occur  in  the 
progress  of  anv  fever  by  the  gradual  deterioration  of  the  blood,  so  the  so-called  spotted  fever 
may  bo  the  result  of  any  febrile  miasm  which  destroys  the  integrity  of  the  blood.  When 
death  is  not  a  cpiickly  following  consecpience  of  this  alteration  perversions  of  nutrition  are 
in  order,  more  activclv  manifested  in  some  organs  than  in  others,  and  depending  generally, 
perhaps  alwavs,  on  local  or  accidental  conditions  involving  among  others  climate,  exposure, 
overwork  and  the  phvsiological  status  of  the  organs  as  determined  by  hereditary  tendencies, 
growth,  age  and  previous  disease.  The  lungs,  the  pleural,  pericardial  or  synovial  membranes, 
the  liver,  spleen  or  kidnevs,  the  alimentary  mucous  membrane  or  the  vascular  membrane  of 
the  cerebro-spinal  system  may  become  the  parts  chiefly  involved,  and  death  is  imminent  in 
proportion  to  the  deterioration  of  the  blood,  the  activity  of  the  localized  hypersemia  and  the 
vital  importance  of  the  part  affected.  When  the  brain,  lungs  or  pericardium  become  involved 
death  may  result  before  those  special  signs  are  manifested  which  permit  of  a  discrimination 
between  one  febrile  miasm  and  another;  hence  spotted  fever  ending  fatally  prior  to  local 
developments  or  with  congestive  or  inflammatory  conditions  of  these  important  organs,  may 
be  attributed  to  malarial,  typhous,  typhoid,  eruptive  or  other  miasm,  according  as  the  locality 
and  other  circumstances  bearing  on  tlie  etiology  appear  to  determine.  When  death  is  not 
so  imminent  the  peculiar  phenomena  attending  the  cerebro-spinal  lesion  are  so  profound  as 
to  veil  the  true  nature,  etiologically  speaking,  of  the  disease,  giving  it  characters  apparently 
sui  generis,  but  in  no  wav  inconsistent  with  its  oricrinal  develoijment  from  the  identical  cause 
that  produced  a  typhoid,  typhus  or  remittent  fever  in  another  sufferer. 

Ill— PREVENTION  AND  TREATMENT. 

Pkeve>:tion. — If  the  views  that  have  been  submitted  on  the  etiolotry  of  the  diseased 
condition  under  consideration  be  admitted,  preventive  measures  may  be  undertaken  with  some 
hope  of  diminishing  the  number  of  attacks.  These  measures  will  embrace  those  necessary 
to  the  suppression  of  existing  epidemics  of  febrile  disease:  Isolation  and  disintection  in  some 
instances,  and  the  application  of  certain  hygienic  rules  to  the  individual,  the  command  and 

*  r::.  hm.nti  MflicalJounial,  Vul.  I,  IsiJC,  [..  2'i5. 

t  S'*e  ii'^ira,  imgo  5Ti,t.  I  f^vfira,  jiai^n  ''83.  \  Siiprti.  pui^t?  5.j7. 


THE    PAROXYSMAL   AXD    COXTINUED    FEVERS.  611 

tlieir  surroundings  in  nil  instances.     But  these  do  not  require  special  mention  in  tliis  connec- 
tion, as  tliey  |)roperly  belong  to  the  specific  diseases. 

It  is  probable  that  in  many  cases  during  the  war  the  use  of  prophylactic  doses  of  quinine, 
as  employed  by  Surgeon  K>"eela^;]:>,  \vould  have  been  of  value,  for  although  cases  occurred 
when  the  patients  had  been  taking  quinine  just  before  the  attack,  other  miasms  than  tiio 
malarial  were  evidently  present  with  the  coimnand  affected  in  these  particular  instances. 

The  avoidance  of  unnecessary  causes  of  exhaustion  is  an  elementary  or  essential  prin- 
ciple in  military  hygiene  sometimes  contravened  by  commanding  officers  ignorant  of  the 
effects  of  the  parades,  drills  and  disciplinary  exercises  imposed  by  their  orders.  In  times  of 
epidemic  febrile  disease  all  exhausting  work  not  imperatively  required  by  the  militarv  con- 
ditions should  be  particularly  avoided,  for  overfatigue,  want  of  sleep,  exposure  to  the  elements, 
hunger  and  overstrain  of  mind  which  the  private  soldier  may  undergo  at  liis  ]->ost  on  picket 
or  in  the  rifle-pit,  appear  to  have  been  factors  of  some  importance  in  the  determination  of 
cerebro-spinal  complications.  Certain  hardships,  exposures  and  anxieties  are  unavoidable. 
Picket  and  guard  duties  have  to  be  performed  in  all  weatliers,  during  tlie  night  as  during 
the  day,  and  when  the  men  are  exhausted  after  a,  long  march  as  when  they  are  fresh  after 
some  days  of  rest  in  camp.  In  such  cases  much  may  be  done  to  control  the  evil  consequences 
of  overfatigue  and  exposure  by  official  inspection  to  insure  that  the  men  be  well  ]>rovided 
against  possible  contingencies  and  that  the  exhaustion  of  hunger  be  not  associated  with  that 
of  overfatigue. 

Treatment. — The  great  disorganization  of  the  blood  in  quickly  fatal  oases,  and  the 
rapidity  with  which  inflammatory  products  were  extruded  on  the  surface  of  the  nervous 
masses  in  the  majority  of  cases,  alike  intimate  the  probable  inefficiency  of  all  plans  of  treat- 
ment; for  in  both  sets  of  cases  a  lesion  was  inflicted  which  proved  fatal  without  affording  the 
time  needful  to  effect  its  reparation. 

In  most  of  the  recorded  cases  purgatives  by  the  mouth  or  rectum  were  administered. 
In  the  early  period  of  the  attack  cold  was  generally  applied  to  the  head,  cups  to  the  neck 
and  counter-irritation  by  mustard  to  the  extremities;  later,  blistering  plaster  or  mustard  was 
applied  to  the  scalp,  neck  and  along  the  spine.  But  although  these  remedial  measures  are 
frequently  found  on  the  records  as  part  of  the  treatment  it  is  seldoni  stated  that  any  benefit 
was  derived  from  them.  In  S3  cold  cloths,  cupping  to  eight  ounces  and  purgation  by  castor 
oil  were  followed  by  temporary  improvement,  and  in  87  and  101  some  relief  was  attributed 
to  cupping,  but  in  86  and  many  others  no  apparent  effect  was  produced. 

These  measures  w^ere  usually  reinforced  by  attempts  at  specific  medication,  (^uiuino 
was  a  favorite  remedy.  In  case  1,  a  recovery  from  cerebral  symptoms  and  sloughing  spots, 
ten  grains  were  given  every  four  hours;  in  48,  also  a  recovery,  the  symptoms  became 
ao-o-ravated  when  quinine  was  intermitted  and  were  relieved  on  the  resumption  of  the  med- 
icine, and  in  6  its  administration  was  followed  by  temporary  improvement.  But  eighty 
o-rains  administered  on  the  first  dav  of  the  attack  in  12,  did  not  prevent  a  raiiidlv  fatal 
course  ;  ten-grain  doses  every  four  hours  in  50  and  half-drachm  doses  in  14  were  not  effica- 
cious, nor  was  the  remedy  more  successful  in  4,  13  and  67.  Indeed,  in  case  92  the  patient 
was  takino-  quinine  with  apparent  success  for  an  intermittent  at  the  time  of  the  cerebro- 
spinal onset.  In  some  instances,  as  5,  7  and  9,  stimulants  were  used  in  conjunction  with 
the  C|uinine.  Evidently  certain  cases  were  benefited  by  quinine,  although  in  others  its 
administration  was  apparently  valueless.      Surgeon  Ira  Russell,  U.  S.  Vols.,  considered 


612  Dlr^EASKS    ALLTEP    TO    OR    ASSOCIATED    WITH 

that  the  remedy,  if  o-ivcu  early  and  l>efore  the  state  of  collapse  came  on.  in  many  instances 
averted  it.s  onset.  Lut  whether  hy  exercising  a  specific  influence  on  the  disease  or  merely 
removing  one  of  its  predisposing  causes  he  was  unable  to  determine,  as  liis  experience  was 
confined  to  cases  occurring  in  a  malarious  localitv. 

Calomel  was  sometimes  given  as  a  purgative;  generally,  however,  it  was  used  in  small 
doses  with  quinine,  as  in  the  favorable  case  17  and  the  slowly  fatal  case  11,  which  was  at 
one  time  regarded  as  a  i-ecoverv.  Calomel  was  o-lven  alone  in  case  32,  which  recovered. 
Ipecacuanha  was  conjoined  with  calomel  or  calomel  and  rpiinine  in  a  number  of  cases,  as  in 
26,  which  recovered:  in  case  2,  in  which  an  improvement  lasting  three  weeks  terminated 
unfavorably  and  in  IS  and  20,  in  which  also  an  amelioration  of  the  symptoms  preceded  a 
fatal  relapse.  In  23  salivation  took  place,  but  it  is  doubtful  if  the  favorable  issue  in  this 
case  should  be  attributed  to  the  constitutional  action  of  the  remedy,  for  two  cases  have  already 
been  submitted  in  which  the  patient  at  the  time  of  the  att;*ck  was  under  the  influence  of 
mercurials. '='  Moreover,  in  16,  19,  20,  21  and  22  the  ])rogress  of  the  disease  does  not  api)ear 
to  have  been  influenced  by  this  treatment.  Similarly,  in  case  3,  in  which  blue-pill  was  used 
instead  of  calomel,  no  manifest  efTect  was  produced. 

In  93  acetate  of  ammonia,  antimonial  wine  and  sweet  spirit  of  nitre  were  used  without 
beneficial  effect.  In  81  small  doses  of  tartar  emetic  and  in  91  two-grain  doses  of  this  sub- 
stance every  two  liours  for  some  tin\e  were  similarly  valueless.  Veratrum  viride,  i[iecacnanha 
and  nitrate  of  potassa  were  without  success  in  104.  loilide  of  potassium  was  given  in  case 
2  during  a  temporary  remission.  Bromide  of  potassium  in  fifteen-grain  doses  every  liour 
was  followed  in  105  In'  subsidence  of  the  tetanic  convulsions;  small  doses  of  strychnia  were 
then  added  to  the  brumido  in  this  case,  whicli  ended  fatally.  Dr.  F.  Le  I^akox  Moxkoe 
claimed  decided  advantages  over  other  remedies  for  the  bisulphite  of  soda,  and  stated  tliat 
two  of  his  recoveries  at  Galloupe's  Island,  cases  12  and  13  of  Page's  series,  were  treated 
exclusively  with  this  substance  ;f  but  a  fatal  case  of  the  same  series  was  also  treated  in  this 
manner.  A  warm  bath  returned  the  patient  temporarily  to  consciousness  in  87.  Morphia 
is  said  to  have  given  relief  in  28  and  93.  Dr.  Lidell  enunciates  the  proposition  that  treat- 
ment to  be  successful  must  prevent  effusion  or  cause  its  absorption  prior  to  fatal  compression 
of  the  nervous  centres,  and  conceives  that  in  o])iuni  freely  administered  we  have  a  remedy 
wliich  will  effect  this,  in  view  of  its  power  to  arrest  exudation  from  serous  membranes,  as  seen 
in  the  treatment  of  pleurisies  and  puerperal  and  traumatic  peritonitis.  J  In  protracted  cases 
stimulants  were  invariably  given. 

General  bloodletting  appears  to  have  been  tried  in  two  cases:  In  25  the  abstraction 
of  eighteen  ounces  was  followed  by  decided  improvement,  which  continued  for  some  time 
under  quinine,  but  deatli  took  place  in  a  relapse;  in  21  the  removal  of  twenty-four  and 
afterwards  of  sixteen  ounces  of  black  blood  Lad  no  influence  in  postponing  the  fatal  issue 
and  but  little  in  relieving  the  restless  delirium.  Regarding  the  disease  as  primarily  a  men- 
ingitis, Joxes  recommends  bleeding  to  faintness,  cups,  purgatives  and  mercury,  with  quinine 
and  opium  during  the  active  period;  but  as  his  pathological  views  are  manifestly  incorrect, 
the  treatment  bv  general  bleeding  cannot  be  accepted  unless  supported  by  better  results 
than  have  hitherto  been  brought  forward. 


*.Si:-e  thi-  case  of  Ourporal  .Joseph  B.  ('Jrow  anil  that  repi-rtni  hy  \V. :?.  AR.M.STR"Xa,  of  3Iol.iI.-.  .\ht.,  snpni,  i>,  .")'.».".. 
f  IJostvii  Medioil  uiid  !iur,j!r-:,lJ,.iiriial,  Vol.  LXXIII,  ISfifi,  p.  2.J3. 

XAiiterinnt  Jour.  Mr'l.  .S/f-jfrcs,  Vol.  XLIX,  1805,  p.  17, — Opiiini,  ho\v<.'Vor,  was  in  (.■oiiiiiion  tisc  in  thu  tn-iitiii'Tit  of  tills  dir^eiisc  a<  oar'y  a-t  tho  ln-giii- 
ning  of  this  c-titury.     S.-t-  .Stii.I-^:.  Oh  Kpi'leHtic  Meiun<jiiis,  Pliihid-li'liia,  ISt'.T.  p.  lo4. 


THE    PAROXYSMAL   AND    CONTINUED    FEVERS.  613 

Catheterization  was  frequently  required,  and  in  some  instances  was  followed  by  decided 
temporary  relief  to  the  restlessness,  as  if  the  distended  condition  of  the  bladder  had  been 
responsible  for  a  part  at  least  of  the  distress  which  was  its  cause. 

Viewing  the  disease  as  a  manifestation  of  a  disordered  condition  v(  the  Uood  produced 
by  a  miasm  which  may  not  be  the  same  in  all  cases,  a  rational  jilan  of  treatment  requires  in 
the  first  instance  the  determination  of  the  causative  miasm.  Ev  this  means  cases  that  will 
be  benefited  by  the  early  and  free  use  of  quinine  may  be  separated  from  those  in  Avhich  no 
satisfactory  results  are  to  be  anticipated  from  its  administration.  ]5ut  obviously,  even  in 
malarial  cases,  no  good  can  be  effected  by  the  specific  after  exudation  has  taken  place.  In 
the  stage  of  collapse  hot  applications  and  other  stimulants  to  the  surface,  with  alcohol  and 
ammonia  internally,  appear  to  be  suggested  irrespective  of  the  nature  of  the  cause.  During 
reaction  cold  to  the  head,  mercurial  purges  in  malarial  cases  characterized  by  constipation, 
cups  to  the  neck,  antimonials  or  ipecacuanha  may  be  used,  with  opiates  when  there  is  much 
pain  and  restlessness.  When  the  manifestations  of  cerebro-spinal  exudation  indicate  that  the 
gravity  of  the  case  depends  more  on  the  local  lesions  in  progress  in  the  nervous  centres  than 
on  the  primary  condition  of  the  blood,  blisters  to  the  back  of  the  head  and  spine  and  small 
doses  of  calomel,  as  generally  used  by  our  medical  ofBcers,  or  ioditle  of  potassium  in  largo 
doses,  may  be  employed.  But  meanwhil(\  if  tv]ihoid  symptoms  supervene,  stimulants  should 
be  administered  and  continued  with  appropriate  nourishment  throughout  the  progress  of 
protracted  cases.''' 

II.— PNEUMONIC  FKVER. 

In  referring  to  certain  of  the  pneumonias  of  our  camps  and  hospitals  under  this  title  the 
writer  departs  advisedly  from  the  olHcial  nosologv  which  regarded,  and  slill  r<'gards,  pneu- 
niuuia  as  a  local  disease  associated  with  catarrhs  and  Ijroiichitic  atfcctiuns  that  are  usually 
ascribed  to  atmospheric  vicissitudes  and  exposures,  lie  has  less  hcsitaucv  in  t;d^iiig  this 
liberty  with  the  official  methods  as  his  investigation  into  the  nature  of  the  continued  levers 
has  shown  that  the  diseases  of  which  our  soldiers  died  were  Ijy  no  means  in  all  instances 
those  vmder  which  they  were  reported  in  the  Monthly  Ileport  of  Sick  and  Wounded.  Indeed, 
the  connection  between  cases  of  pneumonic  disease  and  the  fevers,  malarial  or  typhoid,  of  our 
camps  was  so  striking  that  the  medical  officers  in  attendance  set  the  example  of  a  departure 
from  the  official  nomenclature.  The  term  pneumonia  on  the  blank  forms  in  use  did  not 
seem  to  give  full  expression  to  the  diseased  conditions  present  in  their  cases,  and  in  many 
instances  they  qualified  it  with  the  word  ti/phoid.  But  the  clinical  resemblance  of  the  dis- 
ease in  question  to  typhoid  fever  forms,  as  will  be  shown  hereafter.'f"  no  [lart  of  the  argument 
which  led  to  the  adoption  of  the  term  pneumonic  fever  in  the  present  connection. 

By  this  term  is,  of  course,  understood  a  specific  constitutional  affection  with  a  charac- 
teristic and  constant  lesion  in  the  lungs.     In  the  continued  fevers — typhuid.  modified  tvphoid 

*  Tli<>  Committee  on  "  Spotted  Tever,  so-called,"  of  the  American  MeJieal  ,\!Jsociution,  Vol.  XVUI,  Tt-mi^.  l^Or.,  p.  341,  lifter  revievin;;  the  various 
plans  uf  treatment  that  have  been  used,  recommended,  in  view  of  the  typhous  character  of  the  essi'ntial  fever,  that  the  same  general  principles  adopted  in 
the  treatment  of  typhus  fever  be  applied  to  this  disease.  In  the  first  stage  the  patient  should  be  placed  in  a  hot  bath,  liii-H'G-  Fah.  -\fter  this  he  should 
be  rubbetl  with  coarse  towels,  or  oil  of  turpentine  if  there  is  a  tendency  to  coldness  of  the  surface.  When  the  bowels  are  torjtid  an  enema  of  turpentino 
is  recomniendeJ  ;  jtrostration  should  be  treated  by  alcohol  or  ammonia,  and  pain,  hypeni'sthesia  or  jactitati'-u  by  opium.  If  oi'iuni  is  not  reipiired  in 
the  beginning  large  doses  of  quinine  maybe  advantageously  given  ;  but  this  remedy  is  valueless  and  may  prove  hurtful  if  given  after  exudation  has  taken 
place.  Cold  to  the  head  and  spine  is  advised  when  cerebro-spinal  syjuptonis  are  promim'tit  fn-ni  the  first.  Local  depletion  by  cupping  is  cautiously 
recommended  in  some  instances,  but  the  use  of  the  lancet  is  condemned.  Tincture  of  iron,  mineral  acids  and  tur]»entin6  may  be  used  if  the  stomach 
will  bear  them,  but  care  should  be  taken  not  to  disturb  that  viscus.  The  iodides  Ltf  potassium  and  iron  are  recommended  when  the  case  has  become 
chronic  and  presents  unequivocal  evidences  of  exudation.     The  Committee  failed  to  get  satisfactory  results  from  blisters  along  the  spine. 

t  Iufniy  page  8*>i. 


614  DISEASES    ALLIED    TO    OR    ASSOCIATED    WITH 

and  continued  malarial — conditions  usually  regarded  as  results  of  pneumonic  inflammation 
were  frequently  developed  toward  the  close  of  the  scene  in  fatal  cases.  The  post-niortem 
records  illustrate  this  frequency  by  showing  that  in  no  less  than  sixty-eight  per  cent,  of 
the  whole  number  of  recorded  cases  there  was  congestion  of  the  pulmonary  tissues,  with 
more  or  less  solidification  from  transudation,  constituting  the  conditions  indicated  by  the 
terms  oedema,  splenization,  hepatization  and,  when  histolytic  changes  were  in  progress,  pur- 
ulent infiltration,  or,  as  sometimes  phrased  by  cautious  observers,  puru/oiV/  infiltration.  Gen- 
erallv,  in  these  cases,  the  symptoms  attending  the  progress  of  the  complication  were  obscure. 
There  wp.s  no  aggravation  of  the  febrile  conditions,  and  the  vital  activities  were  so  depressed 
that  the  occlusion  of  a  large  portion  of  the  cellular  structure  of  the  lungs  failed  to  exercise 
a  marked  effect  upon  the  ebbing  life.  Xevertheless  local  changes,  subsequently  verified  at 
t\ie  post-morton  investigation,  were  susceptible  of  definition  by  physical  examination.  The 
blending  of  different  fevers  may  be  considered  at  the  present  time  as  a  well-established  path- 
ological doctrine;""  but  it  is  difficult  to  recognize  in  these  almost  passive  congestive  changes 
the  sui^ervention  of  pneumonic  fever  on  pre-existing  typhoid  or  malarial  fever,  although  in 
many  cases  the  local  lesions  were  precisely  those  of  a  pneumonic  fevei-.  Their  explanation 
must  be  found  rather  in  the  enfeebled  condition  of  the  heart  and  disordered  state  of  the 
blood,  which  together  developed  the  pulmonary  stasis, — the  starting  point  of  pulmonary 
transudation,  hepatization  and  subsequent  degenerative  changes.  In  these  cases  the  post- 
mortem condition  of  the  air-cells  as  to  crepitus,  solidification  or  difiiuence  depended  on  the 
duration  and  activity  of  the  vital  processes  subsequent  to  the  occurrence  of  the  congestive 
stasis.  This  view,  which  associates  these  pulmonary  lesions  with  prostration  and  a  deteri- 
orated condition  of  the  blood,  is  sustained  by  the  frequency  with  which  similar  pneumonic 
changes  were  found  to  originate  in  the  closing  hours  of  otlier  febrile  and  exhausting  diseases, 
as  measles,  small-pox,  acute  diarrhoea  and  dysentery. 

But  similar  changes  took  place  in  the  lungs  at  earlier  stages  of  the  continued  fevers,  con- 
stituting what  was  recognized  as  intercurrent  pneumonia,  illustrations  of  which  may  be  found 
in  the  clinical  records  of  those  fevers.  In  these  cases  the  constitutional  disturbance  marking 
the  invasion  of  the  pulmonary  tissue  was  at  times  so  prominent  as  to  lead  to  a  diagnosis 
of  pneumonia  or  tvplioid-pneumonia  when,  as  in  cases  331-339,  353-360  and  370-372  of 
the  post-mortem  records,  the  primary  disease  was  a  typhoid  or  continued  malarial  fever.  It 
is  diificult  to  sav  whether  in  these  cases  the  lung  disease  was  a  local  congestion  with  conse- 

„■  CD  CD 

quent  transudation  and  a  symptomatic  aggravation  of  the  constitutional  disturbance  which 
was  its  cause,  or  the  local  expression  of  a  pneumonic  fever  which  had  seized  on  the  typhoid 
or  malarious  patient  and  blending  with  the  pre-existing  fever  tended  to  the  more  rapid  extinc- 
tion of  life. 

The  frequency  of  the  occurrence  of  similar  lesions  in  the  advanced  stages  of  the  con- 
tinued fevers,  and  the  intercurrence  of  similar  attacks  in  other  diseases  characterized  by  a 
depraved  condition  of  the  blood,  suggest  that  in  many  of  these  instances  the  changes  in  the 
lungs  resulted  from  the  action  of  the  tyjihoid  or  other  febrile  poison.  Congestions  and  tume- 
factions of  the  S2")leen  are  common  in  all  these  fevers  in  accordance  with  the  testimony  of 
clinical  exploration  and  post-mortern  observation;  but  the  anatomical  characteristics  and 
physiological  uses  of  this  organ  are  such  that  tlie  distention  of  its  vessels  is  not  followed  by 
dangerous  consequences.    Similar  hypenernias  of  the  lungs  interfere  with  their  physiological 

♦  SeeFLlNT^S  Practice  of  Medicine,  Pbila.,  1&S4,  p.  181, 


THE  PAROXYSMAL  A.\D  CONTINUED  FEVERS.  615 

action,  ami  the  anatomical  cliaracters  of  the  puhnonarv  tissue  peniiit  of  transudations  which 
give  a  greater  permanence  to  the  interference.  Local  liypera3mias  occurring  in  tlie  progress 
of  fevers  derive  tlieir  imjiortance  from  their  localitv:  In  the  distensible  spleen  they  are  com- 
paratively harmless,  perhaps  of  value  as  protective  against  similar  manifestations  in  more 
important  sites:  in  the  non-elastic  parotid  thcv  lead  to  necrotic  changes;  in  the  intestinal 
mucous  membrane  they  are  productive  of  diarrlioeal  and  dysenteric  lesions  whicli.  in  many 
cases,  assume  diplitheritic  characters;  in  the  lungs  pneumonia  is  caused;  in  the  nervous  sys- 
tem their  deadly  results  are  those  of  cerebro-spinal  meningitis.  It  seems  probable,  therefore, 
that  in  many  of  the  cases  under  consideration  there  was  merely  a  manifestation  of  the  typhoid 
or  the  malarial  poison  and  not  the  supervention  of  a  new  disease. 

Xevertheless  the  occurrence  of  a  pneumonic  fever  in  the  person  of  uue  suffering  from 
typhoid  or  other  continued  fever  must  be  accepted  if  the  existence  of  a  specitic  pneumonic 
fever  be  allowed ;  for  there  is  nothing  in  the  historv  of  pneumonia  or  of  the  continued  fevers 
to  show  that  the  subjects  of  the  latter  were  less  susceptible  to  the  attacks  of  the  former  than 
liealthy  men  who  had  been  sitBilarly  exposed  to  its  causes.  Pneumonia  was  of  frerpient 
occurrence  as  the  only  disease  affecting  the  system  at  the  time.  It  was  characterized  by 
febrile  accession  and  local  changes  in  the  lungs,  such  as  occurred  in  the  progress  of  typhoid 
or  other  continued  fevers.  But  the  special  lesions  of  those  fevers  were  not  present ;  the  pul- 
monary changes  were  wholl}'  independent  of  the  tvphoid  or  malarial  poisons.  In  many  cases 
the  siileen  was  enlartred  and  various  chanofes  were  occasionallv  noted  in  the  other  viscera,  but 
only  tlie  pneumonic  changes  were  constant. 

Although  unaccompanied  with  tvphoid  lesions  this  disease, as  will  be  seen  hereaftei'.'^'  was 
frecpiently  associated  with  typhoid  symptoms.  Hence  the  term  typhoid-pneumonia  which, 
unfortunately,  became  so  familiar  during  the  war.  The  typhoid  svmptoms,  as  when  occur- 
ring in  the  progress  of  a  continued  malarial  fever,  were  apjiarently  t\\o  result  of  the  febrile 
condition  in  asthenic  states  of  the  system,  especiallv  in  that  brought  about  liy  the  hardships 
of  field  service  and  overcrowding  in  quai'ters.  \\\  Ivjihoid-pneumonia  tlicre  was  no  typhoid 
fever,  although  in  cases  of  concurrent  diarrhixa  there  was  i'requently  a  dithculty  during  life 
in  determining  the  absence  of  the  specific  tyjihoid  poison. 

The  relations  of  pneumonic  fever  to  the  other  continued  fevers  are  thus  seen  to  have 
been  bv  no  means  intimate,  notwithstanding  the  ap})arent  testiniony  of  the  clinical  t\ut\ post- 
mortem jJienomena  to  the  contrarv.  The  seemingly  intimate  clinical  relations  of  ]ineumonia 
to  tvphoid  and  the  seemingly  intimate  ]iost-inorb:ia  relations  of  typhoid  and  typho-malarial 
fevers  to  the  pneumonic  disease  were  the  result  of  similar,  not  identical,  conditions  of  the 
svstem.  Pneumonic  fever  occurred  in  those  fevers  only  as  an  intercurrent  and  accidental 
disease,  and  with  much  less  frequency  than  would  appear  from  the  separate  consideration  of 
either  the  clinical  or  pathological  phenomena. 

III.— DIARRHOEA  AND  DYSENTERY. 

As  has  been  shown  in  the  chapter  on  the  Continued  Fevers,  diarrhoea  or  dysentery  was 
a  frequent  manifestation  of  the  presence  of  a  febrile  miasm.  It  was  due  in  malarial  cases 
to  hyjDersemic  conditions  of  the  intestines  in  which  the  large  intestine  and  its  solitary  glands 
were  generally  implicated ;  in  typhoid  cases  it  was  symptomatic  of  the  condition  of  the  patches 
of  Pever,  although  in  manv  instances  the  mucous  membrane  of  the  large  intestine  and 

*  Infra,  (.age  707. 


616  DISEASES    ALLIED    TO    OR    ASSOCIATED    WITH 


especially  of  tlio  caecum  was  also  involvei.l:  and  in  the  typlio-inalarial  or  niixocl  cases  it  was 
due  in  part  to  the  ty|>hoid  ulceration  of  the  ileum  ami  in  part  to  the  malarial  congestion 
and  follicular  ulceration  frecpiently  observed  in  fatal  cases  in  some  part  of  the  intestinal 
canal.  It  is  not  surprising,  therefore,  that  the  symptom  should  occasionally  liave  been 
regarded  as  the  disease,  the  diao-nosis  of  diarrhcea  or  dvsenterv  having  been  recorded  when 
the  morbid  lesions  in  the  case  were  really  those  of  a  continued  fever.  Moreover,  as  will  be 
seen  directly,  diarrhoea  and  dysentery  were  sometimes  accom[)anied  b)y  constitutional  symp- 
toms of  an  adynamic  character,  thus  tending  to  the  opposite  error  of  regarding  these  diseases 
in  some  of  their  instances  as  cases  of  continued  fever  or  of  paroxysmal  fever  in  which  the 
remissions  were  slirrhtly  indicated. 

But  although  diarrlicea  and  dysentery  were  so  often  an  accompaniment  of  malarial  fever 
that  they  must  be  regarded  in  certain  cases  as  indications  of  the  presence  of  the  febrile  |)oison, 
they  were  by  no  means  so  frequently  accompanied  by  paroxysmal  manifestations;  hence 
intermittent  or  remittent  fevers  may  not  be  considered  as  symjitomatic  of  diarrhoea  or  dys- 
entery, or.  in  other  words,  these  diseases  must  be  ascribed  to  other  causes  than  the  causes  of 
the  malarial  fevers.  Xevertlieless,  of  seven  hundred  and  eightv-six  fatal  cases  of  diarrhoea 
and  dysentery  recorded  in  the  Second  Part  of  this  work,  the  patients  in  thirty-four  were 
reported  as  having  been  affected  with  intermittent  fever  and  in  twenty-seven  with  remittent 
fever.  The  presence  of  the  intermittent  symptoms  in  the  cases  in  which  the  records  men- 
tion them  will  scarcely  be  doubted.  Similar  credit  should  attach  to  the  diagnosis  of  remit- 
tent fever  in  the  cases  so  recorded.  Were  the  cases  in  which  this  association  was  observed 
coincidences,  /.  t'.,  results  of  an  exposure  to  the  causes  of  both  the  fever  and  the  flux,  or  was 
the  latter  a  symptom  of  the  febrile  poison  and  due  to  the  direct  influence  of  that  poison? 
Dr.  "Woodward  has  discussed  this  question  at  length.'^'  He  was  fully  aware  of  the  coexist- 
ence of  dysentery  and  malaria  in  individuals  and  districts,  and  of  the  increased  frequency  of 
the  former  in  malarious  regions, f  as  well  as  of  the  very  general  opinion  of  our  army  surgeons 
that  malaria  was  a  cause  of  dysentery.  Indeed,  at  one  time  he  held  this  opinion  himself; 
but  because  Dutroulau  and  Hirsch  gave  instances  of  the  prevalence  of  dysentery  in  non- 
malarious  sections  and  of  malarial  fevers  where  dysentery  was  unknown,  he  was  led  to  abandon 
the  doctrine  and  to  ascribe  to  malaria  merely  a  predisposing  influence  in  the  causation  of  diar- 
rhcea and  dysentery;  and  so  thorough  a  convert  did  he  become  to  this  new  doctrine  that  he 
referred  to  our  American  observers  as  having  fallen  into  the  error  of  reirardini!;  dysentery  and 
malarial  fevers  as  due  to  a  common  cause. 

But  it  has  not  been  shown  that  our  medical  ofllcers  were  in  error.  On  the  contrary, 
the  argument  derived  from  clinical  and  pathological  considerations  appears  to  sustain  their 
views.  The  intestinal  lesions  of  acute  diarrlicea  consisted  of  a  hypenemia  of  the  mucous 
membrane  of  the  small  intestine,  the  villi  and  closed  glands  being  somewhat  enlai'ged  ami 
not  unfrequently  pigmented,  especially  in  protracted  cases,  with  usually  similar  inflanuaatory 
appearances  generally  more  advanced  in  their  progress  in  the  C;ecum  and  descending  colon. 
In  what  was  regarded  clinically  as  acute  dysentery  there  was,  in  addition  to  tliese  appear- 
ances, a  follicular  ulceration  of  the  colon  with  coincident  thickening  of  its  submucous  coat, 
or  diphtheritic  exudations,  sloughs  and  ulcii's  in  this  part  of  the  canal.     In  chronic  cases 

«  See  iidgi'S  2ST  ami  39.?,  Part  II  of  tbis  wurk. 

t  .Vn  uxiimiiuitinii  iif  tlif  relatiniiri  t-f  iliiinli'i-al  dist-'jisi-;*  to  tli.'  ijialarial  ft.-Vfrs.  a.s  ^h.iwTi  liy  tli.'  ninrtaiity  taMrs  of  tin-  '['.'iitlt  U.  S.  Ct-nsiis  l^so, 
may  lie  of  iutcr'st.  The  folluwint'  talailatiuii  has  l.cen  iirepari-d  fnuii  data  ili-riv-d  from  Taldi'  XI  i.f  tli..-  Mortality  f'tatistiv!',  sliowiiift  dtatlis  in  .:iTtaiu 
grand  groui*  with  sjicfificatiyn  uf  causi'.  rruof-sliwts  of  tills  table  were  courtec  .ii>ly  furnished  to  th.'  writer  by  Geor™  \V.  Hicliards  of  the  Cell-u^  Bureau, 
.Vjiril  10,  1SS4.     The  grand  groups  enib.^lied  in  the  tabulation  comprehend  re^j.eelively  the  following  jiortiou^  of  tie-  eounrry; 


THE    PAROXYSMAL    AND    COXTINUKD    FEVERS. 


617 


ot  diarrlioea  ami  dysentery  there  was  a  chronic  inHammation,  with  or  witliout  ulceration,  of 
tlie  mucous  and  submucous  coats  of  the  intestinal  canal,  especially  of  the  lartre  intfstine; 
and  this  was  frequently  complicated  in  fatal  cases  by  the  development  of  more  acute  lesions 
shortly  before  the  occurrence  of  dealli.  But  these,  especially  in  tlieir  acute  forms,  -were  pre- 
cisely the  conditions,  so  far  as  can  be  learned  iVom  the  records,  that  characterized  the  inci- 
dence of  the  malarial  poison  on  the  alimentary  tract.  It  is  impossible,  therefore,  to  discrim- 
inate liy  the  intestinal  lesions  between  a  diarrhoea  or  dysentery  duo  to  a  malarial  hvpera^mia 
and  that  originating  fronr  other  causes.  Under  these  circumstances  the  clinical  record  gives 
testimony  of  value.  Unfortunately  this  seldom  consisted  of  more  than  the  recorded  diag- 
nosis. jS^evertheless,  as  already  suggested,  it  is  entitled-  to  credit  as  the  opinion  o(  qualified 
men  based  upon  a  consideration  of  the  clinical  phenomena.     Wliea  the  attending  medical 

Croup  2.  The  MuhUe  Atlttnlic  Cmst. — Dcl.awjiri^,  the  Pistrii-t  ut'  Columbia  uml  parts  of  Xow  York.  N'ew  Jrrwy,  >Iarv1aiiil  aiiil  Virj;ini;».  ini'lii.liui;  tli« 
cities  of  Brooklyn,  Xew  Vork,  Camden,  Jersi'y  City,  Newark,  Ilaltimcre,  \Vilniin;rtoii  aiiil  Wa>Iiiii;:luti. 

(.Voi'ji  3.   Tlie  Soiilli  Allniil^c  rv.(is(.— Paris  of  North  t'ar.ilina.  South  Caniliua  auil  Cecirsia.  inelu.liuK  thel'lly  uf  Cliarh ■^lou. 

(iron})  4.  life  Oiilf  Count. — Pai'ts  of  Florida,  Alahama,  Louisiana.  Mississipiii  ami  Texas,  ineluiliri;;  (he  City  of  New  Orleans. 

Group  S,  The  Interior  rhilenii, — Parts  of  New  York,  Pi'nnsylvauia,  "N'ir^inia  anil  Nnrth  Carolina,  ineluilini;  the  eilies  of  .Vlhany,  Syraeuse,  Tr.fv, 
Allegheny  City,  Pliihulelphia,  Pittslmr^,  Koadin-;  and  Itiehiuond. 

droi'p  II,  The  Soitlhern  Cenlral  Appulachiun  //(yioa.— Parts  of  Virginia,  West  Virginia,  North  ('arolina,  Sotitli  Carolina,  Ki'Ulueky,  Tennessee,  tJcorgia 
and  .Vlahaiua. 

Group  10.   The  Ohio  niter  riell.—VnTts  ofOhio,  Indiana,  West  Virginia  and  Kentueky.  inelndini:  the  eiiiis  of  Cineinnati,  Dayton  and  Louisville. 

Group  11.   The  S'tittheni  Interior  Ploteon. — Parts  <d" South  Carolina,  tieorgia,  .\lahania,  Mississippi  and  Ti-rinessee. 

Gronp  12.   The  fymlh  Misnissippi  Hirer  Jlelt. — Parts  of  Kentueky,  Tennessee,  !*Iississippi,  Louisiana  rtU'l  .\rkausas. 

Groi'p  14.   The  S<jiilhirest  Central  }le;/ion. — I'arls  of  Jlisstuiri,  ,\rkatisas.  Louisiana  and  Texas. 

Gronp  l."i.  The  Ceutrat  Kerjion  of  VhiinA  onti  I'rniries. — I'arts  of  Ohio,  Kentmky,  Tennessee  and  Indiana,  iueludiriir  llie  <ilies  of  C.dniulius.  Na^hvilh) 
and  Indianapolis. 


1 

M 

OtTAI.ITV 

IIATKS 

•KIl  1(KI,(HK>  I.IVINO. 

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GiiofP. 

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T  A  1. 

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nr.Arus  to 

.",  Tl  1,  cs:! 

l>i.\i: 

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20 

111 

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l 

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bist 

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ASKS. 

fi2 

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lusi; 

1:1  \l- 

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II VI! i: for  M. 
ot.Ariis. 

.'^ 

21 

1 
21 

20 

1  : 3. 1 

111 

2. 440.  ;co 

23 

21 

21'. 

73 

25 

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4, 370,  IK 

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34 

22 

'.18 

35 

1  :2.8 

15 

4, 403,  C02 

15 

25 

24 

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30 

1  :1.0 

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21 

31 

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1 

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24 

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1112 

117 

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24 

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120 

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28,  832,3(18 

24 

20     I, 

51 

1:1.0 

From  this  table  it  aitpoars  that  in  a  population  of  nearly  twoiity-iiino  millions,  occnpyiiis  certain  ilMiiit:*  of  the  riiitcd  Ptiitop.  tho  ileathri  from 
malarial  fevers  during  the  census  y<ar  avt-raged  01  i^-r  Uui.iNio,  jitnl  th">,'  fruni  iliarrh'i'jil  .Um-ji^cs  reporti.l  ;i,s  .liarrhua.  ilyst-ulery  and  cnliTitis  S:i  \h-t 
l(Xt,OCK;i,  the  former  beinjr  to  the  latti-r  as  1  ;  l.i).  It  may  he  nttted  that  in  (In. up  ll  a  malarial  death-rati'  nf  imly  :V.i  [xt  lini.imi)  was  assoeiatrd  wiili  a 
diarrhu-al  death-rale  which  bore  to  it  tlie  average  ratio  "f  1.*'';  anrl  that  thl^^e  groups  having  a  luwcr  malarial  di-ath-rate  than  thiti  had  the  i-atiu  of 
diarrhceal  to  malarial  deaths  higher  than  the  average,  while  those  with  a  higher  malarial  death-rate  hail  the  ratin  of  diarrheal  t-i  malarial  deaths 
considerably  lower  than  the  average.  AVliere  tho  malarial  dcath-nitewas  small  the  diarrhu-al  death-i-ate  e.xeceded  It  very  largely;  and  on  the  other  Iiaml, 
where  the  former  wlis  large  the  latter  did  not  even  erjual  it.  Thus,  Group  S  had  but  20  malarial  death?,  wliieh  were  to  those  from  enteritie  disease  as 
1 :  3.1,  while  Group  12  had  12i*  malarial  deaths,  which  were  to  the  deaths  from  intestinal  fluxes  as  1  :0.7.  Fromlhi*  it  wnu!d  seem  that  the  relation*,  if  any 
exist,  between  malarial  fevers  and  dlarrluea  and  dysentery  are  not  of  so  intimate  a  character  Jis  to  count'-rbalanee  other  intluences  affecting  the  death- 
rate  of  the  latter  disease.^?.  Xeverthelej^  it  may  not  be  cuncludi-d  that  there  is  im  lelatiou  b<-tweeu  them,  fur  the  dJarrhtial  death-rate  ri.-»es  with  the 
malarial  rate,  although  neither  in  the  same  proportion  nor  regularly  in  any  proportiim.  Thu-^,  while  the  lowest  malarial  rate,  20  per  loO.OiHl  in  Group 
S.  is  asso'iate>l  with  the  lowest  diarrhteal  rate,  (12  per  l(X»,iHHt,  and  the  Ijight-st  diarrheal  rate.  1  !,"►  in  Gnuip  14,  is  associated  witli  a  high  malarial  rate, 
104,  the  highest  malarial  rate,  12!),  occurring  in  Group  12,  corresp.)uds  witha  diarrheal  raf,  ST,  which  is  but  slightly  above  the  average  of  all  the  groups. 
Auiucreasrd  fatality  of  malarial  di:^eilses,  therefore,  implies  an  increased  fatality  of  diarrh<eal  diseasi-s;  but,  a-<  the  increase  of  the  one  does  u<it  cnrre.-ipt)nd 
witli  that  of  tile  other,  it  fulluws  that  they  are  due  neither  tothesam^eausenor  to  the. same  cotiditions  of  causative  devLduianent  in  alhir  even  In  a  majority 
of  cases.  It  may  bo  remarked  that  the  figures  here  given  are  consi>t<-nt  with  the  position  taken  in  the  text,  tn-wit :  that  although  diarrloea  and  dysentery 
are.  in  certain  cases,  symptomatic  of  the  incidence  of  the  malarial  puison  on  the  intestines,  and  although  this  poison  may  exercise  a  strongly  predis[Mwing 
intluence  to  diarrho-al  and  dysenteric  attad-.s.  there  are  uth<'r  causes,  some  no  doubt  of  a  s|H?citie  characterj  which  exercise  a  far  more  jiowerful  iuflucaca 
on  the  prevalence  and  fatality  of  the  intestinal. tluxcs. 

Med.  Hist.,Pt.  Ill— 78 


618  DISEASES    ALLIED    TO    OR    ASSOCIATED    ^VITH 

officers  reeorJeJ  a  case  as  one  of  remittent  fever,  and  the  post-mortcni  examination  discovered 
only  the  lesions  of  acute  or  chronic  diari'hcea  or  dvsenterv,  it  is  fair  to  assume  that  the  flux 
was  the  direct  result  of  a  malarial  cause. 

Manifestly  it  would  be  absurd  to  argue  from  this  that  malaria  was  the  direct  cause  of 
diarrhcea  and  dysentery  in  all  cases.  It  has  been  proved  that  dysentery  may  prevail  in 
non-malarious  regions,  but  our  medical  officers  did  not  hold  that  malaria  was  the  only  cause 
of  dysentery.  It  has  been  shown  that  malaria  n^av  exist  without  dvsentery,  but  they  did 
not  hold  that  malarial  fevers  were  alwavs  characterized  bv  dvsenteric  svmiitoms.  Thev 
believed  that  in  many  of  the  cases  of  dysentery  that  came  imder  their  observation  an  expo- 
sure to  malaria  was  the  direct  and  efficient  cause;  and  in  view  of  the  frequent  incidence  of 
the  malarial  poison  on  the  intestinal  canal,  causing  diarrhceal  and  dysenteric  symptoms,  and 
leaving  in  fatal  cases  only  the  livpera?mic  lesions  common  to  these  morbid  conditions,  it  is 
difHcult  to  sliow  that  they  were  in  error  in  assigning  a  malarial  origin  to  certain  of  these 
diarrhceal  or  dvsenteric  cases. 

Some  of  the  confusion  that  has  crept  into  the  discussion  of  this  subiect  has  arisen  from 
the  mistake  of  regarding  diarrhcea  and  dysentery  as  diseases  p<??'  se,  when  in  reality  they  are 
merely  symptoms  of  active  hypersemic  conditions  of  the  intestines  which,  though  often  due 
to  other  causes,  some  of  which  are  probably  specific,  may  certainly  arise  from  the  malarial 
influence.  Certainly,  also,  this  influence  may  be  viewed  as  a  powerful  predisposing  cause  of 
the  quasi  diseases  in  question,  as  in  the  presence  of  that  tendency  to  intestinal  congestion 
which  is  its  frequent  characteristic,  minor  causative  conditions,  of  themselves  incapable  of 
overcoming  tlie  vis  conservatrix  natura:,  may  readily  determine  the  onset. 

The  arsiument  sucriresting;  that  the  diarrhceal  cases  registered  as  remittents  were  reallv 
febrile  cases  due  to  malaria,  with  diarrheal  or  dysenteric  lesions  caused  directly  by  the  mala- 
rial incidence,  or  indirectly  due  to  a  predisposing  influence  exercised  by  the  malarial  poison, 
applies  to  the  cases  recorded  as  typho-malarial  or  typhoid-remittent.  These  are  enumerated 
in  notes  *  and  "f  to  page  420,  svpra.  Their  anatomical  appearances  Avere  such  as  are  con- 
sistent with  the  theory  of  an  independent  diarrhoea  or  dysentery;  but  since  they  are  ec^ually 
consistent  in  some  instances  with  a  continued  malarial  fever  and  in  others  with  a  true  typho- 
malarial  fever,  there  is  no  evidence  to  show  that  the  views  of  the  attending  officers  as  to  the 
presence  of  a  febrile  element  of  a  malarious  origin  were  erroneous. 

Looking  now  at  the  relations  of  diarrhea  and  dysentery  to  typhoid  fever,  these  will  be 
found  so  close  in  some  instances  that  it  is  difficult  to  discriminate  between  the  diseases  not 
only  from  the  clinical  records  but  even  in  full  view  of  the  recorded  post-mortem  appearances.'^' 
Typhoid  fever,  when  the  intestinal  symptoms  attained  a  notable  prominence,  was  frequently 
called  acute  or  chronic  diarrhoea.  In  the  post-mar  tern  records  of  the  continued  fevers  some 
cases  of  this  kind  have  been  observed,  to  wit:  Cases  304-324,  in  which  the  patches  of 
Peyer  were  ulcerated,  and  343-34<S,  in  which,  although  the  condition  of  the  patches  is  not 
stated,  the  character  of  the  ulceration  in  the  ileum  is  suggestive  of  a  typhoid  element. 

If  the  cases  of  the  diarrhceal  series  be  examined  other  instances  of  typhoid  fever  erro- 
neously registered  as  diarrhoea  or  dvsenterv  will  readily  Ije  discovered.     Thus,  Woodward 

*  Dr.  .J.  .J.  KooKER,  of  Castlcton,  Intl.,  annount-oil,  in  tin--  Trmmnti'ms  of  the  State  Medical  Society  t>f  hvtinno,  Indianapolis,  1883,  p,  3.1,  tli*^  ojiiiiio  t 
tliat  tyi'lioiil  fi-vi-r  ami  camp  liiarrhrpa  are  pr'^luf.-'l  I>.v  tin'  sanipcaus*-,  bt-raust;  "  whi-ii  wo  fliiil  caminUarrliiva  pri'vailing  exTcnsivoly  we  will  timl  t.vplmiil 
f'V.-r  incrrasftl  in  tlu'  i-uni'--  rati*-,  and  viix-  vi-rsa,*'  an<l  Ix-canse  lie  found  y,iM-mnrtem  iu  bi.s  diarrhu-al  raws  '"an  intlainniatury  nleenited  ciindition  '.'f  tl;-.- 
menilprane  and  epithelial  structures  of  the  luwer  iute-stin^^  and  also  ulreration  of  Pe.ver'i^  jjlandrf  as  in  typhoid  fevi.T."  Slaiiif-'stly  tins  opiuii)n  was  has^d 
ujKiu  limited  and  8Ui»erticial  obwrvatiou  aud  iuaccurate  diaj^aosis,  for  the  ditticulti'-s  mentioned  in  the  t'-xt  occurred  only  iu  exceptional  cases. 


THE    PAROXYSMAL    AXD    COXTI.XUED    FEVEKS.  619 

states  =^  that  certain  cases  of  this  series  were  really  examples  of  some  form  of  continued  fever 
in  winch  the  typhoid  aflPection  of  the  patches  of  Peyer  was  the  prominent  lesion.  The  cases 
enumerated  are  163,  164,  174,  210,  531,  854  and  probably  836,  837  and  838.  But  to 
these  must  be  added  141,  192,  240,  365,  461,  7U9  and  777,  in  which  the  ulceration  of  the 
patches  of  Peyer  appears  to  leave  no  doubt  of  the  presence  of  typhoid  fever;  perhaps  278 
and  308  should  also  be  added  to  the  list.  In  most  of  these  the  typhoid  ulceration  of  the 
patches  was  associated  with  prominent  dysenteric  lesions.  In  the  two  cases,  43(i  and  825, 
having  a  typho-malarial  diagnosis,  a  typhoid  element  seems  indicated  by  the  character  of 
the  ulceration  of  the  small  intestine,  and  in  870,  diagnosticated  typhoid  fever,  the  ulcerated 
agminated  glands  fully  support  the  views  of  the  attending  physicians.  Instances  of  tuber- 
cular ulceration  of  the  patches  have  been  excluded  from  the  cases  above  mentioned.  More- 
over, case  609  afiPords  an  interesting  example  of  death  from  pneimionic  comjilications  in  a  case 
of  typhoid  fever  which  was  otlierwise  running  a  favorable  course.  The  fever  supervened 
while  the  patient  was  improving  in  hospital  under  treatment  for  a  deljilitated  condition  of 
system  due  to  diarrhcea  and  a  scrofulous  constitution;  rose-colored  spots  appeared  on  the 
thirteenth  day  and  convalescence  was  apparently  established  on  the  twentieth,  but  some  pain 
in  the  chest  and  muttering  delirium  set  in  and  death  occurred  on  the  twenty-seventh.  As 
the  glands  of  Peyer  in  this  instance  were  thickened  but  not  ulcerated,  the  supposition  that 
absorption  was  in  progress  is  allowable,  in  view  of  the  light  character  of  the  febrile  svmptoms. 
In  addition  to  these  twenty-two  cases  of  typhoid  the  diarrhteal  series  presents  thirty- 
seven  cases  in  which  at  some  period  of  the  patient's  hospital  treatment  his  case  was  regarded 
as  typhoid  fever,  seven  in  which  typhoid  pncunuMiia  was  re}iorted  and  twenty  in  which  the 
records  show  with  certainty  that  the  symptoms  were  of  a.  ty[ihoid  character. 

The  lesions  presented  by  the  sniaU  intestine  in  tliese  si.xty-four  cases  are  worthy  of  consideration.  In  four.  267, 
496,  533  and  020,  its  condition  was  not  stated.  In  twenty,  or  one-third  of  tlie  reniaininf;  sixty  eases,  the  intes- 
tine was  ulcerated,  but  the  state  of  tlie  i)at(lies  of  Teyer  was  not  recorded.  These  eases  were  106,  IS'l,  1SI3,  200,  20S, 
242,317,  340,443,476,501.505,510,513,  661,  750,  775,  812,  832  and  KM,  In  one  case,  6.52,  tlie  intestines  were  j^'angrenous. 
It  is  po8sil)le  that  the  ulceration  in  tliese  was  simply  a  diarrhceal  lesion,  or,  as  in  832,  probaldy  the  result  in  part 
of  malarial  action;  but  in  view  of  the  typhoid  cases  instanced  above  it  is  not  unlikely  that  some  of  these  were 
really  cases  of  typhoid  fever.  Granting  them  to  have  been  all  cases  of  diarrha-al  disease,  their  intimate  relation  clin- 
ically to  typhoid  fever  has  already  been  shown  by  the  cases  of  true  typhoid  found  in  the  diarrh<eal  series.  Grant- 
ing them  on  the  other  hand  to  have  been  all  eases  of  typlioid,  the  presence  of  typhoid  symptoms  without  typhoid 
ulceration  of  the  patches  is  satisfactorily  shown  by  the  remaining  thirty-nine  cases.  In  four  of  these,  cases  111,  263, 
321  and  330,  the  intestine  was  healthy;  in  two,  493  and  494,  intussusception  only  is  mentioned:  in  two,  116  and  540, 
there  was  no  ulceration ;  in  one,  334,  the  ileum  was  thinned ;  in  one,  344,  softened ;  in  one,  338,  slate-colored :  in  eleven, 
194,  246,  331,  352,  391,  397,  547,  624,  631,  639  and  672,  congested;  in  four,  223,  328,  4.52  and  536,  inliamed  ;  in  one,  332, 
the  jejunum  only  w-as  ulcerated:  in  one,  204,  the  solitary  glands  of  a  highly  congested  ileum  were  ulcerated:  while 
in  eleven,  statements  were  made  concerning  the  condition  of  the  patches  of  Peyer, — normal  in  three  cases,  197,  266 
and  467;  not  swollen  but  pigmented  in  one,  366;  thickened  in  three,  132,  264  and  398;  dark  in  one,  388 ;  conspicuous 
in  one,  326,  and  congested  in  two,  425  and  427. 

From  this  list  it  is  manifest  that  a  febrile  action  having  a  similarity  to  typhoid  was 
present  in  at  least  thirty-two  of  the  cases,  although  no  implication  of  the  patches  of  Pever 
was  observed  after  death.  These  were  undoubtedly  cases  of  acute  diarrhaa  or  dysenterv  in 
which  the  deterioration  of  the  blood,  caused  perhaps  by  the  primary  action  of  a  specitic  poison, 
but  certainly  by  the  accumtdation  of  the  products  of  metabolism  during  the  continuance  of 
a  symptomatic  or  coincident  fever,  was  followed  by  such  clinical  phenomena  as  have  been 
shown  to  characterize  typhoid  fever  and  the  protraction  of  acute  malarial  cases. 

The  few  instances  in  which  the  patches  of  Peyer  had  undergone  alteration  do  not  indi- 
cate that  a  typhoid  element  was  present  in  them;  for  in  many  cases  in  which  the  mucous 

*  Page  5-21  of  the  Secuud  Part  of  this  work. 


620  DISEASES    ALLIED    TO    OR    ASSOCIATED    WITH 

membrane  of  the  ileum  was  tlie  site  of  tlie  morbiJ  lesion  the  patches  of  Peyer  participated 
in  the  general  congestion  or  tumefaction,  thus  becoming  more  conspicuous  than  usual, although 
the  associated  symptoms  were  simply  those  of  an  acute  diarrhcea  if  the  lesions  were  confined 
to  the  ileum,  or  of  dysenterv  if  tliev  implicated  as  well  the  lower  portion  of  the  large  intes- 
tine. The  patches  of  Pevcr  in  twentv-six  such  cases  are  said  to  have  been  affected ;'■•'  but 
in  no  instance  does  the  language  of  the  reporter  suggest  that  condition  of  the  glands  which 
was  characteristic  of  fatal  cases  of  tviihoid  fever.  Thev  were  slio-htlv  thickened,  enlarged, 
prominent  or  elevated,  and  witli  or  without  mention  of  this  thickening,  they  were  somewhat 
injected,  congested  or  inilami;'d.  Certainly  speclincii  98,  Army  Medical  Museum,  as  shown 
on  the  plate  facing  page  SUO  of  the  Second  Part  of  this  work,  illustrates  a  condition  of  the 
fdands  that  mav  be  more  consistontlv  referred  to  a  ireneral  involvement  of  the  mucous  and 
submucous  tissues  of  the  ileum  than  to  a  specific  irritant  operating  mainly  on  the  closed 
glands.  Xo  suscestion  of  a  typhoid  element  was  offered  in  this  case,  880  of  the  diarrhoeal 
series,  either  by  its  history  or  its  post-r/wrfi'm  appearances.  "The  intestines,''  according  to 
Dr.  Leidy,  who  was  the  reporter,  "were  inflamed  throughout;  in  the  small  intestine  the 
infiammation  increased  in  intensity  towards  the  ileo-ciecal  valve;  the  agminated  glands  were 
slightly  thickened  and  dark-red  with  inflanuuation.'' 

Moreover,  in  most  of  the  many  diarrhcjeal  cases  presenting  that  pigmentatiuii  of  the 
patches  which  must  lie  yiewed  as  characteristic  of  our  camp  diarrli(_eas,t  there  was  a  con- 
gestion or  slight  tumefaction  of  the  glands,  or,  if  this  was  absent,  the  picrmentation  itself 
indicated  the  antecedent  existence  of  the  congested  and  slightly  tumefied  cundition. 

But  this  tumefaction,  being  in  its  nature  "essentially  similar  to  that  caused  by  the  specific 
irritant  of  typhoid  fever,  was  prone  in  some  aggravated  cases  to  assunre  a  greater  resem- 
blance to  the  characteristic  lesion  of  typhoid  by  the  estaljlishment  of  the  ulcerative  process. 
Thus,  in  426  the  thickened  patches  jiresented  a  spongy  appearance  in  their  centre;  in  342 
and  378  they  were  slightly  ulcerated;  in  463  they  showed  several  small  ulcerations;  in  226, 
311,  374,  743,  748,  800  and  855  a  few  of  the  patches,  generally  near  the  valve,  were  ulcerated. 
It  is  possible  that  in  some  of  these  a  typhoid  element  was  present;  but  in  view  of  the  series 
of  cases  that  lead  up  to  the  ulcerated  condition,  and  in  the  absence  of  any  clinical  indica- 
tions of  typhoid,  this  suggestion  may  not  be  entertained.  /Specimens  600  and  601,  Army 
Medical  Museum,  from  case  881  of  the  diarrhoeal  series,  show  that  these  slight  ulcerations 
of  the  patches  in  the  diarrhoeal  cases  were  wholly  different  in  their  appearance  front  the 
ulcerations  in  fatal  cases  of  typlioid.  A  photographic  representation  of  the  former  specimen, 
facing  page  302  of  the  Second  Part  of  this  work,  gives  clear  evidence  that  the  patch  was 
tumefied  merely  as  a  part  of  the  general  affection,  and  that  the  minute  ulcerations  on  its 
lower  part  were  due  to  local  conditions  of  necrobiosis  consequent  upon  this  tumefaction.  In 
this  case  typhoid  symptoms  set  in  before  the  end,  and  the  cause  of  death  was  reported  on 
the  hospital  register  as  typhoid  fever;  but  as  Dr.  "Woodward  observed,  in  speaking  of  its 
morbid  lesions, — "here  we  have  to  do  with  a  much  less  extensive  disease  of  Peyer's  patches 
than  that  which  is  characteristic  of  typhoii.l  fever." 

In  the  discussion  of  the  post-riiortem  appearances  of  the  patches  in  the  continued  fevers, 
similar  congestions  and  tumefactions  were  referred  to  the  participation  of  the  glands  in  the 
general  affection  of  the  mucous  membrane  of  the  ileum.     The  facts  just  submitted  with  regard 

»Tliefc  cases  are  13:3,  146,  US,  140, 154, 103,  ICO,  1T2,  182,  225,  3O0,  329,  34r.,  .'148,  351,  353,  354,  3Tii,  Z",  42«,  4>s,  -,r,3,  57S,  752,  791  ami  S71. 
+  .\mong  these  may  be  numbcrea  the  fuMuwing:  120,  12S,  l;!r1,  13t,  1;K,  137,  Vl^,  1  t'l,  142,  143,  144,  147,  1.5i,  151,  153,  154,  155,  15S,  li;ii,  1(!2,  ICC, 
170,  173,  174,  175,  203,  30(),  315,  33.5,  355,  300  and  perhajis  also  several  othei-s,  as  3.50,  386  aiitl  450,  in  whit-h  the  glauils  were  reiiorted  as  durk-colurt.il. 


THE    PAROXYSMAL    AXD    CONTINUED    FEVERS.  621 

to  tlioir  implication  in  tlie  congestions  Juo  to  the  irritant  cause  or  causes  of  acute  diarrlicea 
sustain  tlie  views  that  have  1jeen  aJvanceJ  as  to  tlie  absence  of  a  typhoid  element  in  certain 
malarial  fevers,  which,  nevertheless,  owina  to  the  incidence  of  the  poison  on  the  small  intes- 
tine, presented  a  notable  involvement  of  the  agminated  glands. 

From  this  presentation  of  the  facts  hearing  upon  the  connection  between  these  diseases 
certain  conclusions  may  be  reached: 

1.  Tyiilioid  fever  wa«  one  of  the  direct  causes  of  diarrlin-a.  owing  to  tlie  iilcerativi'  i)roc(>sses  in  tlie  agminateil 
glands  and  in  tlie  solitary  glands  of  tlie  ileum  and  ca-cuni,  which  are  its  anatomical  characteristics. 

2.  DiarrlKca,  as  a  syiiiptoni  of  typhoid  fever  due  to  the  [irocesses  aforesaid,  was  siiiiietinies  regarded  as  an  acute 
diarrlid'a  when  the  specitic  idienomena  were  not  well  developed. 

3.  Diarrliiea,  due  to  other  irritant  causes  operating  on  the  mucous  membrane  of  the  ileum  and  ca>cum.  was 
sonietiiiies  regarded  as  typhoid  fever,  esjiecially  in  acute  cases  of  some  jiersistence  in  which  thi'  continuance  of  a  symi)- 
tomatic  or  coincident  fever  induced  the  supervention  of  those  adynamic  symptoms  that  have  been  denominateil 
typhoid. 

These  errors  in  diagnosis,  due  to  intimate  relationship  on  the  one  hand  and  pathological 
similarities  on  the  other,  were  susceptible  of  recognition  at  the  pod-mnrtcm  examination,  for — 

4.  DiarHura,  symptomatic  of  tyiihoid,  was  always  indicated  by  the  condition  of  the  patches. 

">.  Diarrlui'a  from  other  causes  had  the  jiatches  unalVeclcd  or  )iigmeMlcd,  often  congested,  tiimetied  and  oven 
ulcerated;  but  these  conditions  were  usually  readily  distinguishable  from  the  congestion,  tumefacliun  and  ulceration 
of  typhoid  fever. 

In  manv  instances  tliere  were  large  and  deep  ulcerations  of  the  intestine,  but  these  were 
either  chronic  cases  in  whicli  the  history  excluded  all  doubt  as  to  the  character  of  the  disease, 
or  diphtheritic  cases  in  which  an  examination  of  the  mucous  membrane  sufficed  to  determine 
the  character  of  the  ulceration.  Pont-murtcia  examination,  if  suliicientlv  exhaustive,  would 
proliably  have  developed  a  series  of  anatomical  cases  connecting  the  faintest  reddening  and 
thickening  of  the  patches  in  diarrliosa  with  the  well-marked  tumefaction  and  defined  ulcera- 
tion of  tyjjhoid;  but  the  clinical  historv  of  these  cases  would  have  failed  to  show  a  parallel 
or  corresponding  series  connecting  a  simple  diarrhoia  at  one  extremitv  with  a_tvph(.)id  fever 
at  the  other.     In  other  .words: 

G.  Diarrho'a  did  not  become  ;yphf>i<l  fevi'r  by  the  iin)ilicatioii  of  the  ]patclies;  iiordiil  typhoiil  symptoms  depend 
upon  their  congested  or  ulcerated  condition. 

But,  besides  being  the  direct  cause  of  a  symptomatic  diarrJKea,  typhoid  fever  was  other- 
wise associated  with  the  intestinal  ilux.  The  frecjuent  occurn-nce  of  anteeedent  typhoid  in 
the  history  of  diarrhceal  cases,  and  the  known  ulcerated  or  deteriorated  condition  of  the 
mucous  lining  in  such  cases,  warrants  the  conclusion  that — 

7.  Antecedent  typhoid  was  an  intluential  predisposing  factor  in  the  determination  of  diarrhieal  attacks. 

The  connection  of  dysentery  with  pure  or  unmodified  tyjihoid  fever  cannot  be  sh^wn  liv 
a  consideration  of  the  cases  of  typhoid  with  dysenteric  svniptoms  that  have  been  recorded, 
bectiuse  in  these  it  is  impossible  to  exclude  the  probability  of  a  coincident  malarial  febrile 
element;  but  from  the  absence  of  tormina  and  tenesmus  in  the  clinical  history  of  the  pure 
typhoid  cases  treated  in  the  Seminary  hospital,  and  from  the  rarity  of  inflammation  or  ulcera- 
tion of  the  lower  portion  of  the  large  intestine  in  the  fifty  tyiihoid  cases  given  in  the  yv>s^ 
rnortcra  records  of  the  continued  fevers, '•'■  it  mav  be  inferred  that — 

8.  The  coincidence  of  dysentery  and  pure  or  unmodified  typhoid  was  an  unusual  occurrence. 

On  the  otlier  hand,  the  connection  of  dysentery  with  remittent  and  continued  malarial 
fevers  was  so  intimate  as  to  lead  them  to  be  ascribed  to  a  common  cause;  and  in  many 
instances  this  opinion  was  undoubtedly  correct,  for,  as  has  been  shown  above. — 

9.  Malarial  fever  was  one  of  the  direct  causes  of  diarrhoea,  and  especially  of  dysentery,  owing  to  the  active 

*See  ulj'u  the  aiml.vtical  siunniurv.  fmiini,  |iage  423. 


622  DISEASES    ALLIED    TO    OR    ASSOCIATED    WITH 

hyiier:piiiic  conditions  wliioh  it  t'lvtiuontly  ostablislifd  in  any  or  all  jiarts  of  the  intestinal  tract  and  particnlarly  in 
the  large  intestine. 

10.  Diarrhioa  or  dysentery,  as  a  synijitoni  of  malarial  fever  dne  to  the  conditions  aforesaid,  was  sometimes 
regarded  as  an  acute  diarrhtea  or  dysentery  Avhen  the  paroxysmal  features  were  not  well  developed. 

This  eiTOi'  of  Jiaguosi.s  was  not  suscei^tible  of  recognition  by  post-moiieui  examination 
of  tlie  intestinal  lesions,  for  these  were  the  same  in  Jiarrhrea  and  dysentery  due  t(j  malarial 
incidence  as  in  the  diarrhoeas  and  dysenteries  due  to  other  causes. 

11.  Diarrlio?a  or  dysentery,  due  to  malarial  or  other  irritant  or  siiccifle  causes,  was  sometimes  regarded  as  typhoid 
fever,  especially  in  acute  cases  of  some  iicrsistence  in  which  the  continuance  of  a  primary  symptomatic  or  coincident 
fever  called  forth  the  well-kuowu  typhoid  symiitoms. 

This  error,  on  the  other  liand.  was  easily  recognized,  for  the  presence  of  ty}ihoid  was 
alwavs  indicated  bv  the  condition  of  the  agminated  glands. 

From  wliat  has  been  said  it  is  needless  to  enlarge  on  the  connection  between  diarrhcea 
and  dysentery  and  tlie  moditied  typhoid  or  true  typho-rnalarial  feyers  that  formed  so  large 
a  part  of  the  continued  fever  series. 

12.  Typho-uialarial  fever  was  a  direct  cause  of  diarrhtca,  owing  to  the  constant  but  often  localized  operation 
of  its  typhoid  element  and  the  occasional  but  usually  more  extensive  action  of  its  malarial  element  on  the  ileum  and 
Ciecuni. 

13.  It  was  also,  in  some  instances,  a  direct  cause  of  dysentery,  owing  to  the  occasional  incidence  of  its  malarial 
element  on  the  descending  portion  of  the  large  intestine. 

14.  The  freiiuent  attacks  of  diarrluea  to  which  soldiers  who  had  suffered  from  this  fever  were  liable  manifests 
the  predisposing  intluence  of  both  the  febrile  elements,  but  especially  of  the  typhoid,  while  the  frequency  of  dysentery 
as  a  serjuel  of  the  fever  must  be  referred  to  the  predisposition  induced  by  the  local  action  of  the  malarial  factor. 

IV._SCURYY. 

The  scorbutic  complications  of  the  continued  fevers  recjuire  notice  mainly  because  of  their 
undue  prominence  in  the  medical  literature  of  the  war  hitherto  published.  Scurvy,  as  will 
be  seen  hereafter,  threatened  on  several  occasions  to  become  epidemic  in  certain  commands, 
and,  indeed,  in  1865  the  colored  troops  in  Texas  had  a  monthly  rate  of  scorbutic  cases  which 
for  one  month  exceeded  the  maximum  of  the  French  army  in  the  Crimean  campaign.  But 
the  references  to  scorbutic  complications  have  not  been  restricted  to  camp  fevers  as  affecting 
the  colored  troops.  Their  application  has  been  general,  although  at  no  time  was  there  any 
general  scorbutic  taint  among  the  white  troops.  Woodward  held  that  in  the  great  majority 
of  cases  of  camp  fever  the  enteric  symptoms  were  complicated  by  malarial  and  scorbutic 
phenomena.  Acting  on  this  belief  he  divided  the  enteric  fevers  of  the  army  into  three 
classes  according  as  the  typhoid,  malarial  or  scorbutic  elements  appeared  to  predominate.* 
Hu>'T  reported  scurvy  to  the  U.  S.  Sanitary  Commission  as  one  of  the  most  common  and 
easily  recognized  diseases  of  the  army.f  Hammond  also  reported  on  scurvy  to  tlie  Com- 
mission, but  his  materials  were  drawn  wholly  from  foreign  sources,  mainly  from  the  experience 
of  the  allied  armies  in  the  Crimea,  the  intention  being  to  direct  the  attention  of  our  officers 
to  the  importance  of  preventiye  measures. J  Scurvy,  according  to  the  experiences  cited  by 
him,  was  a  formidable  ally  of  the  continued  fevers. 

Typhus  was  at  that  time  (the  winter  of  1854-55)  raging  fiercely,  and  I  am  convinced  that,  if  not  its  main  cause, 
certainly  the  cause  of  its  great  mortality  was  the  scurvy.  Of  twenty  patients  admitted  during  that  period  eighteen 
were  usually  more  or  less  scorbutic;  eight,  perhaps,  would,  be  so  deeply  aftected  (as  indicated  by  sloughing  ulcers, 
gangrene  of  the  mouth,  general  dropsy  and  chronic  diarrhcea)  as  to  render  recovery  impossible. s^ 

Fortunately  in  our  armies  nothing  of  this  kind  was  encountered.  According  to  tlie 
statistics  the  most  marked  outbreak  among  the  white  troops  was  that  observed  in  July,  1S62, 

*  </nini>  L'U'r'ue"  <-f  Oip  I'liitfl  .S/*i/*r.*  Aniii'f''.  Pliila..  18(i;i.  y.  77.      Tiiplio-mul'triut  ftt-f^r :  h  U  a  */>fCi«/  type  ff/frer  f — IMiiln.,  1^76,  ji.  :{7. 

t  v.  .S.  !^'i»itarii  O'nimim'in,  yt'W  York,  18137,  Iwi^re  ■27t».  J  Military  Mt^tUtjal  and  Sitnjiixd  £iM(//s,  lMii!a.,  Pa.,  paj."'  17.'t. 

§  Experience*  of  a  Cirilian  in  EoMtern  Military  lioipiUiU^  by  Petee  PlNCOFFS,  London,  1&67,  p.  25, 


THE    PAROXYSMAL   A>'D    CONTINUED    FEVERS  623 

in  the  Army  of  the  Potomac,  when  the  liarJships  ami  privations  of  the  Peninsular  campaign 
culminated  in  the  desponJencv  -which  attended  the  seven  days'  fight  during  the  retreat  to 
Harrison's  Landing.  Many  causes,  of  which  a  deficient  dietary  was  but  one,  contributed 
to  the  deteriorated  condition  of  that  army  on  its  arrival  at  the  James  River.  An  adynamia 
pervaded  its  ranks,  and  all  febrile  complaints  speedily  assumed  a  typhoid  character  irri-spec- 
tive  of  the  presence  or  absence  of  a  specific  typhoid  element.  This  tendency  to  a  tvphoid 
state  was  independent  of  a  scorbutic  cachexia,  tor  it  was  seen  at  nianv  jieriods  of  the  war  and 
in  other  armies  when  there  was  no  suggestion  of  a  scorbutic  element.  The  deterioration  of 
the  blood  in  typhoid  fever  was  evidenced  in  many  cases  by  the  presence  of  petechia\  which 
sometimes  in  fulminant  instances  appeared  at  an  early  stage  of  the  disease ;  in  malarial  fevers 
similar  petechise  were  observed,  and  in  the  pernicious  cases  congestions,  internal  extravasa- 
tions and  cutaneous  blotches  were  the  rule;  but  these  were  the  direct  results  of  the  typhoid 
and  malarial  poisons  on  the  blood.  It  was  frerpiently  noted  that  deadly  congestive  levers, 
fatal  in  a  few  hours  and  attended  with  hemorrhagic  blotches,  chose  for  their  subjects  the 
healthiest  and  most  robust  men  in  the  command,  in  whom  there  was  no  thought  of  a  scorbutic 
taint.  As  the  febrile  poisons  are  competent  to  accoimt  for  the  hemorrhagic  manifestations, 
particularly  when  the  adynamic  tendency  was  strongly  developed  in  constitutions  impaired 
by  overwork,  want  of  sleep,  exposures  of  all  kinds  and  moral  influences  of  a  depressing 
character,  it  is  needless  to  bring  in  a  scorbutic  element  for  their  explanation.  Undoubt- 
edly, at  the  period  mentioned,  scurvy  was  present  in  the  Army  of  the  Potomac,  and  to  a 
notable  degree  in  certain  regiments;  but  it  does  not  appear  that  it  operated  as  a  complicating 
agency  other  than  by  increasing  the  tendency  to  adynamia.  Of  the  fever  cases  that  have 
been  submitted  in  this  work,  and  these  cover  all  the  reported  cases  that  possess  any  value 
for  other  than  purely  statistical  purposes,  very  few  are  noted  as  having  been  complicated 
with  scurvy.  Of  three  hundred  and  eighty-nine  cases  presented  under  the  title  of  Post- 
Mortem  Piecorch,  two  cases  only,  :UG  and  374,  recorded  a  scorluitic  appearance  of  the  patient. 
Probably  also  starvation  and  scurvy  were  predisposing  causes  of  death  in  311  and  347, 
and  in  perhaps  a  few  other  cases  which,  like  these,  occurred  in  the  jiersons  of  men  who  had 
been  not  only  deprived  of  an  anti-scorbutic  diet  but  absolutely  famished;  but  to  argue  from 
these  that  scurvy  entered  into  the  febrile  cases  of  the  war  as  a  generally  complicating  element 
would' be  inadmissible. 

It  is  allowed  that  a  scorbutic  taint  existed  at  times  in  many  rei/iments  and  that  its 
influence  in  increasing  the  danger  of  typhoid  and  malarial  fevers  was  felt  in  individual  cases; 
but  the  facts  do  not  appear  to  authorize  the  establishment  of  a  class  of  fevers  in  which  the 
scorbutic  element  was  predominant.  Such  a  classification  is  misleading,  as  it  sugLrests  the 
sloughing  ulcers,  gangrene  of  the  mouth  and  general  dro]>sy  just  cited  from  Pixcoffs' 
exjjeriences  in  the  hospitals  at  Scutari  and  other  parts  of  the  East.  A  reference  to  the  dia- 
gram facing  page  694,  in  which  is  delineated  month  by  ntontli  the  prevalence  of  scurvy 
among  our  white  troops,  will  sliow  how  rare  must  have  been  a  recognizable  scorbutic  com- 
plication. There  was  recorded  annually  one  case  of  scurvy  in  everv  72.5  men.  It  is  true 
that  when  one  man  presents  well-developed  scorbutic  symptoms  other  men,  subject  to  the 
same  causative  influences,  will  also  be  affected  to  some  extent;  but  it  is  questionable  if  our 
medical  officers  in  their  reports  did  not  overestimate  the  frequency  of  well-developed  scurvy 
by  reporting  under  that  title  cases  w'hich,  but  for  their  anxiety  to  anticipate  its  outbreak, 
would  have  been  regarded  simply  as  rheumatic  or  diarrhoeal. 


624 


thp:  eru]>tive  fevers. 


The  point  insisted  upon — the  absence  of  a  scorbutic  complication  in  the  camp  fevers 
of  the  war  except  in  rare  instances  of  local  epidemics  in  the  field  and  among  paroled  or 
exchanged  ])risoners  in  the  general  hospitals. — is  sustained  by  the  absence  from  the  suro-ical 
records  of  any  general  references  to  the  indisposition  of  wounds  to  heal.  This  indisposition 
was  frecjuently  noticed  in  the  Confederate  hospitals  and  particulai-ly  in  the  Confederate  pris- 
ons; but  as  no  special  mention  is  made  of  the  scorbutic  complication  by  Surgeons  Otis  and 
HuNTi^-GTOX  in  their  review  of  the  surgical  work  of  the  war,  it  would  seem  strange,  indeed, 
it  the  medical  part  of  its  history  were  permeated  with  a  scorbutic  taint  which  was  capable 
of  assuming  a  predominance  even  in  the  pa-esence  of  the  typhoid  and  malarial  poisons. 


CHAPTER  VI.— UX   THE   ERUPTIVE   FEVERS. 


In  presenting  the  general  statistics  of  the  war  period,  as  in  Tables  II,  III  and  IV,  and 
in  the  diagrams  facing  images  14,  20  and  24,  the  frequency  and  fatality  of  the  eruptive  fevers 
have  been  specified.  The  following  table  gives  a  more  intimate  view  of  the  statistics  of 
these  diseases- 

Table  LII, 

Showing  the  prevalence  and  mortality  of  the  Eruptive  Fevers  among  the  United  States  forces  during  the 

years  of  the  ivar  and  the  year  following  the  ivar. 

WHITE  TEOOP.S. 


May  1,  ISfil,  t.i 
Juiu-  :!(->,  1S''.0. 

ISOl 
279,371 

-t;2. 

1802-03. 

1803-04. 

1804-05. 

1805-60. 

.\vera;_'"t 

annual. 

Mean  strength : 

In  tie!(I  and  garrlteon_  431,237  , 

In  hospital  also 408,275 

■isi/Jia' 

814,325  1 

'059,956 

1                 1 

619,703 

CTMiS" 

574,  022 

845"506 

99, 080 

ioi'ior 

1431,237 

468,"275 

Total  number — 

Eatlos  ( 

f  cases  ai 

111  deatlis 

per  thoi 

sanil  of  s 
Deaths. 

trengtli. 

Cases.     I>eaths. 

Cast's. 

( 

Deaths 

1.30 
1.  97 

:42 

Cas'S.     Deaths. 

Cases. 

Deaths. 

Cases. 

Cases. 

Deaths. 

Cases. 

Deaths. 

Sniall-pox 

Measles 

Srarlet  fever 

Erysipelas 

12.2.3'1       4,717 

07, 703        4,  240 

578              711 

23.270        1,800 

4.08 

77. 57 

.48 

9. 4'J 

4.71         1.45 

28.. 58          1.99 

.34            .(ri 

10.95          1.23 

8.08 
28.07 

lo!50 

3.21 

1.88 
.04 
.01 

4.81 

17.07 

.13 

11.25 

1.75 

1.68 
.02 

.77 

3.37 

1.98 

.08 

8.70 

.69 
.11 

.ol 

.19 

5.40 
30.41 

.20 
111.45 

1.95 

1.75 

.03 

.77 

1(13,  ^.V,      10,  8!I3 

92.  22 

3.78 

44.58          4.09 

40.90 

5.74 

33. 06 

4.22 

14.20          l.(]0 

40.01 

4.50 

COLORED  T] 

{OOPS 

July  1,  18G.3,  to  ' 
.June  30,1806. 

ISO: 

.U. 

1804 

-05. 

1805-60. 

-Vverage 

annual. 

Mean  strength  : 

i;l,l32    

1  (W,923 

44,  785 


'4(V0O7' 

S3,  .571 

'ii),'i43" 

.5.5,039    

50,617 

1 
61,132 

'03^923 

In  hospital  also 

Total  number- 

Ratio  oi 

cases  an 

(1  deaths 

per  tliousand  of  s 

trength. 

Cases.  '  Deaths. 

Cases. 

;Death8. 

Cases. 

Deaths. 

Cases.    Deaths. 

Cases. 

Deaths. 

0,710  .     2,341 

8,.5.->5            931 

118                2 

l..-,30            247 

01.  03 
121.54 

10.52 
12.33 

23.  .30 

33.  88 

1.41 

7.97 

8.60 

3.75 

.02 

1.81 

30. 48        14. 24 
5.11            .51 

.^90            ~14 

38.  62 

48.  05 

.04 

8.38 

12.21 

Measles            

4.80 

Scarlet  fever 

.01 

Erysipelas 

12.10 

1.32 

1.29 

10,92.3        3,  .5-21 

195.  27 

30. 19 

00.  50 

14.  27 

47.  .35  1     15.19 

92.29 

18.30 

July 
Aug. 
Sep. 
Oct. 
Aw: 
Dec. 

o 

o 

o 

ti 

\% 

o 

is  tt 
e  c 

o  c 

>  o  1  o ;  o '  o  1 

^' 

"^ 

■~~ 

—  - 

— 

__ 

"C 

■^> 

/' 

Feb 
Mar 
Apr. 
Mar 
June 
My 
Aug. 
Sep. 
Oct. 
Nov. 
Dec. 
Jan. 
Feb. 
Mar. 
Apr. 
May 
June 
My 
Aag. 
Sep. 
Oct. 
Xar. 
Dec. 
lion. 
Feb. 
Mar. 
Apr 
Mgr 
Jane 
Jafy 
Aag. 
Sep. 
Oct. 
My. 
Dec. 
Jan. 
Feb 
Mar 
Apr 
May 
•Am 

/ 

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Od. 
Nmr. 
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t^ 

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m. 

Mm 
Apr. 
ifor 
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b  w 
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e  o  o  e  o 

GD   JD   p   ^^^1 

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-| 

^~'                          ^Timlmt 

p 

/ 

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\ 

Aug. 

\ 

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I 

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n^r 

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ynr 

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hfhr 

s 
1 

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f 

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t 

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o  o 

b 
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^ 


SMALL-POX.  ^  625 

These  figures  show,  auioiio;  otlier  points  which  might  be  iniiicated,  that  siiiall-jiox  and 
erysipehas  were  present  to  a  limited  extent  thrcughout  thr  whole  ot'  the  period,  the  former 
attaining  its  maximum  in  the  third  year,  the  latter  manifesting  hut  little  lluetuation  in  its 
annual  rates.  Measles  was  a  di.-ease  of  the  early  period  of  the  war  ami  scarlet  fever  an 
accidental  occurrence.  Small-pox  cau>cd  43  ji^r  cent,  of  the  deaths  from  the  eruptive  fevers 
among  the  white  troops,  measles  39  ['cr  cent.,  erysipelas  17  and  scarlet  iever  le<s  than  one 
2)er  cent.;  among  the  colored  troO|is  the  jiercentages  were  small-pox  G'xo.  measles  2*3.5. 
erysi|ielas  7  and  scarlet  fever  almost  itU. 

I.— SMALL-POX. 

Statistics. — Small-pox  was  present  to  a  considerable  extent  in  the  United  States  during 
the  years  of  the  war,  but  at  no  time  could  it  be  considered  a  prevalent  disease  among  the 
white  troops  serving  in  any  of  the  armies  or  departments.  During  the  five  and  one-sixth 
years  covered  by  the  statistics  12,236  cases  occurred  among  them,  cipialling  an  averaij;e 
annual  rate  of  5.5  per  thousand  men;  the  deaths  numbered  4,717,  or  1.95  annually  ])er  thou- 
sand of  strength.  In  accordance  with  the  figures  just  given  the  fatal  cases  constituted  38.5 
per  cent,  of  the  whole  number;  but  this  calculation  exaggerates  the  rate  of  fatality  as  it  does 
not  take  into  consideration  the  many  cases  that  were  taken  sick  at  the  general  hospitals. 
A  more  accurate  estimate  of  the  death-rate  in  small-jiox  may  be  obtained  liv  following  the 
history  of  a  series  of  cases  treated  in  the  small-pox  ho.spitals.  Of  1,1(3G  cases  examined  in 
this  connection  679  reported  as  unmodified  small-pox  furnished  274  deaths  or  40.3  per  cent, 
of  the  cases,  and  487  cases  occurring  subsequent  to  vaccination  gave  3  deaths, — a  total  of 
277  deaths  in  1,166  cases  of  variolous  disease,  or  a  death-rate  of  23.8  ])er  cent. 

The  average  number  of  cases  taken  on  sick  report  iiionthly  was  .46  }>er  thousand  men. 
During  the  warm  months  of  the  vear  the  rate  was  considerably  below  this  average,  and 
during  the  cold  months  proportionately  above  it.  In  Jidy,  August  and  September  the  rate 
was  never  more  than  a  few  hundredths  of  one  per  thousand  n^en.  The  largest  wave  of 
prevalence  extended,  as  may  be  seen  by  the  accompanying  diagram,  from  January  to  April, 
1864,  when  the  maxinutm  rate  of  1.46  was  attained. 

This  maximum  was  the  result  of  no  local  epidemic  seriously  crip])ling  a  ]>articular  com- 
mand, but  of  the  occurrence  of  sporadic  cases  in  all  the  commands.  Small-pox  may  be  said 
to  have  been  present  in  every  department  during  every  year  of  the  war.  The  number  of 
men  in  the  exceptional  commands  was  too  small  to  aftbrd  ground  for  (.ibjection  to  this  gen- 
eral statement.  There  was  no  small-pox  in  the  Department  of  the  Xorthwest  during  the 
year  1861-62,  the  strength  present  having  l>een  1,240  men,  nor  in  the  Department  of  Xew 
Mexico  iu  1863-64,  with  a  strength  of  4,224  men.  nor  in  the  Division  of  the  Pacific  during 
1865-66,  with  a  strength  of  11,332  men. 

In  view  of  this  general  diffusion  of  the  poison  of  the  disease  it  is  creditable  to  the  ofibrts 
of  our  medical  officers  that  there  was  no  serious  outbreak.  Isolation  and  vaccination  were 
recognized  as  efficient  means  of  protection.  Vaccination  and  revaccination  will  preserve 
the  individual  from  small-pox  save  in  exceptional  cases,  such  as  case  9,  submitted  below; 
but  instances  of  this  kind  are  so  rare  that  the  efficiency  of  the  vaccine  virus  to  protect  an 
army  from  small-pox  may  not  lie  called  in  Cjuestion.  Many  officers  could  give  evidence  from 
their  experience  to  corroborate  the  statements  in  the  iV^llowing  re^iorts: 

Mkd.  Hist.,  Pt.  Ill— 79 


626 


THE    ERUPTIVE    FEVERS 


Surfnoii  D.vvii)  Le  Eoy,  dih  III.,  Uroinixrllh .  Ti.i'us.  Fth.  21.  IsiU. —  The  men  of  this  iej;iiiient,  when  prisoners  of 
war  at  Benton  liarracks.  were  all  vaccinated,  and  altlionj;U  surrounded  by  sniall-jiox,  Imt  one  mild  case  of  varioloid 
has  occurred  anionj;  them  dnrin<;  the  year  that  has  elapsed  since  their  vaccination. 

Medical  Iii.ijucto)-  G.  AV.  Stipi'.  T.  S'.  J..  Xnr  (h-haiis.  La.,  March  20.  18G4. — For  some  weeks  previous  to  the  date 
of  this  inspection  there  had  been  a  considerable  i)revalence  of  variolous  disease  aniouf;  the  forces  and  the  jiopn- 
lation  of  the  country  occupied  by  them.  This  was  for  the  most  part  of  mild  typi',  and  its  further  spread  seemed 
almost  wholly  checked  by  sedulous  vaccination. 

That  our  troops  were  not  satisfactorily  protoctod  by  vaccination  is  evident  from  the 
statistics  submitted.  Instead  of  so  many  thousands  of  cases  there  should  not  have  been  so 
manv  hundred.'^.  Regiments  were  raised  by  the  various  States  and  rushed  to  tlio  front,  under 
the  successive  calls  of  the  President  for  men,  without  a  thought  of  small-pox  or  vaccination. 
The  armv  regulations  required  that  every  man  should  be  vaccinated,  but  few  of  the  State 
military  authorities  succeeded  in  fulfilling  this  requirement.  For  many  years  before  the 
war  there  had  been  no  systematic  vaccination  in  the  civil  communities.  Many  of  the  volun- 
teer troops  had  never  been  vaccinated;  few  of  them  had  been  revaccinated,  for  at  that 
time  the  necessity  of  revaccination  was  not  thoroughly  appreciated  by  our  medical  men, 
although  European  experience  had  demonsti'ated  its  value.  There  was,  therefore,  much 
susceptible  material  in  the  ranks  of  our  armies,  but  to  give  quantitative  expression  to  this  is 
difficult ;  as  a  rule  men  from  rural  districts  had  a  greater  susceptibility  than  those  from 
cities.  The  appearance  of  small-pox  in  the  winter  of  1861-62  caused  Medical  Director 
Tripler  to  call  for  a  report  of  the  condition  of  the  regiments  in  the  Army  of  the  Potomac  as 
regarded  their  immunity  from  the  disease.  The  result  of  the  inspection  showed  that  while 
some  regiments  were  thoroughly  protected,  others  adjoining  them  on  the  same  camp  ground 
were  composed  of  susceptible  material.  Thus,  of  four  regiments  of  the  Third  Brigade 
of  Sumner's  Division,  Surgeon  SiiEBELi^'a  represented  the  712  men  of  the  o2d  X.  Y.  as 
sufficiently  protected,  and  Surgeon  Leach  the  744  men  of  the  57th  X.  Y.  as  protected  with 
the  exception  of  20;  while  Surgeon  McDeemott,  66th  X.  Y.,  regarded  325  of  his  738  men, 
and  Surgeon  Ieoxbeeger,  53d  Pa.,  593  of  his  818  men,  as  susceptible  and  requiring  imme- 
diate vaccination  or  revaccination.  Brigade  Surgeon  D.  AV.  Hand,  in  reporting  that  only 
23  of  the  2d  X.  Y.  recjuired  revaccination,  while  315  of  the  1st  ^linn.  appeared  to  be  insuffi- 
ciently protected,  explained  this  by  the  statement  that  the  former  was  a  Xew  York  City 
reciment.  composed  mostly  of  foreigners,  who  were  protected  by  a  previous  attack  of  the 
disease  or  liv  well-defined  vaccination  marks,  and  the  latter,  a  native  regiment  of  Western 
frontiersmen,  whose  antecedents  showed  neither  inclination  nor  facilities  for  vaccination. 

If  the  number  of  unsuccessful  revaccinations  in  a  command  be  resiarded  as  an  index  of 
\i>.  extin^i^aiished  susceptibility  to  small-pox,  some  idea  may  be  obtained  of  the  constitutioual 
condition  of  our  men  when  exposure  to  the  disease  necessitated  a  liurried  use  of  the  virus. 
Every  fourth  or  tiftli  man  was  perhaps  liable  to  be  attacked.'"     In  view  of  this  suscepti- 

*Snrgeon  C.  H.  "WiLcox  and  Ass't  Surgeon  J.  A.Peters,  21st  X.Y.,  stato — Bv_falo  MeiUail  und^nrgimljunrnul.,  Vol.  I,  ISGl,  p.  Hi — that  of  70G  men  there 
was  evidence  of  previous  vaccination  in  tVl-l,  but  tluit  nmre  than  seven  yem-rf  liad  elaipsed  since  tlie  previou-s  vucciuatiun  in  no  less  tlian  477  of  the  luinile  ". 
Of  those  who  exhibited  evidence  of  former  vaccination  43  wcru*  revaccinated  successfully,  to  wit :  11  of  107  who  had  lieen  vaccinated  within  seven  years, 
and  o2  of  477  whose  previous  vaccination  antedated  that  jteriiMJ.  (Hie  man  in  fifteen  was  susceptible  to  the  action  of  the  virus  without  considering  those 
iu  whom  the  failure  of  the  attempted  revaccinutiou  was  due  to  other  causes  than  insusceptibility.  Xo  cast;  was  reported  by  these  medical  officers  as 
successfuUj-  revaccinated  unless  the  vaccinia  mn  its  characteristic  course.  There  is  a  great  diversity  in  the  recorded  results  of  revaccination,  som  *  giving 
so  large  a  i>en-entage  nf  success»es  that,  in  the  absence  of  a  detailed  account  of  what  cuiistitnted  a  success,  we  are  at  liberty  to  suppose  that  liy  many  any 
inOaiuMuitory  apiiearanco  at  the  points  of  insertion  of  the  virus  in  a  man  showiug  evidence  of  a  previous  vaccination  was  irgarded  as  a  true  vaccinia 
n»'.Klified  by  the  jiartial  protecti<.in  of  a  primary  opt- rat  ion.  The  animal  matter  "f  the  crust  fri'ipiently  gavu  ristf  to  inflaimnatiun,  pustulation  and  scabbing 
of  a  non-si»ecitic  character,  which  were  ix-rhaps  often  reported  as  the  evidences  of  a  protective  revaccination. — See  Tiovuie  rs.  Hiimutiized  Viriig  as  affvctuvj 
Ihe prernJeuce  miit  ileath-ntte  of  Varioloid,  by  Charles  .Smart,  Surg(M»n  l*.  .S.  A.,  Jledicd  ynrt',  XL,  Philadelphia,  1!<S2,  p.  2i<0.  Others  recorded  so  small  a 
IK-rcentage  of  successes  that  the  us'!  of  inert  crusts  may  i»;  suspected.  Lyinph-<'oated  points  and  vaccine  crusts,  pjirticularly  the  latter,  furnished  to 
medical  tttficers  during  the  war  wt-re  ociasioiially  inert.  It  bi^came,  therefore,  a  comnnin  practice  in  vaccinating  a  regiment  to  rub  together  for  insertion 
l»arts  i.'f  two  nr  more  f-rusts  in  the  ln'j»e  that  oni>  at  least  of  the  combination  might  prove  effective.  Evidently  the  susi-eptibility,  as  detcrniiied  by  the 
nse  of  the  dried  crust  and  lHng-ke].t  lymph,  and  tli'-  inununity  confi-rred  by  them,  might  freijuently  be  called  in  question.     ISut  tlie  winie  objections  do 


SMALL-POX. 


62^ 


bility  and  of  the  wide  diffusioa  of  the  disease-poison  it  is  evident  tliat  the  prompt  i.sok\tion 
of  suspected  cases  and  tlie  destruction  bv  fire  of  all  infected  clothing",  bedding  and  shelters 
-ft-ere  measures  of  the  first  consequence  in  restraining  the  spread  of  the  disease  until  immunity 
was  conferred  by  succe>^sfiil  vaccination  or  revaccination. 

The  disease  javvailed  to  a  irreattn-  extent  auiung  troops  in  the  vicinity  of  citi>'s  than 
among  those  in  the  field.  Thus,  during  the  vear  c>f  greatest  prevalence  there  \ver(>  as  many 
cases  among  the  30,000  men  in  the  I)e|)artmciit  of  Washington  as  among  the  104,000  in 
tlic  Army  of  the  Potomac,  and  a  larger  number  of  cases  than  was  r<^ported  by  either  of 
these  commands  occurred  among  less  than  15,000  men,  mostly  quartered  in  barracks,  on 
recruiting  duty  in  the  Xorthern  Department.  The  cases  reported  from  tin,'  Army  <:A  the 
Potomac  were  mostly  due  to  exposure  in  the  cities  of  Washington  and  Alexandria.  Tlie 
sufferers  were  usually  men  recently  returned  from  furlough  or  general  hospital.  As  soon 
as  the  disease  Avas  recognized  the  patient  was  removed  to  an  isolated  tent-ward  of  the 
division  hospital,  or,  in  the  absence  of  a  temjiorary  pest-house  lor  tlu*  division,  the  regi- 
mental surgeon  established  one  in  a  suitable  locality  near  tlie  camp,  I  suidly  men  who 
presented  evidences  of  a  previous  attack  of  the  disease  were  detailed  \n  act  as  nurses,'-'  In 
other  commands  similar  precautions  were  taken. 

Surgeon  TiiEO.  H.  Lasiiells,  171«/  /'«.,  Xciv  Verne,  X.  C,  Fch.  I'd,  lSt;H.— li,v  iinip.r  can'  in  viiciinatiii^:.  aii.l  iso- 
lating the  cases,  tlio  s])ii'ail  of  Niiiall-pox  was  Hjx'cdily  clicckfil. 

Surgeon  J.  JI.  CrYl.Eli.  V.  S.  .1.,  MciUiul  Director,  Forlriim  Munnn ,  In.,  ■Inn.  L'8.  IKUL".— A  I'fw  cases  u(  variolous 
disease  have  ai>peare(l,  chietly  ainoiif;  recruits;  but  in  every  instance  they  Inivc  liccn  at  omi'  se]iarale<l  from  the  rest 
anil  carefully  watched  through  the  course  of  the  disease  in  a  hiiihlin;;.  ali'ordiii;;  them  evii  y  comfort,  at  a  <listance  of 
more  tlian  a  mile  from  the  fort. 

e^mall-pc)x  jirevailed  to  a  greater  extent  among  the  culured  tnieps  than  among  tlie  white 
commands.  iJuring  the  three  years  of  their  .•service  ().71<)  cases,  with  2.311  deaths,  we'iv 
reported.  Tlie  cases  equalled  an  average  annual  rate  ef  :>(').(')  per  ihdusaiid  I't  ^treng^]l.  the 
deaths  a  rate  ^A  12.2;  the  fatal  eases  formed  iM,*'  pei-  cent,  df  the  wlml,'  nuuiber.  The 
Cold  mi:inths  of  the  year  were  those  of  maximum  pr''\'ah'nc-e:  Thi'  maxiiiiuin  in  I'^lU 
occurred  in  ^larch,  when  S.04  eases  jter  thousand  men  was  attained;  m  ISil.")  w  maximum 
of  3.57  was  recorded  in  February;  in  186(3  the  hi"hest  rate,  0.73,  was  reached  in  ^larcli. 
During  the  first  winter  tlie  jtrevalence  of  the  disease  was  due  to  the  operation  of  ctuises 
similar  in  character  to  those  affecting  the  white  troops;  but  the  contagion  liad  a  wider  ditl'u- 
sion  and  found  a  greater  susceptibility  to  its  action  among  the  negroes  tlian  among  the 
wliites.  The  smaller  rate  of  the  second  winter  is  the  result  of  eiforts  to  supjiress  the  disease, 
while  its  prevalence  in  the  year  following  the  war  gives  expression  to  llie  carelessness  which 
arose  from  anticijmtions  of  disbandment. 

Xo  case  of  small-]iox  or  varioloid  was  reported  among  the  49,304  iiuMi  of  tlie  Confed- 
erate Army  of  the  Potomac  during  the  nine  months,  July,  ISOl-March,  1S62,  while  380 
cases  occurred  during  this  period  in  the  United  States  Army  opposed  to  it.  Small-pox  may. 
therefore,  be  considered  as  having  invaded  the  South  durinc;  the  iiroixress  of  the  war. 
The  Confederate  States  Jledieal  and  Surgical  Journal  crmtiiiiis  nothiui:;  on  tliis  subject; 
but  Surgeon  W.  A.  Caerixgton,  Medical  Director  of  tlie  (.Tcneral  nos|tilals  in  the  Depart- 

nnt  iiiii)ly  tu  iiistaiicx'S  in  w!iii-li  frt-s^h  vaccitu'  lympli  wus  used,  Surjrfoii  ilcnenil  S.  (».\ki,hv  VANriEKi'oEi.,  tif  Ni-w  York  Stati".  issucl  h(i  nrdor,  May  12, 
18()1,  riM]uinng  rfffiuioiital  siir^r^^onf?  t"  vai-rinatc  tlu'ir  men  irrt'S]>ortive  nf  the  i-xisti-ncii  of  wars  of  jiroviuiis  vacrinatiuii!*.  In  Iiin  rc'iHirt  to  tht*  (I'lvrrnnr, 
January  n.  ISt^:*,  lie  statt-s  that  the  i-pirit  of  this  onlt-r  hail  Ik-cu  jrenerally  ioni]ilii''l  with,  ami  that  up  to  Ili'C»Mnh4-r  1,  If^ill,  l».'J4s  nuMi  had  U'*'\\  n'vacci- 
natctl.  His  statir^tics  t^how  that  2n.O  iht  ct-iit.  of  tin-  whole  iinmln'r  wi-rt-  fmn*!  susiM-ptihU'  to  th-.'  virn«.  In  other  wonls.  nnr  man  in  j\wr  was  liaMt-  to 
Eufft'r  from  the  contagittn  of  small-iiox, 

*The  jtrevrons  attjirk  »li<l  nut  in  all  t-ases  exhaii>t  tlo-  Kuseei.tihility  of  the  iii'li\  i.hiiil.  Suix'-'mm  A.  Mvrrav  Ro.irns.  lii«i-vtnr  '.f  n.'-i.itals.  f.  S. 
A.,  states  that  hi;*  destroyed  ret-i.rds  contained  the  details  of  live  rases  of  tlo-  (nse;i>--  in  iitirs'-  wlin  li;id  -.iitYered  from  <  oiitlu'-tit  -mall-|iox  in  rhildhoo.]  ; 
two  of  t!ie  five  died  v'ftlM' second  attack.— -Vf-.^V/iNoi'/ S'Hrf/iAt/ .U'»//J»/,  I.  Memphis.  Teiiii..  Im.c.  p.  lol. 


62S  THK    EKL'l'TIVK    l-KVKns. 

ineiit  of  Vii'u'inia,  states*  that  tlio  Ariiiv  of  Xorthoi'ii  Virginia  rii-L'iv(_M[  tlic  contagion  wliile 
in  ^larylanJ  during  the  campaign  wliicli  cuhninalcJ  in  the  Ijatile  of  Antictam.  Bej't.  17. 
1862.  In  tlio  hosjMlals  under  ]iis  cliargo  tliei'e  were  treated  frnni  (October.  lS()2.  t^  January, 
1864,  2.513  cases  of  variola  wil'h  l.(  i2(l  deatlis,  giving  a  deatli-ratu  of  40. 5,^.  and  1,196  cases 
of  variidoid  with  39  deatlis,  giving  a  rate  of  3.26  per  cent. — the  fatal  cases  thus  constituting 
28.5  i)er  cent,  of  the  total  number.      Surgeon  Caekinoton  says: 

From  actual  o1)seivation  and  investifration  at  tlie  I  iine  I  can  definitely  pronounce  upon  tlie  orijjin  and  progress 
of  sniall-pox  in  the.se  hospitals.  On  Oct.  IS,  18t)2,  the  lirst  cases  were  brought  to  Kichniond  from  Fort  Delaware.  Vp 
to  that  t  imc  no  cases  had  been  reiiorted  here  for  some  months  in  the  army  or  among  citizens.  ]:>y  the  31st  of  Octoljcr 
twelve  cases  had  been  rejiorted.  In  carefully  tracing  each  it  was  determined  that  those  from  Fort  Delaware  did  ]iot 
disseminate  the  disea.se,  being  quarantined  and  avoided  by  all :  but  that  soldiers  from  the  Army  of  Xorthern  Virginia 
had  brought  the  disease  to  the  hospitals,  and  being  unconscious  and  unsuspected,  had  exposed  many  to  it  before  the 
diagnosis  was  made.  The  army  had  just  reached  tlie  vicinity  of  Winchester  after  evacuating  Maryland,  subsecjuent 
to  the  battle  of  Sharpsburg.  There  were  but  few  cases  from  the  army,  and  those  Lad  not  been  prisoners,  nor  had 
they  seen  any  returned  prisoners.  These  cases  went  to  Charlottesville,  Lynchburg  and  Richmond,  at  which  points 
the  malady  sjiread,  but  much  more  rapidly  and  extensively  at  Kichmond. 

Surgeon  J,  T.  Gilmork  of  McLaw's  Division,  corroborates  GakrinCtTOn's  account  of 
the  outbreak.f  The  first  case  occurred  in  Anderson's  Georgia  Brigade,  while  the  army  was 
reorganizing  in  the  vicinity  of  AVinchester,  after  having  fallen  back  from  Antictam.  The 
disease  did  not  show  itself  in  McLaw's  command  until  toward  the  close  of  October,  when  it 
aj^peared  in  a  soldier  of  the  lOtli  Miss.;  but  the  epidemic  did  not  malvc  much  headway  until 
after  the  battle  of  Fredericksburg  in  December.  No  record  of  its  prevalence  lias  been  pre- 
served; liut  that  it  spread  extensively  among  the  troops  and  the  civil  population  is  evident 
from  its  frecjuent  importation  into  our  prison  depots  bv  recently-cajitured  soldiers,  and  par- 
ticularly from  the  facts  that  have  been  reported  bv  manv  Southern  medical  men  concerning 
the  efforts  to  suppress  the  epidemic.  Indeed,  one  medical  officer  has  stated  that  the  Confed- 
erate Army  was  panic  stricken  by  the  spread  of  the  disease. J 

Small-pox  was  not  a  prominent  disease  in  tlie  Confederate  i>risons.  The  register  of  the 
prison  hospital  at  Andersonville,  Ga.,  covering  the  period  Feb.  24,  1864,  to  April  17,  1865, 
shows  the  presence  of  62  cases  of  variola,  one-half  of  which  were  fatal,  and  of  63  of  vario- 
loid, 31  of  which  were  fatal.  Most  of  the  cases  occurred  shortly  after  the  establishment  of 
the  prison,  the  disease  having  been  brought  from  infected  Richmond  prisons  by  transferred 
prisoners.  The  fatality  of  the  cases  of  so-called  varioloid  may  be  explained  by  the  enfeebled 
condition  of  the  patients  when  attacked  and  their  exposure  to  cold  at  night  during  the  progress 
of  their  sickness.  The  subsidence  of  the  disease  after  its  introduction  into  this  crowded  pen 
must  be  attributed  to  the  protective  influence  of  antecedent  vaccination  and  revaccination. 
Table  XVII §  shows  the  prevalence  of  the  eruptive  fevers  in  the  tobacco  warehouses  of  Dan- 
ville, Va.  Of  the  880  cases  mentioned  818  were  due  to  small-pox ;  144  of  these  were  trans- 
ferred to  other  hospitals,  and  in  110  cases  no  disposition  is  recorded,  leaving  564  cases,  of 
which  159  or  28.2  per  cent,  terminated  fatally.  The  number  of  prisoners  confined  at  this 
depot  is  unknown. 

The  occurrence  of  small-pox  at  Alton,  Camp  Douglas,  liock  Island  and  other  depots  in 
the  Xorthern  States  has  already  been  mentioned. ||  Some  of  the  difficulties  encountered  in 
attempting  its  suppression  have  also  been  instanced,  as  the  want  of  facilities  for  effecting 
isolation,  the  inefficiency  of  virus  furnisheil  for  the  contrcil  of  the  epidemic  and  its  rein- 


*  As  reiinrtcil  I'.v  ,I"3KPIt  .I<ises  in  tlu-  M'^'lirnl  I'nhiiue  of  thf  V.  .S.  ^tinianj  Comttii'ttitnu  Mtitwiy-^,  [k  GUI*, 
t  l.i-tt.T  to  rrcifi-ssor  P.MI,  y.  KvF,  .<!.  ;..."is  M,;I1,,i1  llfp„>1ir,  III.  18US,  jp.  4r,3. 
;  Dr.  li.jI.T.>x.  "f  Richmuli'l,  Vii.,— si-v-  yuHhiMe  Me.lanl  J:iin„„l,  I,  ISr.T,  Ji.  277. 


SMALL-POX. 


629 


troduction  bv  .successive  importations  from  the  Confoilemto  ranks.  The  following  tabic 
sununarizes  the  statistics  uf  tlie  prevalence  and  fatality  of  the  eruptive  fevers  among  the 
Confederate  pri-miers  at  the  principal  prison  Jejiots: 

T.vr.LK  LTTT, 


■^hniciii;/  the  nnmbn-  of  cases  of  the  Erupticc  Fevers  and  of  deaths  caused  by  them  among  the  Confederate 
2)yisoners  of  war  at  the  principal  irrison  depots  for  the  period  covered  by  the  records  of  each  prison. 


P,.iiitI...ok- 


1       I  1    f,  AllHii.  ni..  lin.U  Isl:ui.l.    l';ini|i  ?I..r-      .I.iliris(,h--      I  ami.  Clias.-.    Kliniii,.  N".       K.nlI'.Ia-  ,  .,  , 

,"r.-|  ,,,;"'""    s.ptf.iilHr.  III.,Kil,n.-       t..ii.lii,i.,      Isliiii.l,  II..  li.,F,.l.nmrv.      Y.,  .lulv.       wiuv.  Ii.l..  ^""    ,  ,   ' 

iJ^'.,.    /■.'     18i;L'.t...Iiinc.  iu-v,  lKi;4.  t(i  .rnii.',lf^c,:i.  t(.  .Iuir-,  l."!;:!.        Is^i'.t.  t..      ISiit.t.i.luiio,  .\iii.'U>Mmi:i.  "'J!.';'.' "'"''• 

iw,    tH.)uiu.        ,j,..  j,\,„  i^s,;.-,.     .liuic.  lw,.\   t...l,i,i,..isr,.-,.   .;„„,., Isc."..  in:.",.        t...lun,-.l>i;.-,.  /■"■'■,^^:. 


X...  (ifinuntli.srcci.r.U'a— 
31eau  strciiii'tli  iiri'svut  — 


41 

■i,  ;5iil 


17 
li,  o:;n 


I-.; 
ii..".;ii 


No.  .if  I'l-is  in.rscumniitti-.l-_  'JHjOtlO 


11,4."),S  12,08:;  '  7,(127  ;  lli.lH.'i  ■  12,147 


2:! 
1),  4.»; 

7r7i 
I  i  I  i 


Somll-pox 

Measles 

Srarl.t  fc-v.T 

Erv>iiiil!is 


,2,218       CIS  |l,7il7       i'A   1,1'Jl',  j     370 
S.Hi       li»i  I     22.')  i      I'd       l::4         l.S 

l,.".i;s      li.."i  !    lUii  '      7:1      4i:5        :!s 


125 

1S(! 


411  I 
•I 


0    l,l!ft5  I  298    1,180       »fi:l    1,S:!7  I     341  !     4rir,       212 
'    1(17  l:l       l:!(l  '      l.i       :i4.-i  '      74       4"2         71 

I  I 

-   '  '-- 

n     4:12  .  .-Ill  ,     r.2       II 


Ti.T.U.. 


.  4,  (171 


1,' 


4:ir, 


.-.4,.*  i      .'..■.       1<: 


CONSOLIDATIOX  OK   lUE  STAlISTllS  oF  TllK  DEToTS. 


:i    - 

1.  1     7i.> 

4 

ii;i 

47 

.■-  2,  ".'.i;i 

472 

I.I.:!:! 

:i:i:! 

Ti.tal  .iiM's.   T.ital.l.alli>. 


:SlnaII-|inx 

MiMslis 

Srarlet  f.-v<T_ 
Er.v5i|..'las 


2,  47:l 

i:. 

4.  :i4',i 


Avenijri'  aiiniiiil  rat.'  |..'r 

l.iNiii,.f  stivnL'di.  .\iimtal 

ilialli-ral.- 

|„-,-  l.n,«l 

.•.....„  i.....,i'.         ailiiii»?i..n* 


I'.-r.fiitac'i 
..f  lalal 


2, 1124 
:i:.:! 


1211.4 
:iii.:i 


:i2.1 
4.S 


;i:i.:l 


l.:i 


T..TAL_ 


214.2 


211.8 


Clinical  and  Po.-;t-moetem  Records. — Notes  of  the  history  ami  progress  of  small- 
pox cases  were  seldom  recorded.  The  medical  descriptive  lists  merely  identify  the  patient 
and  give  dates.  Oidy  nine  cases  appear  on  the  clinical  records.  The  hrst  is  one  of  recovery: 
the  others  were  fatal.  Death  occurred  prior  to  maturation  in  cases  2  and  3,  and  during  the 
secondary  fever  in  cases  4-7;  in  G  and  7  there  was  sloudiin"  of  the  skin  and  cellular 
tissue;  in  G  fatal  syncope  while  the  patient  was  on  the  close-stool;  a  mild  case  of  the 
disease,  S,  became  suddenly  fatal  by  implication  of  the  larynx:  in  9  the  patient  at  the 
time  of  the  attack  had  the  scabs  of  recent  revaccination  on  his  arm. 

Cai?e  1. — Fiivate  Ayilliaiu  Coy,  Co.  I,97tli  Ohio:  age  32:  ■was  admitted  March  2.  ISGl,  in  the  evening.  Xcxtday 
he  liad  liigli  fever  and  was  soniewliat  delirious;  iiulse  80:  tongue  slightly  furred  and  cracked  and  very  red  on  the 
margin:  bowels  constipated.  The  paimles  were  sparsely  scattered  on  the  face  and  were  less  numerous  on  the  body. 
According  to  the  patient's  statement  three  days  had  elapsed  since  their  first  appearance :  the  rash  atiected  the  palate 
and  caused  soreness  of  throat.  A  gargle  containing  acetate  of  lead  and  morphia  was  used  frefjuently :  a  Seidlitz  powder 
was  prescribed  every  three  liours  until  the  bowels  moved;  the  body  was  sponged  with  a  solution  of  three  drachms  of 
acetate  of  lead  in  two  pints  of  water.     C)n  the  llth  the  pulse  was  SO  and  the  patient  restless,  although  there  was  little 


630  THE    ERUPTIVE    FEVERS. 

fever  and  iio  delirium  or  lieadaclie:  there  had  beeu  no  pain  in  the  liack.hut  the  hips  and  thighs  were  very  sore ;  the 
tongue  was  cleaner  but  still  cracked:  the  liowels  had  been  moved  three  times;  the  eruption  was  vesicular  on  the 
face  and  the  papules  more  abundant  on  the  body  and  extremities.  The  most  prominent  vesicles  on  the  face  were 
cauterized:  an  eft'ervesciug  draught  was  given  every  few  hours  and  seven  grains  of  Dover's  jiowder  at  bedtin.e. 
Xext  day  there  was  a  little  fever:  pulse  88:  tongue  nearly  clean  and  less  cracked:  throat  still  very  sore:  eruption 
pustular:  bowels  loose:  he  rested  well  during  the  night.  Two  teaspooiifuls  of  the  spirit  of  Mindererus  were  given 
every  three  hours:  a  gargle  of  thirty  grains  of  chloratt'  of  potash  in  four  ounces  of  water  was  used  frequently:  half 
diet  was  given  instead  of  low  diet  as  before.  On  the  13th  he  complained  of  having  rested  poorly  during  the  niight: 
tonguecleau;  pulse  82:  some  febrile  action:  face  swollen:  throat  worse:  muscular  prostration.  Seven  grains  of  Dover's 
powder  were  given  every  tive  hours:  the  gargle  and  spirit  of  Mindererus  were  continued.  On  the  14th  the  tongue 
•was  coated  brown;  pulse  92:  eruption  pustular:  bowels  regular;  he  had  no  apjietite  but  was  very  thirsty,  and  had 
not  rested  well  during  the  night.  Five  grains  of  Dover's  powder  and  three  of  camphor  were  given  every  six  hours. 
He  had  another  bad  night  and  next  day  some  delirium  but  no  headache:  pulse  92;  tongue  slightly  coated:  l)owels 
open;  maturation  proceeding  favorably:  the  patient  had  no  appetite  but  was  still  thirsty;  he  was  quite  hoarse  but 
his  l)reathing  was  easy.  A  gargle  of  a  solution  of  chlorinated  soda  was  used  frequently;  the  eft'ervesciug  draught 
was  taken  every  two  hours.  On  the  16th  he  was  found  to  have  rested  well;  pulse  90;  tongue  covered  with  a  curdled 
whitish  coat:  less  hoarseness:  throat  feeling  better ;  appetite  improved:  bowels  loose.  The  eft'ervesciug  draught  was 
given  every  three  hours:  Dover's  powder  at  bedtime.  On  the  17th  there  was  little  change, — the  eruption  had  ([uite 
subsided  on  the  face  and  had  just  matured  on  the  extremities.  Two  grains  of  (iniuine  in  two  teaspoonfuls  of  whiskey 
were  given  three  times  daily:  the  Dover's  powder  and  eft'ervesciug  draught  were  continued.  Two  days  later  the 
eruption  was  subsiding  on  the  extremities:  there  was  no  fever.  The  patient  was  considered  convalescent  and  full 
diet  was  allowed. — Pest-House,  Camp  Dennison,  Ohio. 

Case  2. — Private  Orange  S.  Xorton,Co.E,  113th  111.:  age  21:  was  admitted  July  17, 1863,  from  Lawsou  hospital, 
St.  Louis,  Mo.,  as  a  convalescent  from  typhoid  fever.  He  was  feeble  and  emaciated  and  had  a  persisting  diarrhrea, 
pain  in  the  left  side  and  mucous  expectoration  mixed  with  blood.  After  a  time  he  began  to  improve,  and  in  Se])tem- 
ber  was  able  to  get  out  of  bed.  In  December  he  could  walk  about  in  the  open  air  but  was  easily  fiitigued:  he  was 
gaining  in  flesh,  although  there  was  still  some  diarrluea  and  pain  in  the  chest.  On  the  21th  he  was  vaccinated.  He 
stated  that  he  had  never  been  successfully  vaccinated  and  there  was  no  evidence  of  protection.  29tli:  Chill:  high 
fever;  pain  in  head  and  back;  nausea:  prostration.  31st:  High  fever;  less  pain;  slight  indication  of  eruption  on 
face.  Gave  Dover's  powder;  low  diet.  Jan.  1.186-1:  Xausea;  vomiting;  great  depression;  eruption.  3d:  Vesicles 
in  great  number.  4th:  Symptoms  violent :  delirium:  indications  of  confluence.  Sent  to  small-iiox  hospital.  Ttli: 
Died  comatose. — Hospital.  Oui)U'ii,  III. 

C.\SK  3. — Private  George  Rol)erts.  Co.  A,  121st  Ohio:  age  35:  robust  and  of  sanguine  temperament :  was  admitted 
March  9, 1864,  with  the  premonitory  fever  at  its  height  and  the  eruption  abundant  on  the  face  but  undeveloped  on  the 
body  or  extremities.  He  passed  a  restless  night  and  on  the  following  day  had  high  fever,  headache  and  pain  in  the 
loins,  dry  mouth,  coated  tongue,  red  and  inflamed  fauces  and  palate,  and  marked  conjunctivitis;  pulse  104,  full  and 
bounding.  He  seemed  careless  as  to  his  condition  although  answering  questions  promptly.  The  eruption  on  his  face 
was  pajuilar  but  confluent,  the  entire  surface  being  involved:  it  was  also  well  developed  on  the  extremities.  A 
gargle  of  acetate  of  lead  and  morphia  was  given:  an  eft'ervesciug  draught  every  three  hours;  nitrate  of  silver  eight 
grains,  in  distilled  water  one  ounce,  was  applied  by  a  cauud's-hair  pencil  over  the  whole  of  the  face.  11th:  Pulse  106, 
full  and  bounding:  tongue  disposed  to  clean:  less  conjutictivitis:  bowelsopen:  noappetite:  eruption  on  face  becoming 
Tesicular;  throat  ulcerating.  A  gargle  of  solution  of  chluriuatcd  suda  a  drachm  and  a  half,  and  water  eight  ounces, 
was  used  and  the  eft'ervesciug  draught  continued.  12th:  High  fever  and  at  times  delirium;  tonguecleau  but  red: 
pulse  104;  face  nuich  swollen,  closing  the  eyes:  eruption  on  the  body  abundant  and  confluent,  covering  the  entire 
surface:  vesicles  on  the  face  receding,  leaving  the  surface  nearly  smooth ;  bowels  loose;  respiration  deep  and  easj : 
throat  much  swollen :  voice  inaudible.  He  was  cupped  on  the  temples  and  a  blister  was  applied  to  the  neck  and 
breast:  Dover's  powder  at  night ;  gargle  and  eft'ervesciug  draught  continued.  13th:  He  had  rested  better;  pulse  136, 
feeble  and  soft ;  tongue  very  red  and  with  a  whitish  fur  in  the  middle :  face  much  swollen ;  mouth  dry;  all  the  mucous 
membranes  near  the  surface  bleeding;  troublesome  phymosis;  eruption  stationary:  some  vesicles  on  the  extremities 
and  body:  the  patient's  voice  was  gone  and  he  lay  <iuiet .  A  mixture  of  carbonate  of  ammonia  fifty  grains,  opiuiri  six 
grains,  whiskej"  live  ounces  and  gum  camphor  a  scrujile,  was  given  in  tablcspoonful  doses  every  two  hours;  hot 
pediluvia  were  ai^plied;  the  body  was  sjiouged  with  lukewarm  water  and  the  blister  was  reapplied  to  the  neck  and 
breast,  it  having  previously  refused  to  draw.  14th:  He  rested  well  during  the  night;  pulse  116,  fuller;  tongue 
parched;  lips  dry;  gurgling  in  trachea;  epistaxis  :  constii)ation:  eruption  returning  without  pustulation;  i)hymosis 
aggravated;  the  blister  had  not  yet  acted.  The  treatment  was  continued;  Dover's  powder  was  given  at  bedtime; 
beef-tea,  egg-nog  and  ice  were  also  prescribed,  loth  :  He  had  rested  well ;  pulse  unchanged;  hemorrhage  from  the 
mucous  membranes;  respiration  difticult  and  stertorous;  less  fever;  swelling  of  the  face,  though  desquamation  was 
in  progress,  leaving  a  clean  and  smooth  surface:  pustules  on  the  hands  and  feet  slowly  maturing:  eruption  on  body 
again  becoming  vesicular;  the  patient  picked  at  his  head  and  bed-clothes;  the  blister  had  not  yet  acted.  The  treat- 
ment was  continued.     He  died  at  4  r.  m. — rint-Hoimc.  Camp  Ihniiinon,  Ohio. 

C.vSE  4. — Private  Enos  W.  Bratcher,  Co.  I,  3d  Ky.  C'av.;  age  25;  was  admitted  March  19,  1864,  with  tonsillitis, 
and  transferred  to  the  pest-house  April  22  with  a  free  and  well-defined  variolous  eruption.  He  presented  no  evi- 
dence of  vaccination.  His  general  health  appeared  good,  but  he  became  aff'ected  with  a  troublesome  diarrhiea  soon 
after  his  admission.  Dover's  powder  in  repeated  doses  was  prescribed.  26th:  Eruption  confluent  upon  the  face.  A 
bottle  of  ale  dailv,  with  chicken  diet.     28th:  A  mixtiire  of  one  ounce  of  collodion  and  one  drachm  of  tincture  of  iodine 


SMALL-POX.  631 

vras  brushed  over  the  face.  May  1:  Pustules  numerous  over  the  entire  body;  face  crusted;  fever  h!jj;h,  although 
the  pustules  were  filled.  Ale,  niilk-puueh,  egg-nog,  chicken  and  beef-tea  were  given.  4th:  Scab  falling  from  face, 
leaving  surface  raw  and  red.  .Stimulants  and  nutritious  diet  continued.  Gth:  Amelioration  of  symptoms:  appetite 
fair.  8th:  Diarrlnva.  delirium  and  high  fever:  tongue  and  teeth  blackened  with  sordes.  .Stimulants  eontinne<l.  He 
died  on  the  10th. — MailiioH  Hwpital.  IiiiJ. 

Ca.sk  o. — Private  Saul  M.  Millhollin.  Co.  K,4th  Minn.,  while  on  extra  duty  as  cook  was  attacked  Di'c.  li.  1802. 
with  fever  and  headache,  (^luiiiiue  and  Dover's  powder  were  rejeoteil  as  soon  as  swallowed,  ."ith:  Severe  liiml)ar  p;iin  ; 
variolous  eruption  upon  face  and  hands.  Gave  cathartic  pills,  followed  by  (juiiiine  and  sotUi.  (Jth:  Kriiption  fully 
deveh>ped.  Gave  Hover's  powder  in  five-grain  doses  every  four  hours;  low  diet.  7th:  Kever  subsiding;  pustules 
forming;  heavy  feeling  in  head.  8tli:  Sore  throat;  slight  tumefaction  on  right  side  of  neck  near  angle  of  jaw:  eruji- 
tiou  well  developed,  distinct;  bowels  costive.  Gave  a  gargle  of  two  scruples  of  alum  and  two  grains  of  suliduite  of 
morphia  in  fourounces  of  water;  to  be  used  four  times  a  day.  !Uli:  Hight  side  of  face  much  swdllen:  eruption  nearly 
confluent;  pain  slight:  bowels  nnmoved.  Gave  oil.  10th:  Swelling  le.sseued:  sonu'  jjustulation  :  throat  still  sore: 
bowels  oi)en.  Gave  acetate  of  ammonia,  sweet  spirit  of  nitre  :iiid  paregoric.  11th:  Swelling  subsiiling  but  patient 
very  restless.  Low- diet.  IL'th  :  Patient  more  comfortable;  throat  tilled  with  tenacious  mucus  ;  bowels  costive.  i;ith: 
Pustules  tilling  well;  swelling  subsiding  slowly:  no  severe  ))ain;  liowels  costive.  Gave  senna  and  rhubarb;  soup 
andsage-tea.  14th:  liowelsopen;  pustules  running  together.  Kith:  Fainted  while  on  theelose-stool. and  died  within 
half  an  hour. — Ilonpittil,  Quincy,  III. 

Case  6. — Private  Addison  R.  White,  Co.  G,  1st  Mass.  Cav.;  age  28:  was  iulmitti'd  Ajiril  ',',  18lVl,  snrt'ering  from 
diarrhfea  contracted  while  a  prisoner  after  the  tight  at  liristow  Station,  Va.,  Oct.  II,  \XkX.\.  On  .\pril  10  he  had 
fever,  headache  and  pain  in  the  back.  12th:  Krujition  of  variola';  ]>atieiit  very  feeble,  (iave  etfervi-seing  draught: 
tamariiut-water;  beef-tea.  lltli:  Kxtreme  thirst :  unable  to  rise  from  bed.  (Jjive  citric  acid  water;  applied  calamine 
ointment.  ir)th  :  No  passage  from  bowels  for  two  <1ays;  weaker;  ])nstules  no  fuller  than  on  the  12th.  (iavi'  .S'idlitz 
powder  with  a  double  allowance  of  Hochclle  salt ;  milk-puiu-h  ;  Dover's  powder  at  night.  18th:  Pustules  umbilieated. 
some  of  an  unusually  large  size.  20th:  Secondary  fever;  delirium;  scrotum  swollen  an<l  glistening,  (iave  :i  lotion 
of  acetate  of  lead.  21st :  Scrotum  as  large  as  an  infant's  head,  its  under  jiort  ion  gangrenous.  The  patient  was  rational 
for  a  few  hours  on  this  day.     lie  died  at  10  f.  M. — IIokjiHhI,  .liiiuijwlis  JiduHhii,  M<I. 

C.VSK  7.— Private  William  T.  HIackwell,  Co.  (',  Kith  Me.,  w:is  received  April  0.  18111.  fi(im  lielle  l>]v.  Va..  "  beie 
he  had  been  im]>risoned  since  his  cai)ture  at  (Jettysbnrg,  .Inly  1, 18(!;i.  He  w:is  emaciateil  and  weak,  having  lost  foity- 
live  pounds  of  l)ody-weight  during  his  captivity.  He  had  siill'ered  from  eongh,  with  thii'k  oli'ensive  sputa.  After 
having  complained  of  i>ain  in  the  hea<l  and  back  for  several  days  he  liecame  feverish  and  a  papular  eruption  ai)peared 
on  his  lace  and  lufnds  on  the  Kith.  Gave  effervescing  draught,  inilk-i>unch  ami  gargh^  of  chlorate  of  potash.  lOth: 
Eruption  fully  out,  confluent:  no  fever;  iiaticnf  s<i  weak  as  to  be  unable  to  talk  above  a  whisjier.  Apjilied  oxide  of 
zinc  ointment.  20tli :  Dyspniea.  21st:  Dyspiuea  ineri'asing;  expectoration  s(:inty;  tongne  dry:  li])S  black  ami 
parched:  sordes  on  teeth:  has  refused  everything  lint  milk-pniu'h  for  three  days.  "Added  syru]i  of  sipiill  to  tri'at- 
ment  and  Dover's liowder  at  night.  22d:  Kespiration  and  exi>eetoration  improved.  'l'o(d<  milk-|iuncli  and  soft  boile  I 
egg.  24th:  Eruption  on  face  drying  uji:  :irnis  and  leg.s  swollen :  no  itihing;  |iuslnlis  livid  at  base:  respiratiiui  less 
embarrassed  but  patient  delirious,  "istli:  Gave  fluid  extract  of  cinclum:!.  :)(lth:  Cough  troublesome:  slight  diarilio^a. 
May  1:  Cough  harassing;  eight  or  feu  ofleiisive  stools  during  night;  expictoration  nincopurulent  ami  fetid. 
Gave  <if  sul]>hate  of  morphia  one  grain,  muriate  of  ammonia,  powdered  acacia  and  whit<'  sugarof  each  halfan  ounce, 
syrup  of  S(]nill  two  ounces  and  water  six  ounces, — a  te;ispoonl'ul  t^vcry  six  hours;  also  tincture  of  opium  and  tincture 
of  rhubarb  of  each  one  ounce,  tincture  of  c:itecliu  aiul  compcniml  spirit  of  lavender  of  each  two  oiiiu'cs, — to  taki'  a 
teaspoonful  every  six  hours.  2d:  Swelling  of  arms  subsiding;  skin  itching  and  des(|Uanuiting:  on  each  ;irm  were 
two  dark-colored  and  boggy  patches  which,  on  tlu^  right,  had  run  intoeach  other.  Applied  simple  cerate  to  the  limbs. 
4th:  Patient  weaker;  patches  on  arms  becoming  white  in  centre.  Ai)plied  lotiim  of  ]iermangaiiate  of  ))otash.  (ith: 
Constantly  delirious.  8th:  Sloughs  of  skin  and  cellular  tissue  removed  from  the  arms.  Otli:  Kational  at  times  but 
unable  to  speak.     Died  at  10  A,  M. — Uospital,  Jiimqiolis  JkiicIUiii.  Mil. 

Casi-;  8. — Private  Ezekiel  Pounders,  Co.  E,  Clth  III.;  age  21 :  was  admittrd  Nov.  20, 18(11,  from  hospital  at  (amp 
Butler, 111.,  where  he  had  a  history  of  erysipelas,  ]uieumonia  :ind  iihthisieal  tendency.  On  ,Ian.  Ill,  18(1.'>,  lie  liucame 
art'ected  with  modified  small-pox,  and  died  Kebruary  8  (d'  laryngitis.  I'ntil  twenty-four  hours  before  death  there 
was  no  reason  to  apprehend  a  fatal  result. — IInKpititJ,  (Jitinvij.  III. 

Cask  9. — Private  Nathan  Clingan,  Co.  A,  12.'')th  111.;  age  22;  was  .admitted  Dec.  2.  lS(i;i,  from  hospital  at  Louis- 
ville, Ky.,  with  ail  abscess  in  the  ischio-rectal  space,  whieli  breaking  left  an  iiKMimidete  external  fistula.  While 
under  treatment  for  this  he,  on  the  27tli  had  a  chill,  followed  by  fever  and  pain  in  the  back  and  limbs,  apjiarently 
indicating  an  attack  of  varioloid.  At  this  time,  the  jiaticnt  had  (Ui  his  arm  two  fully-formed  scabs  from  re  vaeci  nation 
after  his  admission  into  hospital.  On  the  29th  the  eruption  ajipeared  on  the  face  and  the  febrile  symptoms  became 
relieved.  Next  day  he  was  sent  to  the  small-pox  hospital.  The  symptoms  were  not  violent  nor  was  the  eruption 
confluent,  but  the  patient  was  depressed.  On  January  5,  181)1,  congestion  of  the  lungs  was  indicated  by  increasing 
dyspiuea.    Death  took  place  on  the  8tli. — lloainlal,  IJuincij,  III. 

In  auotlier  case  it  is  claiineil  that  successful  vaccinatiuu  taildl  to  }'i'otect  against  a  sub- 
sequent exposure  to  sniall-pox;  but  the  sej^anttiou  of  the  vaccine  crust,  which  is  instanced 
in  proof  of  the  success  of  tlie  vaccination,  occurreil  at  so  etu'ly  day  as  to  suggest  a'douljt 
concerning  its  true  character. 


632  TiiK  Er.ri'TivK  feveks. 

I'livati'  Jdsciili  T.  liatus.  Co.  K.  I'ltliX.  .E:  ai;e  2'A:  was  ailiiiitrod  Dec.  IS,  ISlil'.  with  cliiouic  vliciiiuati.siii,  from 
wliicli  III'  had  partially  looovori'il  wlicii.  on  .'an.  11.  Isi;:;,  lu-  was  takfu  witli  an  acnte  attack  of  articular  rlienina- 
tisni.  On  the  llith.  l»-in,u'  i'onsi<loralily  rclii'vrd  iVoni  pain,  he  was  vaeeiiiated  ah)ng  with  the  other  inmates  of  the 
ward.  He  I'ontinned  to  improve  in  health.  The  \  irus  tocik  Avell  in  his  ease  :nid  in  seven  other  ease.s.  He  was  exposed 
to  small-pox  two  or  three  days  afti'r  vaeeination.  On  tlie  "JSth  he  was  taki'n  witli  all  the  premonitory  symptoms  of 
the  disease,  and  on  Fehruary  1  was  sent  to  the  small-pox  Iiosjiital.  The  seven  otlier  sneeessful  cases  had  a  similar 
exposure  to  the  variidons  poison  luit  have  tints  far  escapeil.  That  the  ea--e  was  one  of  successful  vaeeination  there 
is  not  the  least  doubt,  the  scali  fallin<j;  otf  on  the  lirst  day  of  the  attack.' — Sattcfli'c  HoKjiital,  rkihuldphiu,  Pa. 

Pnsf-iiiort'.'id  appoaraiicos  were  iiote<l  in  the  two  casrs  wliicli  follow: 

Cask  1. — Private  Henry  C.  Thunnaii.  Co.  C.  Gth  Iowa:  age  2(1:  was  admitted  Feb.  4,  1865,  with  coryza,  cough 
and  slight  fever.  Dtiring  his  stay  in  hospital  he  had  some  ohseure  symptoms  whiel'.  culminated  in  a  chill  followed 
!iy  suppurati<m  in  tlu'  glands  of  the  left  groin.  These  were  ojien  and  discharging  when,  on  April  1,  he  complained 
of  great  pain  in  the  hack  and  loins.  An  eruption  ajipeared  on  his  forehead  oti  the  10th  and  spread  during  the  next 
two  days  over  his  abdomen,  back,  legs  and  arms:  his  i)ulso  Avas  accelerated  and  weak;  stomach  irritable  and  general 
condition  low.  On  the  11th  there  was  epistaxis  and  vomiting  of  blood,  sordes  on  the  teeth  and  increased  fieiiuency 
of  pulse.  loO.  He  died  next  day,  the  vomiting  continuing  to  the  last;  Mood  was  passed  from  the  bladder  shortly 
before  death,  rosl-mni-tem  examination  fifteen  hours  after  death :  Rigor  mortis  slight ;  cellular  tissues  full  of  serum ; 
eruption  slightly  nmbilicated.  The  lungs  were  congested  posteriorly.  The  heart  was  flabby,  its  right  side  and  large 
ve.ssels  tilled  with  liqtiid  blood  and  some  soft  and  reddish-brown  clots.  The  liver  and  spleen  were  softened.  The 
solitary  follicles  were  prominent  and  on  puncture  exuded  a  wUitisli  serum;  those  near  the  ileo-ca'cal  valve  presented 
a  distinct  black  spot  in  a  central  depression.  The  kidneys  appeared  normal  but  the  bladder  was  filled  with  blooil. — 
DoiiyJas  Hospital,  Wushinytoiu  I).  C. 

Case  2. — Private  Oliver  Conkling,  Co.  H,  1st  X.  J.  Admitted  I"eb.  15,  1863.  Diagnosis:  small-pox.  Died  on 
the  ITth.  ront-mortcm  examination  iive  hours  after  death:  Xo  rigor  mortis;  age  about  25;  body  completely  covered 
with  pits.  About  half  an  ounce  of  pus  was  found  under  the  arachnoid  on  the  left  side,  and  this  membrane  appeared 
thick,  white  aiid  opaque  over  the  pons  Varolii.  The  bronchial  tubes  and  parenchyma  of  the  posterior  parts  of  the 
lungs  were  congested.  The  heart  w-as  firm  and  contained  white  fibrinous  clots  in  all  its  cavities.  The  liver  weighed 
ninety-four  and  a  half  ounces  and  was  firm  and  mottled  :  the  gall-bladder  contained  scarcely  a  drachm  of  dark  bile ; 
the  spleen  was  flabby  and  light-colored.  The  stomach  was  slightly  contracted:  the  duodenum  congested  and  its 
mucous  membrane  thinned:  the  jejunum  healthy:  the  valves  of  the  ileum  were  thin  and  in  some  places  nearly 
destroyed, its  solitary  follicles  slightly  enlarged  and  its  agminated  glands  somewhat  congested  in  tlio  upper  third;  the 
large  intestine  was  dilated.  The  kidneys  weighed  each  eight  and  a  half  ounces  and  were  dark  and  firm;  the  left 
contained  a  small  cyst. — Liiuoln  Ifosjiitiil,  Wasliliifjiuii.  1).  C. 

Iieterence.';  to  sinall-|iox  in  special  sanitarv  rojiorts  ai'e  of  rai'o  occurrence. 

Siirijton  W.  W.  liiiow.v,  ~th  X.  If.,  Si.  Aiignstiiie.  Fin.,  Hay  1,  1863.— We  were  obliged  to  keep  our  suuill-pox 
patients  in  tents  on  the  island  (Tortugas).  exjiosed  to  the  rays  of  a  hot  sun  during  the  day  and  to  the  heavy  dews 
which  were  always  present  during  the  night.  Xo  doubt  the  fatality  was  much  greater  than  it  would  have  been  under 
more  favorable  circunistances  and  in  a  co<der  climate.  In  the  treatment  the  supporting  plan  is  the  only  judicious 
one.  During  the  tilling  of  the  pustules,  in  all  severe  cases,  the  drain  from  the  system  is  so  great  as  to  cause  serious 
apprehension  of  the  sinkingof  the  patient  from  exhaustion  :  dtiring  the  stage  of  maturation  he  needs  an  abundant  and 
nourishing  diet,  with  a  liberal  allowance  of  good  wine,  ale,  porter  or  brandy.  This  disease,  when  uneomidicated, 
requires  no  medication  except  an  occasional  anodyne  to  allay  nervous  irritation  aixd  procure  rest. 

Snryeon  Allex  F.  PecIv,  lni  X.  M.  Moitiitcil  Voh,,  Fort  Stanton,  Xi'W  ilcxico,  Dec.  31,  1862.— The  idea  occurred 
to  uie  that  if  the  initiatory  fever  could  be  sulidueil  it  might  iiossibly  have  the  eftect  of  lessening  the  subsequent  erup- 
tion. I  therefore  resolved  to  treat  the  cases  with  tonics  from  the  commencement  and  cut  short  the  fever  if  possible. 
Twelve  cases  were  treated ;  but  of  this  number  only  four  were  seen  at  the  beginning  of  the  attack.  The  first  patient 
I  saw  had  suffered  from  a  confluent  eruption  for  many  days  before  he  was  brought  in,  so  that  I  had  no  opiiortnnity  to 
test  the  method  in  his  case,  which  terminated  fatally.  The  secoml  was  seen  about  two  hours  after  the  commencement 
of  the  fever:  he  was  surtcring  from  intense  pain  in  the  head,  back  and  extremities;  very  high  fever;  pulse  strong, 
full  and  frequent;  skin  hot  and  dry:  tongue  slightly  coated  and  bowels  confined.  I  at  once  gave  him  fifteen  grains 
each  of  sulphate  of  qiiinia  and  compound  extract  of  colocyntli.  In  the  evening  he  was  free  from  both  fever  and  pain. 
At  this  time  there  was  no  appearance  of  eruption,  nor  was  it  devehqied  until  nearly  twenty-fotir  hours  later.  As  the 
eruption  advanced  I  gave  small  doses  of  quinine  and  a  cayenne  gargle,  with  good  nourishment.  The  case  progressed 
favorably.  This  treatment  was  adopted  in  the  three  other  cases  and  similar  results  followed;  it  was  used  also  in  the 
cases  that  were  not  seen  at  their  inception. — a  numlier  of  these  were  conlluent  but  all  progres.sed  favorably. 

M'dical  InnptctorT.  H.  Ha.mii.tox,  C  S.  J.,  Xaslirille,  Tcnn.,  April  30,  1863. — Erysijielas,  alisces.ses  and  mumps 
are  conunon  secpiehe  of  variola,  an<l  the  two  former  complications  often  prove  fatal. 


*  Asii't  j^urgf'on  T.  C.  Wall.^ce,  9:M  X.  Y.,  lia'3  nx-nrded — Ainerirait*HIeiIiati  Thm't',  IV,  X.  Y.,  1S»)2,  p.  12*2 — tlie  ca.se  of  a  imui  in  hi:*  cuiiuiiaiul  who, 
altlunigh  sUowin-r  the  ^i-ars  of  two  sur-co?sfnI  vai-ciut.'  cperatioiis  iK-rfuniii-tl  in  chililtiuod  and  a^aiii  in  Is.'.S,  was  t^ncceK-sfully  rrvai'cinated  lirr.  24,  lsi;t. 
Til"  vi--i.l..  wii-  fully  f  iniifHl,  larirf  aud  wt-ll  filU'd  ;  yi-t  ua  .Ian.  S,  1-Sia,  hiirh  foTor  was  dwol.iiifil  and  twi.  ilaya  latm-  tlie  luitieiit  wa.s  covered  with  the 
erni'tion  of  variola.  The  matter  used  iu  his  ca.^e  came  from  the  Eastt-rn  Dispensary,  Xew  Y'ork  I'ity,  n:i>\  \Va<  perfectly  {rood,  as  shuwii  Ijy  its  effects  on 
other  memtx-rs  of  this  man's  cjmiiany. 


SMALL-FOX. 


633 


Siiyi/eon  Thomas  M.  Cook,  10U(  'ihio.  luar  iliirj'rccslioro,  Tiiiii..  J<iii.  V2.  IsiS. — Into  a  solution  of  tlie  virus 
(lip  the  enil  of  a  double  thread  already  in  a  coiuniou  sewing  or  suri;eon".s  needle,  and  introduce  the  needle  as  deep  as 
the  cutis  vera,  drawing  it  through  till  the  part  wet  with  the  virus  comes  into  the  wound,  in  wliieh  it  is  left  to  admit 
of  alisorption.  The  irritation  of  its  jirescnce  increases  the  circulation  to  the  ]iart  as  wi'll  as  alisorption  from  it.  Tliis 
made  tlie  virus  ett'ective  in  many  cases  which  had  previously  resisted  the  connnon  modes  of  Insertion. 

Cii.\i;lk.'5  p.  LfTE.  Act.  Ass't  Sitrricon.  l<iitlerlir  Hospital.  I'liiJaiMphui,  I'd. — On  Dec.  :.'0.  IKiil',  a  case  of  small- 
pox occurred  in  my  ward.  Headache,  pain  in  the  back,  high  fever  and  sore  tliroat  were  followed  on  the  'SM\  liy  the 
eruption.  I  vaccinated  the  patient  along  with  83  others  present  in  the  ward.  The  virus  from  a  primary  vaccination 
was  used  and  not,  as  I  fear  is  too  frequently  the  case,  that  of  a  revaccination,  wliiidi  should  never  he  u.sed.  The 
small-pox  case  was  removed  from  my  ward.  I  believe  his  vaccination  was  unsuccessful.  Of  the  remaining  (<:>  lases 
li  primary  vaccinations  and  14  revaccinations  were  successful.  Twelve  of  the  successful  revaccinations  occurred  in 
men  who  presented  well-marked  scars  of  the  primary  operation.  From  this  it  will  be  seen  that  revaccination  is 
essential,  and  that  the  existence  of  a  genuine  vaccination  scar  is  not  a  sutlicient  guarautei'  against  sniall-jiox.  None  of 
the  inmates  of  the  ward  contracted  small-jiox  from  the  eas<^  in  (jnestion. 

Surgeon  Ezii.v  Re.\I),  21.f(  Iiid..  Locii.it  Point,  near  BiiUiinorr,  Md.,  Oct.  7,  ISIil. — ( )ne  ease  of  variola  occurred  during 
the  month,  contracted  from  exposure  while  on  detached  duty  at  Washington.  At  the  time  the  patient  came  into 
hospital  it  was  not  known  that  he  had  been  exposed  to  the  contagion  of  variola,  and  conseciiiently  no  precautionary 
measures  were  adopted.  Nausea,  vomiting,  i)ain  in  the  head  and  other  i>remonitory  symjitonis  were  not  siitlicieiitly 
pronounced  to  arrest  attention  or  indicate  the  characler  of  the  disease:  and  as  the  wanls  of  the  hospital  were  much 
crowded  at  the  time,  he  was  a.ssigned  a  bed  in  the  main  hall  leading  to  all  the  wards,  where  he  remained  during  the 
febrile  stage  and  until  the  appearance  of  the  eruption  removed  all  doubt  eoneerning  the  nature  of  the  easi'.  In  this 
location  he  was  constantly  passed  by  convah'scents,  hospital  atli'udauts  and  visitors,  most  of  whom  were  unproti'Ctcd 
by  vaccination.  After  that  he  was  removed  to  a  separate  room  in  tin'  hospital,  where  he  remained  for  thirty-six 
hours;  thence  to  a  tent  in  a  secluded  sjiot  and  subsei|Ueiilly  to  the  .Marine  hospiliil  on  t hi' opposit inside  of  the  I'atapsco 
river.     He  is  now  convalescing  and  thought  to  be  out  of  danger. 

It  is  an  interesting  fact  that  nooiie  thus  cxjiosed  to  the  di.sea.so  was  infected.  This  may  be  regarded  as  indicat- 
ing the  absence  of  contagious  ([ualities  dnring  tlie  stage  of  jiyrexia  and  iuciiilent  eruption." 

Tekatment. — -Tlie  vvcdixl.-^  of  tlio  (rciitnu'Ut.  <<{'  .<iii;ill-|i(ix  arc  iiioa^ri'.  In  iiiiM  ca.'^os 
little  was  done  otlier  tliau  to  [H'otcct  tlio  jialicnl  iVmii  iniiiriuus  inlliiciu'cs.  Laxatives,  salines 
ami  I)over's  powder  were  geiicrallv  used  dumiij;  tin'  [icriud  <it'  pyrf.xia.  with  toiiies,  stimu- 
lants and  concentrated  nourishment  after  the  sulisidi'iiee  of  th.'  seccindarv  feVer.  SnriifMii 
J).  \y.  HaM),  U.  S.  Vols.,  reported  iVom  Xew  IJeriie,  N.  ( '..  in  ISdl,  that  tli''  Sarrai-i  nut 
purpurccA.  wliieh  grew  in  great  ahundance  in  the  vieinitv,  had  hecn  I'ailhtnlly  trird  dui'ing 
a  period  of  two  months,  and  that  no  luaielii-ial  ell'ect  ennld  he  aserihed  to  iis  iise.  Some 
external  ajiplieations  were  emploved  te'  allav  entaneous  irritation  and  provi.nt  snbseipieiit 
pitting.  Generally  these  consisted  of  cooling  or  astringent  ointments;  civasote  in  olive  oil 
and  iodine  in  glycerine  were  also  used  for  this  pui'pose.  Intercurrent  laryngitis,  pneiimiuiia. 
erysipelas,  abscesses  and  gangrenous  sloughs  wei-e  treated  on  general  principles,  having  in 
view  the  condition  of  the  patient's  .system  as  well  as  that  of  the  allected  tissnc^s. 

Joiix  E.  McGirk,  of  Latrobe,  111.,  in  a  communication,  Aug.  21,  lS'):'>,  inviteil  the 
attention  of  the  Surgeon  General  to  the  success  which  attended  his  use  of  chlorate  of  potash 
in  preventing  snlFocation  during  the  maturation  of  small-pox.  This  suliject  having  been 
referred  for  iuvestication  and  rei>ort  U>  Act.  Ass't  SurL'con  II.  I.  Thomas,  in  i-harjie  of  the 
small-pox  hospital  at  AVashington,  D.  C,  the  following  was  rendered: 

I  have  found  great  diliiculty  in  ati'ordiug  relief  to  the  symptoms  of  snllbcatiou  during  the  maturative  stage  of 
the  disease  arising  from  the  presence  and  formation  of  pustules  on  the  tongue,  (dieid<s  and  faucesof  the  ])atient.  For 
this  unpleasant  and  dangerous  condition  I  have  been  in  the  habit  of  using  the  chlorate  of  potash  as  a  gargle,  with 
no  precaution  against  swallowing  it.  I  have  at  the  same  tiu\e  given  it  internally  in  eight-grain  doses  every  four 
hours.  In  every  case  I  have  directed  the  free  use  of  lemonade,  and  when  the  )iatient  iircfeired  it,  I  have  ordered  a 
lemon,  which  has  been  sucked  with  apparent  .satisfaction.  The  result  of  this  treatment  has  been  to  atVord  relief  in 
almost  every  case. 

I  am  not  prepared  to  ascribe  prophylactic  powers  to  the  chlorate  of  iiotash  in  the  treatment  of  the  kind  of  cases 
referred  to  by  Dr.  McOlUU.     It  has  been  undoubtedly  beneticial  taken  internally  iu  small-pox  when  the  patient  hail 


*  Surgeon  S.vXFOBn  B.  Ilixi,  V.  S.  Vols.,  is  reiiurtMl  hy  Dr.  El.l.^il.v  Habeis,  in  liis  artiile  liii  Vai'cinatiim,  ['.  .S.  ^inilarii  Commimoii  Memoir;  p. 
119,  n.«  li.iviiis:  written,— "Small-iiox  is  uut  contagriims  in  it-  early  stasris.  If  tin'  i«tient  l>e  seelnil.'il  at  th.'  earliest  i^rioil  when  the  iliseasp  can  lie  recog- 
nized by  the  scieBtiflc  eye,  another  ami  .an  nnjin.tecteil  y^rfu  can  sl.-.|.  iu  th'-  ^a^lc  h.  il'lin;;  with  vry  little  'langir.  We  have  j,-en  this  testeil  'in  a 
large  scale."' 

Med.  Hist.,  Pt.  Ill— 80 


634 


THE    ERL'PTIVK    FEVEES. 


been  previously  reduced  to  a  low  condition  by  other  causes,  as  rheumatism,  typhoid  fever  and  dysentery;  but  -n-liilo 
such  has  been  the  case,  1  have  been  compelled  by  the  urgency  of  the  symptoms  to  resort  to  the  frequent  use  of  the 
probang,  moistened  with  a  strong  solution  of  nitrate  of  silver,  for  tlie  purpofse  of  removing  tlie  accumulated  and 
tenacious  mucus  which  immediately  endangered  life  and  whicli  tlie  patient  himself  was  unable  to  remove, — this 
state  of  things  occurring  frecjuently  when  the  chlorate  of  potash  had  been  used  internally  as  al)ove  stated. 

The  result  of  my  observation  of  the  elhciency  of  this  salt  has  led  me  to  the  conclusion  that,  like  saline  cathartics 
and  stimulants,  it  is  a  reliable  adjuvant  in  the  treatment  of  small-pox  and  nothing  more, 

UXTOWAED  RESULTS  OF  ATTEMPTED  VACCINATION. 

The  ijreseuce  of  small-pox  among  the  troops  raised  a  demand  for  vaccine  virus  which 
was  sujiplied  in  the  iorm  of  crusts  by  the  niedical  dispensaries  in  the  Xorthern  cities.  This 
stock  was  wholly  from  infants,  and  each  crust  was  accompanied  by  a  certificate  bearing  the 
name  of  the  dispensary,  that  of  the  child  from  whom  it  was  procured  and  the  date  of  its 
removal.  A  small  percentage  of  the  virus  used  was  furnished  by  Dr.  Ephraim  Cuttek  of 
Massachusetts,  who  raised  crusts  from  the  calf  by  vaccinating  with  humanized  virus. 

Dr.  Ct'TTEK,  indeed,  appears  to  have  claimed  that  some  of  his  crusts  ■were  projiagations  from  the  natural  or 
spontaneous  cow-pox.  The  following  report  of  an  insiiection  by  Surgeon  J,  J,  MILH.4.U,  U.  S.  A.,  April  4,  1865, 
describes  the  methods  by  which  the  animal  virus  was  procured: 

I  reached  'Woburn,  Mass.,  March  30.  and  called  upon  Epiir.vim  Ci'TTer,  M.  D.,  who  expressed  his  readiness  to 
aftbrd  me  every  focility  for  investigating  the  subject.  As  luy  visit  was  entirely  unexpected  there  was  no  opportunity 
to  make  iireparations  that  might  have  given  me  wrong  impressions.  I  accompanied  him  in  his  rounds  and  visited 
stables  iu  Lexington,  Lincoln,  Xorth  AVol>urn,  Jamaica  Plains  and  Brookline,  personally  inspecting  the  condition 
of  over  fifty  head  of  cattle:  twenty-nine,  mostly  cows,  had  been  vaccinated  and  the  loosened  crusts  were  collected 
l)y  Dr.  C.  in  my  presence,  after  which  I  assisted  him  in  vaccinating  fifteen  other  cows.  All  the  cattle  vaccinated  were 
of  good  stock  and  healthy  appearance,  well  fed  and  kept  iu  clean,  dry,  well-ventilated  barns. 

The  "natural  spontaneous  kine-pock"  occurs  but  seldom  in  the  cows  of  that  district  of  country.  Occasionally 
the  doctor's  attention  has  l)eeu  called  to  vesicular  eruptions  on  the  teats  of  cows  with  their  second  or  third  calf:  he  has 
vaccinated  other  cows  with  the  virus  taken  from  these  vesicles,  but,  until  recently,  he  lias  failed  in  producing  the 
vaccine  disease  in  this  way.  He  is  led  to  believe  that  cows  are  subject  to  eruptions  on  the  teats  which  are  not  always 
kine-iiox.  or  that  the  vesicles  are  liroken  in  milking  and  rendered  too  imperfect  to  communicate  the  disease.  The  virus 
which  he  has  been  using  in  vaccinating  cattle  for  the  propagation  of  crusts  was  originally  taken  from  a  child. 

Some  three  weeks  ago  Mr,  Jewett,  a  tarmer  near  Lexington,  not  iced  a  vesicle  on  the  teat  of  one  of  his  cows  with 
her  third  calf.  Dr.  Cutteu  being  informed  of  it  took  virus  from  the  vesicle  and  introduced  it  into  another  cow,  pro- 
ducing a  characteristic  vaccine  vesicle,  and  with  the  lymph  from  this  second  cow  Mr,  Jewett  and  a  heifer  were  vacci- 
nated, I  saw  them  both.  The  farmer  had  two  tine  vaccine  vesicles  on  the  arm  and  complained  of  a  little  constitu- 
tional disturbance;  he  had  been  vaccinated  in  early  life.  The  heifer  had  a  characteristic  scab  nearly  ready  to  be 
detached,  I  tliiuk  there  is  no  room  to  doubt  that  this  was  actually  the  line-^wck.  The  original  cow  with  the  scar 
on  the  teat,  the  second  cow  with  a  fresh  cicatrix  and  the  heifer  with  the  scab  were  all  in  the  same  stable  at  the  time 
of  my  visit. 

Early  iu  March  Dr.  Cuttei;  found  a  case  of  spontaneous  cow-pox  in  a  cow  with  her  second  calf;  the  virus  was 
tested  by  vaccinating  two  cows  on  Tuft's  farm  in  Lexington  and  obtaining  characteristic  vesicles  and  scabs,  I 
enclose  herewith  a  specimen  crust  of  the  natural  and  spontaneous  cow-pox.  I  examined  twelve  cows  that  had  been 
vaccinated  with  this  matter,  and  the  crusts  on  them  had  the  same  appearance  as  that  on  the  heifer  above  referred  to, 
and  did  not  ditfer  from  those  on  the  cattle  vaccinated  with  the  virus  reproduced  from  the  child. 

As  the  doctor  now  expects  to  furnish  crusts  produced  by  matter  from  the  ''natural  and  spontaneous  "  cow-pox, 
I  recommend  that  he  should  put  them  up  separately  and  mark  them  so  that  they  may  be  known  to  the  department : 
and  I  resjiectfully  suggest  that  when  received  they  may  be  issued  to  such  otliccrs  as  will  give  them  a  fair  trial  and 
report  the  result. 

Iu  vaccinatiag  tlie  kine  Dr.  Cutter  uses  the  lymph  taken  on  the  eighth  day,  or  the  crust  collected  on  the 
twelfth  or  tliirteenth  day  and  rubbed  down  with  a  little  water  to  the  consistency  of  cream.  He  objects  to  glycerine 
because  a  physician  in  his  neighborhood  had  the  misfortune  to  spread  phlegmonous  erysipelas  among  the  patients  he 
vaccinated,  a  result  which  was  attributed  to  some  chemical  change  in  the  glycerine.  In  selectingmatter  for  propaga- 
tion he  is  necessarily  very  careful,  as  he  holds  himself  responsible  to  farmers  for  the  value  of  the  cattle  should  they 
be  injured  iu  the  oi)eration; — this  I  considered  a  good  guarantee  for  the  purity  of  the  virus  used,  particularly  as  the 
farmers  are  not  entirely  free  from  prejudice  on  the  subject. 

In  vaccinating,  tifty  to  seventy-five  insertions  of  virus  are  made  in  the  hairless  spaces  under  the  tail,  about  the 
perrnicumand  in  the  commissure  between  the  hind  legs;  but  more  than  half  of  these  fail  to  take,  A  cow  with  seventy- 
five  puuctures  will  iirobably  not  give  more  than  fifteen  or  twenty  perfect  crusts ;  indeed,  in  some  cases  I  .saw  but  four 
or  five  good  scabs.  About  2  per  cent,  of  all  the  kine  vaccinated  refuse  to  take  the  disease,  being  probably  protected 
by  having  had  the  natural  pock.  The  crusts,  which  are  fully  formed  and  ready  to  be  collected  on  the  twelfth  or 
thirteeutli  day,  fall  otf  by  the  fourteenth,     'The  scabs  vary  much  in  size  not  only  in  diti'ercnt  animals  but  in  the  same 


.<MAi.i.-pox.  635 

imUviilual.  In  collecting  the  crusts  such  as  are  perfectly  formed  are  taken  ;  those  that  have  been  rul>hed  or  scratched 
show  a  peculiar  lustre  and  are  rejected:  hence  to  obtain  a  number  of  j;ood  crusts  vaccination  should  be  performed 
during  the  season  of  the  year  when  the  cattle  are  kept  tjuiet  in  stables  and  are  not  annoyed  by  insects.  Each  crust 
is  put  u]i  in  wax;  this  is  a  nice  operation,  as  the  heat  used  to  cause  adhesion  must  be  so  moderate  as  not  to  injure 
the  virus.     A  tin  canister  filled  with  water  of  the  jiroper  temperature  answers  the  purjyosc. 

Lymph  is  collected  on  the  eighth  day  by  means  of  a  capillary  glass  tube  which  is  afterwards  hermetically  sealed. 

In  conclusion  I  would  state  that  Dr.  Cutter  devotes  mncli  of  his  time  and  attention  to  the  subject,  ami  per- 
sonally attends  to  all  the  details;  the  only  assistance  he  receives  is  from  his  wife  in  putting  nj)  the  crusts. 

Aliout  a  year  later,  in  April,  1806.  a  circular  was  issued  from  the  Oftice  of  the  .Surgeon  General,  l'.  .S.  Army. 
requesting  information  on  the  extent  to  Avhich  vaccination  had  been  practiced  during  the  jirevious  six  months,  the 
source  or  sources  of  the  virus  used,  and  an  expression  of  opinion  as  to  the  relative  value  of  liovine  and  humanized 
virus  as  well  in  their  protective  intlueuce  as  in  the  degree  of  constitutional  disturbance  produced  by  each.  lJe]iorts 
were  filed  by  one  hundred  and  four  medical  officers,  but  the  evidence  obtained,  particularly  that  bearing  on  the  relative 
value  of  the  humanized  and  bovine  nnitter,  was  by  no  means  conuuensurato  with  the  number  of  witnesses.  J-^iifht 
medical  otficers  stated  definitely  their  want  of  exjierience  of  matter  derived  from  the  cow ;  seven ty-f our  gave  no  opinion 
on  the  relative  merits  of  the  two  kinds  of  vaccine  crusts;  flcren  preferred  matter  from  kine;  nine  from  num.  and  two 
had  no  predilection.  Threeof  those  who  preferred  the  bovine  vaccine  acknowledged  at  the  same  time  that  the  prefer- 
ence was  not  based  on  personal  experience;  and  few  of  the  others  who  expressed  a  similar  jireferenee  could  be  saiil 
to  have  had  a  large  experience.  Surgeon  Joil.x  K.  Simmkiis.  I'.  S.  A.,  was  i>erliai>s  the  only  exception.  While  medical 
inspector  in  1803-1)5  he  paid  attention  to  this  subji'ct,  and  grounded  his  preference  on  the  fact  that  sloughing  ulci'r- 
ations  and  glandular  supi)urations  had  never  been  iu  his  ex]ierii'nce  traced  to  the  usi'  of  matter  from  the  cow.  Of  the 
nine  otlHcers  who  preferred  humanized  matter  not  one  appears  to  have  had  more  than  a  few  cases  of  vaccination  with 
the  cow-crnst:  thus.  Act.  Ass't  Surgeon  R.  II.  I.oxiavil.l,,  Fort  Wingate,  \ew  Mexico,  who  objected  to  the  virus  from 
the  co^v  on  account  of  the  severity  of  the  local  and  constitutional  elVects,  liad  used  it  in  only  three  cases.  The  two 
officers  who  had  no  predilection  appear  to  have  b.a.sed  this  opinion  on  the  utter  worthlessncss  of  the  tested  crusts 
whether  said  to  have  been  derived  from  the  cow  or  from  man.  In  fact  the  majority  of  these  reports  indicate  a  want 
of  success  in  vaccinating:  eleven  only  sjieak  of  a  reasonable  amount  of  success  attending  their  ojierations.  This 
fiiiluro  was  ascribed  by  some  to  thi^  protection  of  previous  vaccination  and  by  others  to  a  want  of  activity  in  the 
matter.  Those  who  arraigned  the  (|uality  of  the  matter  did  soon  account  of  subse(|ueut  successful  vaccination  with 
matter  from  ])riviite  sources;  or.  in  a  i'vv,'  cases,  on  account  of  the  subseciuent  occurrence  of  small-]iox  iu  tluisi'  who 
had  been  subjected  to  the  operation.  Ass't  Surgeon  ('.  C.  (illAY,  U.  S.  A.,  w  ho  ilistributed  both  kinds  of  crusts  from 
the  office  of  the  Assistant  Surgeon  (ieneral,  consideri'd  th:it  the  results  in  both  cases  were  e(|Ually  unsatisfactory. 
He  was  of  opinion  that  much  of  tin-  kine  virus  used  was  si>urious.  Ass't  Suri;eou  ('.  I!.  WiiiTK.  l'.  S.  A.,  who.  as 
acting  iue<llcal  ]iurveyor.  distriliuted  virus  from  Xew  Orleans,  La.,  regarded  that  from  kino  as  less  etlicienl,  perhaps 
on  account  of  want  of  care  iu  putting  it  uji. 

In  till-'  Kask'i'ii  iiriulcs  during  tin;  Wiir  u<>  luid  I'lfoct  followcil  tin'  ii-cneral  u»'  nt'  these 
Itumanized  or  bovine  erupts;  ami,  aecording  ti»  Snrgeun  Sankokh  !'>.  IItnt,  I  .  S.  Vols., 
vaccination  in  over  l(i.(,)00  cases  in  tlie  Nnrtliern  l^(>|iai'tini'nt  jir('Ve(l  liarinl<'ss  or  eilective. 
But  in  .some  of  tlio  "Western  l)ejiartnients  tlirre  ueeurriM]  uncxjioctcil  and  untoward  I'esults, 
wliich  were  aseribed  )iv  some  tiljservers  to  a  scurlnitic  or  otherwise  impaired  roiahtion  of 
system  and  bv  otliers  to  an  imjnirity  iu  tlie  virus,  its  contamination  with  tlie  jioisnu  of 
syphilis  having  even  been  asserted. 

Medical  Insjudor  X.  S.  Towxshkxd.  U.  S.  ./.,  Loidnrilli,  Kti.,  Mi'i/'J.  IMII.— \'aciiuatiou  iiad  in  a  majority  of 
the  regiments  been  thoroughly  iierformed,  but  eitln'r  from  the  bad  character  of  tlu'  virus  or  tlu-  comlitioii  of  the  mm 
the  sores  proved  to  be  exceedingly  troublesome. 

Surgeon  C.  Ali.ex,  1st  J/o.,  Port  //«(/•■•()«.  La.,  I'eh.  L'l.  ISiil. —  Those  men  of  tlic  command  not  previously  vacci- 
nated were  vaccinated  at  Benton  Barracks  iu  the  month  of  January,  1801,  w  Ith  virus  obtainnl  from  the  meilical  juir- 
veyor  at  St.  Louis.  In  at  least  one-hali'  the  cases  a  phlegmon  of  greater  or  less  size  w  as  developed  instead  of  the 
characteristic  vesicles;  some  are  still  sutlcring  from  these  irregular  iiillaimuatory  results. 

Surgeon  W.  H.  UitiMES.  \3th  Kaiimis,  Fori  Smith,  Jrk.,  Augunl,  18()1. — Owing  to  some  iieculiarity  of  constitution 
or  climate,  or  from  lilthy  habits,  a  great  many  citizens  of  this  part  of  Arkansas  ate  alllicted  with  obstinate  diseases 
of  the  skin.  Many  of  them  have  a  kind  of  scabies  or  itch  of  an  aggravated  character  which  hat!  affected  then;  for 
years:  others  have  scaly  eruptions  on  different  parts  of  the  body;  others  again  have  old  indolent  ulcers  or  eruptive 
diseases  of  an  anomalous  character.  On  the  advent  of  our  troop.s  many  of  these  persons  were  sufi'ering  from  Avhat 
they  called  kine-pock,  having  been  vaccinated  Ijy  some  surgeon  for  that  disease.  Whether  the  surgeon  who  vacci- 
nated them  used  the  genuine  vaccine  virus  or  the  old  .skin  diseases  so  modified  the  vaccination  as  to  change  its  char- 
acter I  am  unable  to  determine.  The  result  of  this  vaccination  or  rather  inoculation  was  in  many  cases  a  violent 
erysipelatous  inllammation  with  deep  abscesses,  destioying  the  subcutaneous  tissues  and  burrowing  under  the  nniscles 
of  the  parts  affected,  producing  serious  constitutional  disturbance.  Nor  w  as  the  site  <if  the  inoculation  alone  affected  ; 
the  disease  showed  itself  in  other  parts  with  the  same  violence.     Active  antiphlogistic  treatment  usually  subdued 


636  TH1-:    ERUPTIVK    FF.VEKS. 

the  iiirlnmiiiatioii.  leaviiii;  t'oul  and  ill-coiulitionod  sores,  wliii-h  ri'sistfd  almost  every  nictliod  of  treariiioiit  to'.'  luontlis. 
A  few  ot'thosi'  tlius  alllieted  lieeaiiu'  crippled  in  their  arms. 

ifaiiy  oftlie  men  ot'tliis  rogimeiir.  witlumt  ronsultins^  the  surgeon,  had  themselves  inoculateil  with  tin'  matter 
of  tliese  nuiii'.cscript  sores.  TIio  eon.^ennenoe  is  that  all  who  have  lieeu  thus  inoculated  have  been  unfit  for  lUity  for 
Weeks  and  months.  When  the  disease  did  not  utiect  the  deeper  tissues  it  spread  over  the  surface.  i)roducing  ulcers 
whicli  in  appearance  and  character  very  uiueli  resenildfd  chancres.  Iiideeil,  so  completely  did  they  till  the  charac- 
teristics of  this  disease  that  several  surgeons  did  not  hesitate  to  say  that  tlie  patients  had  been  inoculated  with  syphilis. 

Larye  aiul  iinliealtliv  ulcers,  with  swellino-  anJ  .-uppunttioii  ot'  tlie  axilhin'  glaiuls, 
observfil  in  .~onie  ot'  the  regunciits  sorviua'  in  the  Prpaittncnt  ol'  the  CuntberhiuJ  in  June, 
1S63,  were  ascribfil  l.w  ]\[cMlical  Tnspci;tt;)r  F.  H.  ILvmiltox  to  the  existence  ol'  a  scorbutic 
taint.'-'  In  the  autumn  ot'  the  sani<>  war  similar  results  followril  vaccination  in  the  encamp- 
ments arounJ  St.  Louis,  ^[u.:  but  in  some  ot  these,  as  in  the  9th  Iowa  Cav..  the  men  were 
in  viu-orous  health  and  i'r^e  from  scurvy.  Surgeon  In.v  Kussell,  U.  S.  Vols.,  reported  as 
follows  concernino-  the  results  ni  attemptei]  vaccination  in  the  war^ls  uf  the  hosjiital.  Bentcju 
Barracks,  ^[o.: 

About  the  middle  of  December.  ISiio.  the  patients  were  vaccinated  in  tlie  following  luaiiiier:  The  surgeon  in 
charge  directed  Dr.  IvLtiiER,  the  acting  assistant  surgeon  hi  charge  of  Ward  E,  to  vacciuatc  the  patients  of  his  ward 
from  the  arm  of  a  patient  who  appeared  to  have  at  that  time — the  eighth  day  from  his  vaccination — a  genuine  vac- 
cine vesicle.  The  duty  was  performed  as  ordered  and  tlie  vesicle  was  excessively  drained.  Next  day  the  same  man 
was  ordered  into  another  ward  for  similar  service,  with  his  then  irritated  arm.  and  all  the  occupants  of  that  ward 
received  a  charge  in  their  arms  of  what  was  i^resuiued  to  Tic  vaccine  lymph.  On  the  third  day  the  same  man  was 
taken  into  another  ward  and  lent  his  intlaiued  and  now  purulent  vaccine  sore  to  the  jiatients  there.  This  was  the 
tenth  day  after  his  vaccination.  In  successive  days  he  was  still  kejit  moving  through  the  remaining  wards  for  the 
same  unfortunate  service  to  his  comrades. 

Xo  bad  result  followed  the  vaccinations  in  Ward  E.  ami,  as  subsequent  imiuiries  proved,  no  abnormal  result 
was  produced  in  any  arm  except  in  the  men  who  received  inoculation  from  the  iiurulent  matter  which  the  constantly- 
teased  vesicle  and  sore  supplied  after  fifty  or  more  arms  had  been  vaccinated.  The  greater  part  of  all  who  were  vac- 
cinated after  the  first  day,  or  the  eighth  of  the  stock  vesicle,  sutfercd  much  from  local  intlamniation,  obstinate  ulcer- 
ations and  lymphatic  inllammations  and  swellings.  Suppuration  frequently  ensued  in  the  axillarj-  region,  anil  in 
some  instances  there  were  severe  constitntioual  symjitoms  resembling  those  of  py;emia.  Ecthymatous  eruptions 
appeared  upon  the  vaccinated  arm  and  chsewherc.  and  when  that  class  of  pustules  degenerated  into  open  sores  the 
edges  were  ragged  and  the  ulcerations  were  exceedingly  olistiuate.  These  characteristics  led  several  of  the  surgeons 
to  conclude  that  the  morbid  plienonu'ua  were  attributable  to  syphilitic  inoculation. 

Shortly  after  the  uccurrence  of  the  events  thus  recorded  small-pox  spread  through  the 
wards  of  this  hospital,  and  while  it  spared  all  the  inmates  of  AVhird  E,  where  the  first  day's 
work  of  vticcination  hail  lii.'en  pcrtbrmeil,  thu  other  patients — even  those  worst  scarred  and 
ulcerated  l)V  tht-ir  recent  inoculation — became  atTcctud  and  were  transferred  to  the  small-pox 
hospital.     Dr.  Elisiia  IlAKrj.s  has  published  several  of  the  cases  that  occuri'ed  at  this  time.f 

The  cases  of  spurious  vaccination  in  the  Departm.i-nt  of  Arkansas  in  1S61  were  derived 
from  the  outbreak  at  St.  Louis,  Mu.      ^Medical  Director  Joseph  II.  Smith  tlius  refers  to  them : 

The  vaccine  virus  furnished  to  the  army  was  very  unsatisfactory  in  its  results.  Very  many  vaccinations  were 
unsuccessful,  and  some  produced  siuirious  sores  followed  by  constitutional  eli'ects.  The  first  eases  of  spurious  vacci- 
nation coming  under  my  notice  oceuned  in  the  i>ersous  of  recruits  vaccinated  at  ISenton  Barracks  and  arriving  in 
this  department  in  May.  .Soon  after,  however,  vaccinations  made  in  the  regiments  in  the  department  were  followeil 
by  evil  results,  viz:  Ulcers  at  the  seat  of  inoculation  and  its  vicinity  varying  in  size  from  that  of  a  dime  to  that  of  a 
dollar,  difficult  to  heal,  with  hardened  edges  and  resembling,  except  in  size,  the  indurated  syphilitic  sore.  After  one 
or  two  months  these  ulcers  were  followed  by  constitutional  etfects,  sometimes  glandular  enlargements,  always  debility 
and  symptoms  of  a  general  cachexia. 

I  wa.s  at  first  of  the  opinion,  from  the  aiipearance  of  the  sores,  that  they  were  the  result  of  syphilitic  inocula- 
tion. Further  observation,  however,  failed  to  confirm  this  oiiinion.  The  history  of  the  cases  was  not  in  detail  the 
history  of  syphilis,  nor  was  the  amenaliility  to  treatment  identical;  mercury  was  far  from  being  a  specilic,  and  in  my 
observation  the  most  successful  treatment  consiste4l  in  the  use  of  iron,  iiarticularly  in  the  form  of  iodide.  Iodide 
of  potassium  failed  to  cure,  tlunigh  in  combination  with  iodide  of  iron  it  seemed  to  accelerate  and  add  to  the  effects 
of  the  latter.  In  some  cases  change  of  scene  and  air  almie  seemed  to  have  the  desired  efi'ect,  and  cases  that  resisted 
all  treatment  here  speedily  recovered  on  returning  to  their  homes. 

Owiiio-  to  tlie  reported  .-yphilitic  character  of  the  vaccination  sores  at  Benton  Barracks 

"  Iu,f'-".  IMgi.'  Will.  ■'■Ill  lii-  papiT  I'll  Vtiir'iuiith.ii  ;„  II,,-  .I.-.,.;;,  in  tlic  r.  S.  S,:ii:i,iri,  '  V,i„„/;.«;,oi  tf.  ,«..»■,  ]'\k  1  1"-Hs. 


SMALL-POX.  637 

u  coniinitteo.  Avitli  I>i-.  Hammei:  ut'i~^t.  Louis  as  cliainnai],  was  ap])ointed  to  investigate  their 
nature.      The  anoiualous  resuhs  were  not  reLrarJed  as  due  to  the  ini'eetion  ot'  svphilis. 

Diirinj;  tlie  proijres.s  of  the  iiivesti^ritiou  iiuiiiy  rases  were  examined — more  than  200:  they  were  Ntrijiped  and 
examined  tlioronghly  and  uote-s  taken  in  eacli  ca.se.  .Siireadinj;  and  indnrated  sores  existi'il  in  all ;  tint  none  had  any 
symiitoni  of  secondary  syidiilis.  The  only  abnormal  condition  was  swelling  with  indnration  of  the  axillary  glands. 
Ill  .secondary  syi)hilis  the  glands  are  indnrated  Imt  seldom  sni>pnrate.  The  sores  existed  in  two  forms. — aliscess  and 
eczema.  The  latter  is  a  disease  easily  prodnoed:  in  sonic  individuals  slight  causes  will  occasion  its  development. 
The  committee  concluded,  from  the  examination,  that  the  condition  of  the  patients  was  produced  principally  hy 
irregular  and  improper  vaccination  and  exercise.  Many  of  the  soldiers  vaceiuati-d  themselves,  using  for  the  purpose 
rusty  pins,  irregular  incisions,  etc.,  and  while  the  vaccination  was  progressing  they  went  to  drill,  exercising  the 
arms.  Eighty  to  one  hundred  negroes  under  the  charge  of  Dr.  Ri(_a;  were  atfected  in  the  same  way:  they  werestout 
and  healthy,  hut  the  undershirts  with  which  they  were  supplied  were  too  narrow  for  the  arms  and  kept  uj)  irritation 
hy  friction.  The  treatmi'ut  in  these  ca.ses  was  simply  to  cut  the  undershirts  and  use  lead-walc-r;  in  eight  ilays  the 
.sores  were  healed  ;  vet  these  cases  had  lieen  ]ironounced  sy]>hilitic.  Many  of  the  ca.ses  examined  had  heen  placed 
under  specific  treatment:  this  was  ordered  to  be  discontinued  and  all  got  well,* 

Ass't  Surgeon  Georok  0.  Smith,  53d  Ilh,  rejwrti'd  the  oeeurreiuv  in  Deecinber,  I860, 
of  thii-ty-one  cases  of  vaccination  presenting  unusual  cliaractei's  at  Convalescent  Camp. 
Fourth  Division,  Seventeenth  Army  Corps,  Hebron,  ]\Iiss.  The  virus  was  taken  from  the 
arm  of  a  man  of  dissipated  habits.  The  ulcerations  on  the  arm  tuul  forearm  liad  the  appear- 
ance of  chancres;  small,  hard,  red  ]timples  were  observed  on  the  face  and  back :  the  axillarv 
glands  sujjpurated,  and  most  of  the  cases  were  aflected  with  intlammation  of  the  conjunctival 
and  Sehneiderian  membranes. f 

Surgeon  Ottkksox,  V.  S.  Vols,,  recorded  anoinalou.s  results  in  the  18th  Ind.ij;  Three 
hundred  men  were  vaccinated  from  the  crust  of  a  tanlv  and  irregular  revaccination  on  the 
arm  of  a  convalescent,  from  typhoid  fever  .and  pneiunonia.  This  man,  subse([neiit  to  th(> 
removal  of  liis  crust,  had  some  rheumatic  trouble  and  loss  of  power  in  liis  arms,  but  no 
cutaneous  disease.  Eighty  of  the  men  in  whom  this  undesirable  matter  was  implanted 
suflPered,  after  several  weeks  of  latency,  with  ulcei-s  of  the  arm,  congestion  of  the  t'auces  and 
painful  afilections  of  the  joints  and  l.iones.  T>v.  Ottkrsox  attributed  these  results  to  svphilitic 
inoculation,  and  in  explanation  assumed  that  the  typhoid  convalescent  was  suO'ering  fmm 
chancre  while  his  revaccination  was  in  iiroirress;  but,  as  the  recriment.  dui'iiiLr  the  two  mmiths 
succeeding  its  vaccination,  marclied  three  liundred  miles  in  rainv  weatlun-and  throusih  mud 
and  swollen  streams,  sore  throat  aial  rheumatic  afi'ections  might  luive  resulti'd  from  tiiese 
exposures,  while  the  deteriorated  condition  of  the  men  might  be  helil  to  ticcount  for  local 
manifestations  following  the  insertion  of  a  non-svphilitic  Ijut  morbific  matter. 

Surgeon  Gkoege  H.  Hubbard,  U.  S.  Vols.,  Medical  Director,  Armv  of  the  Frontier, 
reported,  November,  1863,  the  disablement  of  about  five  hundred  men,  mostlv  belonging 
to  the  1st  Ark.,  by  virus  taken  from  the  arm  of  a  deserter  from  the  Rebel  armv.  A  Board, 
convened  to  investigate  the  nature  of  the  inoculated  disease,  reported  tliat — 

Soon  after  the  ojieration  was  performed  the  points  at  which  the  matter  was  inserted  commenced  to  itch  and 
inflame,  and  by  the  second  or  third  day  jinstnlcs  were  formed  of  a  yellowish  color,  which  rapidly  increased  in  size 
and  in  a  few  days  burst.  In  some  a  scab  formed,  but  in  all,  by  the  tenth  day,  ojieu  ulcers  yielding  a  thin  ichorous 
discharge,  Avere  developed. 

At  the  time  we  examined  the  patients  some  had  well-marked  Ilnnterian  cliancre:  some  had  large  excavated 
ulcers  with  elevated  edges,  but  with  little  surrounding  induration, — the  centres,  when  not  recently  cauterized,  were 
of  a  brownish  hue: — some,  whose  primaiy  ulcers  were  about  he.aled,  had  secondary  symptoms,  such  as  swelling  and 
ulceration  of  the  glands  in  dift'erent  parts  of  the  body,  wliile  others  had  pain  and  stiffening  of  tho  joints. 

The  disease  was  brought  to  the  1st  Ark.  Vols,  by  deserters  from  the  oiieiny,  and  in  our  opinion  it  is  syidiilis. 

Dr.  HuBBAET)  concurred  in  the  opinion  of  the  Doard,  ami  repurted  as  follows: 

I  have  no  reason  to  believe  that  in  any  oni'  case  did   this  virus  )vroduce  a   true  vaccine  ]Mistnle  or  had  any  of 


*  Set*  liiwimoii  oil  Vifcuiathii,  St.  Louis  ?Itiliral  Sticictv,  ,s/.  Lonii  Mfiltntl  mid  Sin-ijiriiJ  .hiininl.  It,  lSr,."i,  \i.  :V2.S. 
t  Chivago  Mf'tHtitl  Kxniimwr,  V,  IS'Vt,  p.  21 S.  \  Aimrifmi  ^tl■lIi'•,ll  Tim^i^,  VI,  X»-w  Ytirli,  ISf^l,  ji.  207. 


638  THE  eeuptivf:  fevek?. 

the  protecting  powfr  of  vaccination.  Tlio  ulcers  all  possessed,  in  a  j;reater  or  less  degree,  the  well-estahlished  pecu- 
liarities of  venereal  chancre,  beinjj;  of  a  specific  and  progressive  nature,  spreadin*;  in  some  cases  to  the  size  of  a  dollar, 
liut  generally  about  half  that  size;  conniumly  round  in  shape,  but  often  irregular  and  usually  of  the  depth  of  the  true 
skin.  All  had  ragged,  elevated,  indurated  and  overhanging  edges,  little  sensitive  to  the  touch  or  even  to  caustics, 
while  the  bottom  of  the  ulcer  (especially  under  these  indurated  edges)  was  excessively  sensitive.  All  discharged 
dark  ill-conditioned  pus,  which  in  nuiny  cases  caused  painful  excoriatiou  of  the  surrounding  skin,  aud  when  trans- 
ferred to  other  jiarts  of  the  body  reprodiu-ed  ulcers  like  the  origiual;  in  this  way  chancres  were  developed  on  the 
penis  in  several  cases. 

Cases  precisely  similar  occurred  in  the  Indian  Brigade  staticuied  at  Fort  Gibson  in  the  Cherokee  nation.  Act. 
Ass't  Surgeon  Miller,  on  duty  at  that  juist,  reported  as  follows: — -A  private  of  the  1st  Indian  Home  Guards,  who  had 
been  successfully  vaccinated  by  nie  in  March,  1803.  and  afterwards  taken  prisoner  by  the  rebels,  was,  in  spite  of  his 
protestations,  inoculated  by  a  rebel  surgeon,  producing  a  syphilitic  ulcer.  Private  Johnson,  of  the  same  regiment, 
who  had  previously  had  sniall-pox,  was  inoculated,  at  his  own  request,  with  the  same  virus,  and  his  ulcer  presents 
the  same  characteristics,  except  in  extent,  as  those  not  so  protected. 

Moreover,  these  ulcerations  have  spread  anuing  the  people  to  an  alarming  extent  by  self-inoculation.  In  a  large 
proportion  of  the  cases  consecutive  symptoms  have  appeared,. — suppuration  of  the  lymphatic  glands  in  the  axilla, 
sore  throat,  exanthematous  eruptions,  &c.  The  cases  occurring  among  the  troops  have  received  the  ordinary  treat- 
ment for  syphilis  and  generally  with  excellent  results. 

The  mischief  was  widespread  before  the  true  character  of  the  disease  was  recognized,  so  that  few  cases  have 
had  prompt  abortive  treatment,  and  many  are,  in  consequence,  permanently  disabled.  Nearly  every  case  has  required 
constitutional  treatment  in  addition  to  local  treatment  of  the  chancre.  The  milder  caustic  applications  proving 
insufficient  in  many  cases,  acid  nitrate  of  mercury  was  used  to  clear  away  the  indurated  edges,  when  the  ulcer  usually 
healed  rapidly  under  mildly  stimulating  applications. 

But  ■\vhen  these  cases  are  considered  in  connection  with  those  at  Benton  Barracks,  and 
particularly  with  those  common  at  that  period  in  the  South,  some  hesitation  is  naturally  felt 
in  pronouncing  them  to  have  been  of  a  syphilitic  nature. 

Untoward  results  of  vaccination  appear  to  have  been  at  one  period  the  rule  rather 
than  the  exception  among  civilians  as  well  as  soldiers  within  the  Confederate  lines, — so  much 
so  that  for  some  time  after  the  war  the  people,  and  in  some  instances  even  physicians,  mani- 
fested a  fear  of  resorting  to  this  protective  measure.'"  The  subject  was  investigated  by  a 
number  of  medical  officers  whose  reports  were  unfortunately  destroyed  at  the  capture  of 
Richmond,  but  mucli  valuable  material  has  been  preserved  in  journal  articles  published  since 
the  war  by  JoxES,  Habeesham,  Geeexe,  Gilmoke,  Stout,  Bolton,  Ramsay  and  FuQUA.f 

When  small-pox  broke  out  in  the  Army  of  Xorthern  Virginia  at  Fredericksburg,  Va., 
in  1862-63,  a,  general  vaccination  was  ordered.  In  its  progress  the  number  of  cases  of 
spurious  vaccinia  became  alarming  as  affecting  the  strength  of  the  army.  It  was  reported 
by  General  Lee's  Inspector  General  that  when  the  battle  of  Chancellorsville  was  fought  in 
Mav,  1863,  as  rnanv  as  5,000  men  were  untit  for  dutv  because  of  disability  arising  from 
vaccination.  Xumbers  of  these  wore  sent  to  general  hospital;  many  of  the  lighter  cases, 
retained  with  their  regiments,  continued  in  a  disabled  condition  for  several  weeks,  the  ulcera- 
tions wdiicli  followed  the  insertion  of  the  virus  showing  no  disposition  to  heal.  Surgeon 
Ethekidge  of  Dale's  Brigade,  reported  332  cases.  Inflanmiation  began  within  twenty- 
four  hours  after  inoculation;  a  vesicle  appeared  in  two  or  three  davs,  but  in  some  instances 

*Wm.  a.  Greene,  in  his  paiu-r  citt-il  in  iipxt  imti-,  says:  "'lu  the  large  citU-s  provinioii  is  niuile  fur  tlic  vjicciiiatinu  of  the  iuhahitaiits.  hut  in  tlic 
smaller  citit-fi  ami  village?  aud  in  the  coiintry  tht-re  is  uot  only  no  such  provision  made  l»ut  the  jit'ople,  and  iu  mauy  iur-tances  the  jihysit-ian,  uiatiifest  a 
total  difrrM),:ard  fur,  and  even  fear  of,  api)lying  this  only  Huru  preventive  of  tlie  cli.sease.  It  is  not  unetmiinnn  to  lioar  pcoph'  Siiy,  ^vlu-n  urged  to  lie  var- 
cinat«-d.  that  tliey  "iin-fer  ■•niall-pi:>x  to  the  ri.'^k  <<f  vani  nation  with  spurious  matter';  aud  tliey  refer  y<iu,  perhaps,  to  our  soldiers,  who  suffered  so  much 
from  vaccination  ;  and  that  they  knew  such  an  one  who  had  contracted  small-i'ox  when  vaccination  had  jiroduced  a  ti-ewaulous  mre!" 

f  Researches  vpon  '^^Sjmrions  Vaccination,''''  or  the  Ahiwrmal  Phenomena  accompautfiitg  and  fvUoirintf  Vuc-inntion  in  the  Confederate  Amit/ <lnri}uj  the  recent 
Ameriam  Ciiil  War,  1861-€o ;  by  Joseph  Jose^,  yttthriUe  Jnnrnal  of  Medicine  aud  f>iirgert/,  X.  S.,  Vol.  II,  p.  1.  Report  on  Spurious  Vaccination  in  the  Confed- 
erate Annt/,  hy  S.  E.  Habersham,  formerly  Surgeon  in  the  Provisional  Army  of  the  Confederate  States. — Southern  MeditHd  and  Surgical  Journal,  Thinl 
Series,  Vol.  I,  .\upusta,  Ga.,  l^Gfj-CT,  p.  1.  Vaccinatii-n  and  its  Re»uhi',  hy  Wm.  A.  Greene,  of  Aniericus.  <;a.,  Atlanta  Medical  and  Surgical  Jonnial,  VIII, 
18*57-08,  p.  ;;41.  Simrious  Vaccination  in  the  Confederate  Sf'def  Anntj,  hy  .T.  T.  Gilmore,  Mohih',  .\Ia.  (formerly  sur^retpu  C.  S.  A.) — St.  Louis  Medicid  Reporter. 
Ill,  ISViS,  J).  4ilo.  'hitUues  of  the  Hilton/  of  Variolous  luondation  and  Vnccimdinn,  irith  retnitrki>.  ^'y  ^.  II.  Stoit,  Athinta  Medicul  and  Surgical  Journal,  Vol.  VII. 
18fit;-fi7,  \i.  I.  Sjiurinns  Vaccination  in  the  Coiifedfrute  Stat'S  ,lrm,'/,  hy  James  Boltox^  Xashrillc  Jiairnal  of  M'-dirine  and  Snrgerif,  N.  S.,  Vol.  II,  p.  277.  Abiinr- 
malilies  of  Vaccltiaiion.  by  Frask  a.  Ramsay,  formerly  Medical  Director  C.  S.  A.— Medical  and  Surgival  Monthly,  I,  Memphis,  Teiin.,  l^iOO,  p.  110.  On  the 
Commuuicahditg  'f  Sifi>hihshy  Vuccimdion,  by  Wm.  M.  Fvqva,  Ajiponiattox  County.  Va. — Ri'hmund  MaUcal  Jnnnoil.  I,  IsCf,,  jt.  5f)3. 


SMALL-POX.  639 

the  eruption  was  pustular  from  the  first.  The  ulcers  which  resulted  closely  resembled  the 
Huuteriaii  cliancre.  After  several  successive  scabs  granulation  took  place  and  jnu'plish 
cicatrices  were  formed.  Two  hundred  and  twenty-seven  cases  occurred  in  the  44t]i  Ga.; 
tlie  virus  which  occasioned  these  was  derived  trom  a  man  who  stated  that  he  had  been  vac- 
cinated from  his  wife's  arm  wliile  at  home  on  furlougli.  The  cases  in  the  12th  Ga.,  and 
most  of  those  in  the  21st,  originated  in  virus  furnished  hy  the  44tli.  The  popular  impression 
that  these  sores  were  due  to  syphilitic  inoculation  was  not  entertained  by  the  medical 
officers  who  treated  them.  Cold-water  applications,  with  the  occasional  use  of  nitrate  of 
silver,  yielded  the  best  results;  antisyphilitic  treatment  failed  entirely,  having  served  to 
prolong  rather  than  cure  the  disease.  Secondary  R3'raptoms  were  not  observed.  Xor  did 
these  officers  consider  that  scurvy  was  concerned  in  the  production  of  tlie  anomalous  results. 
There  was  some  tendency  to  scurvy  in  the  army,  but  no  connection  could  be  traced  between 
these  sores  and  the  scorbutic  condition;  the  subjects  were  generally  in  robust  and  vigorous 
health,  many  having  just  returned  from  furlough.  The  evidence  indicates  as  the  cause  of 
the  ulcerations  an  inoculation  with  animal  matter  which  was  noitlicr  syphilitic  nor  vaccinal, 
but  derived  from  a  degeneration  of  the  latter.  In  nineteen  out  of  twentv  ca.ses  the  matter 
was  taken  from  the  arm  of  a  comrade  by  some  soldier  or  officer  irrcs|>ective  of  the  period  after 
vaccination.  ]\ratter  was  often  taken  from  beneath  a  scab;  and  large  sores  were  in  request 
by  the  men,  in  the  belief  that  the  size  of  the  sore  was  a  measure  of  the  protection  alTorded 
against  small-pox. 

The  Chimborazo  hospital,  Division  No.  2,  Kichmond,  Va.,  was  appointed  to  receive 
cases  of  this  kind  that  might  be  sent  for  treatment  from  the  field,  and  its  medical  officers 
were  called  upon  to  investigate  and  report  upon  their  nature.  Home  of  the  records  of  this 
hospital  have  been  preserved,  and  among  them  arc  found  the  following  cases: 

1. — /'.  Daiidson.  K,  lOlh  Gii.:  age  17  niut  in  good  licaltli:  wiis  vaocin.atpd  from  the  arm  of  another  man  Kili.  I.'i, 
l*i(i3,  l).v  Ass't  Snrgeon  W'nKiiiT.  His  arm  became  very  sore  and  in  a  week  wa.s  nseless,  continuing  so  until  lie  entered 
this  hospital.  May  12.  There  were  four  elevated  reddened  sears  about  an  ineli  a])art  on  the  right  arm:  the  axillary 
glands  were  enhirged;  lie  liad  diarrhoea  and  his  g<Mieral  health  w;is  had;  he  had  no  syphilitic  taint.  He  was  given 
one  grain  of  opium,  live  of  iodide  of  potassium  and  one  drachm  of  syrup  of  sarsajiarilla  three  times  daily,  liy  ,)uly 
8  his  diarrhd'a  had  subsided,  but  as  he  was  exceedingly  debilitated  iron  and  (iniiiine  were  given.  Hi'  was  returned 
to  duty  August  G. 

2. — J.  S.  Alford,  E.  10th  Ga.;  age  33;  had  good  health  until  March  1,  ISO;),  when  hi"  was  vaccinated  by  a  friend 
from  the  arm  of  a  soldier.  In  three  days  his  arm  became  sore  and  continued  unhealed  until  his  ndmission,  July  23. 
There  was  an  indolent  ulcer  one  and  a  half  inches  in  diameter  at  the  jioint  of  vaccination,  and  several  cicatrices  on 
the  left  breast;  his  general  health  was  good.  He  was  given  acetate  of  zinc  as  a  wash;  vegetable  diet,  with  meat 
once  daily.     He  was  returned  to  duty  August  IG. 

3. — E.  Daridson,E,  IQth  Ga.;  age  18;  was  vaccinated  March  1.  1KG3.  About  a  week  later  the  arm  beianie  very 
sore  and  remained  so  until  his  admission,  Jnne  5.  He  imjiroved  till  the  2!itli,  when,  having  voliinteeri'd  with  others 
to  defend  the  city  from  the  enemy's  expected  attack,  the  marching  to  which  he  was  subjected  caused  a  relai)se,  and 
a  co]>ious  eruption  appeared  upon  the  body  similar  to  that  upon  the  arm.  Full  vegetable  diet  was  given.  On  .July 
8  abies  excelsa  was  given  three  times  daily.  He  improved.  Diarrhu-a.  on  the  28th,  was  treated  with  subnitrate  of 
bismuth  and  tannic  acid.     By  August  8  he  was  convalescent ;  on  the  1.5th  a  furlough  was  granted  for  forty-live  days. 

-1. — G.  L.  Young,  K,  XGth  Ga.:  age  20;  was  in  good  health  when  vaccinated  in  April,  18G3.  His  arm  became  sore 
in  about  a  week  and  remained  so  until  .lune  1."),  when  the  eruption  ilisa])peared.  .Simultaneously,  however,  an  erup- 
tion appeared  upon  the  left  leg.  At  this  time  he  was  admitted  with  ehronie  diarrhn>a.  Cod-liver  oil  was  administered. 
On  August  8  the  characteristic  eruption  of  rupia  appeared.     He  was  transferred  to  Camp  Winder  on  tlie  ITtli, 

5. — C.  TToUiop,  E,  20th  Ga.;  age  23;  was  vaccinated  several  times  during  tlie  winter  of  lsG2-(i3  by  the  regimental 
surgeon,  but  without  success.  He  was  admitted  to  this  hospital  March  2!l  for  continued  fever,  and  was  vaccinated 
April  10  on  the  left  arm.  When  returned  to  duty  on  the  2.5th  he  had  a  small  scar  on  his  arm.  The  virus  was  taken 
from  a  scddier  who  had  chronic  diarrhiea.  About  the  middle  of  May  Wolliop  contracted  diarrhiea,  for  which  he  was 
admitted  June  IG,  He  was  emaciated  and  amende  and  his  arm  was  very  sore:  at  the  point  of  vaccination  there  were 
two  large  elevated  scabs,  discharging  pus,  and  a  large  secondary  scab  upon  his  forearm.  He  was  given  iodide  of 
jiotassium  fivt>  grains,  syrup  of  sarsaparillaone  drachm  and  subnitrate  of  bismuth  ten  grains  three  times  daily,  with 


640  THK  KRUPTIVK  FKVERS. 

full  (lift.  On  the  ISth  ho  w;is  given  svnip  ot  iodiile  of  iron,  ten  drops  in  \v;iter,  three  times  daily.  [The  dispo.sitioi: 
of  tliis  case  is  not  stated.] 

G. — J.  T.  2'Iiiinnaii.  C,  21.-/  Ga.:  age  20  and  in  good  condition;  was  vaccinated  ilarch  3.  1S63,  liy  a  medical  stu- 
dent, from  a  scali.  He  stated  that  every  man  vaccinated  from  this  scab  sntl'ered  with  a  sore  arm  similar  to  his  t)wn, 
and  that  nearly  the  whole  regiment  was  affected.  He  was  admitted  July  :!  convalescing  from  fever  and  diarrha-a. 
There  was  a  large  dark  elevated  scab  about  twelve  lines  in  diameter.  The  usual  treatment  was  prescribed.  He 
improved.     On  the  2Sth  vitiligo  appeared.     He  continued  to  improve  and  on  August  IG  was  returned  to  duty. 

7. — JcDiu's  If.  PuttiUo,  K,  '22il  Ga.:  age  i!f<  and  subject  to  diarrhiea  :  was  vaccinated  March  20, 1863,  in  the  left  fore- 
arm from  a  recent  pnstnle  on  the  arm  of  another  soldier.  A  pustule  appeared,  which  soon  became  an  ulcer.  In  May 
other  pustules  were  developed  on  the  arm  and  continued  to  discharge  until  July  10,  when  they  began  to  dry  nj).  He 
was  adnutted  on  the  2Uth  with  chronic  diarrluea  :  the  eruption  was  nearly  well.  He  was  given  subnitrate  of  bismuth 
ten  grains  and  opium  oue-half  grain  in  a  little  water  three  times  daily,  with  farinaceous  diet, — fried  bacon  once  daily 
and  a  soft-boiled  egg  at  dinner.     He  improved  and  was  transferred  to  Camp  Winder  August  17. 

8. — B.  F.  Adams,  G,  2Gth  Ga.;  age  10:  healthy:  was  vaccinated  April  1.  1863.  In  three  days  the  arm  became 
sore  and  remained  so  about  twenty  days,  when  it  healed.  The  sore,  ho\yever,  secondarily  affected  the  axillary  glands, 
which  discharged  pretty  freely  and  remained  open  until  he  was  admitted  to  hospital,  May  0,  with  intermittent 
fever.  The  usual  treatment  was  employed  and  full  vegetable  diet  given.  On  July  8  he  was  given  abies  excelsa  three 
times  daily.  He  imiiroved.  On  the  2-th  he  had  diarrluea  and  enlarged  inguinal  glands.  The  treatment  was  con- 
tinued.    He  was  returned  to  duty  August  12. 

9. — A.  M.  Crow,  H,  3oth  Ga.;  age  23:  was  vaccinated  about  the  middle  of  February,  1863,  at  which  time  he  was 
convalescing  from  tyi)hoid  fever.  The  arm  became  sore  and  discharged  for  four  mouths.  He  was  admitted,  Juno  7, 
with  diarrha>a.  His  arm  was  very  sore.  The  diarrhiea  imi)roved  and  the  arm  healed.  An  ulcer  formed  upon  the 
left  leg,  which  alternately  became  better  or  worse  as  the  weather  was  cold  or  warm.  The  treatment  was  as  in  pre- 
vious cases.     On  July  12  cod-liver  oil  was  prescribed.     On  September  2  he  was  transferred  to  Camp  .Jackson. 

10. — J.  jr.  Donald,  K,  Zath  Ga.;  age  22  and  in  good  health:  was  vaccinated  Feb.  1,  1863,  and  in  about  two 
weeks  the  arm  became  very  sore  and  remained  so  until  March  1.  Several  pustules  then  appeared  upon  the  right  leg, 
all  of  which  healed  by  May  1.  On  June  1,  after  much  fatigue  and  loss  of  sleep,  the  wounds  reojiened  and  remained  so 
until  he  was  admitted,  July  10,  On  August  8  he  was  given  nitrate  of  silver  ten  grains,  in  water  one  ounce,  to  use  as  a 
wash.  On  the  12th,  there  being  no  improvement,  cod-liver  oil  was  iirescribed.  On  October  5  he  was  put  upon  the 
8yru]>  tif  iodide  of  iron,  the  stomach  refusing  to  retain  the  oil.  The  condition  of  the  ulcer  had  not  improved  but  the 
patient's  general  health  was  good.  Treatment  was  continued  till  the  1.5th  without  improvement.  He  was  then 
furlonghed  for  thirty  days. 

11. — J.  Ti-oiiurliauxir,  K,iiih  Ga.;  age  31:  was  vaccinated  earlyin  March,  18G3,beingat  the  time  in  good  health. 
The  arm  became  very  sore  bitt  irltimately  healed.  About  May  3,  while  at  Chancelloisville,  the  sore  reopened.  When 
admitted,  July  20,  1863,  for  a  wound  of  the  leg  received  at  Gettysburg,  his  arm  was  still  sore.  His  general  health 
was  good.  Vegetable  diet  was  given  but  no  medical  treatment  was  required.  He  improved  and  was  returned  to 
duty  August  16.  ' 

12. — G.  A.  Ledding,  K,iith  Ga.;  age  1^:  had  good  health  >ip  to  the  time  of  vaccination,  March  1,  1863,  The 
virus  was  taken  from  the  arm  of  a  soldier.  Shortly  afterwards  his  arm  became  painful  and  a  large  scab  formed,  dried, 
fell  off  and  left  a  deep  ulcer,  A  new  scab  formed  and  fell  off,  leaving  a  running  ulcer,  and  the  process  of  scabbing 
went  on  to  the  time  of  admission,  July  4,  when  au  elevated  scab  was  found  on  the  arm  and  a  number  of  pustules  on 
the  left  shoulder  and  back.  He  was  given  iodide  of  potassium  and  syrup  of  sarsaparilla,  with  vegetable  diet.  He 
improved  and  was  returned  to  daty  August  12, 

13. — J.  A.  Tomhcrlin,  E,  A9th  Ga.:  age  20:  was  vaccinated  Feb,  1.5,  1863,  and  the  arm  became  sore  in  a  few  days; 
he  at  the  time  had  chronic  diarrhea  and  tonsilitis.  Being  attacked  with  pneumonia  the  vaccine  disease  became 
much  aggravated.  When  admitted,  June  12,  there  were  three  scars  upon  his  arm  and  one  large  pustule  on  the  left 
leg,  all  havingthe  characteristic  appearances  of  the  disease.  The  treatment  was  as  in  the  previous  cases.  The  diar- 
rhoea not  improving  by  July  9,  Fowler's  solution  iir  five-drop  doses  was  given  three  times  daily.  On  the  28tli  two 
additional  pustules  made  their  appearance.     He  was  transferred  cured  to  Camp  Winder  August  18. 

11. — A.  A.  Ireland,  I,  3(?  X.  C;  age  17:  was  vaccinated  on  the  left  forearm  Jan.  15, 18G3,  from  the  arm  of  another 
man  :  his  health  at  the  time  was  good.  After  four  days  a  pustule  was  formed,  which  assumed  a  malignant  character 
and  by  the  tenth  day  had  enlarged  to  a  diameter  of  fourteen  lines.  At  the  end  of  a  month  seven  other  similar  pus- 
tules appeared  upon  the  arm  nearer  the  body.  He  was  adnutted  June  30,  1863,  having  eight  ulcers  upon  the  left  arm 
with  dark  elevated  and  firmly  adhering  scabs.  His  general  health  was  bad  and  he  complained  of  lumbar  pains.  He 
was  given  iodide  of  potassium  and  sarsaparilla,  with  full  vegetable  diet ;  a  poultice  was  applied  to  the  arm.  He  was 
furlonghed  on  the  16th.     The  man  from  whom  Ireland  was  vaccinated  suffered  afterwards  with  malignant  pustule. 

15. — H.  21.  Smith,  A,  60th  Ga.;  age  19:  was  vaccinated  about  the  middle  of  June,  1863,  while  suffering  from 
dyspeptic  symptoms.  The  arm  became  sore  in  about  three  days.  When  admitted,  ,Iuly  5,  with  debility,  he  had  an 
indolent  nicer  at  the  seat  of  vaccination  and  pain  in  the  axillary  region.  The  usual  treatment  was  employed,  with 
full  vegetable  diet.     He  improved  and  was  returned  to  duty  August  16. 

16. — -E.  IT.  Ferree,  I,  \6th  X  C;  age  33:  was  vaccinated  Feb.  14,  1863,  from  the  arm  of  a  soldier  who  a])peared 
to  be  in  perfect  hi-alth.  Ferree  stated,  however,  that  the  soldier's  arm  becanu'  quite  sore  at  the  expiration  of  lifteen 
days.     When  admitted,  June  30,  he  was  much  emaciated  from  diarrha'a,  which  had  affected  him  from  before  the  time 


SMALL-rOX.  641 

of  T.iccination.  There  were  three  scars  on  the  left  arm  from  pustnles  and  two  recent  pustules  in  the  formative  stage  on 
the  left  elbow;  there  was  also  a  pustule  on  the  left  le;;.  Simultaneously  with  the  recent  pustules  upon  the  arm 
appeared  an  indistinct  papular  eruption  upon  the  riglit  leg.  He  stated  tliat  several  soldiers  who  liad  l>een  vaccinated 
at  the  same  time  suft'cred  in  like  manner.  Iodide  of  ]iotasinm  and  syruji  of  sarsaparilla  were  administered,  with  veg- 
etable diet.  On  July  IS  syrup  of  iodide  of  iron  was  given,  and  on  the  27tli  tlie  ulcer  of  t  lie  leg  was  washi'd  with  a  weak 
solution  of  acetate  of  zinc.  On  October.")  he  was  taking  cod-liver  oil. — the  ulcer  and  the  patient's  general  health  were 
both  improving.  Ou  the  24th  there  was  some  enlargement  of  the  lymphatics  of  the  left  arm.  He  was  returned  to 
duty  Koveniber  23. 

17. — C.r.  Grei)i,  K,  \Cilh  X.  C;  age  23:  was  in  good  health  when  vaccinated  in  February,  l?<(i3.  His  arm  con- 
tinued sore  until  April  1,  when  it  healed.  After  several  weeks  of  severe  fatigue  duty  the  erujition  reappeared  on  the 
arm  and  persisted.  While  on  the  march  to  Chancellorsville  an  eruption  api)eared  upon  the  right  leg.  On  August  S 
the  characteristic  eruption  of  rupia  occurred.  He  was  put  upon  cod-liver  oil.  liy  the  \M\  he  was  convalescent  and 
was  transferred  to  Camp  Winder. 

18. — .(.  B.  Coffee, -A,  22(1  X.  C;  age  21;  had  good  health  until  he  was  vaccinated  Feb.  1.  isti:i.  The  virus  was 
taken  from  the  arm  of  another  soldier  who  appeared  to  be  in  good  health.  Aliout  four  days  al'terwanls  the  arm 
became  inflamed  and  the  pustule  increased  in  size  to  two  inches:  tlie  scabs  which  formed  were  continually  rubbed 
off  by  the  friction  of  the  clothing.  Ten  days  later  the  axillary  glands  became  iullaiiied  and  livid  and  discharged 
a  large  quantity  of  matter.  An  abscess,  lanced  in  May,  healed  up  in  June.  When  admitted,  June  3(1,  there  were 
two  scars,  one  healing,  the  other  discharging  pus  from  beneath  the  scab.  The  jiatient's  general  appearance  was 
healthy.  Iodide  of  potassium  and  syrup  of  sarsaparilla  were  given  three  times  ilaily,  with  full  diet.  On  July  2S  the 
right  axillary  glands  were  discharging.  Iodide  of  iron  was  given,  and  on  .Viigust  lIS,  lieing  convalescent,  he  was 
transferred  to  Camp  Winder. 

19. — J.  E.  W<iih,  A,  22(1  X.  C;  age  21;  stated  that  when  an  infant  his  mother  vaccinated  him  with  a  needle 
coated  with  lymjjh  from  the  arm  of  another  child.  The  family  health  was  good,  lie  refiiseil  to  be  vaecinateil  by  the 
surgeon  of  the  regiment;  but  having  lent  his  knife  to  some  of  his  comrades  who  u.sed  it  to  cut  the  rags  binding  their 
vaccinated  arms,  and  himself  afterwards  using  it  to  open  small  pimples  on  his  leg,  ho  became  inoculated.  He  was 
admitted  June  30,  1,-^63,  with  a  declining  imi)etiginous  eruption  on  the  right  leg;  there  were  many  sears.  'I'he  muscles 
were  well  developed,  but  the  i>atient  complained  (d"  general  weakness  in  the  Joints  and  there  was  a  slight  diarrlwra. 
The  eruption  returned  during  exercise  in  warm  weather.  He  w  as  given  iodide  id'  |M)lassiiim  and  syru)i  of  s;iisaparilla. 
Ou  July  18  he  was  improving. 

20. — Lin(hay  McDoiiiIl,  T,  22<l  X.  C;  age  21;  was  vaccinated  in  .laniuiry,  lK<i;i;  the  arm  became  sore  at  once, 
and  healed  only  ou  the  approach  of  warm  weather.  When  admitted,  .June  30,  l-^()3,  there  was  a  huge  elevated  sear  at 
the  ]dace  of  vaccination  and  several  small  ones  below  it :  ho  Avas  si'orlmtic.  Chlorate  of  potash  in  leu-grain  doses 
was  given  three  times  daily,  with  vegetable  diet.  On  July  0  lemon-juice  and  a  mouth-wash  of  tincture  of  myrrh  in 
water  were  added  to  the  treatment.  Ou  August  8  the  disease  was  cured  and  the  scurvy  improving.  He  was  letnrned 
to  duty  on  the  17th. 

21. — fr.  D.  (\mln-dl,  K,\\th  Ga.;  age  22;  was  in  good  condition  until  vacciiiated  in  Fcl)rMiny,  lxti3.  A  fi'w days 
afterwards  his  arm  became  sore  and  the  axillary  glands  sw<dlen.  Ilti  was  admitted  ,)uly  2.  His  grni'ral  hi'alth  was 
then  good  and  the  sore  on  the  arm  had  healed,  liut  the  axillary  glands  discharged  ccipioiisly.  He  w-iis  ordered  io<liile 
of  ixita.ssium  five  graiiu5  and  syrup  of  sarsai>arilla  a  drachm  three  times  daily.  On  the  Mth  tincture  of  iodine  was 
applied  to  the  enlarged  glands  an<l  repeated  daily.  On  the  18th  he  was  given  the  syrup  of  ioilide  of  iron  tiv(>  drops 
ill  water  three  times  daily.  On  the  28th  the  glands  were  still  dischar>{iug  and  he  had  taken  eokl.  lUown  mixture 
was  given  with  Dover's  iiowder  at  night.     He  was  returned  to  duty  August  10. 

22. — J.  TT.  niinhi/,  11,22(1  X.  C.;  age  20;  continued  well,  but  for  some  relaxation  of  the  bowels,  until  the  last  of 
February,  18(53,  when  he  was  vaccinated.  Twenty-four  Ikmiis  afterwards  the  arm  began  to  be  jiainful  an<l  a  pustule 
was  formed  which  discharged  pus,  and  in  three  weeks  develoi)e<l  into  a  deeji  excavated  ulcer  whi(di  contiiined 
unhealed  until  the  middle  of  June.  When  admitted,  June  30,  there  was  a  dark,  slightly  elevated  scab  sixteen  lines 
in  diameter.  He  statt>d  that  the  soldier  from  whose  arm  the  virus  was  taken  sutfered  much  from  the  disease,  and 
that  when  he  left  cam])  his  arm  was  .still  very  sore.  Full  diet  was  given,  with  syrup  of  iodide  of  iron.  Ry  July  2K  he 
had  recovered  except  that  he  was  troubled  with  piles  and  diarrlnea.  He  improved  under  trcatiiient  and  was  trans- 
ferred to  Dauvillc  August  20. 

23. — T.  S.  Haighr,  A,  22(1  X.  C;  age  20;  had  good  health  until  about  the  time  he  was  vaccinated,  Feb.  1,  18G3, 
when  he  had  rheumatism.  IJy  the  15th  his  arm  was  very  sore.  On  admission,  June  3(1,  to  this  hospital  from  General 
hospital  Xo.  21,  where  ho  had  been  under  treatment  for  diarrhiea,  his  appetiti^  was  good  ami  comi)lexiou  tlorid,  but  the 
left  parotid  gland  was  enlarged  and  there  was  a  purulent  discharge  from  the  left  ear:  ten  distinct  reddish  scars  were 
clustered  around  the  place  of  vaccination  on  the  forearm  and  there  was  a  similar  scar  above  the  elbow.  He  was 
treated  with  iodide  of  potassium  and  syrup  of  sarsaparilla;  tincture  of  iodine  was  applied  to  the  enlarged  gland  and 
warm  water  injected  into  the  ear  several  times  daily.     He  was  returned  to  duty  August  1(3. 

21. — T.  M.  Karrin,  C,  23rf -V.  C;  age  23;  had  good  h<alth  until  he  was  vaccinated  from  a  crust  in  March,  1863. 
About  a  week  afterwards  erysipelatous  intlannuatiou  supervened,  with  implii'ation  of  the  axillary  glands.  In  another 
week  the  erysipelas  subsided,  leaving  three  jHistules  on  the  arm,  which  were  healing,  when,  on  April  25.  the  char- 
acteristic pustular  eruption  appeared  U])(>n  tlu'  left  leg.  Wln-n  admitted.  June  30,  the  muscuhir  system  was  well 
developed ;  there  were  three  scars  miou  the  left  arm  and  upon  the  anterior  aspect  of  the  left  lee  was  an  irritable  ulcer 
Med.  Hist..  Pt.  111—81 


642  THE    ERUPTIVE    FEVEKS. 

twelve  lines  in  iliametev,  with  an  inflammatory  areola  and  three  inijietiginons-lookinf!;  pustules.  ITe  was  treated  with 
iodide  of  potassinni  and  sarsaparilla,  a  lotion  ofsulidiate  of  zinc  and  full  diet.  On  July  8  turpentine  was  a])pliodto 
the  ulcer  and  twenty  drops  three  times  daily  were  fjiveii  internally.  On  the  18tli,  as  he  did  not  improve,  he  was 
given  the  syrup  of  iodide  of  iron  in  ten-drop  doses  in  a  little  water.     He  was  returned  to  duty  August  18. 

2."i. — /.  X  AihuHfi.  K,  S'lh  X.  C:  aire  '^'^■.  was  vaccinated  March  1,  1863,  at  which  time  he  had  a  slight  diarrlupa. 
The  virus  was  taken  from  the  arm  of  a  healthy  soldier.  In  from  four  to  six  days  a  pustule  formed  and  ulceration 
proirressed  lieueath  an  elevated  seal).  In  about  a  month  other  prrstiiles  formed  on  the  same  ariu,  which  on  healing 
left  dark  cicatrices,  but  the  prinuiry  ulcer  continued  to  discharge.  Erysipelas  set  iu  Juno  1  on  the  arm.  When 
admitted.  July  17.  his  general  health  was  not  good:  there  were  two  supptirating  ulcers  on  the  riglit  arm.  Cod-liver 
oil  was  given,  with  vegetable  diet  and  meat  once  daily.     He  was  returned  to  duty  xVugust  10. 

•J(l. — /»().  L.  I'linicr,  G,  .")//i  Vii.  I'ki-.:  age  27:  was  vaccinated  by  Ass't  Surgeon  MoSES  from  the  arm  of  a  soldier 
Tvlule  in  liosjiital  at  Farmville,  Aug.  10,  18l>3,  suffering  from  the  etfects  of  a  blow  and  from  chionic  nephritis.  He 
had  lieen  vaccinated  during  the  winter  by  Ass"t  Surgeon  ,1.  C.  Vaidex  without  eft'ect.  He  was  admitted  to  this  hos- 
pital September  5  with  2iustules  resembling  imjietigo  on  the  left  arm  and  leg:  the  pustules  ap]>eared  in  successive 
crops,  tiencrous  diet  was  prescribed,  with  cod-liver  oil.  On  the  19th  the  oil  was  discontinued  and  iodide  of  potassium 
substituted.     He  was  furloughed  on  the  23d  for  twenty  days. 

iSiu'Li-eon  S.  E.  Habersham  coiiiinunieatoi.1  the  result  of  tlie  investigation  into  this  anom- 
alous vaccinia  to  Medical  Director  Carrtxgtox  under  date  Kov.  21, 1863.  His  first  expe- 
rience of  the  diseased  condition  appears  to  have  been  oljtained  not  froin  the  Georgia  cases 
above  mentioned,  but  from  the  revaCcination  of  patients  already  in  hospital  for  other  diseases. 
In  some,  without  much  inflammatory  redness,  a,  scab  was  formed  which  left  an  indolent 
ulceration.  In  more  malignant  cases  the  pustule  became  surrounded  by  an  erysipelatous 
redness,  a  scab  formed  over  a  phagedenic  ulcer,  the  matter  from  which  aflected  other  pxtrts 
of  the  cutaneous  surface,  and  occasionally  the  axillarv  glands  became  swollen  and  suppu- 
urated.  Many  of  these  cases  were  cachectic  and  some  decidedlv  scorbutic.  Dr.  Haber- 
sham ascribed  these  results  to  the  condition  of  the  men  rather  than  to  the  quality  of  the 
inoculated  matter;  for,  to  test  this  pioint,  he  obtained  a  fresh  crust  of  known  purity  and 
efScacy  and  found  that  in  three  of  ten  cases  it  occasioned  anomalous  manifestations.  Tins 
testimony  shows  that  such  results  may  sometimes  be  referred  to  the  condition  of  the  indi- 
vidual. That  vaccinia  might  run  an  irregular  course  in  broken-down  constitutions  can 
readily  be  understood.  Cutaneous  ulcerations  as  a  result  of  inflammatory  processes  were 
to  be  expected  in  soldiers  convalescing  from  typhoid  fever,  debilitated  from  chronic  diarrhoea 
or  cachectic  from  scurvy.  But  although  these  results  occurred  in  three  of  ten  cases  under 
treatment  in  the  Chimborazo  hospital.  Surgeon  Habersham's  generalization  as  to  the  caus- 
ation of  the  sores  in  cases  of  so-called  spurious  vaccination,  must  be  regai'ded  as  inadmissible 
in  view  of  the  many  cases  on  the  Chimborazo  records  in  which  it  is  stated  in  definite  terms 
that  the  patient  was  in  good  health  at  the  time  of  his  vaccination,  and  the  equally  definite 
testimony  to  the  same  efiect  given  by  the  medical  officers  on  duty  with  the  affected  regi- 
ments. The  records  of  this  hospital  are  stronglv  oppo.sed  to  the  tlieorv  of  a  svphilitic  origin 
of  the  sores  under  consideration;  manv  of  the  cases  remained  in  view  for  a  lonii;  time  but 
no  historv  of  secondary  developments  was  recorded. 

Dr.  Habersham's  report  was  as  follows: 

I  have  the  lionor  to  inform  you  that,  in  accordance  w-itli  your  order  of  June  20,  1863,  I  have  received  all  the 
patients  sent  into  this  division  with  a  "peculiar  eruptive  disease,"  supposed  to  be  the  consequence  of  vaccination,  and 
herewith  forward  you  the  results  of  my  investigation  into  this  anomalous  affection. 

In  compliance  with  an  order  issued  from  the  Surgeon  General's  otlice  in  the  month  of  November,  18G2,  general 
vaccination  was  practiced  upon  all  soldiers  as  soon  as  they  were  admitted  into  this  division,  and  in  order  to  insure 
tlie  full  protective  intiuence  of  vaccination  (not  anticipating  any  evil  consenuences  therefrom)  the  order  was  strictly 
obeyed  and  all  the  patients,  even  those  having  recent  scars  ujion  them,  were  revaccinated.  A  few  days  after  the 
insertion  of  the  virus,  and  in  many  cases  within  twenty-four  hours,  the  seat  of  puncture  became  very  nuich  inllamed, 
with  a  deep  inflammatory  lilush  arotind  it,  whicli  gradually  implicated,  in  severe  cases,  nearly  tlie  wlude  of  the 
attected  limb.  A  pustule  rapidly  formed  instead  of  a  vesicle,  which  very  soon  discharged  an  ichorous  fluid.  T'his 
fluid  was,  in  the  course  of  forty-eight  hours,  converted  into  a  dark,  mahogany-colored,  irregularly-shaped  scab. 


SMALL-POX.  643 

prominent  and  firmly  attached  at  its  base.  A  dark-red  areola  of  several  lines  in  diameter,  ineasnring  from  the  edge 
of  the  scal>,  was  then  developed,  which  in  turn  seemed  to  exude  an  ichorous  serum.  This  was  soon  converted  into 
a  scah  surrounding  in  juxtaposition  tlie  first  and  presenting  the  ajipearaiiceof  a  single  seal).  This  process  continued 
for  several  days,  and  there  was  ot'ti'U  a  scali  one  inch  or  two  and  a  half  in  diameter.  I'mi  jxis^ii  witli  the  increase 
of  the  scab  the  erysipi-latous  lilusli  on  the  limb  diniinished,  ami  wlieii  tlie  blusli  had  diyippeared  tliis  scali  ceased 
to  enlarge.  As  this  inlhumiiatory  jjrocess  subsided  the  disi'hargo  lost  its  senius  cliaracter  and  seemi'd  to  be  eon- 
verted  into  pus,  which  exuded  from  under  the  scali,  loosening  its  lirm  attachniciit  at  its  liase,  and  tlnis  rendering  it 
lial)le  to  bi;  renujved  prenuiturely  by  the  jiatient  in  his  sleep  or  even  by  the  friction  of  his  ilolliing.  Wlien  tliis 
occurred  a  foul,  bleeding,  irregularly  shaped  phagedenic  ulcer  was  revealed,  with  everted  edg<'8  and  ])resentiiig  the 
appeanuice  of  a  syphilitic  jihagedenic  ulcer,  involving  the  subcutaneous  areolar  tissue,  exposing,  in  nniiiy  cases,  the 
muscular  tissue  below.  The  process  of  destruction  did  not  end  here,  for  the  ulcer  continued  to  increase  ami  from  the 
loosened  edges  an  ichorous  discharge  continued  to  pour  out  from  under  the  skin,  which  seemc'd  to  dcstioy  ilic  edges 
of  the  ulcer,  thus  increasing  its  dimensions.  Wherever  the  ichorous  |)us  from  this  ulcer  tou<'lu'd  tlie  sound  skiu 
anotlu'r  pustule  of  a  similar  cluuacter  was  fornu'd,  in  some  cases  reaching  tlie  size  of  the  jirimary  sore.  This,  liow- 
ever,  was  seldom  tlie  case,  but  a  smaller  ulcer  generally  resulted,  which  often  healed  and  cicatrized  before  the  first. 

The  axillary  glands  when  the  arm  was  affected,  ami  the  inguinal  glands  wlii'ii  the  leg  was  the  seat  of  the  <li8- 
ea.se,  sometimes  became  intlaiiied  and  discharged  pus,  piesi'utiiig  the  niicrosco])ic  characters  of  lualthy  pus.  'I'liis 
enlargement  of  glands,  however,  diil  not  occur  in  a  siilKcient  number  of  cases  to  make  it  a  natural  scciueiice  of  the 
disease.  Attending  the  early  stages  of  the  formation  of  the  ulcer,  bi^fore  pus  was  disehargeil,  thi'ie  was  always  more 
or  less  pyrexia,  with  furred  tongue  and  loss  of  appetite,  these  symptoms  disappearing  as  soon  as  ulceration  was  estab- 
lished. In  these  highly  aggravated  cases  successive  crojis  of  pustules  made  their  ajipearanee  on  the  affected  limb, 
often  also  upon  the  lower  limb  of  the  affected  side,  but  seldom  crossing  the  mcsian  line  and  never  develo])ing  them- 
selves upon  the  trunk  or  head. 

The  less  malignant  form  of  the  disea.se  resembled  the  first  in  character  but  not  in  degree.  For  ft  few  days  after 
the  insertion  of  the  virus  merely  a  small  inllamcd  sjiot  was  discerned,  which  seemed  to  be  more  the  result  of  the 
injury  done  to  the  skin  by  the  jirick  of  the  lancet  than  any  inlhimmatory  action  resulting  from  a  siieeilic  cause. 
Aliout  the  fifth  or  sixth  <lay  a  minute  ])Ustulo  was  <liseiMiied  u])on  a  scarcely  larger  inllaiiied  basi'.  This  pustule 
and  areola  gradually  iticreased,  but  tlic^  diameter  of  tln'  areola  was  not  as  great  and  there  was  no  deep  iiillammatory 
blush  u]ion  the  arm,  merely  a  dilfiised  redness  of  s<'veral  inches  in  diameter.  'I'lie  same  proci'.ss,  howi'ver,  took  place — 
an  exudation  of  serum  from  the  areol.i — which,  in  turn,  became  a  crust,  ami  which  gradually  incri-ased  in  size,  but 
it  never  reached  the  dianu'ter  of  the  nioro  malignant  type;  and  when  it  was  detached  liy  the  process  of  ulceration, 
which  occurred  at  an  early  period,  the  revealed  ulcer  was  neither  as  deep  nor  ns  iiialignant  in  its  aiiiK-aranee.  The 
edges  were  not  everted  ami  there  was  no  discharge  of  pus  from  under  the  edges  of  the  ulcer:  it  only  ]ire«ented  the 
appearance  of  an  ordinary  ulcer,  showing  no  tendency  to  increase  and  but  little  to  heal.  I'yri'xia  seldom  attended 
this  form  nor  was  the  ai>petite  imiiaired. 

The  third  and  mildest  form  of  the  disea.se  ma<le  its  apjic-iranee  as  a  small  pimple  in  frcmi  two  in  ten  ilays  after 
the  introiluctitiu  of  tlu^  virus,  which  gradually  formed  a  inislule:  a  dark-lirown  scab  suceeedi'd  in  from  three  to  fdur 
days,  which  remained  attached  sometimes  as  long  as  two  weeks,  and  when  it  became  delached  a  livid  or  brown  spot 
was  revealed,  the  size  of  which  was  ei|ual  to  the  scali.  This  sear,  however,  was  very  sensitive  to  the  touch  and  liable 
to  bleed  from  the  least  friction  of  clothing,  and  when  this  occurred  it  woiilil  exude  serum  or  bloojil  and  another  scab 
would  surely  form.  If  the  system  became  suddenly  depressed  from  any  eau.so  it  would  almost  always  a.ssumo  the 
ulcerative  process  and  become  a  sloughing  ulcer,  which  only  healed  with  the  general  iiniirovement  of  the  system. 

As  thus  described  this  disease  has  prevailed  in  the  Army  of  Virginia,  both  in  field  and  hospital.  The  surgeons 
of  the  Army  of  the  Southwest  report  its  prevalence  there.  It  was  developed  in  the  early  part  of  the  year  in  a  cavalry 
regiment  in  the  mountains  of  Virginia,  the  colonel  commanding  siilVering  severely  from  the  disease.  In  every  case 
its  origin  has  been  traced  to  the  introduction  of  vaccine  virus  into  the  system.  How  far  an  ejiidemic  cause  may  have 
exerted  its  influence  in  its  early  development  it  is  impossible  even  to  surmise;  we  know,  howi'vcr,  that  it  originated 
in  Virginia  at  a  time  when  our  army  was  upon  very  short  rations,  and  that  many  of  the  soldiers  sent  from  the  field  at  that 
time  presented  a  decidedly  scorbutic  appearance.  Many  had  been  reduced  and  were  broken  down  by  exposure  to  the 
inclemency  of  a  cold  winter  and  the  depressing  infiucneo  of  low  diet,  want  of  clothing  and  many  other  prolific 
causes  of  disease  calculated  to  dejirive  the  blood  of  its  healthy  constituents,  jiarticnlarly  of  its  fatty  matter,  llcncc, 
this  may  have  produced  a  predisposition.  In  verification  of  this  fact  I  will  state  that  when  it  was  found  how  fre- 
quently the  disease  in  consideration  supervened  upon  vaccination  in  this  hospital  in  lirokcn-down  and  de])ravcd  con- 
stitutions, it  was  deemed  prudent  to  iiostponc  the  introduction  of  the  virus  until  the  jiat  lent  was  restored  to  a  healthy 
condition  by  improved  diet  and  medieal  treatment.  At  the  first  apiicarance  of  the  evil  consei|Ueiices  of  vaceiiiatioii 
I  was  inclined,  with  other  surgeons,  to  believe  that  the  virus  was  impure,  and  because  of  this  suspicion,  I  threw  away 
the  matter  we  then  had  and  olitaiucd  a  vaccine  scab  from  Dr.  Knox,  a  pra<titioner  on  t'hurch  Hill,  w  ho  assurcil  me  ho 
had  used  it  in  several  cases  with  a  perfect  result. 

The  introduction  of  this  virus  into  the  arms  of  some  ten  patients  resulted  in  the  development  of  the  disease  in 
([uestion  in  three  of  them,  wliile  in  the  remainder  it  produced  apparently  a  tine  pustiih'.  From  this  fact,  ami  the 
immunity  which  healtiiy-looking  men  enjoycil,  I  was  led  to  believe  that  the'  predisposing  cause  existed  in  a  vitiated 
and  impoverished  condition  of  the  blood  and  so  reported  in  my  first  report,  and  that  tiic  introduction  of  pure  virus 
into  the  system  was  the  exciting  cause  of  a  latent  disease.  This  view,  I  see,  is  also  held  liy  Surgeon  Kiiaxk  A. 
R.\.\fSEV  of  the  Department  of  East  Tennessee,  in  a  comiiiunieation  on  tile  in  the  office  of  the  Surgeon  (ieiu'ral.  This 
view  I  have  never  had  reason  to  change,  though  I  am  aware  that  many  men,  ainiarently  in  health;  have  suffered  from 


644  THE    ERUPTIVK    FF.VKES. 

the  effects  of  vaccination.  In  one  case,  -n  hich  I  here  (|note.  tlie  inlluenco  of  a  good  condition  of  the  general  system 
seems  to  liave  exerted  a  wonderfully  modifying  intlnence.  * 

The  search  for  parasitic  or  cryptogannc  vegetation,  with  a  good  microscope,  revealed  none.  The  pn.stnle  was 
seldom  developed  where  parasites  make  their  habitation,  namely,  in  the  bulhs  or  at  the  roots  of  the  hair.  The  ])ns 
presented  microscopic  characteristics  of  pus  globules  tloating  in  a  homogeiu'ous  fluid.  These  globules  were  not  as 
abundant  as  in  laudable  |)ns  and  not  so  distinctly  nucleated,  and  were  irregular  in  outline  in  some  of  the  cases  exam- 
ined. This  appearance  of  pus  globules,  however,  often  exists  in  healthy  or  laudable  pus  when  it  has  been  exposed 
to  the  air  any  length  of  time.  In  the  many  ca-ses  I  have  examined  I  have  yet  to  find  a  patient  who  will  acknowledge 
that  he  has  had  any  syphilitic  disease  at  any  i)eriod  of  his  life,  though  many  of  them  have  had  gonorrluca.  This 
exemption  from  syphilis,  however,  is  not  strange,  since  it  is  a  very  nncommou  disease  in  the  rural  parts  of  our  country, 
the  inhabitants  of  which  comprise  the  very  large  majority  of  our  army.  We  also  know  the  tendency  of  the  .secondary 
form  of  syphilis  is  to  develop  itself  on  the  forehead,  chest,  back  and  trunk  generally,  and  yet  no  cases  develoi»ed 
upon  these  parts  of  the  body  have  jiresented  themselves  to  my  observation.  JIany  of  the  patients,  also,  have  suffered 
long  enough  to  liave  had  the  tertiary  form  of  syphilis  developed,  nodes,  etc.,  and  yet  uo  such  symptoms  have  been 
seen  by  me. 

From  what  I  can  learn  the  army  of  the  United  States  has  so  far  escaped  these  evil  results  of  vaccination.  A 
few  cases,  however,  originated  among  Federal  ofticers  in  the  hospital  of  Libby  Prison.  They  were  vaccinated  in 
tlie  i)rison  by  one  of  their  surgeons  from  his  own  arm  some  weeks  after  their  confinement,  and  presented  all  the 
characteristics  of  the  disease  as  it  appeared  in  our  army.  1  was  assured  by  these  officers  that  they  had  neither  seen 
nor  heard  of  such  a  result  of  vaccination  in  their  army.  Does  not  this  fact  aloue  lead  us  to  infer  that  its  cau.se  or  origin 
may  be  traced  to  some  abnormal  condition  of  the  blood  in  these  cases,  induced  by  confinement  in  a  vitiated  atmos- 
phere, without  the  means  of  eliminating  the  matcrU-s  niorbi  from  the  system  by  exercise  and  care  to  the  function  of 
the  skin  ? 

The  classification  of  this  disease  is  difficult  and  unsatisfactory,  since  it  commences  as  a  pustule  and  assumes 
often  the  outward  form  of  rupia.  which  l)y  all  dermatologists  is  classified  among  the  bulhc.  If  we  classify  it  among 
the  pustuhe  we  find  no  disease  there  describing  it  accurately,  some  cases  resembling  ecthynui,  others  impetigo. 
Inasmuch,  however,  as  it  often  assumes  the  characteristics  of  chronic  ecthyma,  either  in  a  mild  or  aggravated  form, 
according  to  the  healthy  or  unhealthy  condition  of  the  jiatient,  Iiirop<Jse  to  name  it  vaccine  ecthyma.  Like  all  chronic 
cutaneous  diseases  it  shows  a  decided  tendency  to  return  whenever  the  system  becomes  reduced  from  any  cause,  or 
when  the  patient  is  exposed  to  causes  which  produce  an  undue  action  in  the  circulation  of  the  capillary  system.  An 
undue  amount  of  exercise  in  warm  weather  seems  to  excite  its  a])]>earance.  This  w  as  illustrated  in  tho.se  soldiers 
supposed  to  he  perfectly  cured,  and  who  were  about  to  be  ordered  to  their  regiments  for  duty  when  a  raid  was  threat- 
ened, in  the  montli  of  July,  upon  the  city  of  Richmond.  These  men  were  among  the  volunteers  from  the  hospital 
to  defend  the  city,  and  were  marched  through  a  hot  sun  some  four  miles  to  the  lines  at  the  extreme  limits  of  the 
western  end  of  the  town.  They  returned  with  a  new  croj)  of  pustules,  which,  however,  healed  by  resolution  in  a 
short  time. 

Treatment. — There  is  every  reason  to  believe  that  the  disease  results  from  a  blood  disease,  only  to  be  eliminated 
from  the  system  by  enriching  the  blood  and  supplying  its  deficiency  of  fatty  matter  with  rich  nutritious  food  and 
the  judicious  use  of  alteratives.  It  is  vain  to  treat  the  ulcers  locally,  for  without  alterative  treatment  with  nutri- 
tious diet  all  the  local  api)lications  which  were  tried  seemed  to  aggravate  rather  than  imitrove  them:  but  as  soon  as 
the  general  condition  began  to  improve  so  did  the  ulcers.  The  milder  ca.ses  began  to  improve  a  few  weeks  after 
admission  without  any  treatment  except  dietetic  in  conjunction  with  the  iodide  of  jiotash,  syrup  iod.  ferri  and  sarsa- 
parilla;  in  others  merely  applying  simple  dressing  to  the  ulcer  was  found  sufficient  to  subdue  it.  Under  this  treat- 
ment all  the  cases  gradually  but  slowly  improved.  In  the  earh'  part  of  August  we  received  a  large  supply  of  cod- 
liver  oil,  and  I  was  thus  enabled  to  test  fully  the  treatment  which  the  supposed  cause  of  the  disease  naturally  sug- 
gested. Some  few  of  the  patients  could  not  digest  the  oil,  but  those  who  could  began  rapidly  to  imjirove,  and  many 
were  well  enough  on  the  l?<th  of  August  to  return  to  their  regiments,  whilst  others  were  thought  well  enough  to  be 
transferred  to  their  respective  State  hospitals,  in  compliance  with  an  order  issued  at  that  time.  Those  who  were 
unable  to  digest  the  oil  continued  the  syrup  iod.  ferri,  which  was  thought  the  best  alterative  indicated  in  their  cases. 
Their  improvement  was  scarcely  perceptible.  In  the  early  part  of  September,  however,  another  effort  was  made  by 
them  to  take  the  cod-liver  oil,  which  they  were  enabled  to  do  in  a  little  whiskey:  their  improvement  soon  became 
very  evident  to  themselves,  and  though  not  yet  entirely  well  the  ulcers  are  rai)idly  granulating.  No  new  pustules 
are  being  developed  and  the  patients  are  in  a  fair  way  to  recover.  I  have  no  doubt  that  the  best  remedy  has  been 
found  in  the  cod-liver  oil;  and  this,  locally  applied  and  internally  administejed,  with  an  entire  change  of  air  and 
nutritious  diet,  ■will  remove  and  eventually  eradicate  this  obnoxious  and  filthj-  disease  from  the  system. 

From  the  above-mentioned  facts  I  am  led  to  draw  the  following  conclusions:  That  the  di.sease  is  juistular  at 
its  first  appearance;  that  it  resembles  ecthyma  in  its  general  character;  that  it  is  but  a  local  manifestation  of  a  gen- 
eral disorder  or  vitiated  condition  of  the  blood:  that  this  vitiated  condition  resulted  from  improper  and  spare  diet, 
together  with  inattention  to  cleanliness,  thus  imjiairing  the  eliminating  functions  of  the  skin :  that  syphilitic  virus 
Las  had  no  influence  in  producing  the  disease;  that  the  morbid  effects  have  in  most  of  the  cases  resulted  from  a 
deficiency  in  condition,  independent  of  any  imperfection  in  the  vaccine  virus;  that  the  disease  can  only  be  removed 
by  those  means  calculated  to  improve  the  general  condition  and  restore  the  healthy  play  of  all  the  functions. 


*  .St-e  ca?*  20  of  tlif  Cliinihur.izo  n-cunls,  sultinitti-'il  on  page  <U2,  xnpiri.  Dr.  Haiieusuam,  in  citing;  tliis  cu-se,  fails  to  stute  why  tin-  man  w:\fi  in  lius- 
pital  at  Karmvilli'  at  thi?  time  of  his  vac-ination.  ''Tfiis  latient,"  lie  pays,  "was  yuunj;;,  vitforuns  ami  ctiruiianitivi'ly  Iicaltliy  when  In'  n-ceived  tliiB 
vaccine  into  Uis  system,"- — yet  the  recurdd  ui  the  Cbimborazu  hospital  represent  him  as  having  been  at  that  lime  nnder  tn-atni'iit  Uif  clirnnii-  nejihritis. 


SMALL-POX.  645 

^leanwliile  cutaneous  ulcerations,  erysipelatous  inflammations  and  occasional  swelling 
and  suppuration  of  the  Ivmphatic  glands  appeared  in  the  South  and  Southwest  as  frequent 
results  of  attempted  vaccination.  The  attention  of  the  profession  became  aroused  bv  reported 
instances  of  the  inefficiency  of  the  protection  afforded  by  these  false  vaccine  sores  and  the 
suspicion  of  svphilitic  infection  associated  with  tliem,  together  with  the  spread  of  tlie  small- 
pox epidemic.  A  belief  in  the  doctrine  of  an  epidemic  constitution  of  the  atmosphere  was 
generally  accepted;  but  the  more  the  subject  was  investigated  the  more  apparent  it  became 
that  the  undesirable  and  unprotective  results  were  due  to  impuritv  in  the  virus  used. 

Thus  BoLTOX,  who  was  engaged  in  growing  crusts  on  healthv  children  for  the  use  of 
the  Confederate  authoi'ities,  tested  his  stock  by  nearly  1,300  vaccinations  without  an  abnor- 
mal result,  and  when,  after  this,  it  was  employed  by  a  Tennessee  physician  in  five  cases,  in 
four  of  which  it  proved  inert  and  in  one  produced  a  succession  of  scabs,  he  attributed  this 
to  decomposition  of  the  crust  from  a  faulty  method  of  preservation.  Subsequent  to  this 
he  collected  about  eight  hundred  crusts  from  healthy  children.  These  were  distributed 
throughout  the  army,  and  no  further  reports  of  abnormal  results  were  forwarded.  Stout 
has  recorded  that  soldiers  were  vaccinated  from  the  arms  of  soldiers,  in  many  instances  by 
themselves  and  even  by  medical  ofiicers,  with  no  care  as  to  the  normal  appearance  of  the 
vesicle  or  dried  scab  employed  in  the  process.  In  many  cases  the  operation  was  followed 
by  extensive  erysipelas  of  the  arm;  sometimes  by  phagedenic  ulceration.  A  f'W  lives 
were  sacrificed,  and  in  one  instance  reported  to  him,  amputation  was  resorted  to  for  the  pur- 
pose of  saving  life.  He  prohibited  the  use  of  virus  obtained  from  the  arms  of  soldiers  or  of 
any  person  supposed  to  be  in  bad  health.  Pure  virus  was  distributed  to  physicians  in  pri- 
vate practice  with  the  request  that  they  iurnish  scabs  from  hcaltliy  children  to  be  usrd  in 
the  army.  A  medical  otHcer  was  detailed  at  every  hospital  to  scour  the  neighboring  country 
in  search  of  children  on  whom  to  propagate  the  virus,  that  a  sutHcient  crop  might  be  secured 
to  avoid  the  necessity  of  using  that  obtained  from  adults.'''  Cases  of  spurious  vaccination 
became  less  frequent  after  this,  and  were  almost  unknown  during  the  later  nionths  of  the  war. 
Many  of  the  unfortunate  cases  he  regarded  as  dissecting  wounds,  putrefactive  matters  having 
been  inserted  along  with  or  instead  of  the  vaccine  lymph.  But  ho  did  not  attribute  the 
gradual  disappearance  of  the  anomalous  results  wholly  to  the  purity  of  the  virus;  for,  coinci- 
dent with  its  use,  there  was  in  the  hospitals  near  Atlanta  a  diminished  tendency  to  erysipelas 
and  gangrene,  which  led  him  to  believe  that  during  the  previous  period,  when  such  tenden- 
cies prevailed,  bad  effects  may  have  followed  the  inoculation  of  perfectly  normal  lymph. 
Gkeene,  as  the  result  of  his  observations,  considered  that  much  of  the  trouble  was  due  to 
vaccinating  with  the  matter  of  bruised  crusts.  Soldiers  crowded  in  small  tents  and  exposed 
to  injury  from  handling  their  muskets  and  accoutrements  in  drilling,  guard  and  police  duties, 
had  the  vesicle  damaged  and  its  natural  ]irogress  interfered  with  by  inflammatory  processes 
which  could  not  fail  to  alter  the  constitution  of  the  crust.  He  subscribed,  however,  to  the 
theory  of  an  atmospheric  influence  predisposing  to  a  morlnd  condition  of  the  tissues  and  fluids 
of  the  body. 

*  C.  I[.  Tebax'Lt,  in  an  article  on  lifofUJiM  riwcttlatimi — S'eic  Orleans  Med.  mid  Surg.  Jotir.,  XIX,  18r.fi,  p.  P,0— n-Iatcs  tliat  wliilo  Iio  wap  Superintendent 
of  Vaccination  at  tlie  po^t  uf  3Iacon,  Gn.,  in  1804,  the  prevalence  of  sniall-pox  and  tlie  scarcity  of  reliuljle  vaccine  crufits  led  bini  to  liavc  recourse  to  inocu- 
lation with  variolous  matter  taken  from  tlie  pock  in  the  vesicular  ytage  and  nii.\ed  with  an  e<iual  (pianlily  of  cow's  milk,  as  jirai-ticed  liy  certain  physi- 
cians in  ^larseillea  and  Lyons  as  early  as  1H:12.  From  an  experience  of  five  liunitred  eases  he  ctnichided  that  the  moditii-d  inmnlation  is  as  mild  in  ita 
manifestations  as  vaccine,— few  of  his  cases  having  liad  more  than  a  single  vesicle  and  none  more  than  six  in  addition  to  that  at  the  site  of  the  puncture  ; 
that  the  iug:rafted  disease  is,  like  vaccinia,  not  conuuunicaMe  hy  mere  <-ontact ;  that  the  innnunity  cttnferred  is  more  lasting  and  otherwise  sui«>rior 
to  that  obtained  hy  vaccination,  and  that,  with  the  occurrence  of  small-pox,  we  are  immediately  supplied  with  an  all-potent  means  for  its  represbion. 


616  THE    ERUPTIVE    FEVERS^. 


Scurvy  was  generallv  exonerated  bv  tliose  investigators,  as  the  civil  population,  living 
at  their  homes  on  vegetable  diet,  were  also  affected  liv  these  anomalies  of  vaccination.  The 
people  were  as  careless  in  their  methods  of  vaccination  as  were  the  soldiers;  matter,  fresh  or 
dried,  from  a  sore  arm  appeared  to  have  been  the  desideratum  rather  than  ripe  vaccine  from 
a  Ivmph-vesicle  or  the  crust  of  a  primary  vaccination  from  the  arm  of  a  healthy  child. 

The  impuritv  in  the  virus  was  held  bv  some  phvsicians  to  consist  of  a  syphilitic  con- 
tamination; but  of  the  many  cases  that  passed  under  the  observation  of  medical  men  not 
one  has  been  recorded  in  which  the  constitutional  symptoms  of  undoubted  syphilis  have 
been  shown  as  the  result  of  the  primary  sores.  Boltox  insisted  on  the  presence  of  syphilis 
in  some  of  the  outbreaks,  and  asserted  that  many  of  the  cases  were  so  situated  that  their 
history  could  be  preserved,  and  that,  in  these,  secondary  symptoms  api)eared,  followed  in  due 
time  by  tertiarv  symptoms.  ''  In  short,''  his  paper  says,  "the  disease  was  genuine  syphilis. " 
According  to  his  account  the  disease  prevailed  most  extensively  among  troops  from  the  State 
of  Georgia,  and  was  thousidit  to  have  been  traced  to  a  soldier  from  that  State  who  had  been 
home  on  furlough  and  was  said  to  have  vaccinated  himself  from  his  wife;  but  although  he 
makes  positive  statements  concerning  the_  syphilitic  nature  of  the  ulcerations,  it  does  not 
appear  that  he  saw  any  of  the  cases  in  the  affected  Georgia  regiments, — he  was  engaged  at 
the  time  in  propagating  vaccine  virus  on  the  arms  of  negi'o  children  on  the  plantations  of  the 
South.  GiLiiORE,  however,  who  had  an  opportunity  of  observing  the  cases  in  the  Georgia 
brigades  of  Semmes  and  Cobb,  considered  that  he  saw  enough  of  the  disease  to  convince  him 
thoroughly  that  the  virus  owed  its  impurity  to  svphilitic  contamination.  He  accounted  for 
the  introduction  of  the  specific  impurity  by  a  soldier  who,  while  on  furlough,  was  vaccinated 
by  a  woman,  an  inmate  of  a  house  of  bad  repute  in  Augusta,  Ga.  The  man  denied  having 
had  syphilis  previous  to  his  vaccination,  and  the  condition  of  the  woman  who  vaccinated  him 
is  acknowledged  to  have  been  unknown. 

On  the  other  hand,  the  testimonv  of  the  regimental  medical  officers,  and  of  those  on 
duty  at  the  general  hospital,  where  the  more  aggravated  and  persistent  cases  of  this  Georgia 
epidemic  were  treated,  together  with  the  yet  extant  records  of  the  hospital,  show  that  not 
one  of  the  cases  developed  the  secondary  manifestations  of  syphilitic  disease,  and  that,  in 
fact,  the  disease  was  not  syphilis. 

The  strongest  evidence  of  the  transmission  of  syphilis  by  the  operation  of  vaccination 
was  reported  by  Surgeon  AVilliam  M.  Fuqua,  7th  Fla.  In  this  instance  it  is  said  that  the 
virus  employed  was  obtained  from  a  sailor  who  was  suflfering  from  primary  syphilis  at  the 
time  of  the  vaccination.  Fifty-two  of  the  men  had  offensive  and  freely-discharging  ulcera- 
tions with,  in  some  instances,  swelling  and  suppuration  of  the  axillary  glands.  Copper- 
colored  spots  appeared  in  two  cases,  the  hair  began  to  fall  off  in  a.  third  and  a  bubo,  regarded 
as  syphilitic,  was  developed  in  a  fourth.  Most  of  the  patients  were  returned  to  duty  after 
specitic  treatment;  a  few  were  sent  to  general  hospital,  one  of  whom  died.  The  regiment 
was  in  bad  condition  at  the  time  of  its  vaccination,  one-seventh  of  its  membership  being  on 
the'  sick-list  with  diarrhoea  and  malarial  fevers. 

Whether  these  eases  were  really  syphilitic  or  the  result  of  a  putrefactive  animal  matter 
in  cachectic  individuals,  some  of  whom  may  have  been  the  subjects  of  syphilis  irrespective 
of  their  vaccination,  appears  immaterial  to  the  settlement  of  the  general  question  relating 
to  the  causation  of  the  ulcerations  and  occasional  glandular  swellings  following  attempted 


SMALL-POX.  *  647 

vaccination  in  the  Soutli.     The  weiLcht  of  the  tes^tiniony  throws  the  responsibilitv  on  the 
matter  used  in  the  inoculations  but  frees  it  from  the  suspicion  of  syphilitic  infection. 

Furllier  lijit  is  shrd  upon  tlie  causatitjn  of  these  ulcerations  by  the  efforts  of  our 
medical  officers  to  protect  from  small-pox  the  Rebid  soldii'rs  ladd  in  confinement  at  our 
prison  depots.  Isolation  and  vaccination  were  em|)loved;  but  at  some  of  the  prisons,  as 
Alton,  the  spread  of  the  disease  was  so  rapid  that  the  former  could  not  be  etlected  until  after 
the  construction  of  a  special  hospital,  and  the  latter  was  unavailing  from  the  inefficiency  of 
the  virus  used.*  Most  of  those  committed  to  tlie  Rock  Island  prison  iiad  large  ugly  scars 
which  affiarded  no  protection  from  the  infection  of  siuall-po.x.  These  scars  were  the  result 
of  attempted  vaccination  while  in  the  Southern  ranks. f  Virus  which  produced  no  bad 
effects  on  the  United  States  troops  stationed  at  Camp  Douglas,  occasioned  phagedenic,  irrita- 
ble or  indolent  ulcers  when  inserted  into  the  arms  of  the  Confederate  prisoners. J  It  is 
evident  from  these  results  that  the  debilitated  condition  of  the  men,  whicii  was  a  subject  ot 
constant  remark  by  our  medical  inspectors,  was  the  essential  in  the  production  of  the  umisual 
sores  that  followed  their  vaccination.  A  report  by  Medical  Director  Cilvklks  S.  Tiuplki:, 
Northern  Department,  gives  interesting  testimony  on  this  point: 

Facts  of  interest  have  been  developed  in  regard  to  bad  results  obtained  from  viiccino  matter  mipimsod  to  bi> 
impure.  At  an  early  period  in  the  events  embodied  in  this  rcjiort  niiiiors  of  virus  said  to  l)i>  contaminated  witli  syjili- 
ilis  became  prevalent.  These  were  calculated  to  excite  Kcrious  alarm,  as  the  evidence  seemed  to  show  that  much  of 
the  virus  issued  by  tin;  purveyors  caused  larj;c,  ])ainful  and  obstinate  iilieis,  cvhiliitiuy;  many  of  tlie  marks  of  sy])li- 
jlitic  disease.  Whether  the  imrveyinj;  d<'))artmcMt  should  on  these  facts  lie  ai'i'uscil  of  carelessness  as  to  tlie  source 
of  its  supply  of  vaccine,  or  whether  the  evil  existini;  might  have  some  other  explanation,  liccame  a  iiiiestion  I  sought 
at  once  to  solve. 

It  was  evident  at  the  outset  that  a  few  localities — Camp  Douglas,  Kock  Island  l!arra<'ks  and  Camp  Butler — all 
prison  depots  in  the  State  of  Illinois,  furnished  most  of  the  causes  of  complaint.  Those  who  siilliicd  from  the 
so-called  impure  virus  were  rebel  prisoners  of  war.  It  was  at  once  BU8])ected  that  by  no  chance  could  nil  the  imiuire 
virus,  if  any  there  was,  concentrate  in  these  localities;  that  our  own  troops  ought  also  to  suH'er  somewhat  in  the  same 
way;  and  that  probably  the  evil  might  be  found  in  the  constitutional  condition  of  the  subject  rather  than  in  the  vac- 
cination itself. 

Kcports  were  called  for  testate  the  facts  in  full  as  to  the  jirobahle  ]ioisoniiig  by  syphilis  or  other  in  feel  ion,  ami 
also  to  inform  me  as  to  dietetic  and  other  c;iuses  which  might  tend  to  explain  the  unfortunate  results.  ,\n  informal 
and  hasty  report  fiom  Kock  Islaml  stated,  in  general  terms,  that  the  same  virus  used  indiscriminately  on  prisoners 
suffering  from  scorbutus  and  on  United  .States  troops  in  ordinary  health  |irodnced  very  dili'erent  results.  With  the 
latter  it  acted  kindly  and  in  the  usual  manner;  w  ith  the  former  it  ])1(mIiic<mI  large  indolent  and  occasionally  slough- 
ing ulcers,  sometimes  indurated  at  the  margins  and  chancroid  in  appearance. 

The  report  made  May  31,  1864,  by  Surgeon  Joii.x  II.  UuovK,  U.  S.  \'ol8.,  in  charge  of  Camp  Douglas,  embodies 
an  iimount  of  evidence  which  seems  to  pre  .e  conclusively  that  there  was  no  fault  in  the  vaccine  furnislie<l  (further 
than  its  deterioration  by  age),  but  that  the  cause  of  the  evil  lay  in  the  cachexia  of  the  subjects  of  the  vaccination. 
He  states  in  brief  that  while  a  large  number  of  the  jirisoners  were  vaccinated  with  ordinary  results,  l,."i80  cases  were 
followed  by  bad  ulcers.  These  commenced  on  the  third  day  with  a  vesicle,  not  uinliilicatcd,  which  filled  with  luis; 
this  speedily  became  an  open  irritable  sore,  with  diffuse  redness,  and  finally  degenerated  into  an  irritable  and  indolent 
nicer  varying  from  one  to  three  or  four  inches  in  length.  In  some  cases  the  ulcer  was  limited  to  tin'  cuticle,  in  others 
it  was  phagedenic,  and  in  some  a  deep  gangrenous  slough  occurred.  Kvideiitly  this  was  not  sy]iliilitic.  Of  the  whole 
number  Gt)8  had  healed  at  the  time  of  the  report;  912  remained  obstinately  ojieii.  Those  which  had  healeil  left  au 
extensive  smooth,  red,  shining  cicatrix.  It  is  noteworthy  that  81(3  prisoners  of  war  who  had  been  vaccinated  w  hile 
in  the  rebel  service  had  cicatrices  of  this  character.     On  these  results  vaeciiiatiou  was  suspended  at  that  post. 

Surgeon  Grove  further  reports  that  the  vaccine  virus  used  was  obtained  upon  re(j[uisitions  from  the  medical 
purveyor  and  used  at  about  the  same  time  njion  the  United  States  troops  (men  and  officers)  at  the  garrison,  without 
any  unpleasant  effects  excepting  in  one  ease  of  an  olUcer's  wife,  who  was  in  a  chlorotic  condition.  In  this  case  an 
irritable  ulcer  followed,  which,  after  about  three  months,  yielded  to  treatment. 

Here  we  have  in  the  same  locality  some  thousands  of  vaccinations  made  with  the  same  virus  at  the  same  time. 
In  one  class  a  large  majority  had  ulcers;  in  the  other  only  one  experienced  any  unpleasant  effect.  It  is  plain  "that 
the  men  and  not  the  virus  furnished  the  oriijo  tiuili.     From  other  localities  the  same  history"  came. 

Isolated  instances  occurred  in  which  i)atients  suffering  from  chronic  diarrlnea  had  ulcers,  and  subseiiuent  to 
the  reception  of  Surgeon  Guove's  report,  the  cases  of  three  recruits  vaccinated  at  Camp  Butler  and  then  forwarded 
to  Arkansas  were  referred  to  mo  for  report.  In  these  cases  as  in  others  the  same  phenomena  were  observed.  The 
same  crust  that  acted  kindly  on  some  produced  ulcers  on  the  three  recruits. 

■*'  Dr.  Wall's  repurt,  sttpia,  la^je  07.  f  ?^i't'  l>r.  3Ioxleys"  sliiti-iinut,  kiijjc'i,  i«aj;e  0;i.  X  Dr.  IIcmpubev;*'  rt'i'urt,  t^nprn,  page  07. 


G48  THE  EErPTIVE  FEVERS. 

The  cause  of  this  cachexia  mast  be  atnilmteil  to  the  inevious  exposures  of  the  subjects.  Many  of  these  pris- 
oners were  poisoned  by  malaria:  many  move  had  and  still  Lave  scorbutus.  The  prison  diet  in  this  department  is 
sufficient  in  ([Uantity,  but  it  lacks  those  component  parts  wliieb  are  essential  to  health.  Aside  from  soft  bread  the 
only  vegetable  issueil  is  thirty  pounds  of  potatoes  to  one  hundred  men  per  diem.  This  is  not  sufficient  to  -ward  ofl' 
scurvy,  and  so  long  as  it  is  continued  a  mortality  not  creditable  to  our  (lovernment  maybe  expected  among  our  pris- 
oners of  war. 

To  conclude,  the  facts  before  me  authorize  me  to  report: — 

1st.  That  the  vaccine  matter  furnished  by  the  purveyor  is  fjood  except  when  rendered  inert  by  ajje. 

2d.  That  the  condition  of  prisoners  of  war  is  so  cachectic  as  to  produce  bad  results  from  healthy  vaccine  virus, 
results  which  do  not  obtain  from  the  same  virus  in  healthy  subjects. 

3d.  That  the  ration  now  issued  to  prisoners  of  war  is  calculated  to  produce  and  continue  scurvy  and  other 
cachectic  conditions. 

4th.  That  the  ration  cau  be  moditied  v»-lthout  increased  expense  so  as  to  bring  about  a  healthy  condition  among 
the  prisoners. 

Undoubtedly,  also,  at  Andersonville  the  condition  of  our  men  sufficed  to  explain  the 
evil  results  even  if  the  quality  of  the  virus  employed  had  been  beyond  Cjuestion, — for  at 
this  prison  mosquito  bites,  abrasions,  pricks  from  wood-splinters  and  other  slight  accidental 
injuries  were  in  several  instances  followed  by  gangrenous  ulcerations  that  necessitated  ampu- 
tation, as  in  cases  in  which  a  reputed  vaccine  was  inserted.  The  hospital  register  of  this 
jtrison  shows  that  four  deaths  occurred  in  six  cases  of  vaccination  admitted  from  the  pen, 
fiftv  deaths  in  ninety-six  of  ulcer  and  sixty-one  deaths  in  one  hundred  of  gangrene. 

In  conclusion,  it  may  be  said,  that  the  anomalous  results  of  vaccination  developed  during 
the  war  originated  in  one  or  both  of  two  causative  influences, — first  and  chiefly,  an  impure 
virus;  and,  secondly,  a  deteriorated  system.  The  one  was  demonstrated  bv  the  production 
of  evil  consequences  in  sound  and  vigorous  men,  the  other  bv  similar  consequences  in 
cachectic  individuals  although  the  lymph  used  was  of  normal  character.  The  impurity  of 
the  matter  may  be  ascribed  mainly  to  the  general  practice  of  attempting  to  propagate  vac- 
cinia from  the  crusts  or  inflammatory  products  of  a  revaccination  sore  on  the  arm  of  an 
adult  or  even,  as  shown  by  the  observations  of  Surgeon  L;a  Rl'ssell  at  Benton  Barracks, 
from  a  genuine  vaccine  vesicle  when  changed  by  injury  into  a  purulent  sore.  The  impair- 
ment of  the  constitution  was  due  to  a  scorbutic  tendency  and  the  prostrating  influences  of 
over-fatigue,  exposure,  mental  depression  and  antecedent  disease. 

This  experience  teaches  the  value  of  the  army  regulation  requiring  the  vaccination  or 
revaccination  of  men  at  the  time  of  their  enlistment,  before  the  privations  and  exposures  of 
active  service  have  had  an  opportunity  to  affect  their  health.  It  teaches  also  the  necessity 
at  all  times  for  a  vaccine  lymph  of  good  stock  and  unimpeachable  history,  free  from  the 
products  of  abnormal  vaccinal  inflammation.  Fortunately,  since  the  introduction  of  the 
Beaugency  stock  into  this  country  by  Dr.  Hexry  A.  Martin,  large  armies  may  be  protected 
from  variola  without  the  use  of  crusts,  80  long  as  this  virus  is  preserved,  charged  points 
free  from  inflammatory  products,  and  from  any  possible  taint  of  syphilis,  may  be  prepared 
at  short  notice  for  vaccination  on  a  large  scale.  It  is  needless  to  say  that  the  preparation 
of  the  points  on  which  an  army  relies  for  its  |n'otection  from  small-pox,  and  from  the  some- 
times severe  effects  of  spurious  vaccination,  should  be  conducted  under  official  supervision.* 

*  Anomalons  results  may  attend  the  use  of  bovine  virus  when  tlie  cnii^t  is  employed.  This  sliould  never  be  used  on  account  of  its  tendency  to 
decomposition  and  liability  to  contain  inflanmuitort-  products.  T.  S.  Hopkins  of  Thoniusville,  Ga.,  speaking  of  vaccination  with  virus  in  the  f-trm 
of  cones,  says,  in  the  linlletin  of  the  Xati'mtd  Board  (,f  JUalih^  March  4,  1SS2  :  "The  result  lias  been  fearful.  Nearly  every  one  vaccinated  has  suffered 
severely  from  erythema  or  erysipelas,  the  arm  swolUli  from  shoulder  to  wrist,  and  the  point  of  puncture  presenting  the  appearance  of  a  sloughing  ulcer 
discharging  freely  sanious  jms.  Many  of  the  cases  have  been  confined  to  bed  with  high  fever  frtun  five  to  ten  days,  rcrpiiring  the  constant  application 
of  poultices  and  the  free  use  of  morithia  for  the  relief  of  pain."  Even  ivory  points  or  quills,  ostensibly  coated  with  bovine  lymph,  nuiy  induce  spurious 
results,  if  by  jiressure  or  other  means  the  vesicle  on  the  calf  Ite  made  to  exiule  an  intlamniatory  serosity  or  be  transfornu-d  into  a  purulent  niatrix. 
During  variolous  ejtidemiis,  when  tlie  demand  for  bovine  virus  is  greatest  and  the  necessity  for  pure  vaccine  is  most  severely  felt,  there  is  the  greatest 
danger  of  an  unprln.  ipled  and  disastrous  vitiation  of  the  supjily.  When  vaccination  is  compalsory,  whether  by  law  or  public  sentiment,  citizens  as  weli 
as  soldiers  require  official  protection  from  the  dangers  of  inii)ure  inoculation. 


MEASLES. 


649 


II.— MEASLES. 

PREVALE^'CE  AXD  FATALITY. — During  tlie  years  covered  by  the  statistics  67,763  cases 
of  measles,  with  4,246  deaths,  were  reported  among  the  white  troops,  the  rate  of  fatality 
having  therefore  heen  6.27  per  cent.  Probably  but  a  small  part  of  this  mortality  was  directly 
referable  to  the  disease.  In  many  of  the  regiments  not  one  death  was  caused  by  its  epidemic 
occurrence.  Most  of  the  mortality  was  the  result  of  secondary  )iulmonary  atlection^;  but 
the  mortality-rate  does  not  express  the  whole  of  these  consequences,  for  many  deaths  were 
jilaced  to  the  account  of  the  pneumonic  lesion  without  a  reference  to  the  primary  cause. 
The  average  annual  mte  of  cases  per  thousand  of  strength  was  30.41, — the  maximum,  77.57, 
during  the  first  year,  the  minimum,  1.98,  during  the  last  year.  ]>ut  tliese  numbers  repre- 
sent only  a  part  of  the  prevalence  of  the  disease,  for  many  regiments  sufierod  while  at  the 
recruiting  rendezvous  before  they  had  been  mustered  into  the  service  of  the  United  States. 

Among  the  colored  troops  8,555  cases,  with  931  deaths,  or  10.88  per  cent,  of  fatal  cases, 
were  reported.  The  average  annual  rate  of  cases  per  thousand  of  strength  was  46.65, — the 
maximum,  121.54,  in  the  first  year,  the  minimum,  5.11,  in  the  last  year  of  their  service. 

The  regiments  in  the  Confederate  service  also  sufTered  from  measles  during  the  early 
period  of  their  history.     According  to  Professor  Paul  F.  Evi-r'' — 

Measles  prevaili'd  extensively  in  the  new  rejjiiiients,  eHpeeially  in  tliose  from  the  eonntry,  iin<l  greatly  inijieded 
their  organization.  It  so  diniiniKluMl  the  efiectiveness  of  (he  troops  and  proved  so  fatal  in  camp  that  eompanies, 
battalions  aud  whole  regimeuts  had  to  be  disbanded  lor  a  time  and  the  uieu  sent  home. 

This  statement  is  fully  corroborated  by  the  records  of  the  Confederate  States  Army  of 
tlie  Potomac,  which  show  that  during  the  months  of  July,  August  and  September,  18()1.  S,G17 
cases  of  measles  were  reported  in  a  maximum  monthly  strength  of  58,360  men.  One  mau 
in  everv  seven  of  the  command  became  atlecti'd  during  these  inonllis.  After  this  tlu'  disease 
subsided;  430  cases  were  reported  in  (Jctolier,  211  in  Xuvembii'.  79  in  Dccemlier.  31  in 
January,  1S62,  and  onlv  8  in  Februarv. 

In  examining  the  monthly  prevalence  of  measles  among  the  white  and  colored  troops 
of  the  army  the  irregularity  of  its  progress  among  the  colored  regiments  appears  to  indicate 
a  succession  of  epidemic  waves  involving  the  susceptible  material  of  successive  additions  to 
the  strentrth  of  the  command.  As  the  new  men  came  within  the  influence  of  the  contamous 
foci  the  disease  spread,  giving  a  sudden  elevation  to  the  line  of  prevalence,  which  thereafter 
fell  until  fresh  additions  occasioned  a  corresponding  rise  in  its  level.  The  highest  rates 
occurred  in  the  early  months,  when  the  command  was  small  and  unprotected  by  a  previous 
attack.  In  subsequent  periods  of  increased  prevalence  the  rates,  if  calculated  on  the  strength 
of  the  new  regiments  only,  would  probably  have  been  equally  high,  but,  calculated  as  they 
have  been  on  a  mean  strength,  part  of  which  had  lost  its  susceptibility  to  the  disease,  thev 
are  necessarily  lower  than  those  of  the  earlier  epidemic  periods.  Thus,  in  April,  1864,  851 
cases  gave  a  rate  of  only  12.66  per  thousand  of  a  strength  partly  protected  by  previous 
attacks,  while  in  July,  1863,  327  cases  gave  a  rate  of  27.63  per  thousand  of  newly-recruited 
men.  The  injury  to  the  new  regiments  was  as  great  at  one  period  as  at  the  other,  although 
the  rates  indicate  a  progressive  decrease  of  prevalence  in  the  colored  command  as  a  whole. 
The  decline  of  the  disease  toward  the  close  of  the  year  1864-65  corresponded  with  the  ces- 
sation of  recruitincr  and  the  commencement  of  disbandment. 


*  Quotod  by  Roberts  B.^rtholow  io  liis  paper  on  Owip  MetmUs — f '  N.  fviuitanj  0'inmmion  Memoirg^  X,  Y,,  18G7,  p.  2:11.  Ttie  article  citi-d  is  an 
excflk'Ut  presentatiim  nf  the  cliniral  liistory.  pathulo>rT  and  treatment  of  tlie  disease,  liased  on  an  analysis  of  one  hundred  ra*'S  oljgerved  at  the  field  hos- 
pital, Chattanooga,  Tenn.,  and  Hospital  No.  1,  Nashville,  Tenu.     Its  substance  was  reported  to  the  Surgeon  General's  Office  .\pril  21,  18<>4. 

Med.  Hist.,  Pt.  111—82 


650  THE    EKUPTIVK    FKVERS. 

Among  the  wiiite  troops,  liuwi-'Ver,  tlio  line  of  ])rev;ilence  shows  a  .seasonal  intiuence  as 
wl'II  as  that  clue  to  tlie  aggregation  of  susci'jitible  inJiviilunls.  The  white  troops  were  levied 
en  masse  instead  of  by  gradual  rt'cruitnifiit,  as  was  tlie  case  with  the  colored  I'egiments.  The 
highest  rate  of  prevalence  occurred  during  the  eai'lv  period  of  the  war  as  the  newly  organizetl 
commands  were  being  mustered  into  service.  But  while  recruiting  continued  active  in  the 
summer  of  1SG2,  undi.'r  the  call  of  the  President  for  more  troops,  as  stated  in  discussing  tlie 
irregular  waves  of  prevalence  of  typhoid  fever,  measles  declined  in  prevalence  almost  to  a 
minimum.  During  each  of  the  Ibllowin'j;  summers  a  similar  decline  was  observed,  while 
each  winter  was  marked  by  an  increase  of  the  disease,  largest  in  the  early  months  of  ISGi. 
when  veteran  troops  were  to  some  extent  being  replaced  by  fresh  men.  This  influence  of 
season,  unnoted  in  the  case  of  the  colored  troops,  appears  among  the  white  troops  to  have 
outweighed  that  of  individual  susccptibilitv.  To  explain  this  it  may  be  assumed  either  that 
the  colored  men  were  more  susceptible  to  the  disease  or  that  the  intiuence  of  the  warm  season 
operated  less  favorably  on  them.  The  annual  rate  of  cases  per  thousand  of  strength  was 
30  among  the  white  and  46  among  the  colored  troops;  but  this  ditlerence,  even  if  it  indi- 
cated a  greater  resistance  to  attack  on  the  part  of  the  whites,  is  too  small  to  account  for 
their  immunity  from  the  disease  durino;  the  summer  months.  The  influences  of  the  warm 
months  must  therefore  have  operated  in  a  special  manner  for  the  protection  of  the  white 
troops.  The  milder  temperature  was  evidently  not  the  cause  of  the  decline  of  the  disease, 
else  the  colored  troops  would  have  been  equally  benetited.  It  was  due  jii'obably  to  a  change 
iu  the  environment  of  the  soldier,  the  free  ventilation  and  open-air  life  of  the  summer  camp 
diluting  the  virulence  of  the  specific  exhalations  to  a  degree  inconsistent  with  the  retention 
of  contagious  equalities.  On  the  other  Land,  the  ignorance  and  helplessness  of  the  colored 
recruits,  with  a  want  of  care  on  the  part  of  those  in  authority  over  them,  rendered  over- 
crowding, defective  ventilation  and  otlier  insanitary  conditions  as  common  in  their  camps 
of  organization  in  summer  as  in  winter,  and  conduced  to  the  spread  of  the  disease  among 
susceptible  individuals  irrespective  of  season. 

The  reports  of  medical  ofRcers  show,  in  some  instances,  the  manner  of  the  introduction 
of  the  poison  of  measles  into  their  C(.)minands, — the  rapid  development  of  the  epidemic,  its 
maximum  having  been  attained  in  about  a  month  and  its  subsidence  having  occupied  a 
similar  period, — its  extent  pro|)ortioned  to  the  number  of  susceptible  individuals  in  the 
camp,  for  efforts  at  isolation  were  seldom  competent  to  restrain  the  disease, — the  mild  char- 
acter of  the  epidemic  when  the  men  were  subject  to  favorable  influences, — and  its  severity 
Avhen  they  were,  as  was  too  often  the  case,  exj^osed  to  the  inclemencies  of  the  weather 
before,  during  or  after  the  attack.  In  a  few  instances  where  the  disease  occurivd  among 
troops  housed  in  crowded  and  badly-ventilated  buildings  it  became  deadly  in  itself,  the 
2")atients  becoming  listless  or  stupid  and  the  eruj)tioa  dusky  or  failing  to  appear  distinctly. 
The  virulence  of  the  morbific  agency  seemed  to  have  been  intensified  by  concentration  and 
the  resisting  powers  of  the  system  enfeebled  by  ochletic  influences.  But  generally  it  was 
dangerous  only  from  its  complications  or  sequelae.  These  usually  affected  the  pulmonarv 
organs,  and  were  due  to  exposure  to  cold  and  wet  during  transportation  or  in  poorly  heated 
or  leaky  tents  or  quarters,  to  insufficiency  of  clothing  or  bedding  or  to  sudden  changes  in 
the  weather  for  which  no  adequate  provision  had  been  made.  Bronchial  inflammations, 
pneumonic  congestions  and  solidifications,  larvngeal  congestions  and  oedema  were  the  most 
prominent  of  the  dangerous  conditions;  but  sometimes  the  diseased  action  was  manifested 


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MEASLES. 


651 


oil  tlio  intestinal  mucous  uienibrano.  Exposures  during  and  after  convalescence  were  also 
pi-oiie  to  1)0  followed  by  pulmonary  disease,  wliich  augmented  the  death-rate  from  pneu- 
monia and  tlie  number  of  discharges  for  disability  resulting  from  chronic  bronchitis  and 
consumption.  Moreover,  in  subsequent  epidemics  of  other  diseases,  as  of  typhoid  fever, 
those  who  had  been  prostrated  by  measles  became  more  severely  affected  than  those  who 
liad  escaped  the  rnbeolous  infection. 

Aft.  Ass't  Siirr/enu  Ai.fkedMt'LI.eh,  Fort  Hidt/rlei/.  Minn.,  J2>rill,  lf<fi2. — In  February  measles  ajipeared  in  tlie  fiar- 
Tisoii  with  the  return  from  furli)Ui,'li  of  two  soldiers  from  this  lower  part  of  the  Minnesota  valley,  where  the  disease  was 
])revailing  at  the  time.  Successively  nearly  all  the  men  of  the  command  here,  who  had  not  jireviously  suffered  from 
the  disease,  were  taken  sick.  Most  of  the  patients  (including  a  great  many  children  at  this  post)  passed  through 
the  attack  with  but  little  treatment  other  than  the  exercise  of  needful  cmtiou  against  exposure  to  cold.  \o  secondary 
affections  commonly  following  this  eruptive  fever  came  under  my  observation. 

Siirijion  W.  \Y.  Brown,  Itli  X.  H.,  St.  Augustine,  Fla.,  May  1,  1803. — Our  first  case  of  measles  occurred  at  Man- 
chester, N.  n.,  in  the  person  of  a  middle-aged  man  in  whose  family  that  disease  existed  at  the  time  of  his  enlistment. 
He  asserted  that  he  had  the  disease  in  early  life.  About  twenty  men  became  infected  by  liim.  These  had  as  mild  an 
attack  as  could  be  desired  and  fully  recovered.  Our  next  lot  of  cases  was  larger  and  of  a  more  severe  type,  as  the 
"weather  was  much  colder.  Nearly  all  of  them  Imd  pneumonia,  nujre  or  less  severe  and  alarming  according  to  the  age, 
constitution  and  habits  of  the  patients.  All  were  immediately  renu)vcd  from  our  hospital  tents  to  the  warmer  atmos- 
jihere  of  a  house  in  the  city;  also  all  new  cases  as  soon  as  they  manifested  the  premonitory  syniiitoms  of  the  disease. 
Several  of  these  assumed  a  typhoid  character  and  died  notwithstanding  our  eH'orts  to  save  them.  After  arriving  at 
INew  York  and  being  subjected  to  the  close  quarters  assigned  them  there,  our  men  suffered  from  measles  in  a  form 
that  is  never  seen  in  New  Hampshire  in  civil  life.  Some  patients  afi'eeted  in  the  ordinary  way  until  the  eruption 
fully  appeared,  and  concerning  whom  we  were  not  at  all  apprehensive,  would  suddenly  become  listless  and  stupid;  the 
eruption  over  the  whole  surface  of  the  body  assumed  a  dusky  hue;  the  ]iulse  increased  in  frei|Uency  and  the  rivspira- 
"tion  became  more  rapid  and  labored.  On  auscultation  and  percussion  we  found  signs  of  congestion  or  hepati/atiun, 
"We  saved  some  of  these  by  activti  stimulation  w  ith  brandy  internally  and  rubefacients  externally.  In  others,  con- 
stituting a  more  hojieless  class  of  cases,  tlic  purple  color  of  the  skin  was  ]iresent  from  the  very  onset.  In  this  variety 
■the  eruption  did  not  ajipear  very  distinctly  or  not  until  ni'ar  the  close  of  life.  In  all  these  cases  a  decidedly  stimu- 
lating course  of  treatment  was  adojited  from  the  fust,  and  by  great  exertion  some  were  saved  that  would  liave  been 
lofit  had  any  other  view  been  taken  of  the  character  of  the  disease.  External  rubefacients,  such  as  nnistard,  with 
internal  stimulants,  constituted  the  main  features  of  our  treatment  in  this  form. 

Surjicon  E.  J.  Bonink,  2(1  Mich.,  Vpton's  IliU,  Vii.,  Oct.  4,  18G2.— The  only  epidemic  we  have  had  was  nu-asles  of 
a,  very  mild  type.  It  made  its  iirst  appearance  in  the  beginning  of  July  and  ceased  about  the  end  of  August,  1861. 
AVc  had  altogether  fifty-three  cases  and  no  deaths.  There  was  nothing  peculiar  about  the  course  or  appearance  of 
the  disease;  the  characteristic  erujition  on  the  fauces  was  present  in  the  beginning  of  nearly  every  case,  and  in  a 
majority  there  was  a  slight  diarrluea.  The  treatment  was  generally  iliai)horetic,  with  laxatives  when  re(iuired.  In 
some  cases,  probably  ten,  the  eruption  appeared  after  the  iirst  day's  light  at  Bull  Kun.  The  men  walked  back  to 
Arlington  through  heavy  rain;  they  suffered  much  from  fever  for  some  days,  and,  though  they  all  recovered,  etl'ects 
were  left  which  required  their  subsequent  discharge  from  the  service. 

Surgeon  C.  N.  CuAMrsERL.^iN,  10(/i  Mass.,  Washington,  Ti.  C,  Oct.  1,  1801. — I  am  gratilied  in  being  able  to  state 
that  no  patient  died  of  nu'asles,  although  many  of  those  atfected  were  very  sick  and  had  entailed  uiion  them  the  ordi- 
nary sequehe  of  the  disease,  rendering  their  convalescence  slow  and  tedious  and  making  them  peoiliarly  susceptible 
4o  disease  under  the  unavoidable  exposures  of  a  soldier's  life. 

Surgeon  M.  E.  Gage,  25(7i  TTi-t.,  Camp  HandaJl.  IVix..  Dec.  31,  18G2. — Rubeola  has  been  somewhat  jirevalent  ever 
since  the  organization  of  the  regiment,  and  although  many  cases  have  assumed  a  considerable  di-grco  of  severity  but 
little  difficulty  has  been  met  in  conducting  them  to  a  hap]iy  termination  by  mildly  anti]>hlogistic  measures.  Nau- 
seants  and  expectorants  were  the  remedies  mostly  administered,  with  sometimes  counter-irritants  over  the  chest. 

Surgeon  J.  JI.  CrYi.ER,  U.  S.  A.,  Medical  Director,  Fortress  Monroe,  Va.,  Jan.  28,  18fi2. — I  have  also  to  report 
another  invasion  of  rubeola,  brought  here  by  the  troops  of  General  Butler's  expedition  on  board  the  transport  Consti- 
tution. A  ward  at  the  general  hospital  has  been  specially  prcjiared  for  cases  of  measles  ;  and  in  order  to  circumscribe 
the  diseas(\  as  much  as  possible,  all  the  cases  brought  on  shore  are  treated  there.  Generally  the  disease  is  of  a  mild 
■character  and  thus  far  unattended  with  those  sequehe  which  have  heretofore  rendered  it  so  troublesome. 

Surgeon  Ezra  Reed,  21st  hid.,  Locust  Point,  Baltimore,  Md.,  Oct.  7, 1801. — During  the  umnth  of  September  rubeola 
in  a  niihl  form  was  very  prevalent;  but  no  death  was  occasioned  by  it.  Pulmonary  and  intestinal  irritation  gener 
ally  coexisted,  manifested  by  troublesome  cough  and  diarrhu-a;  but  in  the  convalescence  there  were  no  accidents 
and  no  supervening  structural  derangements.  Altogether  the  recoveries  have  been  more  satisfactory  than  I  have 
ever  known  in  a  like  number  of  adults.  In  the  treatment  but  little  medicine  was  reijuired  with  the  excejition  of 
smodynes  an<l  astringents.     The  epidenuc  is  now  declining  and  but  few  cases  are  reported. 

Asv'l  Surgeon  II.  M.  Si'Kague,  r.  S.  A.,  Alton,  III,  March  31,  1802.— In  the  13th  V.  S.  Infantry  no  case  of  nu'asles 
»v!is  severe  in  its  primary  etl'ects.     Many,  however,  suffered  from  bronchitis  with  marked  debility,  and  a  few  seemed 


652  THE    ERUPTIVE    FEVEKS. 

to  develop  tuberculosis.     I  found  the  latter  class  to  lie  of  pbtlilsieal  families  and  usually  young  and  undeveloped 
liliysically.     They  have  lieeu  di.seliari;ed.     In  no  case  did  ]ineunii)uia  supervene  upon  the  <Usease. 

Surijioii  John-  (i.  F.  Holstkn.  T.  .S'.  Tn/.s..  (h-irlnn  Jluspilnl.  .Viiiijiliif!,  Tinn.,  Xov.  20,  1862. — All  the  new  regi- 
ments coming  down  the  river  are  atleete<l  with  measles  of  a  somewhat  severe  type.  I  lind  it  impossible  to  effect 
perfect  isolation,  yet  hitherto  no  case  has  lieen  developed  here. 

Siiri/iOii  C.  J.  Waltox.  '2lft  Ki/..  Mitnli  31.  1S62. — At  the  beginning  of  the  (luarter  the  regiment  was  encamped 
about  half  a  mile  southeast  of  Green  Kiver  bridge,  in  Taylor  County,  Ky.,  in  a  bend  of  the  river  making  three-(iuar- 
ters  of  a  circle  one  mile  in  diameter,  on  low  swanqiy  land,  witli  a  tough,  clammy  clay  underlaid  with  slate-stone. 
The  soil  and  clay  were  so  impervious  that,  after  a  light  show  er  or  snow,  the  water  stood  in  any  little  basin  upon  the 
surface  for  some  hours,  and  but  very  little  walking  over  the  streets  made  a  mortar  sufticieutly  tough  for  building 
purposes.  The  soldiers  were  occupying  bell  tents:  using  water  from  a  swampy  spring;  living  principally  upon  bacon, 
salt  pork  and  badly-cooked  beef,  with  tough,  heavy,  hard  bread,  few  vegetables  and  a  good  supply  of  cotfee  badly 
served  up.  They  were  well  clothed  and  each  had  a  pair  of  blankets.  They  slept  upon  a  scanty  sup])ly  of  straw  on 
the  ground,  without  brush  or  boards  under  tlu'm.  The  season  was  unusually  wet — so  much  so  that  there  was  scarcely 
one  day  in  the  week  that  any  drilling  could  be  done.  In  a  word,  nearly  every  circumstance  was  against  the  health 
of  the  camp.  Our  regiment  was  composed  of  about  an  equal  number  of  recruits  from  Lexington,  Ky.  and  vicinity, 
and  from  the  Green  River  country.  The  latter,  with  few  exceptions,  had  not  had  measles.  This  disease  broke  out 
among  otir  troops  at  Canipbellsville,  Ky.,  before  we  moved  to  the  bridge  in  the  month  of  Xovember,  and  raged  with 
fearful  violence,  but  was  attended  with  but  little  mortality,  leaving,  as  is  always  the  case  in  the  army,  those  who 
had  had  it  very  much  debilitated  and  ojien  to  the  invasion  of  such  diseases  as  are  occasioned  b}'  exposure  to  cold, 
the  i-esults  of  which  may  still  be  seen  in  abundance  about  our  camp.  Eight  hundred  and  sixty-eight  men  were 
treated  during  the  quarter,  besides  a  large  number  of  coughs,  colds  and  trivial  aft'cctions  that  were  not  entered  on 
the  record. 

Siiri/coii  Loris  Watson,  16//i  IU.,  PosI  Surgeon,  St.  Joseph,  Mo.,  Dec.  31. 1861. — Most  of  the  eases  of  rubeola  have 
exhibited  a  typhoid  tendency  and  have  been  followed  by  bronchitis,  with  loss  of  voice,  jmeumouia.  otitis  and  aliscesses 
under  the  jaw.     These  sequehe  have  been  troublesome  and  have  protracted  recovery  several  weeks. 

Surgeon  James  M.  Bates,  13//i  JAc,  Ship  TflancI,  Miss.,  March  31,  1862.— During  the  first  half  of  the  (juarter  the 
regiment  was  encamped  at  Augusta.  Me.,  in  the  "Harding''  tents,  each  of  which  was  provided  with  a  stove,  with 
good  hard  dry  wood  as  fuel.  During  Decemlier  and  January  many  of  the  men  were  attacked  with  measles,  there 
having  been  during  the  two  mouths  one  hundred  and  twenty-six  cases.  The  contagion  was  brought  into  camp  by 
one  of  the  recruits.  Many  of  the  cases  were  of  a  severe  tyjie,  accompanied  with  acute  bronchitis  and  some  with 
congestive  conditions  of  the  lungs,  owing  jirobably  to  exposure  in  camp  prior  to  admission  into  hospital. 

Surtjion  William  IIexhy  Thayer,  lilli  X.  H.,  CarroUton,  La..  May  I,  istil. — Measles  commenced  in  February, 
1863,  and  lasted  till  the  removal  to  Washington  in  April.  .Some  of  the  early  cases  were  very  severe,  of  typhoid  char- 
acter, and  two  were  fatal.  The  attendant  bronchitis  in  many  lasted  for  weeks.  It  has  been  recently  suggested  that 
this  disease  arises  from  a  cryptogamous  jilant  growing  on  the  straw  used  for  bedding.  Whether  this  theory  will 
stand  the  test  of  further  investigation  may  be  questioned:  nevertheless  it  is  proper  to  state  that  during  the  winter, 
from  December  to  April  inclusive,  straw  was  used  for  bedding,  but  it  has  not  been  used  since  theu.* 

Surgeon  Geouge  A.  .Spies,  i7th  Ohio,  Gauhy  Mount,  Va.,  March  31,  1862. — The  regiment  became  infected  with 
measles.  January  10,  by  a  soblier  who  had  visited  a  friend  in  hospital  at  Summerville,  where  the  disease  was  prevail- 
ing. Fifty-nine  men  becaiue  affected.  The  attack  was  characterized  by  great  prostration  of  strength  and  putrescent 
tendency,  and  was  complicated  with  bronchitis,  pneumonia,  diarrhiea  and  dysentery.  At  the  beginning  the  fever 
was  asthenic  in  the  feeble  and  indammatory  in  the  more  robust.  It  is  remarkable  that  all  the  patients  were  Ameri- 
cans: no  European  was  affected,  althuugh  the  regiment  consists  of  Americans  and  Europeans  in  equal  number. 
Probably  most  of  the  latter  had  already  suffered  from  the  disease,  as  the  exanthem  in  Europe  is  chietl}'  seen  among 
children  and  young  persons. 

Medical  Inspector  G.  K.  JonxsoN,  U.  S.  .1.,  Baltimore,  Md.,  April  23.  1861. — An  unusual  mortality  from  measles 
occurred  in  February  in  the  Mansfield  hospital,  Morehead  City,  N.  C.  There  were  thirty-seven  admissions  for  this 
disease  in  that  month  and  the  latter  part  of  .lanuary.  All  the  cases  firogressed  favorably  until  Feliruary  IT.  At  that 
time  the  weather  became  intensely  cold,  and,  as  the  supply  of  wood  was  deficient,  the  wards  cotild  not  be  kejit  prop- 
erly warm.  A  number  of  cases  at  once  assumed  a  bad  character  and  eight  died  soon  after.  Autopsies  revealed  in 
two  instances  pulmonary  congestion  and  inflammation,  and,  in  four,  intense  inllaunnation  of  the  intestinal  nmcous 
membrane,  extending  from  the  pylorus  to  the  rectum. t 

About  thirty-seven  cases  of  measles  were  admitted  into  the  Hammond  hospital  in  March.  At  the  date  of  my 
visit  four  of  them  had  died  of  pulmonary  complications  and  several  others  were  then  suffering  from  like  causes. 
These  patients  were  in  a  poor  ward, — the  poorest  in  the  hospital.  It  was  cool,  damp  and  not  very  comfortable;  and 
to  this  I  was  inclined  to  attribute,  in  part  at  least,  the  proneness  of  the  disease  to  these  accidents.     Exposures  to 


*  It  is  needless  at  this  date  to  do  more  than  refer  to  tfie  views  of  Salisbury,  -who  attriijuted  the  disease  to  a  fungus  on  tlie  bed  straw  used  by  the 
troops.     See  American  Jour.  Med.  Scienreit,  Vol.  XLIV,  X.  S.,  1862,  pp.  1T-2;J  and  Jip.  387-304. 

■f-Surgeon  J.  B.  Bellaxoee,  V.  S.  Vols.,  in  charge  of  this  hospital,  has  repcrted  these  ociurrences — .Imer.  3[eil  Times,  VIII,  X.  Y.,  IfiH.  jip.  2."j8-;i. 
The  thermometer  fell  suddenly  from  01°  to  ls°  Fahr.,  witli  a  'oM  northKe^t  niud.  The  bail  elf'ets  of  the  low  temperature  were  soon  maiiif.'sti'd  by  thu 
occurrence  of  a  dry  husky  voice  and  distressing  cough  in  the  rnbeolous  patients,  soon  fulh.wcd  by  'liarrh.ea,  attendc<l  in  a  few  days  witli  bloody  tlis- 
charges,  very  fn-'iuent  in  some  cases  and  quickly  fatal.  Dr.  Hf.llasgek  puts  the  number  of  cases  at  thirty-nine,  of  which  eight  died, — six  of  enteritis, 
oQe  of  acute  broocbitis  aad  one  of  sudden  pulnionar}'  congestion. 


MKASI.KS.  G53 

damimoss,  to  a  low  and  tluctuatiii^  tenijii-ratiiri^  and  to  vitiated  air  diuinij  tlic  ]iro;;r<'ss  of  tin-  disease  arc,  I  am  oon- 
vinocd,  I'ruitfiil  causes  of  serious  and  often  fatal  visceral  congestions  and  inllaniinaliuns. 

Siiryion  Vi".  M.  Gates,  22<l  Mo.,  Ihc  SI,  18H1.' — The  rej;inient  is  ])rin(iiially  eomiioscd  of  men  wlio  liave  been 
engajjed  in  a),'ricultural  ]>ursuits,  owning  tlieir  owu  farms  and  living;  in  tlicir  own  houses  in  reasunaldo  comfort. 
They  have  been  accustomed  to  a  life  of  labor  without  iindcrfioing  any  fjreat  hardshiiis  or  l)ri  vat  ions,  their  food  ]daiu 
and  frugal  and  their  habits  correct.  A  smaller  jiroportion  of  the  men  of  the  n-gimenl,  enlisted  in  towns  and  villa"is, 
Ijrincijially  foreigners,  have  lived  more  irregular  lives  and  their  haliils  are  much  less coriect.  The  hittiT  have  suf- 
fered somewhat  from  diseases  to  which  such  subjects  arc  always  liabh>,  wliieli  diseases,  however,  have  l)ecn  either 
lessened  or  jireveuted  by  proper  discipline.  The  location  of  the  caniji  in  Macon  City  was  well  selected  from  the  sani- 
tary ]ioint  of  view,  being  iii)on  an  elevated  jdateau  which  atlbrdcd  drainage;  but  as  the  tcnis  were  of  the  smallest 
size  and  without  flies  they  were  inconvenient  and  often  crowded.  Under  these  circumstances  it  was  dillicult  to 
enforce  that  desirable  degree  of  neatness  and  cleanliness  favorable  to  jierfect  health.  The  troop.s  renmined  in  camp 
until  the  cold  season  \yas  far  advanced,  and  suffered  much  in  consecjuenco  of  some  severe  storms  which  occurred  jire- 
vious  to  their  removal  to  winter  cjuarters.  The  evil  eftects  of  tlieir  exi)osure  wimo  heighteni'd  by  the  fact  that  their 
clothing  was  not  supplied  in  proper  time  and  when  furnished  was  found  to  be  of  poor  (lualily.  They  sufl'ered  espe- 
cially from  the  want  of  overcoats,  wliich  were  not  provided  until  sometime  aflcr  the  winliT  h.id  set  in.  Their  Coals 
were  of  too  light  a  fabric  to  ati'ord  sutiicient  warmth  and  jirotection  and  were  destilnle  of  capes,  'J'hey  have  never 
yet  been  fully  furnished  with  boots,  although  greatly  needed.  In  consec|uenceof  thi'so  causi's,  tlie  inlluenco  of  which 
has  been  much  increased  by  the  severe  duties  in  which  they  have  been  engaged,  and  which  consisted  in  almost  inces- 
sant scouting  over  a  wide  extent  of  country  in  northern  Missouri,  .1  large  projiortion  of  the  men  Iia\  o  BUtlVreil  from 
those  forms  of  disease  which  result  from  e.\i)osure  to  cold  and  atmosphcrio  changes,  as  catarrh,  bronchitis,  pleurisy, 
pneumonia,  etc.;  from  the  coutinuanco  of  their  causes  these  diseases  were  dillicult  to  tri'at  successfully,  and  relapses 
were  of  frequent  occurrence,  AVliile  the  health  of  the  regiment  was  in  this  unfavoralde  condition,  ineash'S  made  its 
appearance  on  October  IG,  connnunicated  by  the  'J'-Ul  Missouri  regiment,  which,  returning  from  .St,  I.ouis,  remained 
some  days  at  this  station,  Xotwithstanding  all  cllbrts  to  isolate  the  earliest  cases  the  disease  soon  became  general, 
seizing  upon  every  one  not  proti-cted  by  a  former  attack.  The  number  of  th<se  was  laige,  as  the  regiment  wasrecriiiteil 
from  a  scattered  rural  jiopulation.  The  disease  inesented  no  dillieulty  in  its  ttiatment  whi'ii  iiiKoiuplicatcd,  but  from 
the  causes  nu'Utioned,  many  cases  were  complicated  with  broiK'hilisaiidcata'rlial  |>neMnionia.  Ib'iice  thi^  large  number 
of  deatlis  rejiorted  as  due  to  jim'umonia.  As  a  number  of  our  jiatients  wiMn  su  tiering  from  catarrh  and  bioncliitis  on 
the  accession  of  nuasles,  and,  as  might  be  feared  under  the  circumstances,  |ineumiinia  woulil  soon  super\enc,  our 
troops  went  immediately  into  w inter ijuarters.  Thi's<!  consisted  of  unoccupie(l  houses  in  the  town,  generally  in  iiniicr- 
feet  repair,  many  of  the  windows  being  broken,  doors  gone,  ]ilasteriiig  knocked  down  from  the  walls  and  the  build- 
ings otherwise  injured.  They  were  for  tlie  most  part  destitute  of  fire-plai'cs,  and  the  trooiis  without  stoves,  wliicli, 
up  to  this  date,  have  been  but  partly  siijiplied.  The  (juartcrs,  owing  to  these  ciri'umstanccs,  were  uncomfortable  and 
unfavorable  to  the  health  of  the  men, — so  much  so  that  it  lias  been  found  dangi'i'ous  to  return  convali'seents  to  <i  nat- 
ters for  fear  of  relapse.  liy  the  labors  of  the  men  and  etibrts  of  the  olliieis  the  (inarti'rs  ari'  now  in  much  ln-tler 
condition,  and  we  ha\e  reason  to  hojie  that  in  a  sliort  time  tlicy  will  be  further  improved. 

.I».s7  Siiryion  S.  Cdmi'TOX  Smith,  -M/i  TIm.  ('<tr.,  Itihuj  //»«»(•,  MtL,  Scjit.  .'iO,  IXlil, — .\t  l{acin<'  rubeida  made  its 
appearance  among  the  troops,  ami  whei\,on  .July  2,  the  regiment  was  mustered  into  the  service  of  the  rnited  States, 
there  were  two  hundred  cases  of  that  disca.se,  Kacine  is  situated  on  the  west  bank  of  I.ako  Michigan,  where,  until 
the  time  we  left  for  the  South,  cold  easterly  winds  iirevailed  which  greatly  aggravated  the  sei|inda'  of  rul»-(da,  par- 
ticularly congestion  of  the  lungs.  The  disease  continued  to  spread  through  the  regi'nent  to  such  an  extent  that 
during  our  transportation  to  Ilarrisburg  I  liail  two  and  pait  of  the  time  three  passenger  cars  tilled  with  rubeolous 
patients,  and  was  obliged  to  leave  about  twenty  at  Elniira,  N.  V. 

Asn't  Siirgion  'W.M-TKK  B.  Morrison,  .IJ  Mich.,  luhidnVn  T'lrrij,  Mil.,  fkt.  2.">,  IXIf. — l\'ubeoIa  made  its  ajipi'arance 
in  the  command,  previous  to  iinisteriiig  into  the  I'liited  States  service,  while  at  tin'  recruiting  rende/vons,  (Jraiiil 
Eapids,  Mich.  The  di-sease  sjucail  rapidly,  seizing  u)ion  all  who  had  formerly  escaped  the  malaily.  anil  indeed,  a  fi'W 
suft'ered  a  second  attack.  The  acme  of  the  epidemic  was  reached  in  aliout  twenty  days,  after  which  its  decline  was 
rapid,  the  di.sease  having  become  nearly  extinct  when  tlio  command  was  ordered  to  Washington  two  weeks  subse- 
quently. Occasional  cases  were  developed,  however,  during  the  succeeding  two  months.  Kour  deaths  occurred  iii 
one  hundred  and  thirty-four  cases.  Secondary  i)ulmonaiy  affections  were  of  freiiuent  occurrence,  owing  to  exposure 
during  cold  and  damp  weather.     Many  men  were  ]iermanently  disable<l  and  discharged  from  the  service. 

Act.  AshH  ffiirtjcuii  A.  B.  Shai.f.r,  Xiirjtort  ll<iyriirl>i,  Kij.,  April  .T,  1^02. — There  were  thirty-four  cases  of  measles. 
Many  of  the.se  were  treated  in  Sibley  tents  with  board  Hours  and  a,  stove,  without  a  single  complication;  others 
were  cared  for  in  a  new  temporary  hosjiital  consisting  of  two  airy  rooms.  Every  case  in  the  hospital  was  more  or 
less  complicated,  and  the  only  death  from  congestion  occurred  in  this  luiilding.  This  was  in  jiart  due  to  dclicient 
ventilation  at  night  and  in  part  to  want  of  proper  water-closets.  Convalescents  were  exposed  in  going  from  the 
wards  to  the  sinks  in  rear  of  the  hospital  building. 

Siinjron  H.  W.  Kexdali.,  iiOth  III.,  hic.  31,  IStil. — Kulieola  occurred  late  in  November  while  the  regiment  was 
quartered  in  tents  011  an  elevated  and  bleak  prairie  near  Chillicothe,  Mo.,  and  was  followe'l  in  a  majority  of  the  cases 
)iy  pneumonia  and  frei|in'ntly  relapsing  catarrhs.  The  removal  to  St.  .Joseph,  a  distance  of  eighty  miles,  in  ojieu  cars, 
while  most  of  the  cases  were  only  yet  convalescing,  produceil  another  list  of  luieumoiiic  sequehe. 

Suviieon  L,  H.  Ax<;kli..  yi<l  TIL,  I>iv.  ?11,  ISfil. — About  ])eeember  1.  while  in  camp  a;  Benton  liarracks,  measles 
began  to  make  its  ai)pearaucc.     The  exposure  of  the  men  the  first  few  niglits  in  cobl  and  damp  iiuarters  in  a  filthy 


654  THE    KRUPTIVE    FKVERS. 

canij)  lolt  liut  few  of  the  regiiiu'iits  unaffcctod  witU  lniincUitis  or  .some  form  of  inllammatiou  of  the  air  jiassaRcs.  The 
quarters  of  the  men  were  jioorly  or  nor  at  all  veutihiteil,  anil  were  warmed  by  stoves  buruinu;  soft  eoal  (after  stoves 
were  procured),  wUieh  permitted  a  larj;e  amount  of  gas  to  escape  into  the  atmosphere,  so  vitiatinjj;  it  as  to  act  most, 
perniciously  ujion  the  mucous  membrane  of  the  air  passages.  «  *  »  Each  orderly  sergeant  was  furnished  with  a, 
bottle  of  expectorant  medii-iue  which  was  administered  to  the  men  in  (luarters.  At  ^>t.  Joseph,  Mo.,  after  Decem- 
ber 11,  many  cases  of  rube(da  were  accompanied  or  followed  by  pneumonia,  which  is  probably  attributable  to  the- 
exposure  of  the  nuui  at  the  tiujc  and  previous  to  the  attack.  Cases  of  pneumonia  are  occurring  from  exposure  while 
guarding  railroads  and  bridges,  and  I  have  to  cxcum'  from  duty  alarge  number  of  convalescents,  especially  from 
measles,  who  would  be  sure  to  return  in  a  f<-w  days  with  renewed  attacks  were  they  ordered  to  active  service. 

Sttrgcnn  AVilham  H.  rAi,.Mi:R.  nil  X.  Y.  Cur.,  riHihsriUr,  Md.,  Dec.  31,  18C1. — ilany  cases  of  rubeola  occurred 
during  the  present  winter,  and  the  disease  is  still  ou  the  increase.  The  tyjie  is  mild.  The  precursory  symptoms  are- 
attended  with  little  febrile  action:  but  the  pulmonary  aft'ectioii  consecutive  to  the  eruption  has  been  cjuito  severe, 
and  in  many  eases  associated  with  great  and  persistent  dyspnoea  and  complete  aphonia.  Notwithstanding  these 
complications,  recovery  has  been  in  every  case  of  that  degree  which  forbids  apiilication  for  discharge.  Some  of  those 
attacked  aftirm  that  they  have  had  the  disease  before,  Imt  their  assertions  require  confirnurtiou. 

Siirflioii  ,1.  K.  BiGELOW.  Stli  Iiid.,  Tiididiiohi,  Tij-iin.  T'lh.  20.  1861. — Rubeola,  which  occurred  as  an  epidemic  during; 
the  autumn  and  winter  of  ISlU,  was  unusually  complicated  with  pulmonary  lesions  which  frecineutly  en<led  fatally 
or  incapacitated  the  soldierfor  further  service. 

MiiVu'iil  Inxprctov  E.  P.  Toi.l.UM.  T.  .9.  A.,  Wushington,  D.  C,  Die.  1,  18(i2. — There  broke  out  among  the  1st  U,  S. 
Sharpshooters,  while  at  the  camp  of  instruction  near  this  city,  a  form  of  measles  which  directly  or  by  a  subsequent 
congestion  of  the  lungs,  caused  a  large  number  of  deaths.  Jlany,  supposed  to  have  recovered  from  the  disease,  are 
still  sulfering  from  pulmonary  affections  and  jiersisteutly  applying  for  their  discharge.  In  January  of  this  year 
the  1st  Mich.,  while  stationed  at  Annapolis  Junction,  became  subject  to  an  epidemic  of  measles  which  prevailed 
during  that  and  the  following  loonth;  but  the  disease  required  little  attention  except  when  complicated  with  pul- 
momiry  afl'ections,  which,  as  usual,  were  more  formidable  than  the  disease  itself.  One  hundred  ami  ninety-two  cases- 
were  reported,  only  one  of  which  was  fatal.  At  Fortress  Monroe,  during  March  and  April,  while  this  regiment  was 
in  tents,  imeuraonia  and  bronchitis  prevailed  to  some  extent  as  the  sequehe  of  measles,  and  seemed  to  be  induced  by 
the  change  from  an  inland  to  a  nmrine  climate. 

Of  the  recruits  for  the  13th  X.  Y.,  received  about  the  beginning  of  January,  twenty-eight  were  taken  down 
with  nu'asles  soon  after  they  joined.  Four  died  of  i)neumonia  and  two  others  succumbed  to  the  disease  in  general 
hospital.  *  »  »  Jlaiiy  cases  of  measles  in  the  2d  Me.  were  complicated  with  congestion  of  the  lungs,  five  jirovinff 
fatal.  During  the  winter  nine  deaths  occurred  in  the  regimental  hospital,  all  of  which  were  directly  or  indirectly 
attributable  to  measles. 

Surgeon  L.  M.  Sloax.\ker,  \9th  loicci,  Brownsrille,  Texas,  April  20,  ISGt. — An  outbreak  of  measles  occurred  iu 
September,  1862,  and  prevailed  until  tlie  beginning  of  December.  About  thirty  men  contracted  the  disease.  Usually 
it  was  of  a  mild  form  and  when  uncomplicated  rerinired  but  little  treatment.  Some  of  the  cases  transferred  to  general 
hospital  i)roved  fatal:  two  of  those  retained  in  the  regimental  hospital  died  from  pulmonary  complications. 

Surgeon  J.  M.  Merron',  2rf  JV.  if.,  rortsmoiith,  X.  H.,  June,  1861. — There  were  about  fifty  cases  of  measles,  numy 
of  them  complicated  with  pneumonia:  yet  a  rapid  recovery  was  the  rule;  no  case  terminated  fatally.  Treatment 
consisted  chiefly  of  mild  febrifuges  and  diaphoretics,  with  a  mixture  composed  of  antimonial  wine,  syrup  of  squill, 
sweet  spirit  of  nitre  and  paregoric. 

Surgeon  Hexry  Manfred,  22(?  Ki/.,  r,aion  Houge,  La.,  March  29, 1864. — In  December,  1861,  while  at  Camp  Swigert, 
Greennj)burg.  Ky.,  the  entire  regiment  was  attacked  with  rubeola,  two  or  three  hundred  men  being  sick  at  one  tiuu;. 
The  winter  was  very  wet  and  cold  and  many  chronic  ati'ectious  of  the  lungs  were  engendered  by  this  eiiidemic. 

Ad.  Asu't  Surg.  li.  E.  I'ai.mer.  Sau),  Centre,  Minn.,  .fun.  2,  1>'63. — Kubeola.  which  took  its  course  through  the  ca!up„ 
was  introduced  by  Wisconsin  troops.  Severe  pirlmonaiy  irritation,  pneumonia,  diarrluea  and  dysentery  accomiiaiued 
or  followed  the  disease. 

Surgeon  A.  J.  McKelway.  HIJi  X.  ■/.,  Camp  Van  Lear,  near  Alexandria,  To.,  f)ci.  20.  1862. — Toward  the  end  of  Feli- 
rnary  and  through  the  month  of  March  rubeola  to  tlie  extent  of  about  thirty  eases  juevailed  in  the  regiment. 
Although  the  disease  was  of  a  severe  type  no  case  proved  fatal ;  but  in  several  cases  tuliercular  and  bronchitic  devel- 
opments necessitated  the  discharge  of  the  men. 

Aa^'i  Surgeon  J.  W.  Masox,  Vlth  Corps  (VAfri<iue,  J'orf  IJudwn,  La.,  Frh.  23,  1861. — In  September,  1863,  the  camp 
was  visited  with  measles,  mild  in  itself,  but  followed  by  acute  bronchitis  and  pneumonia,  which  either  proved  fatal 
or  left  the  system  in  an  adynamic  condition. 

Surgeon  Jotiiam  DoxxEt.I,,  loth  Me.,  Carolhi  I'li'tt,  Texn",  Fih.  0,  1.S61. — Measles  and  catarrhs  were  very  preva- 
lent at  Augusta,  and  (juite  severe  both  in  the  regimental  camp  and  the  surr<mndiug  country.  A  few  cases  resulted 
in  severe  bronchitis  and  pneiuuonia.  Ko  great  mortality  occurred  at  that  time,  three  men  only  having  died  during^ 
the  winter.  *  *  »  Xlie  ntimerous  cases  of  i)hthisis  jmlmonalis  during  tin;  first  season  at  the  South  may,  I  think,, 
be  attributed  in  part  to  the  measles  and  the  exposures  of  the  men  iit  Augusta. 

>'h»-(/co«  Madisox  Eeese,  118(/t  III.,  Port  Ifuihuu,  I.n..  Fih.  21,  1x61. — 'Iwo-tliirds  of  all  the  imlmonary  disease.'* 
were  caused  by  measles. 

Siirgion  WiLLI.\-M  Dekrv,  'Hi  Kg-,  liaton  Houge,  La.,  .l/iril  27,  1S61. — i>iii!ng  the  latter  jiart  nt'  .Sejitemlier  an<I 
all  of  October,  1861,  measles  prevailed  as  an  epidemic.     Nearly  four  hundred  cases  ocean  ed.     Much  of  I  lie  sulis<'(jiu'nb 


MF.ASLKS. 


655 


disease  from  ■(\'liich  tlie  re]t;imeiit  siittereil  is  attiibuialile  to  tliis  epiiU-inio.  Its  sefnielip  affected  the  nieu  in  two  ways: 
Some  suffered  fromlironeliial  irritation  or  liroiicliitis:  others  iVom  irritaliility  of  the  bowels.  In  suliseijuent  epidemies 
of  typlioid  fever  and  pneumonia,  those  patients  who  had  measU-s  during  tlie  period  mentioned  were  more  dangenuisly 
affected  tlian  their  more  fortunate  comrades. 

Siirnriiit  U.  F.  V.vNDEiiVEKn,  ."Wft  X.  J.,  Ali'.riiii(lriii,  I'd.,  (k-i.  21,  ISlG. — An  epideuii<'  of  measles  ajipeared  ahout 
the  end  of  Feluuary  and  sulisided  in  >[ay.  Twenty-three  eases  occurred  in  tlio  rc^;imcnt  anil  one  ilealh  resnllcd  in 
division  hospital.  The  disease  was  severe,  the  eruption  ofti'U  hecoming  liviil  and  recedinj;  on  the  second  or  third 
d!iy,  which  was  sure  to  he  followed  hy  danucrous  pulmonary  congestion.  This  change  was  often  excecilingly  sudden  ; 
two  hours  sometimes  changing  the  symiitimis  of  rnlieola  to  those  of  tyidiold  jiucumonia.  F.nu'lics  and  stiiiinlants 
were  the  means  of  cure  employed  in  this  condition.     Tnliercular  disease  ajipcared  in  several  instances  as  a  si'(|uel. 

Siiryioii  A.  W.  McC'LUHK.  itii  Imnt,  SpriniiftiUI,  .Vd..  Jjiril  2.  ISlil'. — About  l>ecember  L'(1  measles  broke  out  in  camp. 
A  large  number  of  uumi  were  attacked.  Consecutive  pulmonary  troubles  disaiiiiearcd  only  whi'U  the  wealhi'r  became 
warm,  so  as  to  permit  the  patients  to  get  into  the  open  air.  All  the  fatal  cases  of  pneumonia  exce|it  two  resulted 
from  measles. 

Siii-gcOH  C.  G.  PkaSE,  2(1  ITis.Cuf.,  C((HariUf,  Mo.,  July  1,  1802. — While  at  Milwaukee  we  had  a  large  nnniber  of 
cases  of  rubeola.  To  an  enfeebled  condition  of  the  hings,  conse(|nent  <in  this  disease,  I  attribiito  the  fre<|uency  of 
diseases  of  the  respiratory  organs  that  has  since  occurred;  nearly  all  the  eases  of  tubercular  disease  observed  iu  the 
regiment  since  the  first  of  March  appear  to  have  originated  in  the  previous  attack  of  nu-asles. 

Siinjioii  Fkan'Ki.ix  B.  Ilonin,  '.nth  X.  Y.,  Mircrrsrillc.  .l/o.,  Oct.  5,  IStVJ. — Wliile  recruiting  in  winter  (|iiartersHt 
ISooneville,  X.  Y.,  during  the  winter  of  l?<(il-t)2,  rubeola  )>revailed  as  an  epidemic,  atlacUing  some  lil'ty  or  sixty  men, 
of  whom  thirteen  died.     Many  who  recovered  traced  lasting  pulmonary  dilliculties  to  this  disease. 

The  CLIXICAL  RECORDS  of  iiieaslc's  sliow  .1  ivturn  to  duty  three  or  four  weeks  after  the 
on.set;  but  in  niany  cases  tlie  stay  in  liospital  was  jH-oloiii/cil  for  as  many  months  hy  the 
continuance  of  bronehial  inilammation  or  the  sui)er\cntion  of  liroiirho  [nicumoiiia  or  diar- 
rhoea. In  some  cases  the  speeilic  a'j;"ni'V  maiulrsU'd  its  viruK'nre  hv  a  dark-purple  color  of 
the  eruption  and  symptoms  of  internal  cf)ngestion.  Generally,  howevc^r,  ihc;  puintof  interest 
in  the  record  is  the  consecutive  dis(>ase  rather  than  the  progress  of  the  eruptive  iVvcr.  Boine- 
times  pneumonic  conirestion  was  suddenly  developed  hv  exposure  while  tin'  skin  was  afTected, 
Imt  more  frequiMith'  piilmonai'v  disonk'rs,  ineluding  consumption,  appeared  to  he  engrafted  on 
the  patient  during  convalescence.  Laryngitis  in  some  cases  caused  sudden  death  and  in 
others  a  temporary  or  even  permanent  aplioina.  C'erehral  meningitis  sometimes  occurred, 
and  intercurrent  or  sequent  attacks  of  erysipelas  wer(>  common.  Coniunclivitis  was  a  fre- 
quent sequel,  and  deafness  followed  the  invasion  of  the  middh;  ear  hy  way  of  the  Kustacliian 
tube;  occasionally  the  ear  became  involved  in  the  suppuration  of  the  glands  in  its  neiglibor- 
liood.  QEdema  of  the  feet,  orchitis  and  absci'ss  of  the  ischio-rectal  space,  inducing  ii<tula  in 
ano,  appeared  among  the  sequelos. 

Cask  1. — Private  James  W.  Simmons,  Co.F,,  obth  111.;  age  22;  was  admitted  Feb.  2S,  1st;:!,  from  liis  regiment 
near  the  city,  with  high  fever,  the  eruption  of  nu'asles,  sore  throat  and  lioarseness.  (Jave  Dover's  powder  and  ]ue- 
scribed  rest  in  bed  and  low  diet.  He  improved  si)eedily,  but  some  cougli  persisted  untU  .March  10.  He  was  ri'tnrned 
to  duty  on  the  22d. — llonpital,  Quiiicy,  III. 

Case  2. — Private  Nathan  H.  Moore,  Co.  H,  lliTth  111.;  ago  IS;  was  admitted  .June  !•,  IStll,  from  regimental  camp 
in  this  city  with  the  eruption  of  nu'asles,  some  febrile  exciteuu'ut  and  eoiigb,  pain  in  Ihi!  Imwcls.  ciuistiiiation  and 
coated  tongue.  He  improved  under  treatment  by  sweet  sjvirit  of  nitre  and  syrup  of  Ipecacuanha,  with  rest  in  bed 
and  low  diet.     He  was  returned  to  duty  on  the  2Sth. — Huk^iHiiI,  (Jniiuij,  III. 

Case  3. — Private  Charles  II.  Moulton,  Co.  P,  22d  Mass.;  age  27;  was  admitted  iKim  guard  duty  .Ian.  22,  IStl.S, 
with  measles.  He  had  slight  fever;  his  face  and  the  upjicr  ]iart  of  his  body  were  covereil  with  tlie  eruption,  wliiili 
was  also  discovered  on  the  roof  of  his  mouth;  tlu'rc  existi'd  also  slight  bronchitis  and  con.jnnctivitis.  Flaxseed  tea 
was  juescribed  in  large  riuautities,  with  a  tablespoonfiil  of  Mimlerenis'  spirit  every  thice  hours;  the  diet  was 
restricted  to  milk  aiul  farina.  On  the  2.jth  his  broiu'hitis  was  aggravated;  two  days  later  he  was  nnich  better  iu 
cveiy  respect,  S(iuill,  wild  cherry  and  morphia  having  been  substituted  for  the  acitate  of  ammonia.  Chicken  was 
allowed,  liy  February  ti  he  had  only  a  slightly  inllamed  comlition  of  the  brouehial  and  conjunctival  membranes. 
On  the  isth  he  resumed  his  duties  as  a  member  of  the  hospital  gnard. — ■'<(iUerlie  Iluxpilul,  riiiladilpliid,  I'ti. 

Cask  4. — Private  Lewis  Walters,  Co.  15,  3Pth  >Io.:  age  2S:  was  admitted  Dec,  17,  ISW,  with  alternate  shiver- 
ings  and  heat,  anxiety,  lassitude,  pain  and  weight  across  the  foreliead  ami  eyes;  skin  liot  and  studded  with  tho 
characteristic  eruption  of  measles:  apjietito  jioor.  (iave  cautharides  and  stimulants.  Jan.  20,  ISil."):  Still  weak; 
coughing  severely.  February  20:  Improving  slowly.  March  20:  Still  weak  and  with  severe  cough.  April  1:  Dis- 
charged.— Hospital  Xo.2'S,  Xushiillc,  Tciin. 


656  THK    KKUPTIVK    FKVF.R?. 

Case  "). — Private  Frank  P.  Henian,  Co.  ('.  liitli  T.  S.  Inf.;  ajic  21 :  -was  attacked  Avitli  measles  Jan.  IG,  1863,  and 
transferred  to  Fort  Ontario,  wliere  lie  reniaiiu'd  .sufferinji  from  fever  till  late  in  February,  "when  lie  was  returned  to 
dnt3-  ■with  liis  regiment,  then  werving  in  tlio  Army  of  the  Cumberland.  In  a  short  time  he  was  again  seized  with 
fever,  and  after  staying  about  a  month  in  liospital  at  JIurfreesboro',  Tenn.,  he  was  transferred  to  this  hospital  May 
22.  ^Vlicn  admitted  he  was  scarcely  able  to  walk  :  tongue  coated:  ]iiiIselL'4;  jiaiu  in  eliest :  cough;  slight  exiieetoia- 
tion;  apiietite  impaired;  urine  scanty  and  high-eolored.  Gave  tepid  bath:  Dover's  powder  at  bed  time;  also  sweet 
spirit  of  nitre, syrup  of  squill  and  Xorwood"s  tincture  of  veratrum  viride,  w  itli  comiter-irritation  to  th<'  chest.  21itli: 
Cough;  slight  exjiectoration ;  but  little  pain  ;  jinlse  75;  unable  to  walk.  Oave  paregoric,  syrup  of  sijuill  and  tluid 
extract  of  senega.  June  3:  Pain  in  the  bowels  for  several  days,  relieved  by  jiiiregorie.  Improving;  able  to  walk. 
8th:  Stools  fre(|nent  and  watery.  Gave  nitrate  of  silver  and  opium.  11th:  Severe  chill  at  night  followed  by  fever, 
great  thirst  and  pain  iu  the  bones.  Gave  quinine  and  Dover's  jiowder.  lie  was  transferred  next  day  to  Xo.  1  hos- 
pital, Louisville,  Ky.,  whence  ho  was  returned  to  duty  June  2(1. — lloipiud  Xo.  23,  XushrUh,  Tiiiii. 

Case  C. — Corporal  Aaron  Munsell,  20th  Mich.;  age  20:  enlisted  Feb.  20,  1S(U.  He  contracted  measles  on 
April  13,  and  was  admitted  on  the  2tlth  to  Third  Division  hospital,  Alexandria,  Va..  where  he  became  convalescent. 
On  May  G  he  was  transferred  to  this  hospital.  Gave  compound  tincture  of  cinehmia  and  full  diet.  Keturned  to 
duty  JIarch  21,  ISGo.—Suttirh'i;  JlonpitaJ,  riiilu(U-lphia,  I'a. 

Cask  7. — Private  John  Edeiis,  Co.  A,  13th  West  Va.:  age  l!l;  was  admitted  March  Ui,  l!^65,  with  diarrhiea.  He 
was  convalescing  slowly  when,  on  April  27,  the  eruption  of  measles,  dark  purple  iu  color,  appeared  on  his  face,  lie 
complained  of  great  oppression  aliout  the  chest,  and  ha<l  subsec|iiently  nausea,  jiersistent  vomiting  and  proi'iise 
diarrh<ea.     He  died  May  8. — Cumhcrltaiil  Ilospilal,  Mil. 

Cask  8.— Private  Alfred  Lord,  Co.  (i,  20th  Ind.:  age  22:  was  admitted  Feb.  8,  18ti.'),  with  chronic  diarrhiea.  On 
March  15  he  had  a  severe  chill,  which  was  followed  on  the  17th  and  18th  by  the  eruption  of  measles  over  the  entire 
surface.  On  the  Itlth  the  patient  sat  iit  an  open  window,  and  iu  the  evening  the  eruption  had  almost  disap]ieared, 
while  a  dull  pain  in  the  right  side  of  tlu^  chest,  aphonia,  fever  and  pain  in  the  head  were  devidoped.  Ga\e  diapho- 
retics and  applied  cups.  Next  day  the  pain  in  the  chest  was  increased  and  there  was  dulness  on  percn.ssion  over  the 
lower  lobe  of  the  right  lung;  jiulse  100.  Kepeated  cups  and  ajiplied  sinapisms;  gave  expectorants,  stimulants  and 
beef-essence.  Tlie  pneumonic  C(UMplicatiou  assumed  a  typhoid  character,  and  on  the  2Itli  erysipelas  attacked  the  face. 
He  died  two  days  later,  retaining  consciousness  to  the  last. — Muivir  Iloxpitid,  I'hiUiililpliiti,  I'li, 

Case  9. — Private  O.  P.  I'oster,  Co.  P,  2Gth  Jlich.;  age  lil;  suHVred  with  measles  while  in  cam]).  Pneumonia 
supervened,  and  the  patient  was  admitted  March  12,  1SG3:  Skin  hot  and  dry;  delirium  at  times;  breathing  hurried 
ami  oppressed:  cough  with  viscid,  rusty  sputa:  bronchial  res]iirati(ni  and  slight  dulness  over  the  lower  lobes  of  the 
lungs.     He  sank  gradually,  dying  on  the  IGth. — Tliird  Diri-iioii  ILmpitiil,  AhxiiiHJria,  V(t. 

Case  10. — Private  C.  L.  Brocket,  Co.  G,  ."Oth  HI.:  age  lit :  was  admitted  Fell.  23,  1864.  iu  a  condition  of  typhoid 
delirium  due  to  pneumonia,  which  had  supervened  on  an  attack  of  me.asles.  Ho  was  treated  with  opium  euemata. 
beef-tea,  brandy  and  cordials:  liut  he  grew  worse  and  died  March  1. — llonpital,  Quincy,  III. 

Case  11. — I'rivate  Matthew  Dyson,  Co.  G,  72d  111.,  had  uu'asles  in  September,  1862,  but  did  no  duty  after  his 
convalescence,  as  he  continued  affected  with  cough  and  occasional  diarrhtea.  When  admitted,  April  17,  1863,  he  was 
greatly  debilitated  and  had  bronchial  breathing  on  both  sides.  A  chill  on  the  25tli  was  followed  by  violent  pain  in 
the  right  and  afterwards  iu  the  left  side:  the  respiration  became  hurried  and  the  diarrhtt'a  aggravated.  He  died 
May  3. — Luunon  Hospital,  St.  Louis,  Mo. 

Case  12. — Private  William  A.  West,  Co.  (i,  7th  Vt.;  age  18;  enlisted  Jan.  23.  18G5,  and  had  measles  iu  February, 
followed  by  iialu  in  the  chest.  After  treatment  at  New  Orleans,  La.,  he  was  admitted  to  this  hospital  June  17,  with 
diarrhiea  and  dull  jiain  in  the  region  of  the  liver;  skin  liot;  pulse  full  but  not  strong;  resi)iration  on  right  side 
diminished,  on  left  side  increased.  Gave  cod-liver  oil,  syrup  of  wild  cherry  and  extra  diet,  with  neutral  mixture  as 
required.  On  the  20th  a  sharp  jiain  with  well-marked  friction  sounds  and  dulness  was  developed  on  the  right  side. 
Beef-essence  and  wine-whey  were  given  and  nuish  poultices  applied  to  the  chest.  28th;  Kemoved  ])Oultices.  He 
improved  by  July  1,  but  there  was  still  much  efi'usion  in  the  chest.  He  was  discharged  on  the  20th  because  of  chronic 
diarrhita  and  pleuro-pneumonia. — Sutterlee  llospiiiil,  Philaddphiu ,  Pii. 

Case  13.— Private  Alvin  C.  Kvitt,  Co.  I,  9i)th  111.;  age  22;  was  admitted  Sept.  23,  1863,  with  diarrhiea  and  pneu- 
monia following  measles.  He  had  severe  cough  with  pain  in  both  sides,  headache  with  tiausea  in  the  morning; 
severe  umbilical  pain  when  at  stool, — about  twelve  ])assages  daily.  Gave  turpentine  emulsion  and  milk  diet.  He 
improved  slowly.  l!y  December  5  the  di.irrluva  was  reduced  to  five  or  six  jiassages  daily  and  by  .Ian.  10,  1864.  to 
three  or  four.     He  was  returned  to  duty  March  0. — Hospital,  Quiiicij,  III. 

Case  14. — Private  William  Tibby,  18th  Pa.  Cav.,  was  admitted  JIarch  0,  1861,  with  measles  and  bronchitis. 
Gave  an  expectorant  mixture  during  the  day,  Dover's  powder  at  night ;  nutritious  diet.  On  the  25th  the  eruption 
was  almost  gone  and  the  bronchitis  nearly  cured;  but  dysentery  had  stipervened:  Tormina;  tenesmus;  stools  fre- 
<iuent,  bloody  and  slimy;  pulse  full  and  bounding;  tongue  red,  dry  and  thickened.  Gave  emulsion  of  turpentine 
three  times  a  day  and  an  opiate  enema  at  night ;  milk  and  farinaceous  diet ;  rest  in  bed.  On  the  2itth  the  cough  had 
ceased  and  the  dysentery  was  relieved;  a  cutaneous  eruption  of  doubtful  character  had  appeared.  The  patient  w  as 
returned  to  duty  Ajjril  4. — Second  Difision  Uuspital,  Fifth  Army  Corps. 

Case  15. — Private  Hiram  Steanbrook,  Co.  D,  97th  111.,  was  attacked  at  Memphis,  Tenn.,  Dec.  19,  1862.  with 
measles,  which  left  him  with  a  bad  cough  and  so  weak  that  he  was  unable  to  walk.  When  admitted.  March  21,  1863, 
be  was  emaciated  and  had  slight  diarrhiBa;  pain  iu  left  side;  no  dulness;  edges  and  tip  of  tongue  red,  dorsum  coated; 


MF.ASLKS.  6-")7 

j)nlse  -n-cak  and  rather  frequent.  On  the  2i)tli  he  ■\vas  taken  -witli  erysipelas  of  the  face.  Iron,  iininiuc  and  liran<ly 
were  iirescril]ed.  By  April  1  his  comliticiu  was  nmch  iniincived.  On  the  10th  the  ahdonicn  was  nbserved  t<i  lie  dis- 
colored liy  a  snbcntaneons  extravasation  of  Mooil.  Lemonade  was  ^iven.  This  symptom  disajipeared  hy  the  liitli. 
The  patient  was  returned  to  duty  April  2!'. — l.dirxDU  Huspit<(I,  Si.  Linii".  Mo. 

Cask  111. — Private  Joseph  "\V.  f'onrad,  Co.  IC.  1st  X.  Y.  Knir'rs:  auo  IT:  enlisted  A)iril  I.  ISiU.  and  was  tak<-n 
•with  measles  on  the  2ilth.  He  was  admitted,  May  G.  from  Ilarewood  liospital.  Washington.  D.  C,  with  hronchitis. 
On  the  l-'ith  the  tongue  and  suhniaxillary  glands  beeanie  inflamed:  pleurisy  w-as  developed  on  the  19th,  with  a  large 
effusion  on  the  2Tth.  On  Jnne  11  the  patient's  synijitoms  lieeame  aggravated  on  aeconnt  of  the  lloor  (d'  the  waid 
having  been  scrubbed.  On  ,July  18  he  was  evidently  failing ;  the  effusion  was  being  absorbed  gradually,  but  gurgling 
•was  heard  in  the  apex  of  the  left  lung  posteriorly  and  i-espiration  in  the  snbelavieular  region  was  harsh  and  jmdonged. 
On  August  3  th(^  symptoms  of  jihthisis  were  considered  uueijuivoeal.  Death  took  jilace  on  the  lOth. — Satlii-hi-'  Ilos- 
jiitiil.  I'liilddi'lpliid,  Pa. 

Ca-se  17. — Private  George  Damon.  Co.  C.  11th  Vt.:  age  21:  was  taken  sick  Feb.  20.  18C2,  with  jaundice.  While 
■convalescing  he  was  admitted,  March  (!,  with  lieadache  and  .i  dry  cough  with  bron<'hial  rales.  Next  day  the  eruiition 
of  measles  was  apparent  over  the  whole  surface;  pulse  100;  thirst ;  cough  dry;  throat  sore:  bowels  confined :  urine 
high-colored.  His  case  progressed  favorably  until  the  14th,  when  the  velum  palati  and  arelu's  beeanu^  swollen  and 
red  and  the  voice  whispering.  Later  in  the  day  laryngotomy  was  ]ierformed  an<l  artificial  residration  kept  up  for 
■soiuo  time  without  success. — Siirgt'oii  E.  H.  Si>raijiu,  Utli  /"/.,  UrtillUhoro',  It. 

Case  18. — Private  George  A.  Boyce,  Co.  P>,  11th  Vt.,  had  a  severe  attack  of  measles  .Tan.  1, 18()l,at  Washington. 
a  few  weeks  after  his  enlistment.  He  lost  his  voice  and  became  niuch  debilitated.  While  under  treatment  at  Hare- 
wood  hospital  he  was  taken,  June  4,  with  dysentery.  On  liis  arrival  in  Vermont  via  Davi<rs  Lsland,  New  York 
Harbor,  he  was  in  a  very  low  state.  Treatment  has  relieved  his  diarrluea  and  imi)ro\ed  his  general  condition,  but 
his  voice  has  not  been  restored.     He  was  transferred  to  the  Invalid  Corps  Aug.  21.  18(11. — HoKjiital,  lUiiiimjtoii.  It. 

Case  10. — C.  H.  Flury,  8tli  Mich.  Bat'y,  was  admitted  March  27.  1803.  with  ajihonia.  cough,  painjn  the  chest 
and  diarrho'a  following  an  attack  of  measles  in  >Se]iteuiber,  1802.  He  was  tieatcd  with  alteratives,  turpentine  emul- 
sion and  milk  diet.     He  recovered  his  voice  and  was  sent  to  his  regiment  Aug.  20.  180o. — Ilusiiituh  Qiiiiici/,  III. 

Case  20.— Private  Milton  TI.  Beecher,  Co.  M.  l.">th  N.  Y.  Cav.:  age  20:  was  admitted  May  23,  1864,  from  field 
hospital.  He  liad  been  attacked  with  measles,  April  "i,  at  Burlington.  Vt..  and  had  been  treated  in  hospital  at  Spring, 
field,  Winchester  and  Martiusbnrg.  At  the  last-mentioned  place  ho  had  a  relapse  ami  was  sent  to  this  hospital.  He 
Lecanie  delirious  while  en  route.  On  arrival  he  was  wild  and  unmanageable.  He  was  spongi'd  at  once  and  given  a 
Dover's  powder.  Next  day  his  appearance  was  wild ;  pulse  rapid  and  thready:  tongue  moist  and  natural :  face  tlnshed  : 
slight  dry  cough.  A  cathartic  was  given;  also  an  aiitinioiiial  cougli  mixture;  evaporating  lotions  were  ajiplied  to 
the  head  and  blisters  behind  the  ears.  On  the  2.")th  the  delirium  ccnitinued.  The  patient's  head  was  shaved  and 
<louclied  with  cold  water.  On  the  20tli  there  was  much  jactitation  with  snbsultus  and  dysuria.  Sweet  spirit  of  nitre 
was  given  three  times.  On  the  27tli  there  were  clonic  spasms  and  rigidity  of  the  muscles  of  the  arms,  muttering  deli- 
Tium  and  partial  coma  ;  pulse  120  and  wiry,  with  occasional  remissions.  Fluid  extract  of  veratruin  viride  was  given 
in  three-drop  doses  every  three  hours  and  the  ice-water  to  the  head  was  continued.  Next  day  the  pulse  fell  to  7.">, 
-with  increase  of  volume  and  softness.  After  this  the  coma  deepened  and  the  pupils  dilated.  Iodide  of  potassium  was 
given  with  wine  and  beef-tea.     He  died  Juno  1. — Hospital,  CitmherUind,  Mil. 

C.VSE  21. — Private  James  M.  John,  Co.  I,  8th  Pa.  Eescrves;  age  19:  was  admitted  July  6,  18(34,  on  account  of 
intlamniation  of  the  eyes,  with  purulent  discharge  and  photophobia  following  measles.  Gave  full  diet;  applied  a 
lotion  of  borax.  He  improved;  was  furloughed  Augitst  2(5  and  returned  to  duty  September  6. — Sutterlee  lloxpilul, 
-Philadel^thia,  Pa. 

Case  22.— Private  William  Martin,  Co.  B,  33d  Wis.:  age  20;  was  admitted  Aug.  20.  18(33,  with  slight  congestion 
of  the  conjunctiva  and  photophobia,  the  result,  according  to  the  patient's  statement,  of  an  attack  of  measles  in  Jan- 
uary. Gave  cinchona  and  iron  at  each  meal:  full  diet.  Sejitember  3:  Photophobia  distressing;  appetite  good: 
bowels  regular.  Applied  laudanum  diluted,  but  as  this  proved  too  irritating,. an  infusion  of  tea  was  prescribed. 
7th:  No  better.  Gave  small  doses  of  extract  of  coniuni,  suljihate  of  cinchonia  and  citrate  of  iron  at  each  meal:  the 
-eyes  to  be  kept  shaded.     October  1:  Improving.     November  10:  Keturned  to  duty. — Uonpitid,  (Jiiiiici/,  III. 

Case  23. — Private  George  Tinker,  Co.  K,  2d  Wis.;  age  23:  was  admitted  Sep.  2."!,  1801,  with  lumbago  fidlowing 
an  attack  of  measles  and  intermittent'fever.  He  had  jiain  in  the  loins,  aggravated  by  motion,  and  a  slight  swelling 
■over  the  seat  of  pain;  conjunctivie  intlained;  pulse  72;  tongue  natural.  He  was  treated  by  a  blister  to  the  loins, 
Dover's  powder,  quinine  and  an  eye-wash  containing  sulphate  of  zinc.  He  was  transferred.  October  1,  to  Annapolis, 
Md.,  whence  he  was  returned  to  duty  December  2. — Semiitarii  Hospital,  Geovyetuien,  D.  C. 

Case  24. — Private  George  W.  Gill,  Co.  F,  4th  N.  Y.  Art'y  ;  age  21 :  enlisted  Dec.  11.  ls(i3.  and  contracted  measles 
•while  with  his  regiment  at  Fort  I2than  Allen,  Va.  He  was  treated  in  regimental  hospital,  in  the  Carver  hospital, 
Washington,  and  the  Mower  hospital,  Philadelphia,  before  his  admission  to  this  hospital  May  13,  1804.  He  had 
catarrhal  ophthalmia,  granulations,  purulent  discharge  and  photophobia.  Ajiplied  suliihate  of  copi)er  daily;  full 
diet.  July  20:  Lids  much  inllamed  and  closed;  profuse  purulent  discharge.  Applied  cold  compresses  soaked  in  a 
solution  of  borax  and  atropia.  31st:  Discharge  abated;  indammatiou  subsided.  August  5:  Furloughed.  21st: 
Eeturned.  December  20:  Slight  fever.  3lst:  Much  better.  Jan.  1.  18(5."i:  Pneumonia.  February  1:  Improving 
xapidly.  Gave  iron  and  quinine  three  times  a  day  and  applied  locally  a  solution' of  borax.  March  25:  Furloughed. 
Mki>.  Hist.,  Pi'.  Ill— «3 


658  TUK    KKUPTIVK    FKVEKS. 

April  II):  Returned:  eyes  souiewliat  iullaiiied:  still  feelile.  t'oiitiuued  foiiiiei-  treatment.  Jlay  1!':  Hiseliaryed. — 
Satferhe  Tfospital,  riilladiliihia,  I'd. 

Case  25. — Privato  Alvin  1'.  I'.arnaby,  Co.  M,  1st  Mich.  Cav.:  a^e43:  was  admitted  Aug.  IS,  istil,  from  Hanis- 
biiri;,  I'a.,  with  conjunctivitis  consci|ueut  on  an  attack  of  measles.  The  membrane  was  loose  and  swollen,  and  small 
yellowish-red  vesicles  apiieared  at  the  margin  of  the  cornea  :  there  was  also  a  frequently  recurring  ocular  hypera^niia, 
with  retinal  irritation  and  astbcnoitia :  his  general  liealth  was  fair,  lilisters  were  applied  over  the  mastoid  process 
and  saline  purgatives  occasionally  given  :  pedilu\  ia  were  also  used  :  a  green  shade  was  put  over  his  eyes;  a  lotion  of 
corrosive  sublimate,  three  grains,  laudanum  two  drachms  and  distilled  water  four  ounces  was  applied  lukewarm  on 
rags  for  a  half  hour  three  times  daily;  full  diet  was  given,  lie  improved  steadily.  The  treatment  was  afterwards 
changed  for  an  eye-water  of  bora.K  six  grains,  cherry-laurel  water  fifteen  drops,  decoction  of  (luince  seeds  a  drachm 
and  distilled  rose-water  three  and  a  half  ounces.  .Ian.  2().  ISt!.'):  Furloughed.  February  2."):  Eetnrned.  lie  had  fre- 
quent relapses  till  March  23,  after  which  he  improved.     JIuy  20:  Discharged. — Sattcrhc Ilosjjitul,  rkilaihlpkiu,  I'a. 

C.vsE  20. — Private  James  A.  Muuck,  Co.  ti,  lUOth  I'a.;  age  18;  enlisted  Feb.  2.5,  1864.  Ho  contracted  measles 
and  Avas  admitte<l,  March  27,  to  Division  Xo.  1  hospital,  whence  he  was  transferred  to  Mower  hospital,  Philadelphia, 
and  on  May  13  to  this  hospital.  Diagnosis:  Deafness  of  the  right  ear.  Warm  water  was  used  by  syringe  and  a 
few  drops  of  a  weak  solution  of  sulphate  of  zinc  were  instilled  daily  into  the  ear.  Improvement  followed  and  the 
liatient  was  returned  to  duty  August  0. — SathrUf  Ilotijiittil,  I'liiladclphia,  Pa. 

C.vSE  27. — .Sergeant  Hobcrt  Myers,  Co.  I,  1st  East  Tenn.  Cav.:  age  21:  was  admitted  May  2.">,  1M1;>,  having  lieeu 
treated  in  various  hospitals  for  measles  and  its  seiiuehe  since  Dec.  5,  18(!2.  On  admission  he  was  much  jiros- 
trated,  and  had  pain  in  the  chest,  fever,  nausea  and  irregular  abdominal  pains.  Gave  calomel,  quinine  and  Dover's 
powder  every  three  hours,  with  sinapisms  to  the  abdomen.  2()th:  Xo  fever:  stools  fretiuent  and  copious;  epigastric 
pain,  (lave  powders  of  subuitrate  of  bismuth,  persulphate  of  iron  and  opium.  30th:  Fever;  pulse  full;  tongue 
white  :  pain  in  right  hypochondrium.  Gave  powders  of  quinine,  Dover's  powder  and  ipecacuanha  every  three  hours, 
with  ten  grains  of  blue  nuiss  and  five  grains  of  Dover's  powder  at  bedtiiue.  31st:  Very  weak:  fever;  twenty  stools. 
Continued  powders  and  gave  iiills  of  nitrate  of  silver  and  o])ium.  June  3:  Caught  cold  from  kicking  away  the  bed- 
clothes during  the  night;  lymj  ilia  tic  glands  of  face  niucli  enlarged:  severe  cough  with  tliin  glairy  sputa.  Continued 
medicine:  applied  hot  fomentations  to  face:  expectorants,  i'tli :  liested  badly;  delirious;  pain  in  the  face  from  enlarged 
glands:  diarrlnea  persisting.  Kith:  Purulent  discharge  from  ear:  stupor.  8  r.  .M :  Unconscious;  extremities  cold; 
profuse  suppuration  from  both  ears:  involuntary  stools:  died  at  8.30  i'.  M. — noi<i)Htil  J\'o.  23,  XiishviUc,  Tinn. 

C\SE  28.— Private  William  11.  Shultz,  Co.  li.  30th  111.:  age  21:  was  admitted  March  18,  1805,  from  David's 
Island,  Xew  York  Harbor,  with  ledema  of  the  feet,  following  an  attack  of  measles  in  Deci-mber,  1801,  lioth  feet 
were  swollen  and  pitted  on  pressure.  He  was  treated  with  cream  of  tartar,  s(|uill  and  iodine,  but  without  success. 
He  was  discharged  from  service  May  9. — Hoxpitiil,  (Jtdiici/.  III. 

Case  29. — Private  Rector  Cornwall,  Co.  K.  130th  111.:  was  admitted  April  13,  1803,  with  orchitis,  resulting  from 
exposure  to  cold  while  convalescing  from  measles.  His  left  testicle  was  very  painful  and  enlarged  to  three  or  four 
times  the  natural  size.  Treatment  consisted  of  strapping  and  small  doses  of  mercury  and  chalk.  Improvement 
followed  and  the  patient  was  returned  to  duty  July  20. — Lawaon  Hospital,  St.  Louis,  Mo. 

Case  30. — Sergeant  William  Litter.  Co.  K,  4th  Va.  Cav.;  age  20;  was  .admitted  May  4,  1863,  with  bronclio-pneu- 
nionia  and  diarrhcea  after  measles.  He  was  treateil  with  blisters  and  mercurial  alteratives.  A  large  abscess  on  each 
side  of  the  anus  developed  into  listula.     He  was  discharge<l  from  service  June  27. — Citij  Hospital,  St.  Louis,  2Io. 

Post-mortem  Kecord.s. — The  frequency  of  the  puhiionaiy  Jiffection  in  fatal  case.s  of 
uieaslcs  maybe  appi'cciatei.1  from  the  many  instances  submitted  among  i\\e  po.^t-morteni 
I'econls  of  pneumonia.'-'  In  addition  to  these  there  are  but  seven  recorded  cases:  In  case 
1  the  blood  was  black  and  uncoagulated ;  in  2  and  3  there  was  cerebral  congestion;  in  4 
pleurisy;  in  5  pericarditis;  in  6  sudden  death,  probably  from  heart  failure,  and  in  7  an  exten- 
sive consecutive  inflammatioii  of  the  knee-joint  and  femur. 

Case  1. — William  D.  Emberg,  prisoner  of  war,  was  admitted  May  23,  1864,  with  measles.  Desquamation  was 
in  progress,  and,  as  the  patient  was  debilitated,  tonics  were  prescribed.  Ou  May  26  he  had  chills  followed  by  fever, 
with  frecjuent  feelile  jiulse,  constipation  and  severe  pain  in  the  head,  back  and  limbs.  A  low  form  of  delirium  siqier- 
vened,  and  he  died  .June  4.  Tlu;  attending  idiysician  supposed  the  case  to  be  one  of  typhus,  rost-mortcm  examination : 
The  blood  was  lilack  and  fluid  and  the  tissues  tiabby,  but  no  actual  lesion  was  anywhere  observed. — Third  Dirision 
Hospital,  Alexandria,  V<(. 

Case  2. — Private  S.  Hammock,  Co.  H,  13th  Ky.;  admitted  Feb.  28,  1865.  Diagnosis — Rubeola.  Died  March  16. 
Fost-morlem  examination:  There  was  serum  effused  between  the  membranes  and  the  brain.  The  gall-bladder  was 
collapsed;  the  spleen  enlarged;  tlie  bowels  congested. — Act.  Ass't  Suryeon  J.  E.  Brooke,  Hospital,  Sock  Island,  III. 

Case  3.— Private  Abel  AV.  Taylor,  Co.  B,  32d  Me.;  age  10;  was  admitted  April  22,  1864.  Ho  had  been  sick  for 
about  three  weeks,  having  suffered  during  a  part  of  that  time  from  an  attack  of  mumiis.  On  admission  there  was  no 
parotid  swelling,  1)ut  the  face  was  dusky-red,  the  body  covered  with  the  eruption  of  measles;  the  pulse  was  rapid, 
130;  the  breathing  hurried,  30:  and  there  was  frequent  expectoration  of  rust-colored  mucus,  with  dry  rales  over  the 

*  See  infra,  page  783. 


MEASLES. 


659 


clipst  antfriorly  and  suhcrppitaiil  rales  posteiioily  lint  no  marked  dulness  ;  low  delirium  wa.s  jireseiit.  lie  died  on  the 
24tli.  J'dsl-iiioytciii  exaniinatidu:  There  was  venous  eongestiou  and  lino  arterial  inject  ion  of  the  jiia  uniter,  with  inter- 
stitial eouKestion  of  the  hrain  and  someetfusion  of  bloody  serum  in  the  ventrieles  an<l  subarachnoid  sjiaee.  The  lower 
lobe  of  the  right  lung  w  as  liepatizi-d,  the  pleura  of  the  atTected  part  covered  with  nuisses  of  lymph  and  tlie  iileiiral 
cavity  filled  with  liquid.  The  heart  was  healthy  and  contained  small  red  and  w  hite  clots  in  its  v<'ntricles.  The  liver 
was  somewhat  graunlar;  the  spleen  a  little  softened;  the  other  organs  healthy. — Cuyhr  HospHul,  rkU(i(hlj)liia,  Pa. 

Case  4. — Private  Thomas  Thompson,  Co.  ]I,  20th  Me.;  age  20 ;  was  admitted  April  0,  1864,  presenting  the  gen- 
eral ap]iearauce  of  one  aflccted  with  tubercular  disease  of  the  lungs.  On  the  22d  the  eruption  of  measles  a]>peared. 
I'efore  it  faded  the  patient  was  attacked  with  pleurisy,  and  died  May  1.  roxt-mortim  examination:  The  ai>ex  of  the 
right  lung  contained  tubercle  in  tlie  inllaunuatory  stage ;  the  right  pleura  was  thickened,  adherent  in  places  and  cov- 
ered with  lymph  ;  the  sac  contained  a  large  elfnsicm.     The  liver  was  fatty. —  Third  lUrUiun  JfunjiiUd,  Ahjinidria,  Va. 

Cask  ,">. — Private  Jeftersmi  JIarsh,  recruit,  2Sth  Mass.;  age  24  ;  was  admitted  May  S,  1S04,  with  measles.  On  the 
irith  pneumonia  of  the  left  side  was  dcveloi>ed,  and  five  days  later  the  physical  signs  of  pericarditis  were  observed. 
On  June  1  the  tonsils,  base  of  the  tongue  and  epiglottis  were  found  to  be  extensively  ulcerated,  lie  died  on  the  3d. 
Pos<-Hioi'/cm  examination:  The  blood  was  liquid.  The  trachea  was  much  inflamed  and  dcuinded  of  mucous  membrane. 
The  lower  part  of  the  left  lung  was  consolidated.  The  iiericardiuni  was  nearly  filled  with  serniii.  The  abdominal 
viscera  were  healthy. — Third  Divinion  Hospitui,  Alcxiindriii,  ]'a. 

Cask  0. — Private  James  K.  AValker,  Co.  A,  3d  West  Va.;  agi^  20  ;  was  admitti'd  Ajiril  80,  18()."),  convalescing  from 
measles.  He  was  weak  and  had  a  slight  cough  w  itli  luucoiis  expectoration  ;  but  his  ajipetite  was  good  and  his  tongue 
moist.  He  improved  and  was  feeling  quite  well  when,  on  Jlay  11,  while  sitting  on  Iiis  bed  and  talking  Iio  suddenly 
put  his  hand  to  his  heart,  fell  over  on  the  bed  and  died  w  ithont  convulsions  or  apparent  pain.  I'oKt-mortrm  examina- 
tion: Body  hut  little  emaciated.  Tlie  ujiper  lolic  of  the  right  lung  was  stmlded  willi  lulicnle  and  its  apex  contained 
a  small  cavity.    The  walls  of  the  left  ventricle  of  the  heart  were  hypertrophied  and  softened. — Ciiiiili(r!<iiid  Jloxjiita!,  Md. 

C.\SE  7. — Private  Chester  Morse,  Co.  E,  2d  Colo.  Cav.,  was  admitted  Jan.  ^iO,  ISdl,  with  measles.  As  convales- 
cence progressed  the  left  knee  and  thigh  became  alVectcd  with  jiain  of  a  rheumatic  character,  and  in  time  a  true  syn- 
ovitis of  the  knee  and  jieriostitis  of  the  femur  were  developed.  Large  opiate  doses  were  required  to  alleviate  liis 
Kuft'ering.  liy  JIarch  31  the  tliigli  and  knee  were  much  swollen  and  the  intermuscular  spaces  distended  w  ith  sero- 
purulent  matter,  which  had  established  an  external  communication  for  its  discharge.  Hectic  supervened,  and  death 
occurred  ilay  1.  Fost-mortem  examination:  Bony  spicula  were  fouinl  in  the  diseased  periosteum;  the  outer  condyle, 
and  the  shaft  of  the  femur  at  the  junction  of  its  middle  and  lower  third,  were  honey-conibed  ;  the  cavity  of  the  knee- 
joint  was  filled  with  sero-purulent  matter;  the  outer  part  of  the  head  of  the  femur,  the  great  trochanter  and  the 
digital  fossa  were  involved  in  the  disease. — Iloitpital,  Kainsan  Cily,  Mo. 

Treatment. — According  to  tlio  medical  rocoi'i.ls  of  the  war  the  treatment  of  camp 
measles,  whether  in  the  individual  ur  in  the  Cdmmaiid,  appears  to  have  involved  measures 
of  sanitary  supervision  rather  than  clinical  instructions  or  pharmaceutical  furnuihe.  An 
epidemic  of  measles  in  a  susceptihle  command  subject  to  tlie  exposures  of  active  service  was 
often  as  disastrous  in  its  consequences  as  a  severe  engagement  witli  the  enemy.  Men  and 
regiments  of  men  insusceptible  to  the  poison  of  this  disease  are  by  .so  much  the  more  efficient 
as  a  military  machine.  Recruits  from  the  city  are  more  likely  to  have  passed  through  the 
disease  in  childhood  than  those  fnjm  the  rural  districts, — city  regiments  are  therefore  to  be 
preferred  in  this  connection.  But  when  the  call  to  service  is  urgent  tliis  becomes  a  sec- 
ondary matter;  the  liability  to  disease  under  exposure  to  its  causes  must  be  accepted  as  a 
part  of  the  danger  to  be  faced.  Measles  will  thus  continue  to  be  a  subject  of  interest  and 
anxiety  to  ai-my  medical  men  until  the  discovery  of  a  means  of  protection  against  it  inde- 
pendent of  subjection  to  its  influence  in  previous  epidemics. 

The  mildness  of  the  disease  when  running  its  course  under  favorable  conditions,  as 
compared  with  its  virulence  in  crowded  quarters  and  hos|)itals,  and  the  disability  and  death 
resulting  from  its  complications  and  sequelae  in  commands  exposed  to  the  vicissitudes  of  the 
weather,  suggest  the  propriety  of  an  attempt  to  divest  it  of  its  gravest  dangers  by  an  inten- 
tional infection  at  a  time  when  the  sanitary  environment  of  the  men  may  be  absolutely 
controlled.  Inoculation  for  small-pox  was  practiced  before  the  discovery  of  vaccination. 
Of  late  years,  liowever,  the  eflforts  of  sanitary  officers  have  been  so  successful  in  controlling 
the  spread  of  communicable  diseases  that  few  medical  men  would  counsel  the  intentional 
propagation  of  measles  among  large  bodies  of  newly  organized  and  susceptible  troops.     The 


66i)  THE    KRUPTIVF.    FEVEKS. 

military  necessity  wliieli  r-nlls  tor  tlie  levy  does  iK^t  usually  adinit  of  this  preliminary  cotirse 
of  hospital  treatment:  nur  d'>r>  the  experience  of  uiir  rccnhting  depots  and  camps  ot  urgam- 
zatimi  indicate  this  earlv  pei'ind  of  the  historv  oi  a  rL-u.'iiin'iit  as  prupitious  lur  an  encDtuiter 
with  disease:  Men  and  otiieers  are  alike  ignorant  of  military  methods  and  ot  the  ways  ot 
camp  or  barrack  life.  Privations  are  endured  which  a  larger  experience  would  have  rendered 
wholly  unnecessary,  and  manv  needless  exposures  ai'e  entailed  upon  the  men.  There  is, 
moreover,  in  time  of  war  an  excitement  in  the  atmosphere  of  a,  recruiting  camj)  which  would 
render  the  propao-atinn  of  this  disease  a  hazardous  ex|)eriment,  even  if  conducted  under  the 
supervision  uf  veteran  medical  otHcers. 

At'ter  some  months  of  active  service  the  troops  become  sobered  down  to  the  stern  reali- 
ties of  war.  They  are  better  disciplined,  better  qualified  to  protect  themselves  and  to  appre- 
ciate and  cooperate  with  elTorts  lor  their  protection.  They  may  possess  fewer  facilities  than 
at  an  earlier  period  for  meeting  the  attacks  of  disease;  but  they  are  able  to  utilize  all  that 
are  available.  They  are  perhaps,  except  in  cases  of  unusual  exposure  and  privation,  better 
able  to  protect  themselves  against  the  accidental  introduction  of  measles  into  their  camp 
than  they  were  formerly  to  submit  to  its  intentional  conveyance. 

The  aim  of  the  medical  officer  is  to  prevent  his  men  from  becoming  sick.  Measures 
should  lie  taken  to  exclude  all  known  sources  of  infection:  but  should  these  fail  and  a 
man  become  ai^ected  with  the  disease,  he  shottld  be  promptly  isolated  for  the  protection  of 
the  others,  and  carefullv  guarded  against  the  dangers  that  threaten  his  own  safety.  Blankets 
and  articles  of  clothing-  used  in  common  bv  the  sick  man  and  his  intiiuates  shottld  be 
removed  with  him.  Those  men  that  have  been  most  in  contact  with  him  should  be  restricted 
to  open-air  communication  with  others  of  the  command  until  time  has  been  afforded  for 
further  developments.  The  patient  should  be  well  sheltered  in  an  equable  and  temperate 
atmosphere,  wannly  covered  and  attended  with  care  and  intelligence  for  the  avoidance  of 
unnecessary  exposure. 

Should  a  regiment  or  a  ])ortion  of  a  larger  command  become  affected  arrangements 
should  be  made  for  its  relief  If-om  duty,  its  isolation  from  the  remainder  of  the  troops  and 
the  appropriate  treatment  of  its  sick.  In  this  way  oidy  may  the  epidemic  be  circumscribed 
and  the  affected  men  preserved  for  tluure  service.  The  extracts  that  have  been  submitted 
show  conclusivelv  the  evil  conseqtiences  of  injtidicious  management  during  the  prevalence  of 
measles  in  a  command.  The  duty  of  the  affected  regiment  should  be  to  take  care  of  itself 
until  again  fit  for  military  service,  guarding,  meanwhile,  against  the  extension  of  its  con- 
tagion beyond  the  lines  of  its  isolated  camp.  If  the  cases  are  numerous  adequate  accom- 
modation should  be  provided  lest,  by  overcrowding,  an  increased  virulence  be  developed. 
On  the  subsidence  of  the  epidemic  the  men  who  have  escaped  attack  tnay  be  returned  to 
active  service,  while  the  convalescents  are  retained  or  furloughed  until  restored  to  their 
normal  condition. 

Isolation  proved  inefficient  in  restricting  the  disease  during  the  war;  but  there  is  no 
record  of  its  liaving  been  systematically  carried  out.  The  disease  was  generally  considered 
trivial  by  our  medical  officers,  who  realized  its  disastrous  consequences  only  after  it  became 
too  late  to  effect  its  supj^ression.  Nevertheless  it  subsided  among  our  white  troops  during 
the  warm  months  of  1862  while  new  regiments  were  being  organized  and  mustered  into 
service.  Fresh  air  apparently  controlled  its  spread.  Hence,  in  winter-camps  exposed  to 
the  disease,  efforts  to  prevent  or  quell  an  outbreak  should  be  directed  to  the  removal  of  con- 


MEASLES.  661 

taglous  foci  and  the  dilution  and  disinfection  of  suspected  atmospheres.  In  fact  tlie  sys- 
tematic isoktiun  and  protection  of  tlie  sick  in  hospital  with  free  ventilation  and  sanitary 
supervision  for  the  as  vet  unaffected  members  of  the  command,  may  be  regarded  as  the  only 
trustworthy  measures  for  the  limitation  or  sup]:iression  of  the  disease  and  the  mitigation  of 
its  possible  C(jnsequences. 

The  following  from  the  report  of  Ass't  Surgeon  Bartholow,  U.  S.  A.,*  relates  to  tlie 
therapeutic  management  of  the  disease: 

Many  cases  of  measles,  if  left  to  tbeniselves,  terminate  favorably.  An  increase  in  tlie  excretion  of  nvine,  a 
smart  diarrluea,  are  the  plienomena  which  mark  the  crisis  and  decline  of  the  disease.  We  may  have  the  ojniortuuity, 
when  the  iiroper  time  arrives,  of  prodncing,  imitating  or  favoring  the  occnrrence  of  these  critical  discharges  ;  but  it 
would  be  idle  to  attempt  to  cut  short  an  attack  by  such  means  at  other  periods  of  the  disease. 

In  those  cases  where,  from  malignity  of  the  poison  or  peculiar  states  of  constitution,  patients  do  not  recover 
from  the  first  impression  of  the  morbid  cause,  and  death  is  innnineut  from  cerel)r,"il  disease,  intense  pulmonary  con- 
gestion or  hyiiera^mia  of  the  kidneys  before  the  eruption  appears,  remedial  measures  have  little  i)o\ver  to  avert  a  fatal 
Issue.  Congestion  of  organs  essential  to  life  is  the  chief  source  of  danger.  How  are  we  to  treat  it?  Coma  and 
delirium  are  produced  by  engorgement  of  the  vessels  of  the  brain,  by  extravasations  of  blood  on  the  hemispheres, 
by  indamnuitiou  of  the  meninges  and  by  exudation  of  lymph:  coincident  with  these  phenomena  is,  in  many  cases, 
suppression  of  urine.  I  have  seen  these  symptoms  nuich  imjiroved  by  a  copious  bleeding,  but  the  patient  died  in 
every  instance.  Whiskey,  no  matter  how  freely  administered,  had  no  great  elfieaey.  The  true  way,  in  my  opinion, 
to  treat  this  condition  of  the  brain,  is  to  excite  the  action  of  the  kidneys  by  saline  diuretics,  to  relieve  the  vessels  by 
local  cupping,  being  careful  not  to  extract  too  much  blood,  to  produce  couuter-irritatiou  by  hot  sinapisms  to  the 
extremities  and  by  saline  cathartics,  and  to  remove  a  ]>ortion  of  the  lilood  by  ligatures  to  the  thigh,  applied  tightly 
enough  to  arrest  the  superficial  venous  circulation.  It  is  not  worth  while  to  give  calomel  and  antimonials  in  the 
vain  hope  of  subduing  inllammation;  if  these  agents  possessed  this  power  time  is  not  aftbrded  for  its  manifestation. 

The  most  important  «; /nptoms  and  the  largest  mortality  are  dui>  to  pulmonary  complications.  The  morbid 
anatomy  of  the  disease  mows  that  a  capillary  bronchitis,  accompanied  by  copious  exudation,  lobular  pneunumia,  an 
intense  congestion  of  the  vessels  of  the  lungs  and  a  gorged  condition  of  the  right  cavities  are  the  sources  of  danger; 
the  left  side  of  the  heart  is  found  empty.  These  pathological  focts,  if  they  mean  anything,  teach  that  stimulants  are 
not  indicated.  In  practice  they  produce  only  injury  when  administered  in  this  state.  Bleeding  gives  temporary 
relief,  but  the  patients  die  if  bled.  Mercurials  and  antimonials  do  not  relieve  but  only  add  complications:  nu)rtality 
is  increased  by  their  use.  I  think  we  ought  to  rely  on  counter-irritants  and  eujis  to  the  thorax,  counter-irritants 
and  derivatives  to  the  inferior  extremities,  ligatures  to  the  thighs  to  control  the  venous  circulation  and  on  remedies 
to  maintain  and  increase  the  renal  secretion.  The  best  counter-irritant  in  these  cases  fs  turpentine  applied  as  a  stupe, 
but  not  jiermitted  to  remain  long  in  one  place,  followed  by  warm  applications.  These  remedial  agents  may  be  assisted 
by  sinapisms,  hot  pediluvia  and  small  doses  of  opium.  Active  diuretics  should  be  avoided  not  only  on  aci'ount  of  the 
hyper;emia  of  the  kidneys  but  of  the  irritable  state  of  the  mucous  membrane  of  tlu!  intestinal  canal.  liitartrate,  bicar- 
bonate and  citrate  of  potassa  arc  the  proper  remedies  of  this  class.  They  should  be  given  in  snuiU  doses  largely 
diluted.  If  the  atl'ection  of  the  kidneys  be  a  prominent  symptom,  cups  and  sinapisms  should  be  ajiplied  to  the  loins. 
Remedies  to  control  diarrhcea  are  saline  cathartics  with  tincture  of  rhubarl),  followed  by  astringents  and  opiates. 
When  increased  heat  of  the  abdominal  walls  and  increase  in  the  number  of  dejections  evidence  increase  in  the  hyper- 
lemia  of  the  submucous  tissue  and  enlargement  and  thickening  of  the  solitary  glands  and  follicles  of  Lielierkiihn, 
then  dry  or  wet  cups,  turpentine  stupes  and  sinapisms,  followed  by  Wiirm  moist  applications,  are  indicated. 

The  diet  should  consist  of  nutritive  matters  which  nuiy  be  taken  uii  in  the  stomach  and  duodenum.  Animal 
broths  and  small  doses  of  wine  are  proper.  If  the  intestinal  lesion  be  not  decided,  milk,  eggs,  butter  and  iVesb,  ripe, 
acid  fruits  may  also  be  added.  In  the  stage  of  desiiuanuition  the  skin  is  excessively  sensitive  to  change  of  temper- 
ature; it  is  during  this  stage  that  pneumonia  is  developed  out  of  lobular  pneumonia  and  pulmonary  engorgement, 
and  diarrhfca  and  dysentery  out  of  intestinal  congestion.  Olive  oil,  lard  or  glycerine  is  useful  w  hen  applied  to  the 
desquamated  surface.  Carefully-prepared  nutriment  and  stimulants  become  necessary,  but  the  stimulation  should 
not  be  excessive.  With  the  decline  of  febrile  action  there  is  a  progressive  lowering  of  the  vital  i>owers :  the  kidneys 
resume  their  activity  and  diarrlnra  usually  supervenes, — and  these  phenomena,  although  often  critical,  may  still 
further  reduce  the  patient,  and  therefore  reiiuire  watching. 

During  this  stage,  also,  lesions  of  various  organs  commence  and  progress  without  the  knowledge  of  the  physician, 
if  he  is  not  awake  to  the  prol)ability  of  such  accidents:  daily  examination  should  be  made  of  the  organs  likely  to 
become  atfected.  The  typhoid  state,  which  results  when  the  intestinal  lesion  goes  on  unchecked,  and  when  chronic 
pneumonia  follows  the  lobular  attack,  should  be  treated  by  approiiriate  remedies.  This  state  will  be  less  alarming 
if  proper  nutriment  has  been  supplied  from  the  beginning,  and  if  the  excessive  use  of  brandy  or  whiskey  has  not  so 
impaired  the  process  of  digestion  as  to  prevent  the  primary  assimilation.  It  is  constantly  necessary  to  obviate  the 
tendeuej'  to  death.  The  physician  should  study  this  tendency,  whether  by  the  brain,  the  lungs  or  the  intestinal  canal, 
and  be  prepared  to  counteract  it.  In  camp  measles,  more  than  in  almost  any  other  disease,  is  the  physician's  duty  one 
of  care  and  watchfulness. 

*  See  note  st#pra,  page  049. 


662  TII>:    ERUPTIVE    FEVERS. 

III.- -SCARLET   FEVER. 

Searlft  ll-vor  was  rarulv  Sfuu  Juriuii;  tlio  war.  A.  iVw  cases  orcunvd  at  iiUt-rvals  ia 
most  of  the  large  military  forniiuinils,  Imt  the  disease  does  not  a})|n'ar  to  Jiave  spread  in 
any  instance  from  the  primarv  case.  Tlie  records  do  not  show  whether  this  immunity  was 
due  to  antecedent  attacks  or  to  insusceplibilitv  developed  by  age  and  independent  of  pre- 
vious exposures.  Among  the  wliite  troops  578  cases  were  reported,  70  of  wliich,  or  12.1 
per  cent.,  were  fatal;  among  tlie  coloreil  trooj'S  the  cases  munljered  1  IS,  with  2  deaths, 
erpiivalent  to  a  fatalitv  rate  of  only  1.7  pel'  cent.  This  was  therelore  one  of  the  exceptional 
diseases  less  fatal  to  the  negroes  than  to  the  wlute  men. 

The  medical  records  contain  only  the  following:  1  and  2,  imdouhted  scarlet  fever;  3, 
entered  as  a  case  of  2'>>''''pura,  and  4,  perhaps  a  sequel  of  measles,  although  regarded  by  the 
medical  officers  in  attendance  as  a  se(juence  of  scarlet  fever. 

Case  1. — Piivati"  Dominic  AVoyIiiih"!,  Co.  G,  4th  Minn.;  age  25;  was  admitted  Ma.v  10,  1863,  with  a  spraineil 
ankle,  and  was  next  day  tianslt.Tied  to  tlie  convalescent  ward,  where  lie  assisted  as  Burse.  Ou  June  1  ho  was  read- 
mitted and  on  the  2d  scarlatina  was  diagnosed ;  pulse  120 ;  skin  hot ;  temperature  102°  Fahr.  Prescribed  tartar  emetic 
two  grains,  chlorate  of  potash  eight  grains,  nitrate  of  potash  one  scruple,  Flemmiug's  tincture  of  aconite  twelve 
drops,  camphor  mixture  eight  lluid  ounces  ;  to  take  a  talilespoonfiil  every  four  hours;  the  throat  to  lie  swabbed  with 
a  strong  solution  of  nitrate  of  silver;  chlorate  of  potash  to  be  used  as  a  gargle;  gave  also  a  full  dose  of  castor  oil  and 
sponged  the  surface  with  te])id  water,  lie  was  convalescent  on  the  7th,  but  had  a  slight  wcikness  of  the  eyes. 
Ketunied  to  duty  Jul}-  21.1. — Lawson  IJosintal,  St.  Louix,  J/o. 

(/.vSE  2.— Private  Charles  II.  AVitham,  Co.  D.  31st  Jle.;  age  21:  was  admitted  May  7,  l.^(il,  v.itli  high  fever  and 
delirium;  sore  throat  and  a  scarlet  rash  covering  the  wliole  of  tlic  body.  Neutral  mixture  and  muriate  of  amiiHuiia 
in  three-grain  doses  every  four  hours,  with  alum  and  chlorate  of  potash  as  a  gargle,  weie  used  in  the  treatment.  lu 
four  days  the  rash  disappeared,  the  fever  abated  and  the  throat  improved,  but,  as  the  patient  was  much  prostrated, 
milk-punch  was  administered.  On  the  13th  he  was  seized  with  great  dyspnu'a,  excessive  irritability  of  the  stomach 
and  extreme  prostration.  He  died  on  the  IGth.  Puist-mortcm  examination:  The  lungs  were  healthy.  The  pericar- 
dial sac  contained  eight  ounces  of  colorless  .serum. — Moii-tr  Jlosj^iital,  PJiihiddph'ui,  I'd. 

Case  3.— Sergeant  J.  P.  Taylor,  Co.  CI,  5th  111.  Cav.;  age  23;  was  admitted  March  15,  18t)3,  with  purpura.  A 
scarlet  rash  covered  the  lower  extremities  from  the  lower  third  of  the  legs  to  above  the  nates,  except  an  irregular 
narrow  strip  on  the  inner  aspect  of  the  legs  and  thighs.  It  was  most  intensely  developed  anteriorly,  but  presented 
no  tumefaction,  vesication  or  other  unusual  characteristic  except  a  little  cnticular  corrugation  with  much  itching 
and  a  slight  burning  sensation.  There  was  but  little  accompanying  fever,  although  the  patient  was  extremely  pros- 
trated and  had  headache  with  furred  tougue  and  constipated  bowels.  Gave  tincture  of  iron  in  thirty-drop  doses  in 
water  every  six  hours :  also  ten  grains  of  calomel  and  eight  of  Dover's  powder  to  be  taken  at  night  and  an  ounce  of 
Epsom  salts  in  the  morning;  applied  locally  a  solution  of  acetate  of  lead  every  four  hours.  The  medicines  operated 
well  and  next  day  there  was  no  fever,  pain  or  itching;  the  rash,  which  seemed  indisposed  to  s))read,  was  chauging 
color  by  the  deposition  of  a  whitish  or  grayish  ])seudo-niembrane  in  irregularly-shaped  and  sized  blotches  under  the 
cuticle.  This  involved  the  entire  extent  of  the  rash  except  a  few  lines  in  width  on  the  inner  aspect  of  the  thighs  and 
legs  around  the  margins  of  the  strip  above  mentioned.  On  the  morning  of  the  18th  the  fever  assumed  a  typhoid 
character,  the  mouth  and  fauces  becoming  dry;  a  rough  grayish  elevated  eruption  with  red  areolie  appeared  on  the 
upper  extremities,  chest  and  face,  extending  into  the  month  and  fauces  and  covering  the  conjunctiva'.  Added  qui- 
nine and  turpentine,  with  Dover's  powder  at  night  and  an  occasional  aperient,  to  the  treatment.  The  patient  sank 
gradually,  dying  ou  the  21st. — Jlo-spital,  5lh  III.  Car. 

Case  4.— Private  James  M.  Myers,  Co.  C,  144th  X.  Y.;  age  25;  was  received  June  19,  18(53,  having  been  unfit 
for  duty  since  December,  18G2,  and  under  treatment  most  of  the  time  in  the  Fairfax  Seminary  hospital.  He  had  been 
injured  by  a  fall,  and  while  sufTering  from  its  effects  was  taken  with  an  eruptive  fever  which  he  says  was  measles, 
but,  as  it  appears  that  his  throat  reiiuired  cauterization  and  the  glands  of  his  neck  were  enlarged,  the  disease  was 
probably  scarlet  fever.  His  feet  and  legs  began  to  swell  about  April  15.  The  urine  was  scanty  and  contained  only 
a  trace  of  albumen,  although  showing  under  the  microscope  a  few  blood  corpuscles  and  pale  clots;  no  oil  globules 
were  present.  He  was  treated  with  compound  .jalaii  jiowder,  tincture  of  muriate  of  iron,  bitartrale  of  ]Mitash  and 
tincture  of  digitalis;  but  as  his  condition  failed  to  improve  he  was  discharged  August  1  for  debility .—Satloice  IIos- 
pitaJ,  I'hiladilpliia,  Pa. 

lY.— ERYSIPELAS. 

Prevalence  and  Fatality. — Among  the  white  troops  23,276  cases  of  ervsipelas  were 
reported  during  tlio  war  jieriod,  equalling  an  average  annual  rate  of  10. -IS  cases  per  thousand 
of  strength.     But  these  numbers  do  not  correctly  represent  the  frequency  of  the  disease. 


KKYSIPKLAS: 


663 


Xo  (.louLt  tlioy  give  with  i'air  aceuracv  tlie  nuinlicr  of  cases  roportti.1  iVuin  tlic  ik-kl,  but  ery- 
sipelas was  a  scoui-go  of  tlie  hospital  wanls  ratlu-r  than  of  the  roginiental  caiiips.  IFiav 
many  cases  were  developed  in  the  hospitals  cannot  be  ascertained,  nor,  for  this  reason,  can 
the  fatality  of  the  disease  be  learned.  According-  to  the  reports  the  fatal  cases  constituted 
8  per  cent,  of  the  total,  but  this  is  necessarilv  an  exaggeration. 

The  di.-ease  pi-evailed  to  a  greater  extent  in  the  camps  of  the  AVestern  than  in  those  ot 
the  Eastei'ii  arniics;  dnring  the  four  veai'S,  Julv  1,  1861,  to  Jtuie  oO.  ISGo,  the  average 
animal  rale  per  tlmusand  men  in  the  latter  was  7.8,  in  the  former  khi.  It  was  also  more 
connnon  or  more  fatal  in  the  hospitals  nf  the  Central  region  than  in  those  of  the  Atlantic 
commands;  for  during  the  }K'r!od  mentioned  the  deaths  in  the  former  constituted  10.2  per 
cent,  of  the  cases  and  in  the  latter  oidy  4.1  per  cent.  During  these  four  years  1*21  deaths 
from  erysipelas  were  reported  from  the  Western  liosjiitals  in  an  average  population  of  I'd, 156, 
and  only  l<d4  from  the  Eastern  hospitals,  which  hail  an  average  population  of  26,187. 

Similar  restdts  were  observed  amung  the  colored  troeip.s.  During  the  three  years  of 
their  service  the  cases  of  erysipelas  numl)ered  1  ,")36,  or  8.38  aiuutally  per  thousand  of  strength, 
and  the  deaths  front  the  disease  217,  or  16.1  per  cent,  of  the  cases.  In  the  Atlantic  region 
the  cases  averaged  5.4  per  thousand  men  annually,  with  12. 1  per  cent,  fatal,  Avhile  in  the  Cen- 
tral region  the  rates  were  9.1  per  thou.-an.l.  with  17  ixa-  cent,  fatal.  Enquiry  into  the  cause 
of  tliese  differences  apjiears  to  point  to  insanilarv  conditions,  mainly  arising  irom  over- 
crowding in  the  camps  and  hospitals  of  the  AVestern  commands. 

Like  small-pox  and  other  diseases  which  owe  their  propagation  in  jxtrt  to  a  concen- 
tration of  orgaihc  emanations,  erysipelas  was  sonKnvhat  more  prevalent  during  the  winter 
months,  when  warmth  was  sought  at  the  expense  of  ventilation.     See  diagram  facing  page  624. 

So  far  as  can  be  ascertained  the  Coidederate  surgeons  had  an  experience  of  erysipelas 
similar  to  that  of  our  own  niedieal  oihcers.  Dui'ing  i\n'  nine  months,  Jidy,  18()1,  to  i\Iarch, 
1862,  300  cases  were  reported  from  the  Armv  of  the  Potomac,  whieh  iuimb>ered  40.391 
men.  This  is  er|uivalent  to  an  annual  rate  of  ]0.~)  eases  per  thousand  of  strength.  The 
records  of  the  Chimborazo  hospital,  Riclucond,  Va.,  make  note  of  22  deaths  among  236 
cases  treated,  a  mortality  of  9.3  per  cent. 

The  prevalence  and  fatality  of  the  disease  among  the  rebel  prisoners  may  be  gathered 
from  the  figures  of  Table  LIII."'' 

Sometimes  erysipelas,  as  seen  in  the  wards  of  our  general  hos])itals,  was  connected  with 
traumati.sm;  in  cases  1  and  23  of  the  subjoined  series  an  injury  of  the  knee  or  leg  appears 
to  have  determined  the  attack.  Generally,  however,  the  disease  was  developed  independent 
of  a  pre-existing  lesion.  To  give  emphasis  to  this  fact  Surgeon  Alexander  McBbide,  in 
charge  of  the  hospital  at  Camp  AYallace,  Colundjus,  Ohio,  mentions  a  nurse,  who,  having 
received  some  injury  to  the  face,  was  attacked  four  days  later  by  erysipelas,  whicli  was  mani- 
fested primarily  on  a  feature  that  had  escaped  injury.  Occasionally  the  trunk  or  the  extremi- 
ties were  affected,  as  in  cases  2  and  20-24,  given  below:  Ijut  the  face  was  the  usual  site, 
the  ridsi'e  of  the  nose,  the  ear  and  the  intraorbital  region  being  the  more  common  points  of 
attack. 

The  contao-ious  nature  of  the  disease  -was  regarded  as  undoubted  by  those  medical 
officers  wdio  had  the  best  opportunities  for  its  study.  In  some  hospitals  where  cases  of  ery- 
sipelas Averc  treated  in  the  general  wards  the  disease  affected  a  large  number  of  the  patients 


*  Si'pra^  page  G2it, 


66i  THE    ERUPTIVE    FEVEE3. 

unJer  treatment  for  other  maladies,  particularly  those  debilitated  by  typhoid  fever,  measles-, 
or  pneumonia.  To  relieve  the  inmates  from  this  source  of  danger  special  wards  were  pro- 
vided for  the  treatment  of  erysipelas.  Few  of  the  nurses  in  these  wards  escaped  attack. 
The  freedom  of  the  surgical  wards  from  erysipelas,  a§  compared  with  the  frequency  of  the- 
disease  in  the  medical  wards,  points  definitely  to  communicability.  In  the  Third  Part  of 
the  Surgical  Volume  of  this  AVork*  it  is  stated  that  only  .4  per  thousand  of  the  whole  num- 
ber of  wounded  had  a  record  of  erysipelatous  complications.  Tins  statement,  of  necessity, 
underrates  the  frec^itency  of  traumatic  erysipelas,  as  the  records  in  many  cases  may  have 
failed  to  note  its  occurrence.  It  indicates,  however,  the  infrequency  of  the  disease  in  the 
surgical  wards.  It  is  impossible  to  determine  what  proportion  of  the  medical  cases  suffered 
from  erysipelas ;  but,  as  suggestive  of  its  frequency,  it  may  be  observed  that  eleven  of  the 
three  hundred  cases  forming  the  post-mortem  records  of  lobar  pneumonia  were  thus  compli- 
cated."!" Again,  of  the  forty  cases  herewith  presented,  nineteen  were  received  into  hospital 
with  erysipelas,  while  twenty-one  occurred  in  patients  already  in  hospital.  The  surgeon 
dreaded  the  presence  of  erysipelas  among  his  wounded  and  had  every  case  at  once  isolated; 
the  physician  was  less  alive  to  tlie  contagious  nature  of  the  so-called  idiopathic  erysipelas, 
and  2^ermitted  cases  to  remain  in  the  general  wards  until  a  larger  experience  demonstrated 
the  necessity  for  their  isolation. 

Symptoms. — A  chill  ushered  in  the  attack.  This  was  followed  by  febrile  reaction, 
sometimes  accompanied  by  inflammatory  and  even  diphtheritic  appearances  in  the  fauces. 
A  few  hours  later  an  erysipelatous  blush  on  some  part  of  the  cutaneous  surface  showed  what 
was  in  prospect.  In  other  cases,  however,  which  generally  ran  a  mild  course,  the  disease- 
began  without  premonitory  symptoms  of  a  character  to  attract  notice;  in  case  8  the  patient 
said  he  had  never  felt  better  in  his  life  than  be  did  a  few  minutes  before  the  development 
of  the  local  manifestatio.ns.  Spreading  gradually  from  the  point  of  attack  on  the  nose,  cheek 
or -ear  the  inflammatory  blush  extended,  without  abatement  of  the  associated  fever,  over 
more  or  less  of  the  face  and  scalji,  subsiding,  perhaps,  on  one  side  as  it  invaded  the  other. 
In  cases  of  greater  severity  the  pain  and  febrile  excitement  culminated  in  delirium;  the 
tumefaction  blotted  out  the  patient's  facial  expression;  the  eyes  were  hidden  by  the  swollen 
lids  and  bullae  rose  upoir  the  inflamed  surfaces.  This  condition  of  aggravated  suffering 
occuri'ed  at  a  time  when  the  case,  if  mild,  would  have  lieen  ending  in  convalescence.  It 
sometimes  lasted  for  many  days;  in  case  6  five  days  elapsed  before  signs  of  amelioration 
were  observed.  The  disease  terminated  in  desquamation  and  scabbing;  yet  occasionally,  as 
in  eases  2,  4  and  6,  convalescence  was  delayed  by  the  occurrence  of  a  diarrhceal  or  dysen- 
teric attack.  Circumscribed  purulent  deposits  were  found  in  some  of  these  cases,  as  in  7, 
which  was  prolonged  for  several  weeks  by  suppuration  in  the  lower  eyelids,  under  the  chin 
and  in  the  superficial  tissues  of  the  posterior  cervical  region.  The  fever  in  the  milder  cases 
was  generally  sthenic;  but  when  the  disease  was  prolonged,  severe,  or  occurred  in  a  debili- 
tated subject,  the  familiar  symptoms  of  adynamia  were  rarely  absent.  Relapse,  as  in  case 
8,  sometimes  followed  an  injudicious  exposure  to  the  weather.  Relapses  or  recurrences 
were  generally  less  severe  than  the  primary  attack. 

As  contrasted  with  these  mild  cases  the  disease  sometimes  assumed  a  malignant  or 
typhus-like  aspect,  characterized  by  the  rapid  development  of  coma  and  the  appearance  of 
petechial  spots,  which,  as  in  40,  became  quickly  resolved  into  sero-purulent  depositories. , 

«  Pagf  8S1.  t  See  infra,  page  773. 


ERYSIPKLAS.  665 

Otorrlicea  and  deafness  were  frequent  results  of  severe  attacks.  Parotid  abscess,  as  in  25, 
not  unfrequently  found  an  exit  through  the  external  auditory  meatus,  and  death,  as  recorded 
in  26,  was  sometimes  to  be  feared  from  hemorrhas;e  into  the  site  of  the  dlscro-anized  gland. 

O  C2  CD 

In  9,  a  convalescent  with  consecutive  aural  disease,  died  from  the  effects  of  a  cold  douche 
indulged  in  as  a  luxnry  during  oppressively  hot  weather. 

In  dangerous  cases,  characterized  by  deeply  seated  inllammations,  the  brain  and  its 
membranes  frequently  became  involved.  In  27  the  cerebnd  strurtures  were  attacked  by 
way  of  the  orbit.  Cases  in  which  the  scalp  was  largely  tumefied  were  generally  associated, 
as  in  18,  with  pronounced  cerebral  symptoms,  due,  according  to  the  post-viortem  records  of 
28,  29  and  30,  to  congestion  or  some  excess  of  eflused  liquid;  death  by  coma  was  the  usual 
end  of  such  cases.  In  31,  which  was  complicated  by  meningeal  inflammation,  death  was 
hastened  by  a  fall  during  the  patient's  delirium. 

Sometimes,  instead  of  the  cerebral  membranes,  the  serous  lining  of  the  pericardial  sac 
became  implicated;  in  32  the  heart  was  covered  with  fibrinous  deposits  and  the  cavity  of 
the  pericardium  distended  with  purulent  liquid. 

The  gravity  of  the  erysipelatous  attack  was  in  many  instances  intensified  by  a  concur- 
rent inflammation  of  the  fauces.  In  33  the  tongue  was  much  swollen;  in  7,  l^*,  17,  20 
and  29  the  fauces  were  inflamed  and  in  1-1  and  31  diphtheritic  sloughs  were  formed.  Tume- 
faction of  the  epjiglottis  by  congestive  or  inflammatory  infiltrations  leading  to  occlusion  of 
the  rima  glottidiswas  occasionally  the  immediate  cause  of  death,  as  in  a  case  mentioned  by 
Suro-eon  Shubal  York,  54th  111.'-'  Act.  Ass't  Suro-eon  DeWitt  C.  Day,  who  had  a  large 
experience  at  the  special  hosjiital  for  erysipelas,  Xashville,  Tenn.,  observed  that  in  the 
majority  of  cases  the  disease  was  first  manifested  on  the  mucous  memljrane,  as  is  always  the 
case  in  measles  and  scarlet  fever;  he  inferred  from  this  that  a  striking  analogy  existed 
between  these  diseases  in  their  formative  stage.")" 

In  some  cases,  as  21  and  35,  pneumonia  appears  to  have  been  the  immeiliato  cause  of 
death.  Dav  believed  the  pneumonia  to  be  a  result  of  the  erysipelatous  influence,  and  as  aii 
illustration  of  many  cases  that  might  be  adduced,  recorded  that  of  a  soldier  who,  after  the 
amjiutation  of  his  arm,  was  attacked  with  erysipelas  at  the  site  of  the  operation.  In  a  few 
days  the  inflammation  faded  at  the  stump  but  spread  rapidly  over  the  chest  and  back.  He 
had  been  carefully  nursed  in  a  ward  kept  at  an  equable  temperature,  but  nevertheless  pneu- 
monia supervened  and  became  intensified  as  the  diseased  action  subsided  on  the  surface. 

A  determination  to  the  mucous  membrane  of  the  intestine  was  also  observed  in  some 
instances.  This,  which  occasionally  caused  death,  as  in  cases  17  and  19,  not  unfrequently 
prolonged  the  period  of  convalescence  in  mild  or  favorable  cases  of  the  disease.  Dr.  Day 
was  of  opinion,  as  the  restflt  of  his  observations,  that  the  disease,  when  originating  from  or 
by  extension  involving  the  mucous  membranes,  was  of  a  more  dangerous  nature  than  when 
confined  to  the  skin  and  cellular  tissue.  Bo  long  as  the  skin  alone  was  its  seat  its  exten- 
sioa  over  a  larger  surface  was  not  attended  by  a  corresponding  aggravation  of  tlie  constitu- 
tional disturbance.! 

*  Soe  his  report,  infra,  pago  CT2.  t  Anmiean  Mcliral  Tums,  YI,  Xew  York,  ISfvl,  i«ige  208. 

I  In  .-l  lirUf  account  of  Kpmeiiiic  Ertjnipehis  as  it  ajypeared  at  Molino  tlel  Ji''ii,  uetir  the  City  of  3Icxico,  tbtriiig  (he  months  of  Febnuiry  and  March,  1848, — 
Charh-i^ton  Medkul  Journal  and  liericn;  IV,  ±849,  p.  27, — Surgeon  J.  P.  Evans,  V,  S.  Vul.  Service,  statos  that  a  cutaneous  inflammation  was  present  only  in 
abuut  one-fifth  of  the  cases.  Internal  parts,  as  the  fanci-s,  the  salivary  glnndr*,  the  inner  ear,  the  lun^^s  or  their  pleural  memhranes,  were  seized  at  the 
onset ;  and  almost  complete  relief  to  these  i-arts  followed  the  external  manifestations  of  the  diseaM-.  On  the  other  hand,  the  sudden  retrocession  of  tlio 
external  inflammation  always  enhanced  tho  severity  and  danger  of  the  malady.  Fortunately  not  many  such  cases  were  witnessed.  One  is  meutionej 
in  which  erysipelas  of  the  face  disappeared  su<ldenly,  and  diarrluea,  with  constant  tormina  and  extreme  temlerncKa  of  the  alKhmien,  ensued  and  proved 
fatal  in  a  short  time.    The  erysiiwlatou-;  fever  that  aflfected  the  troops  near  the  City  vf  Mexico  and  the  inhabitants  of  tlie  burrounding  country,  appears- 

Med.  Hist.,  Pt.  111—84 


666  THE    EF.rPTIVK    FEVERS. 

Mill  or  crvtliematou?  cases  nffectiiiLr  the  limbs  or  trunk  ended  in  desquamation  in  four 
or  tlve  davs.  In  the  liiu'lic-r  grades  of  thi'  disease  abscusses  'were  formed  in  various  parts, 
or  the  subrut;\neous  and  intermuscuU\r  tissues  brranie  iniiltrated  with  purulrnt  mattri';  in 
some  cases  canu'rene  was  develo[>ed;  occasionally  the  joints  were  involved  and  destroyed. 
Great  emaciation  and  jtrostration  resulted  from  the  profuse  and  prolonged  discharges  in  such 
cases.  Bedsores  aggravated  the  sulTering,  and  the  patient  ultimately  died  exhausted  by  the 
continued  drain  or  earried  oil"  bv  intercurrent  diarrha-a  or  pulmcMiary  congestion.  Ery- 
sipelas of  the  head  and  i'ace  was  generally  regardcil  as  more  dansi'erous  than  an  attack  involv- 
iiiij;  the  truid<:  or  extremitii-s;  but  the  accuracy  of  this  oi>inion  has  not  been  established. 
Facial  erysipelas  was  common,  and  in  the  majority  of  cases  ran  a  mild  and  rapid  course. 
Act.  Ass"t  Sui'geon  ^V.\sHI^■l:To.^"  Matthews,  who  had  favorable  opportunities  for  observing 
the  disease  in  the  ervsipelas  wards  of  the  Rock  Island  hospital.  111.,  considered  that  while 
cases  involving  the  extremities  were  infrequent  their  course  was  usually  prolonged  by  the 
profressive  invasion  of  contiguous  regions  and  their  danger  heightened  by  consecutive  sup- 
puration in  the  underlying  cellular  tissue.  Thi:>  progress  of  such  cases  to  a  fatal  issue  is 
illustrated  by  cases  2U-2d:  of  the  following  series: 

CLIX1C.\L   RKroliTS   OF    EHYSII'ELATOCS   C.VSES. 

Case  1.— Piivaro  .Siunuel  (Jriiiiiitov,  Co.  A,  41st  X.  Y.,  \vas  .idmittcil  ,Inlj  28,  l»t!l,  with  erysipelas  of  the  left 
leg,  which  was  i>f  a  liery-ied  color  and  swoUeu  to  twice  the  natural  size;  it  was  purplish  for  eight  inches  above  and 
six  inches  lielow  the  knee  and  vesicated  largely  over  the  purplish  parts.  He  had  sprained  the  knee  four  days  before; 
the  resulting  pain  and  swelling  had  been  treated  by  bread  ])oulticcs.  On  admission  a  tei)id  bath  was  given,  nitrate 
of  potash  and  tincture  of  iron  prescribed  and  acetate  of  lead  lotion  applied.  Next  day  the  swelling  had  subsided  a 
little;  a  doseof  sulphate  of  magnesia  and  tartar  emetic  was  administered  and  cold  water  was  substituted  for  the  lead 
lotion.  On  the  31st  the  cuticle  around  the  joint  separated  en  mnsse,  and  there  was  a  general  improvement  in  the 
patient's  condition.  On  August  1  there  was  a  slight  blush  on  the  knee,  but  mohility  was  perfect  and  there  was  uo 
pain,  swelling  or  constitutional  disturliauee.  Kext  day  pain  with  some  stitt'ness  returned  on  account  of  using  the 
joint  too  freely.  On  the  3d  there  was  much  a-denui,  with  pain  along  the  inner  aspect  of  the  knee.  A  cathartic  of 
calomel,  jalap  and  gamboge  was  given.  The  patient  was  transferred  on  the  9th  and  was  discharged  from  the  service 
November  2.5. — Seminary  Hospital,  Gcort/t'toifn,  JJ.  C. 

Case  2.— Sergeant  David  W.  Thomas.  Co.  II,  2tlth  Ohio,  was  admitte<l  Sept.  1(3,  1863,  with  erysipelas  affecting 
the  anterior  tibial  region;  pulse  106,  feeble:  tongue  moist  but  coated;  appetite  poor;  skin  natural.  Gave  Dover's 
powder  every  six  Lours,  muriated  tincture  of  iron  before  meals  and  tincture  of  iodine  in  water  for  topical  use.  On 
the  18th  sulphate  of  magnesia  was  given  for  constipation.  The  inflammation  subsided  on  the  19th  and  next  day  full 
diet  was  allowed.  Convalescence  was  interrupted  October  2  by  an  attack  of  diarrhcea,  which  lasted  four  days. 
The  patient  was  returned  to  duty  November  14. — Second  iJirixion  Ilo^pitnl,  AUxundriii,  Vti. 

Case  3.— Jackson  L.  Marsh,  a  rebel  prisoner,  was  admitted  April  IT),  1865,  with  erysipelas.  He  had  been  iu 
prison  since  December  of  the  previous  year  and  had  sutlered  from  chills  and  vaccine  sores.  He  had  scorbutic  stains 
on  his  limbs  and  was  subject  to  constipation,  seven  days  sometimes  passing  without  a  movement  of  the  bowels.  The 
erysipelatous  attack  began,  without  premonitory  symptoms,  by  a  swelling  of  the  lower  eyelid  of  the  right  side  on  the 
morning  of  the  14th.  He  was  treated  with  castor  oil  iuteiually  and  resin  oiutment  as  a  local  application.  The 
swelling  never  exceeded  two  and  a  half  inches  in  diameter.  It  subsided  in  a  few  days  and  was  followed  by  desqua- 
mation.    He  was  returned  to  barracks  on  the  28th.— Jc^  Asu't  Siirycoii  Wtishiuijton  MaWwws,  Bod;  Island  Hospital,  III. 

Case  4.— Private  Frederic  O.  Johnson,  Co.  E,  3-5th  Ala.;  was  committed  to  prison  Feb.  18,  1865.  He  had  been 
suffering  from  chills  and  diarrhoea  for  a  long  time  previous  to  his  capture.  He  was  admitted  on  April  6  for  cough, 
debility  and  diarrhoea.  On  the  20th  he  was  seized  with  lassitude,  chills,  fever  and  pain  in  the  glands  of  the  neck. 
Next  day  erysipelas  set  iu,  and  on  the  22d  he  was  transferred  to  Ward  C  for  treatment.     One  drachm  of  saturated 


to  trnvu  Ill-en  a  maniftstation  of  an  ciiiili-niic  that  lia.l  iirevailed  fxtensivi-Iy  in  the  Uuitea  States  from  tlie  year  1K41.  Dr.  II.  N.  Uennett  of  Bri.lgeiiort, 
Conn.,  has  describi'il  the  disease  iu  an  article  entitled  A  TreuliK  e.i  the  Kpidnnk  Erijtq.elalom  Fiier  of  llie  I'niled  «<^/«,— .Yt«'  IV.ri  Juiinial  vf  MiJUiiw,  IX, 
18-">:),  lip.  9  et  Kq.  It  was  regarded  aa  a  communiealilo  disease,  afleeting  especially  the  old,  the  infirm,  those  afflicted  with  otli.T  maladies  and  iwrsous  of 
ana.-niic  appearance  ami  lax  fibre.  The  febrile  action,  -Bhich  sjieedily  assumed  a  typhoid  character,  was  associated  with  intiainmatory  lesions  of  various 
parts.  Sore  throat  was  generally  present.  In  mild  cases  the  mni-ons  membrane  was  of  a  bright-rod  color  and  but  little  tumefied.  In  the  malignant 
form  tlie  pharnyx  assnnn-d  a  dark-purple  color,  which  spread  gradually  over  the  palate,  tongue  and  sides  of  the  cheelss,  the  tongue  becoming  much 
rwollen  and  ultimately  of  a  dark-brown  color,  from  which  was  derived  the  popular  appellation  of  the  disease— L'/.kA:  Tongue.  Aeh-colored  sloughs  were 
formed,  which,  on  their  sc^paration,  left  ulcerations  of  consideralile  dejith  and  unhealthy  ca^t.  The  breath  was  horribly  ofrensive.  The  Iym|ihatic 
glands  became  swollen  and  sometimes  suppurated.  In  about  one-sixth  of  tlie  cases  erysipelas  appeared  on  the  cutaneous  surface,  sometimes  erythema- 
tous and  fleeting,  sometimes  phlegmonous  and  dangerous  in  its  results.  The  lungs,  pleura-  and  cerebral  membranes  were  occasionally  the  site  of  the 
Inflammatory  developments.  But  the  most  formidable  lesion  of  tlie  malady  was  peritonitis  in  the  post-puerperal  state ;  of  30  cases  in  Caledonia  county, 
Vermont,  onlv  one  recovered. 


Kr.ysii'Ki.A.-.  *i'"i7 

Nohiiiou  of  oliliiratf  of  pi)t:>sli  was  <,'i\-cii  iiiliMiKiUy  three  tiiiirs  a  <la\  .  ami  the  ^aml•  S(]hitiuii  wa.s  um-iI  oh  lint  as  a 
local  apiilicatioii.  On  the  L'4th  the  iiillaimiiatioii  began  to  siihsiile  and  the  patieiil's  eyes  became  visihle.  JSy  the  :.'Uth 
lie  was  oonvalesceut  and  conijilained  of  nothinfj  lint  Aveakiiess.  Desi|iiaiiiatioii  was  completed  on  May  2.  after  which 
his  strength  was  slowly  regained  under  nonrisliing  diet,  tonics  and  stimulants.  For  a  time  a  slight  dyseiiteiie  al  tack 
delayed  his  recovery,  lint  liy  the  li'th  he  was  able  to  return  to  barracks. — Jcl.  .hx't  Siirijeon  JVanhiiu/luii  Mtitth'iis. 
HlH'k  Ishllld  llu.-<pit,il,  JU. 

(ask  .%. — Isaac  li.  Kcid.  a  rebel  ]irisoner:  age  L'7;  A\as  admitted  A]iiil  12,  lsii."i.  lie  had  always  bi-en  in  good 
hrali  li  lint  for  an  occasional  fil  of  ague  anil  an  attack  of  varioloid,  tlie  latter  having  iiccni  icil  snbseiincnt  to  his  ca]i- 
Inre.  .\  spelling,  mistaken  for  miinips,  began  Ajiril  -1  and  increased  for  a  week,  during  wliicli  time  he  became  very 
weak,  as  he  was  unable  to  eat  anything.  At  length  an  cry sijielatous  blush  ajqieared  on  the  stirlace,  when  the  swelling 
became  reduced  in  size.  Castor  oil  ami  turpentine  emtilsion  were  prescribed  for  internal  use  and  resin-cerate  with 
turpentiuo  as  a  local  application.  His  tongue  was  dry,  brown  and  cracked  on  the  llltli,  on  which  day  a  pint  of  alo 
was  iirescribed  for  daily  use.  dn  the  18th  niilk-puncli  wa.s  substituted.  The  tongue  at  this  time  continued  dry  and 
brown  and  was  jirotruded  with  dilliciilly;  the  inllammatiou  had  moved  from  the  right  to  the  left  side  of  the  face; 
desiiuaniation  was  in  progress  on  the  right  side;  pulse  rajiid  but  soft ;  a]i|iii  iie  poor:  two  or  time  evacuations  from 
the  bowels  daily.  The  erysipelas  did  not  entirely  subside  until  the  \l>*t  h,  \\  hen  t  lie  tonguo  liecame  cle.iu  and  moist 
and  the  appetite,  strength  and  pul.se  improved;  but  sonic  injeclion  ol'  the  conjunctiva'  remained  and  thi'ie  was  com- 
plaint of  pain  in  the  ear.  The  internal  nse  of  turiicntiiic,  which  \v.is  soiucwIkiI  iN]ierimi'ntal,  seemed  neither  to 
aggravate  nor  alleviate  the  sym]itoins  nor  to  ati'eet  tlie  condition  of  the  tongue.  He  was  returned  to  barracks  May 
8. — Acl.  Axu't  Siirycoii  Wtishbujioi  Miittluvn,  Hod:  IkUdhI  Jhnjiihil.  III. 

C'.\SK  I'. — Private  Iliram  Michael,  Co.  C,  1st  I'a.,  had  a  chill  .\]ii  il  12,  iMil,  while  at  Camp  Cadwallader.  'J'his 
^Tas  followed  by  headache  and  sore  throat,  and  on  the  Ititli  by  redness  .-inil  swelling  of  tlie  right  side  of  the  face, 
wliicli  led  to  liis  admi.ssion  on  the  following  day.  Tincture  of  iron  was  ]iresci'ibrd  w  ith  full  diet  :  llie  nlieelcd  parts 
were  painted  with  tincture  of  iodine  and  a  lead  solution  was  applied.  Cu  the  1!M  h  the  whole  of  the  iipiier  pai  I  of 
the  face  was  involved;  the  eyes  were  swollen  and  closed  and  several  bulhe  aii)ieareil  on  the  left  ear  and  side  of  the 
face.  Quinine  in  two-grain  doses  hourly  Avas  added  to  the  treatment,  with  biel'-tea  and  egg-nog.  J)eliriiim  supei- 
vened  on  the  2<Uh,  when  anodynes  were  given,  Init  the  symptoms  did  not  begin  to  show  amelioration  until  the  iTith.  , 
He  was  convalescent  on  the  28th  and  was  returned  to  duty  May  21. — Tiinitr's  Liiiir  llospitnl,  rhihuhljihiti,  I'a. 

Ca.se  7. — Private  Andrew  .?■.  Mortcr.  Co.K,  ll.Mh  Ohio;  age  :i2:  a  man  with  a  history  of  chills,  chronic  diarrlwipa, 
recurring  sore  throat  and  injury  to  the  loins  by  a  fall  from  a  mule,  was  ailmil  ied  Nov.  il,  lsi;2.  with  hot  and  dry  skin, 
full  pulse.  100,  furred  tongue,  constipated  bowels,  anorexia,  great  thirst,  lieadache  and  iliiiv,sim-s>.  Cave  every  three 
hours  two  grains  each  of  calomel  and  bicarbonate  of  soda  and  one  grain  of  ipecaiuanha.  to  be  followed  next  morning  by 
a  small  do.s6  of  castor  oil.  Next  day  the  febrile  symptoms  continued  and  the  tonsils  weio  swollen.  Cavo  a  saturated 
solntion  of  chlorate  of  potash  as  a  gargle.  A  slight  blush  was  observed  under  the  eyes  in  the  evening;  several  stools 
were  passed  after  taking  the  oil.  The  fever  continued  on  the  llth  ;  the  blush  under  the  eyes  was  accompanied  with 
a  tingling  pain  in  the  cheeks;  the  throat  was  very  sore  and  there  was  some  delirious  muttering.  U'he  calomel  was 
discontinued.  On  the  12th  the  cheeks,  eyelids  and  forehead  were  of  a  deep-red  color  and  the  eyelids  closed,  swollen 
and  doughy;  liulhe  had  formed  on  the  cheeks;  delirium;  aphonia;  tongue  furred;  pulse  iH)  and  soft.  Gave  beef- 
essence  and  stimulants;  applied  cotton  lightly  over  the  Bwolleii  parts,  btit  towards  evening  this  caitsed  Jiain  and 
tlour  was  used  instead.  Piy  the  llth  the  ears  were  involved,  but  the  swelling  around  the  left  eye  was  siilisiding;  tlie 
bulhe  had  burst  and  were  forming  scabs;  the  delirinm  continued.  Cave  tincture  of  iron,  brandy  and  egg-nog,  and 
replaced  the  tlour  by  glycerine.  Kext  day  jiersulphate  of  iron,  ten  grains  in  two  ounces  of  glycerine,  was  used  locally. 
The  delirium  did  not  subside  until  the  18tli ;  an  enema  of  castor  oil,  turpentine  and  soap  was  given  with  benefit  ou 
this  day.  JCe.xt  day  desiiuamatiou  was  progressing,  but  the  eyelids  remained  inllamed;  the  pulse  was  we.ik,  com- 
pressible atid  intermittent.  On  the  20th  the  ]iatieiit  was  able  to  sit  up;  the  iron  was  omitted:  poached  eggs,  toast 
and  cliicken-sonp  were  allowed.  The  spots  under  the  eyes  becaiiui  imtfy:  they  were  painted  with  iodine  on  the  2."ith 
and  lanced  and  poulticec].  on  the  27th,  after  which  they  continued  to  discharge  for  several  days.  On  the  28th  a  hard 
lump  was  felt  beneath  the  chin  near  the  antericn-  belly  of  the  digastric  muscle.  This  was  poulticed  and  on  December 
2  opened,  liberating  a  ijuantity  of  pus.  From  some  imiiroiiriety  in  diet  the  patient  was  attacked  on  the  8th  with 
diarrlnea,  headache  and  hoarseness,  which  lasted  four  or  live  days.  After  this  some  large  abscesses  formed  on  the 
back  of  the  neck  and  discharged  freely  when  oiiened.  He  was  returned  to  duty  Jan.  30,  1803. —  West  Ktid  lloxpiiaJ. 
CinciniKiti,  Ohio. 

Case  8. — Private  lieiijamin  F.  Cobbs,  Co.  B,  Wood's  ilissonri  Uatt.,  was  admitted  from  prison  May  2,  186.^, 
with  idiopathic  erysipelas.  The  iiatient  said  he  never  felt  better  than  he  did  ten  minutes  before  the  attack  began 
by  a  stitt'ness  or  cramp-like  feeling  in  the  cervical  muscles  of  both  sides.  From  these  localities  a  painful  cutaneous 
inllammation  spread  over  the  face.  He  was  treated  with  one  drachm  of  turpentine  emulsion  and  ten  grains  of  bicar- 
bonate of  soda  three  times  a  day.  After  a  course  of  four  days  the  inllammation  subsided  and  the  patient  was  returned 
to  barracks  on  the  9th  quite  well  and  strong.  Xext  day,  having  been  exposed  to  the  vicissitudes  of  the  weather,  he 
relapsed  and  was  readmitted.  On  the  16tli  he  was  again  well  and  able  to  go  out  on  release.  He  received  no  treat- 
ment during  the  second  attack. — Act.Asn't  Siiryeon  Waahinijlon  ilaitkewii,  Jlovl:  Islainl  IJofipititl,  III. 

Case  9. — Private  Richard  Smith,  Co.  A,  4th  X.  J.  Cav.;  ago  21 ;  contracted  erysipelas  and  was  sent  to  the  field 
hospital  for  treatment  June  1(5,  18G4  ;  was  transferred  to  White  House  Landing  ou  the  18th;  to  Mount  Pleasant  Hos- 
pital, Washington, on  the  21st  and  to  this  hospital  ou  July  22.  (Jn  admission  he  was  delirious  and  much  jnostrated; 
pulse  freqtieut  and  feeble;  excessive  discharge  from  both  ears;  scalp  swollen;  bowels  loose.     Cave  morphia,  half  a 


66S  THE    ERLTTIVE    FEVERS. 

grain,  at  bedtime:  extra  tliot.  Xext  day  iron  and  i|niuine  were  prescribed,  with  porter,  milk-pnnch  arid  ice-cream. 
He  improved  under  this  treatment.  On  the  2i5th  he  was  able  to  sit  np  and  on  tlie  31st  to  walli  uliout  tlie  ward.  At 
this  time,  while  suftering  from  the  ojipressive  heat,  the  patient  went  into  the  wash-room  and  hehl  his  head  for  several 
minutes  under  the  hydrant.  He  had  then  to  lie  carried  to  bed:  pulse  120;  skin  very  hot;  severe  headache:  great 
distress.    Gave  one  drachm  of  brandy  every  half  hour.    He  died  early  next  morning. — Mower  Hospital,  Philadelpliiti,  Pa. 

Case  10. — Private  Michael  Brown,  Co.  L,  25th  X.  Y.  Cav.;  age  30:  admitted  Xov.  26,  186J-,  with  prolapsus  ani 
and  piles,  was  taken  on  the  2i1th  with  a  chill  followed  by  fever,  pain  in  the  bones,  nausea  and  an  erysipelatous 
swelling  of  the  right  side  of  the  face,  closing  the  right  eye  completely.  Gave  tincture  of  iron,  opium,  calomel  and 
ipecacuanha;  applied  sugar  of  lead  to  the  face:  special  diet.  He  was  discharged  March  2,  181)5,  because  of  chrouic 
ulcer  over  the  left  tibia,  piles  and  strabismus. — Finley  Ilospital,  Wa^hinijtun,  I).  C. 

C.vSE  11. — Private  Patrick  Firney,  Co.  1?,  31st  N.  Y.,  while  under  treatment  for  scrofulous  ulcers  of  the  neck,  had 
a  chill  Xov.  15, 18G2.  Next  day  he  was  feverish.  A  saline  purgative  was  ordered,  with  snuill  doses  of  acetate  of  ammonia 
and  low  diet.  On  the  17th  the  left  ear  was  atteeted  with  erysipelatous  redness.  Tincture  of  iron  was  prescribed.  Xext 
day,  as  the  disease  evinced  a  tendency  to  spread,  a  broad  line  was  painted  with  tincture  of  iodine  around  the  scalp. 
The  intlannuation  began  to  subside  on  the  22<1 ;  a  nutritions  diet  of  eggs,  chicken  and  oysters,  with  an  allowance  of 
milk-punch,  was  prescribed.  He  was  able  to  sit  up  on  the  2()th,  and  was  transferred  December  2  to  another  ward  to 
await  discharge. — Sattcrlec  Hospitiil,  Philndvlphia,  Pa. 

Case  12. — Private  Michael  Ruft',  Co.M,  8th  X.  Y.  Cav.;  age  33;  was  placed  on  duty  in  the  kitchen  Aug.  30,  18(53, 
while  under  treatment  for  opacity  of  the  cornea  resulting  from  an  acute  conjunctivitis.  December  30:  Pain,  swelling 
and  redness  back  of  left  ear:  constipation.  Gave  five  grains  of  calomel  and  ten  of  rhubarb  at  once.  .Jan.l,  1801: 
Copious  stools;  pain  and  swelling  increased.  Gave  syrup  of  iodide  of  iron  three  times  a  day  and  applied  llaxseed 
mucilage.  2d:  Eiysipehis  well  marked.  Continued  the  iron  and  aiijilied  cranlierry  poultice  over  the  entire  face; 
gave  brandy,  milk-punch  and  extra  diet.  3d:  Inllammation  increased  on  right  side  of  face:  constipation,  (iavo 
castor  oil.  4th:  Easier;  stool;  slight  delirium.  Gave  small  doses  of  Hott'iuann's  amxlyne  every  hour.  5th:  ."flight 
delirium;  tongue  dry  and  heavily  coated:  pulse  140.  Oth:  Tongue  cleaning;  pulse  full  and  soft,  1*8 :  skin  moist ; 
features  more  natural.  8th:  Removed  cranberry  poultice;  reapiilied  llaxseed  nuicilage.  ilili:  Pulse  small  and  quick; 
, delirium.  Gave  half  an  ounce  of  brandy  every  hour.  10th:  Easier;  inflammation  subsiding.  15th:  Improving 
slowly;  abscesses  at  back  of  head.  Applied  poultice.  21st:  Opened  two  abscesses.  30th:  Improving  steadily;  able 
to  sit  up.     February  10:  On  light  duty.     April  23:  Returned  to  dutj'. — Mower  Hospitiil,  Philiiili-lpliiii,  Pa. 

Case  13. — Private  Floridan  Covert,  Co.  1, 80th  X.  Y.:  age  27:  was  admitted  Dec.  14, 1802,  deaf  from  disease  c)f 
the  middle  ear.  X'othing  of  interest  occurred  in  his  case  nntil  Jan.  2il,  1803,  when  he  was  seized  with  chill  followed 
by  violent  fever,  rapid  pulse,  intense  headache,  pain  in  the  back  and  sore  throat.  Small-pox  was  anticipated,  as 
some  cases  of  this  disease  were  in  the  house  at  the  time;  but  about  twenty-four  hours  after  the  chill  a  red  erysipe- 
latous spot  appeared  ou  the  nose.  The  intlaninuition  spread  so  rapidly  that  in  thirty-six  hours  it  had  overs[iread  the 
face,  closing  the  eyes  entirely.  The  patient  was  so  prostrated  by  the  violence  of  the  attack  that  stimulants  were 
necessary  to  keep  him  from  sinking.  Tincture  of  iodine  and  afterward  collodion  were  applied  to  the  alfected  surface 
and  appeared  to  act  benelicially.  He  was  transferred  to  another  ward  two  weeks  later  somewhat  weak  but  wholly 
recovered  from  the  erysipelas. — Sattcrlie  Hospital,  Pliiludtlphid,  Pa. 

Case  14. — Private  Henry  Webber,  Co.  C,  31st  X.  Y.,  while  under  treatment  for  granular  lids  was  taken,  Xov. 
23,  1862,  with  erysipelas  of  the  face  and  complained  of  pain  in  swallowing.  On  examination  the  throat  was  found 
extremely  swollen  externally  and  internally,  and  the  tonsils  and  posterior  nares  covered  with  a  whitish  pultaeeous 
membrane,  portions  of  which  could  lie  wijied  off  with  a  sponge;  the  pulse  was  rapid  and  une(|ual;  eyes  red  and 
injected  and  the  patient  much  jirostrated  and  alarnu,-il  at  his  condition.  The  treatment  consisted  of  twenty  drops  of 
muriated  tincture  of  iron  every  two  hours  in  a  talilespoonful  of  a  saturated  solution  of  chlorate  of  potash  ;  the  tonsils 
and  throat  were  well  brushed  with  an  eighty-grain  solution  of  nitrate  of  silver  and  the  erysipelas  circumscribed  with 
tincture  of  iodine;  the  diet  was  stimulating  and  nourishing.  The  mixture  was  continued  in  gradually  decreasing 
doses  for  ten  days,  after  which  the  patient  was  considered  cured. — Siittirlic  Iloxp'tiil,  Philiidtlpliiii,  Pa. 

Ca.se  15. — Private  Fred.  Bachman,  Co.  D,  1st  X.  Y.  -Art'y;  age  35;  while  under  treatment  for  rheumatism,  or  a 
lameness  of  the  right  side  from  injury,  was  seized,  Jan.  4,  1863,  with  erysipelas  of  the  face,  attended  with  much  fever, 
severe  hea<lache  and  drowsiness.  Un  the  l!Stli  the  blush  extended  over  the  forehead  and  anterior  portion  of  the 
scalp,  jiitting  on  pressure  and  developing  bulhe.  A  solution  of  sulphate  of  iron,  half  an  ounce  in  a  pint  of  water, 
was  applied  by  means  of  compresses;  tincture  of  iron  was  given  with  Dover's  powder  at  night:  milk  diet.  The 
inllammation  subsided  by  the  21st ;  l)Ut  fetid  matter  cairie  from  the  left  ear,  which  was  inunediately  washed  out  with 
a  solution  of  nitrate  of  silver.  The  patient  was  delirious  on  the  25th,  but  by  the  end  of  the  month  he  was  able  to  sit 
up.  The  discharge  had  nearly  ceased,  leaving  deafness  on  that  side.  A  blister  was  apjilied  behind  the  ear.  He  was 
discharged  March  30  because  of  deafness  of  one  side  and  lameness  from  injury  occasioned  by  a  horse  falling  on  him. — 
Satttrtci-  Hospital,  Philadtlphia,  Pa. 

Case  16.— Private  Lewis  J.  Russell,  Co.  B,  87th  111.;  age  21;  was  admitted  April  17,  1863,  with  an  abscess  of 
the  parotid  gland,  which  was  opened  on  the  27th.  The  gland  of  the  opposite  side  became  affected,  and  on  May  1 
erysipelas  set  in,  involving  the  whole  of  the  face  and  scalp.  A  severe  diarrhcea  supervened  on  the  17th,  and  death 
occurred  ou  the  20th. — Laivsoti  Hospital,  St.  Louis,  Mo. 

Case  17. — Private  William  W.  Paxton,  Co.  H,  114th  Ohio,  was  admitted  March  21,  1863,  with  diarrhfea  follow- 
ing typhoid  fever.    On  tlie  25th  he  had  a  chill  which  ushered  in  an  attack  of  erysipelas  of  the  face.    Iron,  quinine 


ERYSTPKLAf 


669 


and  lirAiulj-  were  administered  and  iodine  applied  to  the  surface.  The  erysipelas  disappeared  next  day.  lint  t!it> 
patient'.s  strength  failed,  and  he  died  on  the  28th. — Lnuson  Jloijiilal.  St.  Liiiii«.  Mo. 

r.\SE  18.— Private  Asa  Fry,  Co.  K.  83d  Ind.,  was  admitted  Marrli  21.  IsOIH.  in  a  weak  C(in<lition  resulting  from 
typhoid  fever  and  diarrha-a;  he  nas  nnahle  to  sjieak  louder  than  a  -vliisjivr.  i)\\  the  2.")tli  he  had  a  had  eongh  and 
his  throat  was  red  and  congested.  Applied  a  strong  solution  of  nitrate  of  silver.  On  the  28th  tincture  of  iron  and 
t'hlovate  of  potash  were  preserihed.  A  chill  on  April  3  was  followed  hy  erysipelas  of  thf  face,  heginniug  on  the  nose. 
.Syn\]itonis  of  inllammation  of  the  hrain  attended  the  rapid  extension  of  tlie  disease  to  the  Sja'.j).  lleath  to(di  jilace 
on  tlie  9th,  after  thirty-six  hours  of  convi. — Lawaon  Ho.^pit<il.  Si.  Louis,  .Mo. 

Case  W. — Private  Robert  Vantes.sen,  Co.  E,  12th  Va.  Cav.:  age  ;V,l:  was  admitted  Oct.  1.").  18fi3.  on  account  of 
an  injury  lo  the  chest  hy  a  fall  from  horseback.  In  December  he  was  attacked  with  jihlegmonons  erysi])elas,  whieli 
first  affefted  the  head.  In  January.  1801,  the  eyelids  were  (edematous  and  the  neighboring  subcutaneous  tissues 
infiltrated  with  serum.  Treatment  at  this  time  was  palliative  and  expectant,  but,  the  disease  extending,  tincture  of 
iron,  quinine  and  diffusible  stimulants  were  administered  freely,  with  generous  diet  and  l)<iver's  powder  .at  night; 
strong  tincture  of  iodine  was  a]i))lied  frc(iuently  to  the  aii'ected  jiarts.  Pus  was  discharged  eo|iiously — as  niuoh  as 
eight  ounces  daily — the  inllannuatiou  at  this  time  involving  the  h'gs.  arms  and  chill.  Collii|iuitive  diarrliiea  super- 
vened; a  large  bedsore  on  the  back  caused  much  suffering.     lie  died  March  1. — CiuiilifrUiii<l  Jloxpital,  M<l. 

Case  20. — Private  Jiio.  Thornton,  Co.  E,  Kith  Iowa:  agi'  23:  was  admitti'd  Oct.  4,  1803,  ]iale  and  I'eeble  i'unn 
malarial  fever,  with  torpid  bowels,  jiain  in  the  region  of  thi'  spleen  and  sonu'  cough  with  white  rojiy  exjiectoration. 
On  December  2  he  was  so  much  improved  as  to  be  able  to  assist  as  nur.se:  but  on  the  7th  he  had  a  chill,  followed  next 
day  by  fever  with  heat  and  soreness  in  the  left  axilla.  Laxatives.  (|uiiiiiie  ami  low  diet  were  prescribed.  On  the  i'th 
the  throat  was  sore  and  the  tumefaction  about  the  left  shoulder  extc-nded  ujiward  into  tlie  neck  and  downward  along 
the  trunk.  On  the  lOtli  the  breath  was  offensive  and  swallowing  was  accomidished  with  ditlicnlty.  'I'lie  iiuiniiie 
was  omitted  and  eight-grain  doses  of  iodide  of  jiotassium  substituted;  tincture  of  iodine  was  applied  to  the  intlamed 
parts.  On  the  12tli  tincture  of  iron  was  given  in  place  of  the  iodide  of  ])otassiuin;  ]>ort  wine,  two  ounces  daily,  was 
also  prescribed,  with  special  diet  and  morjihia  at  night.  The  fever  abated  somewhat  on  the  l.'ith,  but  the  jiatient 
was  greatly  prostrated;  pnlse  120;  the  swelling  extended  from  the  axilla  to  the  ileum.  A  chill,  with  other  indica- 
tions of  suppuration,  was  noted  on  the  18th:  on  the  20tb  the  inflammatory  redness  extended  as  far  as  the  knee  and 
on  the  22d  to  the  foot.  At  this  time  the  patient  was  greatly  emaciated:  he  slejit  but  little  and  had  no  apjietite;  an 
opening  just  below  the  iliac  crest  gave  exit  to  a  purulent  discharge.  Incisions  above  the  crest  on  the  28th  liberated 
a  pint  or  more  of  pus.  liy  Jan.  .">.  18t)4,  his  condition  was  consideralily  improved:  he  rested  better  and  was  aide  to 
sit  up  in  bed.  Aromatic  sulphuric  acid  and  the  sulphates  of  iron  and  cinehonia  w  ere  administered.  ( in  the  12tli  an 
opciiiiig  made  on  the  outside  of  the  thigh  iiermitted  a  large  quantity  of  pus  to  cscajie.  Three  days  later  an  o]iening 
was  made  on  the  shoulder.  Matter  was.  nieanw  hile.  discharged  freely  from  all  the  a]iertures.  lieer  or  wine  was 
taken  at  desire;  but  the  patient  was  much  depressed.  He  continued  to  lose  strength  until  the  24th,  when  the  dis- 
charges became  somewhat  reduced  and  tlie  appetite  improved:  but  on  the  2Stli  diarrhn>a  supervened  and  jiersisted, 
with  occasional  remissions,  to  the  end.  Apertures  for  the  escape  of  pus  had  to  be  made  along  the  leg  and  foot.  He 
died  exhaasted  April  1. — Hosjnidl,  (Juhicy,  III. 

rOST-MdIiTEM    (in.SEItVATIONS. 

Case  21. — Robert  Sparks,  a  citizen  of  Missouri,  was  admitted  .Ian.  11.  IxG.".  with  erysipelas  of  the  arm  and  fore- 
arm. The  skin  and  cellular  tissue  became  destroyed,  exiiosing  the  muscles  for  three-fourths  of  the  circumference  of 
the  arm  from  the  insertion  of  the  deltoid  to  the  wrist-joint.  The  patient  was  treated  with  quinine  and  niuriated 
tincture  of  iron  and  did  well  for  seven  or  eight  days,  but  ]inenmoiiia  set  in,  the  nicer  assumed  an  unhealthy  ajipear- 
ance  and  death  occurred  February  7.  rost-mortim  examiiiati(ui :  Tlie  iijiper  and  lower  lobes  of  the  right  lung  and  the 
lower  lobe  of  the  left  lung  were  hepatized  gray;  the  middle  lobe  of  the  right  Inng  ajipcared  to  lie  healthy;  the  upper 
lobe  of  the  left  lung  was  highly  congested.  The  heart  was  normal.  The  liver  was  healthy;  the  spleen  twice  its  nor- 
mal size  and  amemic:  the  intestines  healthy:  the  mesenteric  glands  enlarged. — .Ut.  Ai^a'l  Siinjioit  Jumts  McCurtiitiif 
Hock  hlund  HoxpUal,  111. 

Case  22. — Private  John  Farlow,  Co.  C,  2stli  Pa.;  age  44;  was  admitted  March  20,  1864,  with  erysiiielas  of  the 
right  lower  extremity.  He  had  been  taken  sick  while  at  home  on  furlough.  On  admission  the  limb  was  red  and 
swollen  to  the  middle  of  the  thigh,  its  color  livid  and  its  temperature  lower  than  normal.  About  April  10,  as  the 
erysipelatous  inllammation  subsided,  the  knee-joint  was  found  to  be  swollen  and  distended  with  li(iuid:  this  disten- 
tion increased  for  a  week  and  then  gradually  diminished,  the  pain  also  ceasing.  At  the  beginning  of  May  the  left 
knee  became  swollen  and  painful,  and  on  the  lltli.  when  it  had  attained  the  size  of  a  man's  head,  it  ojiened  sponta- 
neously and  discharged  about  a  pint  of  sanious  pus.  At  this  time  a  bed.sore  formed  over  the  sacrum  and  rajiidly 
enlarged;  another  appeared  shortly  after  over  the  right  hiji.  Death  took  ])lace  June  3.  I'Dst-morti in  examination: 
Hody  much  emaciated;  both  lower  extremities  greatly  swollen.  There  was  some  hyjiostatic  congestion  of  the  lungs, 
and  the  cavities  of  the  heart  contained  fibrinous  clots.  The  liver  was  fatty  and  slightly  larger  than  normal;  the 
other  abdominal  viscera  were  healthy.  An  incision  into  the  right  knee-joint  gave  exit  to  a  pint  of  pus;  the  articular 
surfaces  of  the  femur  and  tibia  were  much  eroded,  nearly  the  whole  of  the  cartilages  having  disappeared.  A  similar 
condition  was  found  on  the  left  side.  The  veins  were  carefully  examined  without  the  discovery  of  auytliing  abnor- 
mal.— Act.  Ass't  Surgeon  Wm.  i?.  iJunton,  Ciiyler  Hospital,  Philadelphia,  I'a.* 


*  .\ii  account  of  tliis  case,  gubmittcU  by  I)r.  John  Asuvrst,  jr.,  was  published  iu  the  Procft^diiigs  of  the  Piithuh'<jkal  S')cklii  o.f  Phiiwidphia,  /'<i.,  Vol. 
II,  1867,  iwgc  17-2. 


670  Till-:  f:iu'ptivf,  fkvers. 

Case  23. — John  W.  Kojiers-  ui;i'  T2:  a  iclicl  ('onscii]it :  was  admitted  Aiiril  1,  1865,  vritli  erysipelas  and  gan- 
grene of  the  riglil  lower  cxtremit.v.  He  had  surtVred  uiiuh  iVoni  bilious  and  intermittent  fevers  followed  liy  dropsy. 
For  seven  years  his  h'gs  and  feet  had  been  more  or  less  (edematous.  A  week  before  admission  he  fell  over  a  chair  and 
the  injury  thus  inllicted  on  his  leg  aggravated  the  chronic  swelling  and  devidoped  erysipelas,  which  was  preceded 
by  a  chill.  A  saturated  solution  oi'  chlorate  of  potash  was  ordered  to  be  ajiplied  copiously  to  the  limb.  Delirium 
came  on  during  the  night  and  continued  until  the  nuirning  of  the  1th:  during  this  tiuu^  he  would  rise  from  bed  and 
run  about  the  ward.  Nitrate  of  silver  was  applied  around  the  limb  to  eonline  the  erysipelas,  lint  it  proved  useless. 
Bromine  was  then  used  and  milk-punch  and  tincture  of  iron  ordf  red.  Large  blood-blisters  formed  on  the  leg.  which 
began  to  look  yellow,  black-spotted  and  gangrenous.  Labarra<|ut's  solution  was  used  as  a  dressing.  After  the  deli- 
rium subsided  the  patient  became  comatose  and  died  on  the  Jith.  I'o.il-moiinn  examination  revealed -nothing  but  the 
gangrene  of  the  limb. — Act.  Asu't  Siirij<oii  Wa«h\niiliin  .Untthcivn,  Hock  Island  UonpUal,  111. 

Cask  24. — Josiah  K.  Small,  a  rebel  conscript  from  Missouri,  was  admitted  Dec.  fi,  180f,  with  acute  pneumoni;.!. 
The  patieiii:  had  an  attack  of  pneumonia  in  1S63  and  has  suliered  more  or  less  since  then  with  pain  in  the  left  side. 
On  admission  his  tongue  was  coated  except  at  the  margins,  which  were  red:  bowels  regular:  pulse  ilO;  respiration 
hurried;  he  had  cough  with  some  exiiectoration :  i)ain  in  the  right  side,  which  was  dull  on  percussion  and  yielded 
crepitant  rales  over  the  mammary  region.  He  improved  under  treatment,  and  when.  .Jan.  ti,  18(i."),  he  was  taken  with 
erysijiclas  .all  signs  of  the  lung  disorder  had  disappeared.  The  erysipelas  ran  its  course  in  four  days,  but  was  inmie- 
diately  followed  by  an  abscess  in  the  hij),  which  was  opened  on  the  2r)th,  discharging  about  a  pint  of  pus  on  that  day. 
On  the  27tli  lis  was  transferred  to  the  surgical  ward  in  good  spirits,  with  a  fair  share  of  strength  and  a  good  appetite. 
The  treatment  while  in  this  ward  consisted  of  flaxseed  poultices  with  quinine  and  Dover's  powder,  and  afterwards, 
for  six  days,  simple  dressing,  with  a  powder  given  every  six  hours  consisting  of  three  grains  of  tannin  anel  one  and 
a  half  each  of  opium  and  camjihor.  On  F>l)ruary  5  poultices  were  again  ordered  and  the  face  and  hip  directed  to  be 
painteil  with  tincture  of  iodine,  which  treatment  was  continued  u^itil  his  return  to  the  medical  ward  ou  the  9th, 
when  his  face  was  found  to  present  the  desquamating  cuticle  cousecjueiit  on  a  recent  erysipelatous  attack.  He  was 
emaciated  to  a  great  degree,  exhaled  an  exceedingly  offensive  stench  from  his  person  and  had  deep  bedsores  on  his 
sacrum  and  on  each  iliac  crest;  his  left  lower  extremity  showed  almost  every  process  of  bone  in  conseiiueiice  of  the 
emaciation,  while  his  right  limb  was  swollen  to  a  large  size  throughout  its  entire  length  in  conseciueuce  of  purulent 
infiltration.  77ns  swdliiig  was  comphtehj  reduced  in  the  course  of  lircnty-foitr  lioiirx  by  the  application  of  a  tight  bandage 
from  the  toes  to  the  hip,  Avith  the  further  effects  of  causing  a  large  qiiaiitlty  of  fetid  pus  to  be  discharged  from  the 
old  aperture  and  of  entirely  relieving  the  excruciating  pain  which  the  patient  formerly  experienced  in  the  swollen 
limb.  The  bandage  was  readjusted  twice  daily.  The  position  of  the  patient  was  fre(iuently  changed  by  an  attendant 
for  the  purpose  of  taking  the  iiressiire  otf  the  bedsores:  his  surface  was  cleansed  once  daily  anil  disinfectants  freely 
used  about  the  bed.  Ale,  inilk-puuch  and  whiskey  were  successively  used  as  stimulants:  lead  lotion  was  apidied 
to  the  bedsores  and  an  astringent  pill  gi\en  when  needful.  He  died  on  the  20th.  ront-inortein  examination:  The 
body  was  extremely  emaciated,  the  abdomen  concave:  the  integument  aluaded  over  tiearly  every  bony  prominence; 
the  course  of  the  purulent  deposit  among  the  muscles  of  the  hip,  thigh,  leg  and  foot  was  distinctly  marked ;  the  bed- 
sores had  not  increased  to  any  noticeable  extent  since  his  admission.  There  was  some  congestion  and  blueness  of  the 
bowels,  particularly  of  the  large  intestine:  a  jiart  of  the  ileum,  three  inches  long,  was  invaginated. — Act.  Ass't  Sur- 
geon H.  C.  Xewkirk,  Buck  Island  Uospital,  III. 

Case  25. — Private  William  V.  Bracken,  Co.  G,  Bfith  N.  Y.;  age  22;  was  admitted  Oct.  2, 18t)4,  with  chronic  rheu- 
matism. About  May  1,  1805,  he  had  an  attack  of  erysipelas  of  the  face,  which  gradually  extended  to  the  scalp  and 
back  of  the  neck.  He  was  treated  with  tincture  of  iron  internally  and  a  lotion  of  half  a  drachm  of  sulphate  of  iron 
to  the  pint  of  water.  The  case  progressed  favorably  and  by  the  6th  the  erysipelas  had  altogether  disappeared;  but 
the  patient  was  feeble  and  had  some  irritability  of  stomach,  which  was  checked  by  hydrocyanic  acid  in  effervescing 
draughts ;  after  which  stimulants  and  a  nutritions  diet  were  ordered.  On  the  8th  he  complained  of  pain  over  the  left 
parotid,  where  an  abscess,  opened  next  day,  discharged  a  quantity  of  fetid  pus;  there  was  also  a  discharge  of  pus 
from  the  left  ear.  From  this  date  he  refused  nourishment  and  sank  rapidly,  dying  on  the  15th.  Post-mortem  exam- 
ination: The  cerebellum  was  softened,  but  no  abnormal  effusion  was  observed  beneath  the  membranes.  Both  parotid 
glands  were  enlarged.     The  lungs  and  abdominal  viscera  were  normal. — Third  Division  Hospital,  Alexandria,  Fa. 

Case  26. — Private  ,James  Montgomery,  Co.  E,  llOtli  Pa.;  age  27;  was  admitted  March  29,  1864,  with  erysipelas. 
He  was  delirious  and  in  low  condition,  his  face  and  scalp  swollen  and  doughy.  One  grain  of  quinine  and  five  drops  of 
tincture  of  iron  were  given  every  two  hours,  with  milk-punch  and  beef-es.scnce ;  mucilage  of  slippery  elm  was  applied 
to  the  face  and  scalp  and  flaxseed  jwultices  over  the  parotid  glands.  On  April  11  the  left  parotid  became  swollen 
and  on  the  15th  the  right  submaxillary  gland;  the  swelling  of  the  latter  subsided  on  the  23d,  but  the  parotid  con- 
tinued much  enlarged,  indurated  and  painful.  On  the  morning  of  the  21th  blood  and  pus  escaped  from  the  left  ear; 
an  hour  later  an  incision  was  made  into  the  softest  part  of  the  swelling,  about  one  and  a  half  inches  below  the  iiuglo 
of  the  jaw,  giving  free  exit  to  a  quantity  of  pus.  At  midnight  a  pint  of  blood  issued  from  the  ear  and  the  incision, 
and  thereafter,  for  four  days,  hemorrhage  occurred  at  intervals  notwithstanding  efforts  to  suppress  it  1)y  tents  satu- 
rated with  solution  of  persulphate  of  iron.  Meanwiiile  the  erysipelas  reappeared  and  diffused  itself  over  the  entire 
face.  Pus  continued  to  be  discharged  and  the  tumor  became  much  reduced  in  size;  but  at  5  a.  m.  of  May  2  twelve 
ounces  of  blood  came  from  the  ear  and  abscess,  and  a  further  loss  occurred  while  readjusting  the  styptic  plugs  on  the 
giving  way  of  part  of  the  wall  of  the  abscess.  At  this  time  the  patieut  became  inclined  to  8tui)or  and  there  was  much 
jactitation,  which  was  equal  on  both  sides,  but  after  11  P.  M.  motion  on  the  right  side  ceased  and  clonic  spasm  was 
developed  on  the  left  side:  the  right  eye  became  glassy  and  its  pupils  dilated,  while  the  left  continued  bright  and 
had  its  pupQ  contracted ;  the  left  radial  pulse  was  absent  during  the  spasm,  the  right  radial  pulse  was  constant.     He 


KKYSIPKLAS 


671 


ili-,(l  fit  2.30  A.  M.  of  the  3<1.  Posf-mortcm  exaiiiinatiiiii :  IJif^or  mortis  well  marked:  Kkiii  blanched.  The  brain  was 
healthy  lint  liale:  the  thoraeic  and  abdominal  vi.seera  anaMiiie.  The  internment  on  the  left  side  of  the  face  and  neck 
was  swollen,  softened  and  discolored.  There  was  an  opeiiinj;  through  the  lower  wall  of  the  external  auditory  canal 
an<l  an  oriUco  below  the  ear  large  enough  to  admit  four  lingers,  leading  into  a  large  cavity  tilled  with  soft  coagula 
and  the  disorg!iuize<i  remains  of  the  parotid  gland.  The  arleiies  in  this  cavity  are  supposed  to  have  been  intact,  as 
no  extravasation  took  jilacc  from  them  iijiou  injecting  from  the  arch  of  the  aorta.  The  ramus  of  the  lower  jaw  was 
denuded  of  periosteum:  a  pr<die  was  passed  readily  from  the  lateral  sinus  through  the  jugular  foramen  inio  the 
abscess;  the  external  jugular  vein  was  health}-  below  the  abscess  but  not  traceable  through  the  cavity.  (The  jioint 
of  s])e(ial  interest  in  the  pathology  of  this  case  is  the  8U])punition  of  the  )parotid  gland,  a  most  rare  occurrence,  and 
probalily  dependent  on  the  condition  of  constitution  induced  by  the  erysipelas.  Death  was  the  result  of  unavoid- 
able hemorrhage,  probably  from  the  internal  jugular  vein,  it  having  been  involved  in  the  disorganization  of  tin'  gland. 
The  identity  of  the  cerebral  symi)ti>nrs  immediately  before  death  with  those  of  compri'ssion  is  wortliy  of  mention, 
the  actual  i>aihological  condition  of  the  brain  being  that  of  amcmia.) — (iiiilcr  IIo!<pitiil,  I'liihidtljiliUi,  I'<i. 

t'ASK  L'7. — Private  Kobert  Work,  Co.  1),  KU\  Ohio;  agt^  27:  admitted  March  21,  l!KG3,  with  diarrhiea.  lie  was 
very  weak,  had  a  slight  bronchitis  and  an  ulcer  on  the  cornea.  Erysipidas  of  the  nose  and  right  cheid<  was  devclojied 
oil  April  12.  (Quinine  and  Iron  were  given  freely  and  iodine  ajudied  locally,  lie  died  on  l  he  2ltli.  I'lmt-mHrlim  exam- 
ination: There  was  pus  in  the  anterior  chamber  of  the  right  eye,  traceable  along  the  course  of  the  o|)tic  nerve  to 
the  brain,  which  was  congested.  The  lachrymal  giaiul  was  softened.  Tlie  bones  f<irmiiig  the  orbit  were  di'iiuded 
by  purulent  intiltration. — Lairnoii  Iliixjiita!,  St.  Louin,  Mo. 

Case  28. — Private  Solomon  Osborne,  Co.  F,  Kith  East  Tenn.  Cav.,  was  admitted  ,Jaii.  27,  1><(!1,  with  measles. 
On  February  6,  before  the  eruption  had  entirely  disappeared,  he  was  attacked  with  facial  erysipelas,  lie  died  on  the 
11th.  Post-mortem  examinati(Ui:  The  scalp  was  (edematous,  the  calvaria  thick,  the  brain  and  its  mcmliranes  much 
congested.  There  were  slight  pleuritic  adhesions  on  the  right  side:  the  lungs  weighed  forty-nine  ounces  and  were 
congested  posteriorly:  the  bronchial  membrane  was  injected.  The  inner  surface  of  the  iiericardiiim  was  yellowish  and 
softened:  the  heart  soft  and  easily  crushed  between  the  fingers:  the  arch  of  the  aorta  atheromatous.  The  peritoneum 
was  congested.  The  mucous  membrane  of  the  stomach  was  injected  and  thickened :  that  of  the  snuill  intestine  some- 
what injected,  of  the  large  intestine  thickened  and  softened.  The  liver  was  cirrhosed:  the  gall-bladder  full:  the 
s])lecn  soft:  the  kidneys  much  injected,  the  left  showing  a  cyst  with  a  draelmi  of  li(juid.  The  blood  in  the  veins  was 
dark  and  semilluid. — Act.  Ani't  Siiryion  C.  S.  lliyyill,  Ho8j>ital  111,  ynsJiviUc,  'J'aiii. 

Case  29. — Private  Charles  Agugo,  Co.  K,  1st  Mich.  Sliarpshooters,  was  admitted  May  HI.  IStil,  with  rheumatism. 
There  is  no  record  of  his  case  until  Jan.  7, 1865,  when  he  was  attacked  with  erysipelas,  ushered  in  by  a  decided  chill. 
The  fauces  and  right  side  of  the  face  first  became  aftected  ;  the  intlammation  then  crossed  the  nose  and  involved  the 
entire  left  side  of  the  face:  there  was  much  swelling  and  both  eyes  were  closed.  He  was  treated  with  tincture  of 
iron,  (iuinine.  stimulants  and  a  nutritious  diet.  Delirium  set  in  on  the  17th.  He  died  connitose  on  the  IStth.  Post- 
mortem examination:  The  membranes  of  the  brain  were  highly  congested.  Other  organs  nornuil. — .(c(.  .(.v.s7  .SMiv/con 
Lcifi-i  Heartl,  VOurcrtiirv  Hospital,  Alcxaiidria,  J'a. 

Case  30. — Private  Nathan  .Sprechor.  Co.  A,  S)9th  Pa.;  age  21:  was  admitted  Nov.  .30,  IStil,  with  pneunM)nia, 
from  which  he  had  recovered  sufficiently  to  do  light  duty,  when,  on  Feb.  23,  iNi.").  his  right  ear  became  inllamed.  A 
blister  was  applied  behind  the  ear  and  opium  and  blue-pill  administered.  On  March  ^  he  became  affected  w  ith  nausea, 
and  an  erysipelatous  intlannnatitui  spread  from  his  right  ear  to  his  neck.  I|>ecacuanlia  was  given  and  afterwards 
veratrum  viride,  and  the  inflamed  parts  were  covered  with  C(dd  flaxseed  tea:  but  the  inllammation  extende<l  to  the 
side  of  the  face  and  delirium  came  on.  Tincture  of  iodine  was  ajiplied  and  a  lotion  of  suljihate  of  iron,  with  (]uinino 
and  iron  internally:  but  the  disease  s])read  rapidly  over  the  bead,  neck  and  upper  jiart  of  the  chest,  and  the  ])atient 
died  on  the  lOth.  I'ost-mortim  examination:  There  was  a  slight  effusion  in  the  ventricles  of  the  brain  and  two  ounces 
of  serum  at  the  base;  the  cerebellum  was  softened. —  Third  Dirisimt  Hospital,  Aluaiidria,  I'a. 

Case  31. — Private  Felix  Kennedy,  Co.  B,  10th  Vt.,  was  admitted  Xov.  2,5,  1863,  suffering  from  facial  erysijielas, 
more  marked  over  the  left  frontal  region,  where  the  disease  encroached  upon  the  scalp:  juilse  fre(iuent  and  feeble; 
tongue  furred;  skin  dry  and  rough.  The  patient's  aspect  and  general  condition  indicated  habits  of  intemperance. 
Stimulants  and  cold-water  dressings  were  employed.  There  was  much  gastric  irritation  during  the  i)rogress  of  the 
case, — even  liquid  nourishment  given  in  small  quantity  was  occasionally  rejected.  On  the  night  of  December  1  there 
was  a  tendency  to  low  delirium;  but  on  the  following  day  the  mind  was  aitparently  clear.  The  inllamnuition  of  the 
face  and  scalp  was  not  at  this  time  so  marked  as  on  admission,  but  his  pulse  continued  weak  and  frequent  and  his 
stomach  rejected  everything.  Next  night  the  delirium  returned,  and  during  its  continuance  the  patient  opened  a 
window  and  fell  to  the  ground,  a  distance  of  twenty  feet,  broken,  however,  by  striking  the  roof  of  an  adjoining 
piazza.  When  brought  back  he  complained  of  pain  in  the  lumbar  region  and  in  the  right  ankle,  also  in  the  left  side 
of  the  chest  near  the  angles  of  the  sixth  and  seventh  ribs.  He  died  on  the  8th,  I'ost-mortem  examination:  In  the 
brain  were  evidences  of  meningitis;  the  lungs  were  crepitant;  the  heart,  liver  and  kidneys  fatty:  the  stomach  con- 
gested and  its  mucous  membrane  thickened. — Central  Park  Hospital,  -Vcic  York  City. 

Case  32. — William  H.  Rushing,  a  citizen  of  Tennessee;  age  42;  was  admitted  March  5,  1861,  with  erysipelas. 
Died  15th.  Post-mortem  examination:  The  face  was  swollen.  There  was  some  congestion  of  the  bronchial  tubes  in 
the  left  lung.  The  pericardium  was  distended  with  purulent  li(iuid:  the  heart  covered  with  fibrinous  deposits;  the 
endocardium  normal.  The  liver,  spleen  and  kidneys  were  healthy:  the  intestines  slightly  inflamed. — Hospital  Xo.  1, 
XashviUe,  Tenn. 

Case  33. — Private  Francis  Nooliu,  Co,  H,  110th  Ohio;  admitted  Xov.  23, 1863;  died  Jan.  12,  1864,  oi  eryci;:ela.':; 


672  THE    KRUPTIVK    FF.VF.RS. 

ami  glossitis.  Post-inortim  examination:  Tongue  niucli  swullcu  and  completely  filling  tlie  month;  spleen  very  large 
and  soft.     Other  organs  healthy. — As-it  Surgeon  Harrison  Alhii,  C  .S.  .1.,  lAiiculn  llofpitid,  JTasliUujton,  D.  ('. 

Case  34. — Private  Teter  W.  ISradburn,  Co.  A,  9th  X.  Y.  Heavy  Art'y:  age  52:  was  admitted  Pec.  8.  1801.  with 
intermittent  fever.  Ho  recovered,  but  on  Jan.  27.  18C."),  was  attacked  by  erysipelas  of  the  head.  Tincture  of  iron 
was  administered  internally  and  a  lotion  containing  acetate  of  lead  and  laudanum  was  applied.  On  the  2!'th  the 
patient's  head  was  greatly  swollen,  pulse  120  and  very  weak;  he  was  unable  to  swallow  and  his  throat  and  tonsils 
were  extensively  ulcerated ;  he  was  delirious  at  night.  Heef-tea  and  brandy  were  given  freely  by  inject  ion :  the  throat 
and  mouth  were  mopped  with  a  solution  of  the  chlorate  of  potassa  and  muriatic  acid;  a  solution  of  half  an  ounce  of 
sulphate  of  iron  in  a  pint  of  water  was  applied  to  the  erysipelatous  parts  and  morphia  administered  at  liedtime. 
t)uring  tlie  following  day  the  patient  expelled  a  large  amount  of  i)sendo-mcmbrane  from  his  throat.  On  the  31st  an 
aqueous  solution  of  bromine,  containing  a  half  drachm  to  the  pint,  was  substituted  for  the  iron  solution  as  a  local 
application.  Death  occurred  on  February  7.  I'ost-mortem  examination:  The  mucoiis  membrane  of  the  small  intestine 
was  much  injected  and  .softened;  Peyer's  glands  were  prominent,  a.s  in  the  early  stages  of  typhoid  fever.  [The  con- 
dition of  the  throat  and  respiratory  organs  is  not  recorded.] — Act.  Ass't  Surgeon  E.  II.  Quid,  Hospitid,  Frederick,  ild. 

Case  35. — Private  George  Washington,  Co.  M,  10th  III.  Cav.,  was  admitted  March  24,  1864,  with  erysipelas,  and 
died  ou  the  27th.  Post-mortem  examination:  The  scalp  and  neck  were  greatly  swollen.  There  were  recent  pleuritic 
adhesions  on  both  sides,  and  about  six  ounces  of  scrnm  with  some  broken-down  lymph  in  the  right  pleural  sac:  the 
lungs  were  much  congested.  The  heart  contained  large  light-yellow  clots.  The  liver  was  fatty  and  weighed  eighty- 
two  ounces;  the  spleen,  thirteen  ounces,  was  pulpy  and  of  a  dull  purplish  color.  The  stomach  and  kidneys  were 
healthy. — Hospital  Xo.  1,  yushvilte,  Tenn. 

Cask  36. — Private  Benjamin  Barnes,  Co.  K,  5th  Md.;  age  59;  was  admitted  from  Slave  Pen  prison  Jan.  3,  1865, 
with  i>leurisy.  The  acute  symptoms  had  subsided  under  the  u.se  of  anodynes,  diaphoretics  and  sinapisms  to  the  chest, 
when  a  swelling  of  tlie  under  lip  and  right  cheek  and  a  gangrenous  condition  of  the  mouth  were  discovered,  the  tlesh 
hanging  in  black  shreds.  Nitrate  of  silver  was  applied  and  a  mouth  wash  used  containing  chlorate  of  ]>ota.-<sa  and 
crea.sote.  On  February  1  erysipelas  of  the  face  set  in  and  was  treated  with  tincture  of  iron  internally  and  locally, 
milk-punch  and  nourishing  diet.  He  died  on  the  9th.  ront-mortem  examination  :  The  salivary  glands  were  enlarged. 
The  anterior  portion  of  the  left  lung  was  coated  with  pseudo-membrane  and  adhered  to  the  thoracic  ]iarietes:  the  left 
pleural  sac  contained  a  considerable  quantity  of  effused  liquid;  the  bronchial  mucotis  membrane  was  of  a  dark-puiple 
color.  The  pericardium  was  full  of  clear  yellow  serum  and  the  heart  distended  by  a  soft  yellow  clot.  The  liver  was 
large  but  otherwise  normal;  the  spleen  large  and  pale;  the  kidneys  granular.  The  stonuich  was  i>ale  and  contained 
several  black  masses,  apparently  clotted  blood;  nothing  abnormal  was  observed  in  the  rest  of  the  alimentary  canal. — 
Act.  Ass't  Surgeon  W.  C.  Minor,  Third  Division  Hospitetl,  Alexandria,  Vu. 

Case  37. — Private  General  Denning,  Co.  G,  12th  Tenn.  Cav.;  age  18;  was  admitted  March  25,  1804,  w  itli  con- 
tinued fever,  and  died  April  3  of  erysii)ela8.  I'ost-mortem  examination:  The  bronchial  tul»es  of  both  sides  were  intlamed. 
The  heart  weighed  eleven  ounces  and  a  half;  the  endocardium  was  discolored.  The  liver  weighed  seventy  ounces; 
the  spleen  sixteen;  the  kidneys  five  and  a  half  each.     The  intestines  were  healthy. — Hospital  No.  1,  Xashville,  Tenn. 

Case  38. — Private  Charles  A.  Eowell,  Co.  M,  1st  Vt.  Heavy  Art'y.  was  admitted  April  24,  1805.  with  erysipelas, 
and  died  on  the  28th.  Post-mortem  examination:  The  thoracic  viscera  were  normal  lint  for  extensive  adhesions  of 
the  right  pleura.  The  spleen  was  much  enlarged;  the  other  alidominal  viscera  healthy. — Depot  Field  Hospital.  Sixth 
Armij  Corps,  City  Point,  Va. 

Case  39. — Private  James  M.  Brown,  Co.  H,  11th  N.  H.;  age  18:  was  admitted  March  26,  1804,  with  erysipelas, 
and  died  April  3.  Post-mortem  examination:  The  mass  of  the  left  lung  was  healthy,  but  there  were  some  superticial 
abscesses,  one  of  which  adhered  to  the  thoracic  wall ;  the  bronchial  tubes  were  slightly  inllamed.  The  heart  and 
the  abdominal  organs  appeared  healthy. — Hospital  Xo.  1,  XashriUe,  Tenn. 

Case  40. — Private  Thomas  Sarfas,  Co.  E,  19th  Y.  R.  Corps,  was  admitted  June  8,  1804,  with  erysipelas  of  both 
wrists.  Tincture  of  iodine  was  applied  and  citrate  of  iron  and  'jainine,  whiskey  and  beef-tea  prescribed.  On  the 
11th  the  face  was  attacked,  the  scalp  becoming  speedily  involved.  On  the  13th  the  tongue  was  dry  and  brown. 
Coma  supervened  and  the  body  became  covered  with  a  dark-blue  petechial  eruption  which  rapidly  tilled  with  sero- 
purulent  matter.  Death  occurred  next  day.  Post-mortem  examination;  The  lungs,  liver,  kidneys  and  arch  of  the 
aorta  were  filled  with  sumll  al)scesses  resembling  those  on  the  skin.  [.See  SjJccimen  323,  Med.  Sect.,  Army  Medical 
Museum.] — Sherburn  Barracks,  Washington,  D.  C. 

Surgeon  S.  York,  54(/i  III.,  Jackson,  Tenn.,  April  30,  1803. — In  one  of  the  cases  which  terndnated  fatally  the 
disease  attacked  the  throat  to  a  linuted  extent  over  the  parotid  and  submaxillary  glands.  The  skin  was  not 
extensively  affected,  l)ut  tlie  fauces  soon  became  considerably  swollen.  The  patient  died  in  a  few  hours,  after  a  short 
difficulty  of  breathing,  from  oedema  of  the  glottis  ;  the  epiglottis  was  about  half  an  inch  in  tliickness  and  the  entrance 
into  the  larynx  nearly  closed.  In  the  other  fatal  case  the  eruption  made  its  ajipearance  Ijetween  the  cheek  bones 
and  the  no.se,  extended  over  a  small  surface  only,  and  after  a  duration  of  two  days  became  suddenly  translated  to 
the  liver,  stomach  and  diaphragm.  The  patient  had  severe  pain  in  the  right  hypochondrium  and  epigastrium,  bilious 
vomiting  and  singultus.  He  died  in  about  six  days  thereafter  with  plain  indications  of  gangrene  of  the  organs 
involved.     In  this  case  no  post-mortem  examination  was  held. 

I  have  used  in  the  treatment  of  this  disease  saline  purgatives  in  cases  where  there  was  biliary  derangement, 
mercurials  as  indicated,  and  emetics  of  ipecacuanha  in  those  attended  with  gastric  disorder;  chlorate  of  potash, 
tincture  of  iron,  quinine,  iodide  of  potassium  and  wine,  whiskey  or  Ijrandy  have  also  been  given.     The  best  diet  after 


ERYSIPELAS.  673 

till-  iicntr  stagp  had  subsided  somewhat  was  found  to  he  suft-lmiled  f-ggs,  Iieet'-tea  and  s""'l  wheaten  Ijread.  The 
local  leniedies  in  which  I  have  phiced  most  confidence  aie  tincture  of  iodine,  acetate  of  lead  and  vinegar.  In  one 
case  of  phlegmonous  erysipelas,  in  which  the  head  was  greatly  swollen,  I  applied  a  lemon  poultice  apparently  with 
lienetit.  This  was  suggested  Ijy  the  virtues  ascribed  by  some  writers  to  the  cranberry  poultice.  I  supposed  the 
virtues  of  the  latter  to  Ije  due  to  its  acidity,  and  as  the  berries  could  not  lie  obtained  I  tried  the  lemon. 

Surgeon  W.  H.  White,  '2'2iJ  lawn,  iieu)'  IVint  I'lahis,  J/o.,  Fih.  1.  18C3. — The  disease  which  gave  us  most  anxiety 
was  erysipelas.  The  lace  was  ehietly  attacked.  Most  of  the  cases  were  severe  and  associated  with  marked  derange- 
ment of  the  liver  and  digestive  organs.  They  generally  yielded  to  active  cathartics  in  conjunction  with  tonics  and 
local  applications  of  nitrate  of  silver  or  tincture  of  iodine. 

Sin-iji'on  J.  Cooper  McKek,  I'.  S.  A.,  Camp  Iliilhr.  near  Sjirbu/fieh},  III.,  Jiili/  1.  lt<G2. —  I  can  speak  «  ith  the 
highest  satisfaction  of  the  use  of  niuriated  tincture  of  iron  in  the  treatiueut  of  erysipelas.  Alternated  with  (juiniue 
it  controlled  the  disease  in  all  its  forms.  I  found  local  applications,  as  of  iodine  and  nitrate  of  silver,  unsatisfactory 
in  their  results;  as  they  failed  to  limit  the  spread  of  the  disease  I  abandoned  their  use  and  applied  emulsions  of 
flaxseed,  thereby  relieving  my  patients  from  much  unnecessary  suffering. 

Extract  from  the Ilecords  of  the  Chimhora:o  UoipUul,  Ilichmonih  ]'a. — Erysipelatous  cases  have  occurred  within  the 
last  month  [March,  1861],  none  grave.  They  are  treated  with  iodine  or  niuriated  tincture  of  iron  tojiically.  and 
the  latter  internally  with  saline  purgatives  as  recjuired.  In  the  case  of  Hicks,  who  entered  March  5,  this  treatment 
was  changed  on  the  9th  for  the  sulphate  of  iron,  there  being  no  iodine  in  the  pharmacy.  At  this  time  the  erysipelas 
was  leaving  the  Imnds  of  the  patient  and  invading  the  upper  arms.  Velpeau  says  that  sulphate  of  iron  arrests  the 
malady  sooner  by  two  days  than  any  other  agent.  His  foriuula  for  the  lotion  was  employed.  It  arrested  the  disease 
in  thirty  hours.     At  the  same  time  the  patient  took  quinine  three  times  daily.     On  the  12th  lie  was  convalescent. 

TeeatmeIsT. — Tlte  essentials  to  success  in  the  inanagenient  of  erysipelas  comprised  the 
prompt  isolation  of  the  afiecteJ  intliviJnal,  the  dissipation  of  causative  miasms  by  free  ven- 
tilation and  the  disinfection  or  cremation  of  articles  known  or  suspected  to  be  dangerous. 
The  gradual  establishment  of  special  wards  and  hospitals  for  erysipelatous  cases  during  the 
progress  of  the  war  gave  a  practical  recognition  to  the  contagious  cjualities  of  the  disease 
and  to  tlie  other  intimate  analogies  which  classed  it  for  prevention  and  treatment  among 
the  eruptive  fevers.  This  view  held  good,  however,  onlv  in  hospital  practice.  Erysipelas 
occurred  in  the  field  independent  of  the  infection  of  a  pre-existing  case.  Sometimes  it 
appeared  due  to  atmospheric  exposures;  sometimes  no  apparent  cause  could  be  assigned  for 
its  development.  Here  it  presented  no  analogy  to  the  eruptive  fever  save  in  its  course  in 
the  individual, — a  self-limited  febrile  action  with  an  associated  inflammatory  condition  of 
the  skin,  and  frequently  of  the  internal  surfaces,  constituting  the  cerebral,  tonsillar,  laryn- 
geal, pulmonary  or  dysenteric  complications  of  the  disease.  There  was  no  inherent  suscepti- 
bility which,  until  exhausted  by  an  attack  of  the  malady,  made  victims  of  those  subjected 
to  contact  with  the  afiected  individual.  There  was,  therefore,  no  apparent  communicabilit3^ 
But  when  this  same  case  was  transferred  to  the  crowded  ward  of  a  general  hospital  a  dis- 
tinctly contagious  quality  was  manifested.  Defective  ventilation  seemed  to  concentrate  the 
causative  exhalations  to  a  degree  of  virulence  that  overwhelmed  the  conservative  powers  of 
those  exposed  to  their  influence, — or  the  inmates,  as  a  result  of  previous  disease,  had  these 
powers  so  weakened  as  practically  to  have  developed  susceptibility  to  attack.  Probably 
both  of  these  conditions  were  concerned  in  the  spread  of  the  disease.  Overcrowding  was 
generally  regarded  as  a  predisposing  factor,  and  the  susceptibility  of  enfeebled  convalescents 
was  shown  bv  the  experience  of  every  hospital. 

Bromine  vapor  in  quantity  sutEcient  to  be  perceptible  in  the  atmosphere  of  the  wards 
was  used  in  some  of  the  western  hospitals  for  the  prevention  of  erysipelas.  Surgeon  M. 
Goldsmith,  U.  S.  Vols.,  published  directions  for  the  use  of  this  agent, '='  with  a  communica- 
tion from  Dr.  B.  Woodward,  in  which  it  is  stated  that  since  the  use  of  the  vapor  in  the 
crowded  wards  of  the  Park  Barracks  Hospital,  Louisville,  Ky.,  not  a  single  case  had  occurred, 
although  prior  to  its  use  from  five  to  eight  cases  had  been  developed  every  week.     In  wards 

*/li)ieri«iii  Jleilicnl  Tiuict,  VI,  New  York,  ls(;3,  \k  141. 

Med.  Hist..  Ft.  111—85 


674  THE  KRUPTIVE  FEVERS. 

containing  as  many  as  sixteen  cases  at  a  time,  side  by  side  with  other  >ick  and  wounded 
men,  the  disease  did  not  spread  after  the  use  of  tliis  disinfectant,  and  nurses  wliu  furnit-'rlv 
dreaded  the  danger  of  having  erysipelas  in  tlieir  wards  lost  all  fear  of  the  disease/-' 

Clinically,  treatment  was  directed  to  the  constitutional  state  of  the  imlividual  to  mod- 
erate the  violence  of  the  local  inliammation,  limit  its  spread  and  control  its  results.  When 
the  constitutional  disturbance  was  of  a  sthenic  character  salines,  laxatives  and  diaphoretics 
were  administered;  but  these  were  seldom  continued  for  any  length  of  time,  as  the  disease, 
if  mild,  speedily  subsided,  and  if  severe,  as  speedily  induced  a  state  of  prostratiuu  which 
called  for  careful  nursing,  sup|>ort  and  stimulation.  Emetics  were  rarelv  used  at  the  com- 
mencement of  the  attack:  laxatives  or  purgatives  were,  on  the  contrary,  freely  prescribed, 
particularly  in  the  presence  of  cerebral  symptoms.  Dr.  Day  has,  however,  entered  a  protest 
ao'aiust  the  use  of  the  latter  on  the  uruund  of  their  lialjility  to  induce  prostration  and  increase 
the  tendency  to  diarrlaeal  complicatiuns ;  he  claimeil  that  constipation  was  a  fa\-orable  con- 
dition in  the  erysipelas  cases  of  Hospital  Xo,  10,  Xashville,  Teim.  Tincture  of  iron  a[ipears 
to  have  been  regarded  in  the  light  of  a  speciric:  In  most  cases,  as  soon  as  the  inflammatory 
blush  indicated  the  nature  of  the  attack,  this  remedv  was  administered,  many  medical  otficors 
considering  that  it  controlled  the  disease  and  others  acknowledging  Ixuietit  from  its  use  but 
doubting  whether  the  duration  of  the  attack  was  in  any  case  shortened.  Chlorate  of  potash 
was  also  largely  used  by  some  practitioners.  As  soon,  however,  as  the  pulse  became  weak, 
the  delirium  muttering  or  the  general  prostration  notable,  beef-essence,  milk  and  eggs,  with 
wine,  whiskey  or  brandy  were  fretdy  administered.  Convalescence  was  promoted  l.iy  quinine, 
iron  and  extra  articles  of  diet,  and  to  these  stimulnnts  were  added  during  the  tedious  iiro- 
gress  of  consecutive  suppurations. 

Local  treatment  was  rational  or  empiric.  The  aim  of  the  one  was  to  relieve  suffering 
and  allay  local  inflammation, — of  the  other  to  exercise  a  controlling  influence  on  the  cutaneous 
manifestations.  The  feelings  of  the  patient  invariably  testified  to  the  efficacy  of  soothing 
methods,  seldom  to  that  of  the  emiurio  measures,  the  repute  of  which  was  sustained  chiefly 
by  the  favorable  dictum  of  the  medical  men  who  applied  them.  Protection  from  the  air 
atlbrded  relief.  This  was  liest  effected  bv  smearing  the  surface  with  oil,  fresh  lard,  glycerine 
or  some  unirritating  unguent.  Dusting  the  parts  with  flour  or  lightly  covering  them  with 
cotton  answered  the  jmrpose  at  first;  but  these  substances  generally  became  a  source  of 
irritation  afterwards  liy  forming  incrustations  with  the  exudations  from  the  affected  sur- 
faces. Lead  and  other  cooling  lotions  proved  of  value  in  many  cases.  Flaxseed  emulsion 
and  glycerole  of  starch  were  also  regarded  as  useful.  Collodion  had  its  advocates  us  forming 
a  liu'ht  protective  and  erpiably  cunstringent  film. 

The  empiric  methods  consisted  of  the  application  of  tincture  of  iodine  or  nitrate  of  silver 
to  the  inflamed  surface  with  the  view  of  favorably  influencing  the  local  action.  Occasion- 
ally the  attempt  was  made  to  limit  the  spread  of  the  inflammation  by  circumscribing  it  with 
an  application  of  one  or  other  of  these  agents  to  a  strip  or  band  of  the  sound  adjacent  skin. 
The  tincture  of  iron  and  solutions  of  the  sulphate  or  persulphate  of  this  metal  were  also 
empl<n-ed  on  the  affected  surface  to  subdue  the  yiolence  and  arrest  the  progress  of  the  inflam- 
matory action.  The  repute  of  the  cranberry  poultice  was  such  that  one  medical  ofiicer,  in 
the  absence  of  this  acid  fruit,  made  use  of  lemons,  and  in  his  opinion  with  benefit  to  his 
patients.     A  saturated  solution  of  chlorate  of  potash  was  sometimes  used  as  a  wash  to  the 

♦Journal  last  cited,  p.  23U. 


MUMPS — YKLLOW    FEVKK.  675 

.surface  by  medical  men  who  prescribed  this  salt  for  intrrnai  adiniiiiitration.  Unguents  of 
resia  and  turpentine  appear  to  liave  been  used  extL-nsively  in  tlie  erysipelas  wards  of  the  prison 
hospital  at  Rock  Island,  111. 

Abscesses,  diti'nse  sujtpurations  and  other  local  results  of  the  acute  intianimation  were 
treated  in  accordance  with  tlio  general  principles  of  surgery. 


CHAPTER  VII.— OTHER  .MIASMATIC  DISEASES. 


I.— MUMPS. 


This  disease  occurred  to  a  notable  extent,  particularly  in  tlie  first  vear  of  the  war,  wiwn 
40  cases  were  reported  among  every  thousand  men.  The  rate  of  prevalence  fill  to  '2'.^  in 
the  second  and  third  years,  to  14  in  the  f)urth  year  and  to  less  than  3  per  thousand  i>\' 
strength  in  the  fifth  year.  Suppurative  inflammation  of  the  parotid  glands  was  not  uinisual 
in  the  advanced  stages  of  the  continued  fevers,"^'  but  the  tumefaction  of  the  glands,  reportdl 
under  the  present  heading,  generally  subsided  at  the  end  of  a  iVw  davs.  Of  4^'^, 128  cases 
reported  7'2  died.  The  t'ollowing  case  probably  illustrates  the  character  of  those  having  a 
fatal  termination : 

.Ser,!j;eaut  Josepli  1!.  Brown,  Co.  E,  3(1  Ky.;  ago  2<>:  was  admitted  Maicli  21.  lt<i!:i.  with  sliglit  ilianlio'a  and 
pain,  redness,  heat  and  swelling  in  tlio  region  of  the  parotid.  A  jionltice  of  arnica  leaves  and  flaxseed  was  ajiplied, 
and  in  a  day  or  two  the  abscess  communicated  with  the  external  atiditory  canal.  On  the  27th  a  free  incision  gave 
exit  to  six  ounces  of  pus.  On  April  2  he  was  restless,  but  became  unlet  after  the  administratiim  of  liyosoyanius  and 
opium.  He  was  found  dead  in  tied  on  the  morning  of  the  3d.  l\)>il-iiiorti'm  examination:  The  mastoid  jiortion  of 
the  teiuporal  bone  Avas  denuded  and  carious  and  its  cells  filled  v.ith  pus.  The  deep  vessels  and  nerves  were  com- 
pletely dissected  by  the  progress  of  the  supimratiou.  The  right  ventricle  of  ilie  heart  contained  a  tibrinons  clot. 
The  left  lung,  its  apex  especially,  was  studded  Avith  miliary  tubercle.  The  liver  was  large  but  healthy:  the  gall- 
bladder full;  the  liowels  filled  with  llatus. — Imu-hoh  Ilof^pital,  SI.  Loitis,  Mo. 

II.— YELLOW  FEVER. 

Our  armies  fortunatclv  escaped  visitation  from  cpiileinics  of  exotic  origin.  Cholera  did 
not  invaije' the  countrv  until  aft(.'r  the  war  period.  Yellow  fever  was  imported,  but  by 
timely  conservative  action  most  of  the  troops  in  the  invaded  or  threatened  departments 
were  preserved  from  the  disease.  The  regiments  stationed  in  the  Department  ot  the  Gulf 
wholly  escaped. 

The  freedom  of  Xew  Orleans  from  visitation  while  garrisoned  l>v  unacclimated  men  from 

CD  * 

the  North  has  been  ascribed  to  the  institution  of  active  measures  of  local  sanitation  and  the 
strict  entbrcement  of  quarantine  regulations  by  General  Butler's  military  government.  The 
following  remarks  by  Surgeon  T.  II,  Bache,  U.  S.  Vols.,  who  was  Medical  Director  during 
the  first  summer  our  troops  spent  in  the  city,  bears  on  this  point : 

Was  the  exemption  from  yellow  fever  due  to  quarantine  or  to  the  cleanly  condition  of  the  city,  or  to  both? 
Following  La  Roche  and  others  I  was  not  originally  in  favor  of  establishing  a  (luarantine  to  keep  out  yellow  fever. 
By  originally  I  mean  prior  to  the  summer  of  1862.  My  views  were  changing  about  that  time,  chietiy  on  account  of 
the  exemption  of  New  Orleans  from  the  disease  during  the  summer  of  18111.  This  I  was  inclined  to  attribute  to  our 
blockade,  which  was  the  strictest  sort  of  a  quarantine.  During  that  summer  the  city  was  as  dirty,  if  not  dirtier  than 
usual,  owing  to  the  war;  the  ditches  for  artificial  drainage  were  obstructed  on  our  arrival.  Moreover  the  epidemic 
was  "over  due,"  as  they  say.     I  relinquished  the  position  of  Medical  Director  on  August  15,  1862.    About  the  Dth  or 

*  Svprn,  page  4a4. 


676  OTHER    MIASMATIC    DISEASES. 

6tli  of  September  a  man,  who  arrived  on  a  vessel  wliicli  liail  jiassed  ([Uarantine  a  lUiy  or  two  liefure,  sickened  and 
died  of  lilack  vomit  on  the  tiftli  day  of  the  disease.     I  never  heaid,  liowexer,  of  any  otlier  case  following  it. 

The  quarantine  e.stablislied  during  the  summer  of  lS62  was  kept  U|)  with  unremitting 
care  durinir  the  foUowino;  season,  witli  the  effect  of  excluJina-  the  fever  from  the  city,  althouo-h 
many  cases  were  treated  at  the  quarantine  station.  Ass"t  Surgeon  George  M.  Sternbeeg, 
U.  S.  Army,  says  on  this  subject; 

On  the  fourth  of  July,  18(53,  the  Spanish  man-of-war  Pizarro  arrived  at  quarantine,  and  the  vigilant  resident 
physician  in  his  examination  discovered  cases  of  yellow  fever  on  hoard  of  her.  Every  etfort  was  made  by  the  com- 
mander of  the  vessel  and  the  Spanish  Consul  at  New  Orleans  to  obtain  permission  for  the  vessel  to  come  to  the  city; 
but  they  were  assured  that  it  would  be  allowed  to  come  no  further  until  at  least  thirty  days  had  elapsed  after  the 
last  case  of  yellow  fever  had  occurred  and  the  vessel  was  thoroughly  fumigated.  The  Pizarro  therefore  put  to  sea 
again  with  yellow  fever  still  on  board,  after  having  remained  at  the  station  three  weeks.  There  were  tifteen  cases 
landed  from  this  vessel  and  treated  in  the  hosjiital  at  the  station;  of  these  three  died.  About  October  .5  cases  of 
yellow  fever  occurred  on  some  vessels  of  our  navy  which  liad  recently  connnunicated  with  infected  vessels  at  Pensa- 
cola  and  off  Mobile.  The  fact  that  the  disease  was  then  prevailing  in  the  blockading  sijuadron  was  not  known  at 
this  time  to  the  authorities  in  New  Orleans,  and  tlie  lirst  intimation  of  it  was  received  when  it  made  its  apjiearance 
in  the  Holyhock,  which  was  then  lying  in  front  of  the  city.  The  vessel  was  at  once  sent  to  quarantine.  When  she 
arrived  there  were  three  dead  liodies  on  board;  and  four  afterwards  died  out  of  twelve  eases.  The  disease  soon  after 
made  its  appearance  in  the  Fear-not,  the  Pensacola  and  the  Estrella.  all  of  which  were  sent  to  quarantine.  Fortu- 
nately it  was  so  late  in  the  season  that  it  did  not  spread  any  further  in  the  navy  and  not  at  all  in  the  city.  The  last 
case  occurred  late  in  October  on  the  Estrella. 

The  Department  of  tlie  South  was  visited  in  the  autumn  of  1862  and  again  in  1S64, 
wlien  also  some  of  the  stations  in  tlie  Depai'tinent  of  Xorth  Carolina  became  infected.  On 
the  first  occasion  382  cases  were  recordeil  with  lUU  deaths;  on  the  second  783  cases  with 
309  deaths  among  the  while  and  190  cases  with  27  deaths  among  the  colored  troops. 

On  June  20, 1862.  the  bark  Adventnre,  three  days  from  Havana,  Cuba,  put  into  Key  West,  Fla.,  in  distress.  She 
was  (quarantined  for  ten  days  and  lay  at  the  station  for  three  days  longer  than  the  official  term.  About  this  time 
four  of  her  crew,  sick  with  fever,  were  taken  into  the  JIarine  hosjiital.  where  one  died  and  the  others  recovered.  On 
July  27  a  soldier  of  the  iiOth  N.  Y.  was  attacked,  and  the  disease  afterwards  spread  through  the  garrison,  which  con- 
sisted of  148  men,  yielding  2  cases  in  July,  153  in  August,  137  in  September  and  39  in  October,  or  a  total  of  331  cases, 
71  of  which  proved  fatal.  It  is  thus  seen  that  this  garrison  furnished  87  per  cent,  of  the  cases  and  71  per  cent,  of  the 
mortality  occasioned  by  yellow  fever  during  the  year  1862. 

Surgeon  E.  S.  Hoffman,  90th  K.  Y.,  in  an  able  repiort  of  his  experiences  at  this  time, 
states  that  yellow  fever  in  Key  West  has  always  been  traced  to  direct  importation  from 
Cuba.  Ass't  Surgeon  Cornick,  U.  S.  Army,  denies  this  and  suggests  a  local  origin.  How- 
ever this  may  be,  the  weather  in  1861  was  similar  to  that  prevailing  in  1862,  and  in  both 
years  the  island  contained  a  large  number  of  unacclimated  men,  but  in  the  latter  only  did 
the  disease  appiear.  Some  local  conditions  no  doubt  favored  its  spread  and  added  to  its 
virulence,  such  as  a  large  amount  of  decaying  vegetation  resulting  from  the  clearing  of  land 
for  military  purposes,  the  breaking  of  ground  for  gardens,  the  excavations  involved  in  the 
construction  of  fortifications,  and  during  the  progress  of  the  last,  the  opening  and  removal  of 
about  three  hundred  graves  which  is  said  to  have  occasioned  an  intolerable  odor.  The  clin- 
ical features  of  the  disease  are  thus  depicted: 

Premonitory  symiitoms  for  the  most  jiart  were  wanting  throughout  the  epidemic.  In  a  few  cases  the  patient 
complained  for  some  days  of  slight  headache  and  constipation,  with  trilling  jiains  in  the  back  and  loins.  In  two  cases 
diarrhtea  was  followed  on  the  second  or  third  day  by  the  sudden  appearance  of  black  vomit  and  a  similar  black  matter 
in  the  stools.  Death  liy  conux  took  i>lace  soon  after;  but  both  these  men  had  been  weakened  by  typhoid  fever,  from 
which  they  were  convalescing  at  the  time  of  their  fatal  seizure.  A  similar  case,  remarkable  from  its  bearing  on 
the  question  of  fright  and  nervousness,  was  that  of  Private  George  Cornwall  of  Co.  I,  who  was  admitted  August 
21  with  diarrhoea  of  five  or  six  stools  daily.  He  had  no  fever  nor  headache.  Ajijiropriate  medicines  relieved  the 
diarrhtea,  and  the  patient  was  prejiariug  to  leave  the  hospital  on  the  third  da,v  when  a  soldier  was  brought  in  w  ith 
fully-developed  yellow  fever.  The  complaints  and  evident  alarm  of  the  latter  frightened  Cornwall,  and  within  one 
hour  of  the  admission  of  the  new  patient  he  was  himself  seized  with  violent  fever,  headache,  intense  injection  of  the 
conjunctiva'  and  distressing  pain  in  the  back  and  lower  extremities.  Next  morning  suppression  of  urine  came  on, 
soon  followed  liy  vomiting, — the  fluid  at  first  watery  afterward  showed  the  coftee-gronnd  sediment, — and  a  strong 


YELLOW    FKVER.  67 


urinoTis  odor  ■^as  perceptible  in  the  perspiration.  Tlie  other  caso  now  iniiiruving,  Cornwall's  spirits  rose,  liope  retunuMl 
to  bim,  anil  for  six  days  be  stnigj^leil  unavailingly  aj;ainst  tlio  disease. 

Xearly  every  case  presented  a  ditt'ercnt  series  of  symptoms,  inlluenci-d  liv  tlie  eonstitntioii,  teni]ieiainent  and 
idiosyncracy  of  the  patient.  In  ojiposition  to  observations  made  in  most  otbur  epidemics  of  this  disease  tliere  was 
no  particnbir  time  durint;  tbe  twenty-four  hours  when  the  attacl<  occurred,  the  patient  lieinj;  seized  at  all  hours  both 
of  day  and  night.  In  most  tlie  onset  was  sudden.  The  patient  was  seized  witli  a  severe  jiaiii  in  tbe  bead,  j;enerally 
supra-orbital,  and  often  preceded  by  a  regular  chill.  Tbe  pain  soon  extended  to  tbe  back  of  the  neck,  the  hnubar 
region,  the  knees  and  calves  of  tbe  legs,  and  with  this  were  associated  intolerance  of  light  and  deep-seated  pain  in 
the  eyeballs.  In  a  few  cases  the  head  symptoms  reached  a  high  degree  at  once,  delirium  setting  in  aliuost  from  tbe 
first,  but  I  fottnd  that  these  yielded  more  readily  to  prompt  measures  than  where  meningitis  manifested  itself  at  a 
later  period.  The  eyes  were  injected  and  watery;  the  skin  generally  hot  and  dry,  but  sometimes,  particularly  in 
fatal  cases,  cold  and  covered  with  clammy  perspiration.  Tbe  pulse  varied  from  !S5  to  lno  and  was  full  and  incon:- 
pressible  save  in  tbe  cases  of  cold  skin,  where  it  was  small  and  gaseous.  Tbe  tongue  was  usually  covered  with 
white  fur,  its  tip  and  edges  red;  but  sometimes  it  was  perfeclly  clean,  with  or  without  tbe  red  tij);  the  edges  and 
tip  corresiionded  exactly  with  the  i)tilso  and  febrile  excitement — the  higher  tbe  fever  the  redder  the  tip  anil  edges. 
()nly  in  two  cases  was  there  a  dry  timgiie  ami  in  but  one  a  brown  or  dirty  coat.  Tin-  bowels  were  generally  con- 
stipated— sometimes  diflicult  to  move,  but  usually  readily  atfected  by  cathartics.  In  many  cases  after  the  administra- 
tion of  calomel  the  patients  continued  to  have  inky  ami  freijueut  stools  for  souu'  days.  Tbe  urine  was  luoslly  normal 
at  tbe  onset,  but  in  severe  cases  scanty,  ami  the  little  that  passed  was  dark-colored  an<l  threw  down  a  copious  sedi- 
ment. Nausea  frequently  was  present  at  first  and  tbe  stomach  easily  rejected  its  uiuligested  contents, — sometimes 
accompanied  by  bilious  matter. 

These  symptoms  continued  for  a  longer  or  shorter  period.  Sometiiues  tbe  fever  lasted  froiu  twelve  to  forty- 
eight  hours,  and  in  a  few  fatal  cases  to  seventy-two  hours.  During  the  fever  tbe  lu'adache,  pain  in  tln'  back,  legs 
and  eyes,  with  unsatiable  thirst,  were  the  most  distressing  syuijitoms.  (ieiierally,  after  treatuu'Ut,  jierspiration  was 
speedily  established  and  continued  through  tbe  fever;  lint  in  some  all  available  and  known  means  failed  to  induce 
moisture  on  the  hot,  dry  surface.  In  a  few  cases  there  were  distinct  remissioirs,  and  in  live  patients  who  had  passed 
through  the  second  stage  ami  were  convalescent  the  fever  returned  on  the  ninth  day  ami  tbe  whole  programme  was 
repeated  as  if  an  original  attack. 

At  the  beginniirg  of  the  second  stage  the  patient  was  free  from  headache  and  iiaiii,  but  still  comidained  of 
weakness  in  the  liack.  The  stomach,  mostly  irritable,  often  rejected  its  contents  without  etibrt,  while  in  some  there 
was  constant  retching  without  emesis.  Pain,  more  or  less  acute,  according  to  tbe  severity  of  the  attack,  with  tender- 
ness on  pressure,  Avas  manifested  in  the  epigastrium.  Tatieiits  apparently  convalescent  and  desirous  of  getting  u\< 
would  show  great  uneasiness  on  pressure  at  this  point,  and  before  long  black  vomit  revealed  to  tbeiu  tbe  dc-sperate 
nature  of  the  disease  and  its  treacherous  character.  As  a  rule  tbe  worst  symptoms  came  on  aftm-  tbe  patient  bad 
been  from  six  to  twelve  hours  in  the  second  stage.  The  pain  in  the  epigastrium  increasi'd  and  burning  thirst  accom- 
panied it;  vomiting  followed,  at  first  of  tbe  lluids  ingested,  often  clear  and  transparent,  but  sometimes  mixed  with 
chyle  or  more  or  less  colored  with  bile;  in  three  or  four  hours  the  fiuid  assuiued  ibe  ajipearance  of  water,  with  a 
browuisb-black  sediment.  On  clo.ser  examination  this  I)lack  matter  was  found  to  l>e  in  lojiy  feculent  nnisses,  soiue 
of  lighter  specific  gravity,  suspended  in  the  fiuid,  others  sinking  to  tbe  bottom  and  adhering  with  considerable 
tenacity  to  the  containing  vessel.  The  cjuantity  of  lii|uid  ejectcil  was  sometimes  very  great,  ami  tbe  stomach  relieved 
itself  in  some  cases  by,  as  it  were,  involuntary  muscular  action,  casting  tbe  vomit  to  a  distance  of  several  feet  by  a 
single  spasmodic  act.  The  matter  thrown  up  reseml)le<l  chocolate,  and  on  settling  deposited  a  grumous  coli'ee-ground- 
like  mass,  which,  when  expressed  through  filtering  paper,  lost  much  of  its  dark  color.  It  etiervesced  with  bicaibo- 
uate  of  potash  and  turned  blue  litnnis  paper  red.  Ileateil  in  a  test-tube  tlie  lluid,  if  previously  transparent,  became 
opaque  and  curdy  like  albuminous  urine.  In  those  cases  in  which  urainia  was  present  tbe  vomit  when  heated  gave 
off  ammonia,  as  shown  by  the  white  fuines  that  were  developed  when  a  rod  that  bad  been  dijiiied  in  muriatic  acid 
was  held  over  it.  Tbe  urine  was  invariably  albuminous  and  sometimes  largely  mixed  with  blood.  I  ob.served  as  one 
of  tbe  characteristics  of  tbe  ei)ideinic  that  tbe  matter  was  not  ejected  in  large  iiuantities  at  a  time  from  the  stomach; 
and  only  in  a  few  cases  did  tbe  quantity  thrown  up  at  once  exceed  two  cpmrts.  In  these  it  was  very  dark,  resembling 
a  mixture  of  soap  and  water,  very  acid,  aud  accompanied  by  a  sensation  of  rawness  and  extreme  distress  in  tbe  epi- 
gastrium; hiccough  also  troul)led  tbe  patient  considerably  during  tbe  intervals.  Tbe  matter,  froui  its  acrimonii.us 
nature,  freiiuently  excoriated  the  tongue,  throat  and  lips;  tbe  stools  also,  being  often  of  a  similar  character,  caused 
painful  sensations  in  their  passage.  Tbe  period  from  tbe  begiuuiiig  of  tbe  black  vomit  until  its  termination  in  couva- 
lesceuce  or  death  was  variable — sometimes  it  terminated  fatally  in  twenty-four  hours ;  sometimes  it  lasted  longer,  aud 
in  one  case  was  even  protracted  for  four  days,  ending  in  recovery.  I  always  considered  its  appearance  a  very  grave 
symptom,  although  twelve  well-marked  cases  recovered  out  of  fifty-two  that  presented  it.  During  this  stage  of  the 
fever  the  pulse  was  generally  from  50  to  lio,  small  anil  easily  compressible,  but  in  two  fatal  eases  it  reached  100  per 
minute.  The  bowels  became  loose,  particularly  if  they  had  been  coustipateil  in  tbe  first  stage;  tbe  fa-ces  of  a  dark 
color  and  fetid  odor.  The  color  of  tbe  skin  varied  considerably — in  some  natural,  in  others  presenting  various  shades 
of  yellow,  luit  generally  this  color  did  not  make  its  appearance  uutil  shortly  Vicfore  tbe  closing  scene.  In  two  oises, 
which  afterwards  recovered,  I  observed  previous  to  convalescence  a  distinct  third  stage  of  the  fever.  The  matter 
thrown  up  changed  its  color — in  place  of  a  tarry  appearance  it  became  streaked  with  blood ;  the  tongue  cracked  and 
blood  began  to  flow  from  it  aud  from  the  gums,  lips  and  nose ;  blood  appeared  in  the  stools  also,  aud  the  yellow  color 
of  the  skin  passed  into  a  dark-orange  color.  Tbe  ha'mateniesis  in  one  case  was  checked  with  tincture  of  iron  every  two 
hours,  ami  in  tbe  other  the  persulphate  had  an  excellent  eft'ect.    The  ten  remaining  cases  of  black  vomit  convalesced 


678  OTHKR    MIASMATIC    DISEASE?. 

rapidly  on  the  subsidence  of  the  voniitiug,  and  resumed  their  duties  sooner  than  others  who,  from  a  severe  attack  of 
yellow  fever,  passed  from  the  first  stage  to  couvalescenee  without  going  through  a  second  and  third  stage.  Fatal 
cases  died  generally  on  the  second  or  third  day.  One  case  died  three  weeks  after  being  attacked  with  the  fever.  He 
passed  through  all  the  stages. — the  hot  stage  lasting  forty-eight  hours,  the  second  with  evident  signs  of  the  coft'ec- 
ground  vomit,  the  third  with  lueuiaturia.  hiematemesis  and  bleeding  from  the  tongue  and  luiigs.  after  which  he  fell 
into  a  tyiihoid  condition,  which  ended  in  death. 

Recovery  was  rapid.     Ten  days  after  the  onset  the  patients  resumed  their  duties. 

The  treatment  adopted  in  this  epidemic  is  described  by  Ass't  Surg.  W.  F.  Cokxick, 
U.  S.  A.,  as  foUows: 

As  soon  as  the  patient  is  attacked  with  symptoms  of  tlic  fever  he  is  placed  to  his  chin  in  a  hot  bath  containing 
from  four  to  eight  ounces  of  mustard  until  he  gets  into  a  profuse  perspiration  or  complains  of  being  faint ;  he  is  then 
put  in  bed  between  blankets  and  fifteen  to  twenty  grains  of  calomel  are  administered,  followed  in  four  hours  by  an 
ounce  or  two  of  castor  oil.  By  the  time  the  oil  has  had  a  good  ettect  his  pulse  as  a  rule  becomes  almost  natural, 
though  in  many  cases  quite  frequent.  I  then  give  him  ten  grains  of  cjuiniue  every  hour  until  he  has  taken  two 
doses,  after  which  five  grains  every  two  hours  until  he  comjilains  of  ringing  in  his  ears  or  other  indications  of  the 
action  of  the  remedy.  I  also  give  sweet  spirit  of  nitre  to  keep  the  kidneys  in  good  working  order,  from  the  derange- 
ment of  which  we  liave  so  much  to  fear.  Should  the  jiatient  after  tliis  complain  of  gastric  uneasiness  I  give,  as  a 
lireventive  fif  black  vomit,  one  droji  of  crcasoK'  in  the  form  of  a  pill  :  this  has  been  attended  with  tlie  hajipiest  results, 
sometimes  even  after  black  vomit  has  made  its  ajipearance.  If  the  jiatient  comjilain  of  nuich  uneasiness  about  the 
stomach  I  generally  resort  to  sinapisms,  which  will  in  most  instances  give  relief.  After  this  he  is  treated  upon 
general  jirinciides. 

The  otlier  points  affected  during  the  year  18'62  were  Hilton  Head,  8.  C.  and  Fort 
Jefferson,  Fla.,  l>oth  of  which  received  the  disease  from  Key  West.  Surgeon  C.  H.  C'kaxe, 
U.  S.  A.,  Medical  Director  of  the  Dejiartiiient,  placed  on  record  the  facts  connected  with 
its  appearance  at  tlie  tirst-mentioned  station.'" 

The  steamer  Delaware,  with  General  Terry  and  staff  on  board,  left  this  jilace  [Hilton  Head]  July  26  for  St. 
Augustine,  Key  West  and  Fort  .Jetfersnu.  She  returned  August  2t),  bringing  a  detachment  of  the  7th  X.  H.  that  had 
been  left  sick  at  Fort  Jeft'erson  when  the  regiment  was  relieved  from  that  post  in  June  last.  These  men  ha<l  all  been 
invalids  for  a  long  time  and  were  broken  down  in  constitution. 

This  steamer  left  Key  West  on  her  return  trip  August  14,  and  on  her  arrival  here  was  sent  to  quarantine  at 
St.  Helena,  about  thirty  miles  distant.  Among  the  passengers  was  Ass't  Surgeon  COKXICK,  U.  S.  A.,  who  had  been 
on  duty  at  Key  West  for  some  time  and  much  exposed  to  yellow  fever.  Shortly  after  embarking  this  officer  was 
taken  with  what  he  supposed  to  be  a  mild  attack  of  tlie  fever;  but  he  had  completely  recovered  before  the  arrival 
of  the  steamer  at  this  place,  and  no  case  of  sickness  then  existed  on  Ijoard.  The  vessel  renniined  at  the  quarantine 
station  twelve  days,  when,  as  Surgeon  Daltox,  I'.  S.  Vols.,  who  was  a  passenger,  reported  to  me  that  there  was  no 
sickness  on  board,  she  was  allowed  to  come  to  Hilton  Head.  Three  days  subsequent  to  the  landing  of  the  passengers 
yellow  fever  appeared  among  the  New  Hampshire  men,  and  to  date  (September  19)  there  have  been  eight  deaths  in 
the  detachment :  but  the  disease  has  not  spread  beyond  it,  and  during  the  past  three  days  there  has  been  no  new  case. 
As  the  remainder  of  the  detachment  has  been  sent  to  Xew  York  in  the  Delaware  I  am  hoi)eful  that  no  more  cases 
will  occur.  The  other  chartered  vessels  with  Government  supplies  aboard,  which  have  arrived  here  from  Key  West, 
have  also  been  sent  to  Tsew  York.  I  am  satisfied  that  the  only  sure  method  of  excluding  yellow  fever  from  this  jdace 
is  to  stop  all  connnunicatioii  with  infected  ports.  In  the  instance  of  the  Delaware  twenty-eight  days  elapsed  between 
th(^  time  the  vessel  left  Key  West,  the  only  infected  port  she  visited,  and  the  development  of  the  disease  after  the 
debarkation  of  her  jiassengers  at  this  place. 

At  this  time  there  were  about  ten  thoustmd  troops  at  Hilton  Head  and  Beaufort,  but  the 
disease  did  not  spread  among  them,  although  some  cases  occurred  in  October  and  I^ovember 
in  the  vicinity  of  the  wharf  at  which  the  Delaware  had  landed  her  passengers.  In  all, 
including  the  men  of  the  7th  N.  H.,  there  were  forty  cases  at  Hilton  Head,  twenty-tive  of 
which  were  fatal. 

During  October  eleven  cases  with  four  deaths  were  reported  from  Fort  Jefferson,  Fla., 
garrisoned  by  a  detachment  of  the  90th  N.  Y.,  the  main  body  of  which  -was  then  suffering 
from  the  disease  at  Key  West.  Ass't  Surgeon  Chapman,  of  that  regiment,  denied  the 
importation  of  the  fever,  as  a  quarantine  of  seven  to  fourteen  days  bad  been  imposed  on  all 
vessels  from  infected  ports.     It  is  needless  to  advert  to  the  weakness  of  this  argument  in 

*See  also  Ytlhw  Fn-er  al  Purt  R'ajnl,  S.  C,  by  Thomas  T.  Smilev,  U.  S.  Hospital,  Hilton  Heail,  S.  C.—BosUm  Med.  ami  Surg.  Jour.,  LXVII,  1803,  p.  44'J. 


YKLLO'W    FKVKR.  679 

favor  of  tlio  douiestie  origin  of  yellow  fever.     The  ca^e^  of  the  AJwaiture  and  Dc'laware  are 
.sufficient  to  jirove  its  fallacy. 

The  reports  of  Surgeon  I''.  AV.  IIaxp.  U.  S.  VoU..  state  that  during  this  autumn  the 
disease  affected  the  citizt- ns  of  AVilmington,  X.  C.  and  Charleston.  S.  C.,  attributing  its  intro- 
duction in  both  instances  to  blockade  runners  from  infected  ports.  The  evidence  appears 
to  throw  the  responsibility  of  the  Wilmington  oj^demic.  which  is  reported  to  have  occasioned 
1,1'fH)  deaths  among  the  3,(^00  whites  anil  negroes  who  remained  in  the  city,  on  an  infected 
steamer  (vna  Xassau.  which  ran  the  blockade  uu  August  6. 

The  epidemics  of  1S64  affected  the  garrisons  of  Key  AVe>t.  Fla..  and  Xew  IJerue.  X.  ("". 
From  tlie  first-mentioned  station  132  cases  with  12  deaths  wei'c  reported  as  having  occurred 
among  the  2d  U.  S.  Colored  Troops  in  May  and  June,  and  7'^  cases  with  21  deaths  among  white 
troops  in  July  and  August;  but  no  particulars  c.f  their  origin  were  furnished  bv  the  medical 
officer  in  charge.  The  fever  appeared  at  !New  JSerne  about  the  beginning  of  September  and 
continued  until  the  frosts  of  Xovember.  J)iu'ing  this  jKU'iod  7<'.")  cases  with  28S  deaths 
were  reported  among  the  white,  and  58  cas(.'s  with  L")  deaths  among  the  coloretl  trooj^s. 
Eight  medical  officers,  out  of  sixteen  affected,  I'ell  victims  lu  the  disease.  The  origin  of 
this  epidemic  is  involved  in  ol^scurity.  The  first  cases  among  the  troops  occurred  in  the 
jiersons  of  men  attached  to  District  Headquarters  as  clerks  and  orderlies.  It  is  known, 
however,  that  two  citizens  were  taken  siek  on  the  same  date  as  the  earliest  of  the  cases 
among  the  troops;  and  it  is  impossible  to  say  how  many  cases,  unobserved  and  unreported, 
mav  have  occurred  among  the  civil  population  at  an  earlier  period.  It  does  not  appear  that 
the  infection  was  introduced  from  a  foreiu'u  iiort,  nor  bv  refucrees  from  AVilmine-ton,  for  the 
disease  did  not  afiect  the  citizens  of  the  latter  place  until  some  time  after  its  appearance  at 
Xew  Berne ;  but  as  the  fever  was  at  this  time  prevailing  in  Charleston,  S.  C.  the  infection  may 
have  been  carried  northward  by  refugees  from  that  afflicted  city.  Surgeon  Haxji.  who 
investigated  the  outbreak,  was  so  impressed  with  the  difficulties  besetting  the  priuM'  of 
importation  that  he  referred  the  disease  to  local  causes,  and  enumerated  in  his  report  the 
various  unfavorable  hygienic  influences  which  in  his  view  contributed  to  its  }ii'oduction. 
It  is  needless  to  say  that  the  history  of  yellow-fever  e}iidemics  in  the  South  since  the  close 
of  the  war  does  not  sustain  the  theory  of  their  local  origin, 

AVhen  the  presence  of  tlie  disease  was  recognized  at  Xew  Berne  soldiers  and  citizens 
were  at  once  moved  to  ]\Iorehead  Citv,  Beaufort,  llatteras,  Boanoke  Island  or  other  places. 
Certain  individuals  who  had  become  infected  prior  to  their  departure  with  these  detachments 
suffered  from  an  attack  at  their  new  stations,  but  the  disease  did  not  sjiread.  excejit  to  a 
limited  extent  at  Beaufort. 

Surgeon  C.  A.  Cowgili.,  U.  S.  A^oIs.,  reported  that  292  cases  of  fever  were  admittel 
into  the  Foster  hospital  at  Xew  Berne  during  the  jirogress  of  the  epidemic,  and  that  some 
time  after  the  first  cases  were  received  the  disease  spread  through  the  wards,  aftccting  first 
convalescents  from  malarial  diseases,  then  convalescents  from  other  diseases,  and  finallv  the 
attendants;  of  these  118  were  attacked,  giving  a  total  of  410  cases  and  131  deaths  among 
the  white  troops  in  the  establishment. 

Surgeon  D.  AA'',  Hand,  U,  S.  A^ols.,  reported  of  this  epidemic  as  follows: 

New  Berne  is  situated  on  a  point  of  low  land  at  the  junction  of  the  Trent  and  Neuse  rivers  and  is  almost  wholly 
surrounded  by  marsh  and  swamps.  The  highest  i>art  of  the  town  is  onl.v  a  few  feet  al)0ve  the  surface  of  the  river, 
and  the  streets,  beinj;  without  paving,  have  an  imperfect  drainage  and  in  wet  weather  are  a  mass  of  mud.  The  elms 
and  maple  trees,  which  iu  times  past  have  been  planted  in  every  yard  and  street  without  regard  to  taste  or  utility, 


680  OTHER    MIASMATIC    r)I:^EA.^KS. 

have  grown  into  a  port'ect  t'oif>t.  iiud  duiini,'  xlu-  wot  (l;iys  of  July  la>t  tlio  dense  foliage  kept  the  whole  town  damp 
and  mouldy:  durinj^  that  nioMili  tln-re  were  few  days  witliniit  a  shower  of  rain.  In  the  spring  and  summer  laborers 
were  kept  at  work  on  the  streets  and  srweis.  ami  (Jovernnient  teams  were  sent  regularly  to  remove  such  filth  and 
garbage  as  might  he  collected,  the  citizens  hcing  rei|uiied  by  the  coninnniding  oftieer  to  dei)i)sit  all  such  refuse  where 
the  teams  could  get  it.  The  backyards  were  not.  however,  very  closely  examined,  and  the  accumulations  of  years 
were  afterwards  found  in  many  ]ilaces  :  liut  n\  il  li  all  this.  I  believe  the  general  sanitary  condition  of  Xew  Berne  wlteu 
the  fever  broke  out  to  have  been  better  than  tliat  of  most  Southern  towns. 

During  the  winter  of  IstjiJ-iU  and  spring  of  1)<G4  several  small  docks,  near  the  foot  of  Union  street  on  tlie  Xeuse 
river  and  Craven  street  on  the  Trent,  were  tilled  up.  in  ji.-ii  r.  ir  is  said,  with  stable  nuinnre.  for  the  purpose  of  extend- 
ing the  wharve.s.  Between  two  of  these  docks  thus  tilled  up  at  the  foot  of  Craven  street  was  a  row  of  old  franu? 
buildings,  several  of  which  were  built  on  piles,  with  tlu'  river-water  formerly  washing  tinder  them.  Through  care- 
lessness or  neglect  no  drainage  was  provided  for  the  ca  \ crn  under  tliese  buildings.  In  consei|Uence  the  summer  rains 
made  a  pond  under  them,  where  dead  rats  and  tilth  ra|iidly  accumulated  and  where  the  intense  heat  of  August  gen- 
erated fearful  poison. 

On  the  Xeuse  river  front  there  was  l>uilt  in  .July  anil  August  an  embankuu-nt  to  prf\  ent  the  water  ciieroachiiig 
on  the  carriage-way  between  Pollock  and  .Short  streets.  This  was  nuide  of  a  solid  wood  t'ront.  tilled  in  for  the  nu)st 
part  with  clean  sand ;  Iiut  during  several  days  of  excessively  low  water,  sand  and  mud  were  thrown  into  it  from  tl;e 
exposed  river  bottom. 

During  July  and  August  the  weather  remained  steadily  hot.  the  thermometer  averagijig  at  midday  s:!.L'.""  in 
July  and  f'j^  in  August.  The  fall  of  rain  in  July  was  S)  inches  and  in  August  -1..")  inclu's.  The  jirevailing  winds 
during  both  months  were  from  the  southwest.  The  continual  showers  of  rain  during  these  mouths  and  September 
kejit  the  ground  and  air  very  moist  without  mitigating  the  heat.  In  July"  we  hail  several  thunder  storms  with  heavy- 
winds,  but  in  August  the  wind  was  steadily  from  the  southwest  or  south  and  very  light. 

There  is  no  regular  ebli  and  dow  of  the  tide  in  the  X'euse  river,  but  these  continual  southwest  winds  drove  the 
water  out  ami  we  had  for  many  days  the  lowest  tides  that  had  been  known  for  years.  Many  acres  of  sand  and  mud 
on  both  river  fronts  were  thus  exposed  to  the  hot  sun.  In  the  summer  and  fall  the  vicinity  of  Xew  Berne  is  always 
priditic  of  malarial  fevers,  and  the  warm  season  of  1801  was  one  of  the  worst  known  not  only  here  but  in  all  jiaits  of 
Xorth  Carolina.  Each  year  since  the  occupation  of  X'ew  Berne  it  has  been  lujticed  that  the  regiment  doing  jprovosr 
duty,  and  remaining  in  town,  has  been  almost  exempt  from  intermittent  and  renuttent  fevers  an<l  much  more  healthy 
than  the  troops  encamped  on  the  outskirts.  It  was  noticed  through  the  jiast  August  that  the  men  in  town — ]iart  of 
the  l.'ith  Conn. — were  generally  escaping  the  nuilarial  fever,  but  early  in  September  some  bad  cases  of  cougestivi-  fever 
(iccurred  anmng  them. 

On  the  (Jtli  of  this  mouth  yellow  fever  existed  in  X'ew  Berne,  altlnnigh  not  then  aeknowleilged  or  jiositively 
recognized.  an<l  this  disease  undoubtedly  ori:j\iintid  in  the  town. 

The  X'euse  being  blockaded  we  are  sure  no  vessel  arrived  at  Xew  Berne  from  an  infected  port  at  any  tinu'  during 
the  summer.  A  few  refugees  came  in  during  August,  but  none  of  them  brought  more  than  the  clothing  they  could 
carry  themselves,  and  we  can  find  none  who  came  in  about  that  time  from  Wilmington.  X'o  sailors  or  soldiers  were 
lauiled  at  Morehead  City  and  thence  transferred  to  Xew  Berne  from  any  Southern  port.  On  August  25  thirty-four 
men  arrived  at  Morehead  City  in  the  steamer  Xew  Berne  from  the  receiving  ship  Xorth  Carolina  at  Brooklyn  X'avy 
Vard.  and  were  forwarded  by  rail  to  X'ew  Berne  for  vessels  in  the  sounds.  Xo  disease  existed  ann)ng  them,  and  this 
was  the  only  shipment  of  sailors  through  X'ew  Berne  between  August  1.5  and  Sept.  10,  1S(U. 

The  first  cases  of  the  disease  which  came  under  my  notice,  and.  so  far  as  we  can  learn,  the  initial  ones,  were — 

Private  Orlando  Pollock,  3d  X'.  Y.  .\rt'y,  clerk  at  district  headcjuarters,  coriu'r  Union  and  East  Front  streets. 
Admitted  to  Poster  hospital  Sept.  2, — died  on  the  Gth. 

Private  Francis  Coates,  3d  X'.  Y.  Cav..  orderly  at  district  headquarters.     Admitted  Sept.  1, — died  on  the  (ith. 

Private  C>.  C.  Lillie,  U.  S.  Signal  Corps.  Admitted  Sept.  4  from  signal  otilice  on  ojiposite  corner  from  district 
headiiuarters, — died  ou  the  6th. 

Mrs.  Wilcox,  a  white  refugee,  corner  of  (ieorge  and  South  Front  streets;  had  chills  for  a  month  or  more:  taken 
quite  sick  Sept.  1;  had  lilack  vomit,  turned  yellow,  and  died  on  the  7th.  This  woman  had  lived  in  that  house  one 
nujnth  and  in  X'ew  ]5erne  eight  months. 

Mrs.  Prudence  Rice,  whom  I  did  not  see,  died  Si'pt.  •!,  in  the  next  house  to  Jlrs.  Wileox,  of  what  was  probably 
yellow  fever. 

Sergeant  M.  Rogers,  15tli  Conn.,  jailor  at  Confederate  prison,  corner  George  and  Pollock  streets,  was  taken  sick 
and  admitted  to  regimental  hospital  on  Sejit.  7:  had  black  vomit,  and  died  on  the  i>th. 

These  occurred  at  two  points  widely  separated,  and  preceded  by  nearly  a  week  the  irruption  of  the  great  ejii- 
demie.  I  could  not  at  the  time  believe  they  were  genuine  cases  of  yellow  fever;  but  on  Septend)er  12  Eieut.  \. 
li.  ,Jidinsr)n,  street  inspector,  and  two  soldiers,  died  in  the  Foster  hosi)ital  with  unmistakable  symptoms  of  that  dis- 
ease. From  this  time  cases  began  rai)idly  to  appear  in  ditferent  parts  of  the  town  near  the  two  rivers;  but  it  was 
soon  found  that  the  worst  cases  were  among  the  Government  enij)loyes  in  the  vicinity  of  Craven  street  wharf.  This 
led  to  an  examination,  and  on  tearing  up  the  lloors  of  some  of  the  old  buildings  used  as  storehouses  V)y  the  ijuarter- 
masti't  and  ccnnmissary,  a  pool  of  stagnant  water  was  found  the  efHuvium  from  which  sickened  the  workmen.  It 
was  at  once  decided  to  burn  down  the  houses  and  fill  up  the  pond.  This  was  done,  but  the  poison  generated  there 
uo  doubt  existed  many  weeks  after. 

The  epidemic  iutluenee  seemed  to  prevail  with  greatest  force  in  the  vicinity  of  the  water,  and  for  several  weeks 
was  confined  to  a  district  two  squares  broad  along  each  river  bank.     It  was  most  violent  in  the  rotten  old  frame 


YELLOW    FEVKK.  681 

liiiiisis  wbicli.  on  several  streets,  are  built  iiuiiiediately  on  the  >;ronu.l  and  wi.icli  are  always  ilamii:  but  every  house 
in  the  inl'eeted  district  had  more  or  less  of  the  disease.  (.Jrailually  the  eiiideniie  inlluence  sjiread  over  most  uf  tlie 
town,  ami  hy  Xovenilier  1  almost  every  white  jierson  in  the  ])laee  had  suti'ercd.  The  negroes  were  at  lirst  exi-mjit  : 
but  after  a  few  weeks  tlie  disease  extended  to  them  and  nearly  all  in  New  liernc  had  it.  generally,  however,  in  a  eom- 
parativcly  mild  form.  The  eiiidemie  prevailed  violently  f(ir  only  forty-live  days,  but  cases  occurred  from  .September 
2  to  Xovembcr  li-'.  ISetweeii  these  dates  eight  hundred  ainl  sixty  wliites  and  one  hundred  and  tifty-tive  negroes  died 
in  Xew  Berne  from  yellow  fever.  Children  nearly  all  recovered,  while  with  the  aged  and  jn^rsous  recently  arrived 
fr(nn  the  North  it  was  very  fatal. 

liiuing  this  epidemic  it  was  clearly  proved  that  no  contagion  existed.  .'Soldii-rs  iVoui  the  Kosti'r  ho^jiital  ami 
provost  gnard.  as  well  as  citizens,  were  sent  away  as  rapidly  as  possil)le  to  Morehead  (  ity.  I  lean  foil,  llattera-.  Koanoke 
Island.  ISaclielor's  Creek  and  to  the  country  about  here,  where  many  of  them  soon  al'ier  sickened  and  died  :  lun  !it  no 
place  except  Beaufort  did  the  disease  extend  to  any  other  jirrsons.  At  Moieln-ad  City  jiatients  rcnio\eil  from  N^w 
Berne  were  placed  iiidiserimiiiately  in  the  wards  of  the  Mansiield  hospital,  and  citi/eiis  of  New  I'xiii'-  throngicl  the 
hotel.  Twenty-one  soldiers  and  thirty-four  citizens  died  of  yellow  fever:  yit  not  a  siii;;li>  ]icrson  contracti-d  the  clis- 
ease  unless  he  had  visited  Xew  Berne  or  Beaufort.  At  otlier  jioints  similar  observations  were  made.  Cases  Imve 
lieen  reported  as  occurring  in  the  country  about  here  conllicting  with  this  idea,  but  1  have  bei'ii  able  to  trace  every 
one  of  them  to  a  visit,  often  very  short,  to  Xew  Berne.  The  town  of  lieaufort  was  b.-idly  crowded  witli  refugees  fi-om 
Plymouth  and  Little  Washington,  and  the  iiolicing  was  not  good.  'I'he  iiroju'r  atmos]diere  for  the  spread  of  the 
epidemic  Mas  found  there,  and  from  a  few  cases  brought  from  Xeu  lierne  tlie  disease  sjiread  to  a  considerable  extent 
over  the  more  crowded  portion  of  tlie  town.  Kilteen  stddiers  and  sevi'iity-six  citizens  dii'd  there;  biit  jl  slioiild  be 
noted  that  at  the  B.eaufort  hospital,  whidi  is  pushed  out  on  the  sea-face  of  tin-  town,  not  a  single  ease  of  the  lever 
occurred  among  patients  or  attendants  wlio  had  not  been  exposed  elsewhere. 

The  patients  were  generally  taken  in  the  evening  wiih  a  sliglit  chill,  followed  in  a  short  lime  by  fi\rr  and 
severe  pain  iu  the  sacral  and  lower  jiart  of  the  lumliar  region.  It  was  rare  to  have  severe  neiiialgie  ]iains,  bui  the 
patients  were  always  restless  and  sleepless.  I'ain  iu  the  head  was  almost  universul  but  iKit  severe:  it  was  generally 
over  the  eyes,  sometimes  much  worse  on  one  side  than  on  the  other,  and  with  a  feeding  of  fulness  and  deep-.seated  jiain 
in  the  eyeballs.  The  conjunctiva  was  always  more  or  less  injectcil  and  often  very  red,  with  a  yellow  hue  of  tiie  scle- 
rotic coat  ajipearing  through  it  and  extending  back  over  the  eyeball.  The  face  was  not  much  llushed:  but  the  skin 
felt  hot  to  the  touch  or  else  quite  cool,  the  circulation  being  bad  even  in  the  early  stage.  I'lid'use  sweating  often 
continued  for  hours,  the  pulse  remaining  unaltered,  from  101  to  12l>  as  m  rule.  \v  ith  a  .piick  beat  .-ind  id'tcn  i:ivin^ 
the  impression  of  air  Ijeiiig  in  the  artery:  it  sometimes  had  a  thrill  like  an  aneiirisni.  I'he  tongue  was  clean  and  its 
character  varied  at  different  periods  of  the  epiilcmic.  Ihiring  the  lirst  two  weeks  it  was  genei':illy  of  natural  si/e. 
with  a  slight  Avhite  fur  in  the  middle  ami   red  tip  aud  edges.     Afterwards  in  almost  every  ea^e  it  aei|iiired  a  ilull 

leaden  hue  with  no  other  unusual  appearance.     In  only  a   l\-w  ea.~es  did  we  ha\e  the  largi yster  loiigui-."      I'li.' 

stomach  was  irritable  and  ti-nder  on  jiressuie  from  the  be^'inning;  the  bowels  eon>tiiiated  or  leiiulai,  uitli  no  sore- 
ness or  diarrlnea. 

This  first  or  febrile  stage  lasteil  from  twenty-four  to  eighty  hours,  geiieriilly  about  Mxty  liouis.  anil  uas  fol- 
lowed by  a  decided  remission,  the  patient  lieing  left  greatly  prostrated  but  free  from  jiain  and  ol'ten  fueling  tint  ;ill 
danger  was  past.  In  the  second  stage  the  circulation  was  feeble  and  the  greatest  can-  had  to  br  takiii  to  pii'>ei\e 
an  even  temperature,  ilosijuito  bites  at  this  time  left  piii'lile,  ]uirpura-like  spots,  and  I  he  cut  icle  w.is  hai-li  and  I'.iy . 
Till-  ]inlse  became  unite  slow,  often  going  down  as  low  as  titi-70  and  easily  eoinpio^M'd  umler  tie-  lingi'r.  'I'hr  irrita- 
bility of  the-  stomach  now  often  subsided  and  the  tongue  would  get  a  slight  coaling  of  whitish  fur  or  wouhi  swell 
con.sidiMably.  In  this  condition  the  patient  would  remain  from  twelve  to  twenty-four  hours  cheerful  and  cinilideiit. 
The  third  stiigo  then  coming  on  our  patients  would  be  found  with  great  restlessness,  an  anxious,  often  frightene<l 
expression  of  countenance,  increased  irritability  of  stomach,  with  a  feiding  of  tineiisiuess  or  opjiression  ai  the  jieii- 
eardium  and  a  tendency  to  belch  or  bring  up  wind  from  the  stiunach. — a  <leepi'iiing  of  the  yellow  in  the  eyes  and  a 
brownish-yellow  tinge  of  the  whole  skin.  An  otfensive  odor  was  at  this  time  often  exhaled  from  the  body,  and  fre- 
ijUently  there  was  suppression  of  uriiii>.  ^fhis  condition  was  often  followed  by  black  vomit  ami  ilealli,  llu-  fatal  li-r- 
minatiou  being  generally  on  the  tifth  day — sometimes  as  early  as  the  third,  rarely  later  than  tin'  eighth. 

Fortunately,  however,  many  cases  did  not  terminate  in  death.  The  syini>toms  above  rid:ited  gradually  >uli- 
sided,  and  decided  convalescence  was  established  by  the  seventh  or  eighth  day.  A  few  recovered  after  having  had 
black  vomit;  but  such  cases  were  rare.  Xo  one  was  known  to  recover  after  having  entire  suiiprcssiou  of  urine. 
Retention  occurred  in  only  a  few  instances — in  very  nervous  persons.  Death  was  sometimes  lueceded  by  stujior 
with  stertorous  breathing;  but  ofteuer  by  great  nervous  irritability,  witli  slight  spasms,  opisthotonos  and  jactitation. 
Secondary  fever  was  not  observed  iu  many  instances.  It  was  found  to  be  not  unfavoralde  when  it  did  occur.  Con- 
valescence was  slow,  and  the  yellow  tinge  of  the  skin  and  eyes  did  not  disapjiear  until  the  third  or  fourth  week. 

At  the  beginning  of  the  ei>idemie  we  believed  the  disease  to  be  ot  malarial  origin  and  treated  it  with  iiuiiiine: 
but  our  cases  died.  The  disease  was  one  evidently  of  blood  poisoning,  (jiiiinine  would  not  cheek  its  action  on  the 
brain  :  the  indications  were  therefore  to  eliminate  it  liy  the  liver  and  kidneys.  Calomel  treatment,  not  jinshed  quite 
to  ptyalism.  was  adopted.  A  cathartic  dose,  followed  by  oue-grain  doses  every  hour  or  two  hours,  generally  brought 
a  blue  line  on  the  gums  between  the  second  and  third  day.s,  and  we  found  it  best  then  to  stop  the  mercurial.  In  very 
few  cases  was  severe  salivation  produced.  The  medical  olticers  who  had  any  considerable  experience  in  this  epidemic 
agree  with  me  as  to  the  utility  of  mercury.  Besides  this  we  gave  as  a  drink  ice-water  acidulated  with  bitartrate 
of  potassa;  ice  and  the  smallest  portions  of  animal  jelly  and  beef-tea  were  employed;  sinapisms  and  blisters  were 
useful  over  the  stomach,  and  minute  doses  of  ipecacuanha  sometimes  stopjied  the  vomiting.  We  derived  no  benetit 
Med.  Hist.,  Pt.  Ill— 86 


682  OTHKK    MIASMATIC    IHSKA.^KS. 

from  acetate  of  lead.  Occasionally,  in  tliu  third  fita<x*\  small  doses  of  opium  of  m(H-])liia  were  useful:  and  ,i:e!ierally, 
in  tluit  sta<^e.  mild  stimulatin-:;  drinks,  .stich  as  iced  slien-y.  ^vere  jrrateful  and  soolliiu.i;  to  the  patient,  rronipt  and 
active  trt.^aiment  iu  the  early  stage  was  found  to  lie  necessary.  Later,  the  exi)eetant  i>lan  was  as  tjood  as  any;  hut 
I  should  not  dare  trust  it  from  the  beginning.  Several  cases  recovered  after  I)laek  vomit  api)eared,  liut  in  no  case 
could  this  result  be  attributed  to  treatment.  In  no  disease  that  T  luwr  seen  is  careful  nursing  so  much  demanded. 
I  cannot  s]>eak  in  terms  too  high  ol'  the  noble  conduct  of  the  medical  officers  here.  To  Surgeon  C.  A.  CowoiLL, 
V.  S.  Vols. J  Surgeon  Nathan  Mayp:k,  16th  Conn..  Surgeon  1'.  li.  Rick.  132d  X.  Y..  Ass't  Surgeon  J.  H.  Dotghty,  U. 
S.  A'ols.,  Ass't  Surgeon  E.  F.  Hexdkicks,  ir)th  Conn..  Ass't  Surgeon  J.  M.  Dan  ies.  9th  X.  J.,  Dr.  J,  "W.  Paok.  I^  S. 
Sanitary  Commission,  and  many  other  brave  na-n  whu  did  their  whoh'  duty,  soldiers  and  citizens  alike  are  under 
lasting  obligations  for  their  heroic  labors. 

Tlie  inefficiency  of  a  quarantiiio,  consisting  merely  of  detention  for  a  given  number  of 
clays,  ^va3  so  manifest  in  1862  that  tiie  late  Surgeon  (.Tcuural  Chaxk  insisted  on  nc^n-inter- 
course  fur  the  protection  of  a  threateneJ  locality.  Obviouslv  this  is  the  onlv  sure  inethoJ; 
and  w]\Qn  the  conditions  are  such  as  to  admit  of  its  successful  o})eration  troops  should  always 
be  thus  protected.  Commercial  intercourse,  however,  does  not  brook  an  interference  of  this 
kind  with  its  progress,  and  occasions  may  occur  when  oven  military  command  is  incomi)e- 
tent  to  c<:'ntrul  the  conditions  that  mav  arise  to  render  intercourse  imperative.  Fortunately, 
recent  progress  in  sanitary  science  and  experience  in  the  prevention  of  yellow  fever  have 
demonstrated  that  protection  may  be  aflbrded,  not  onlv  without  the  promulgation  of  an 
ordinance  of  non-intercourse,  but  even  without  the  detention  involved  iu  the  original  accep- 
tation of  the  term  quarantine.  Sanitary  supervision  and  disinfection  have  been  substituted, 
and  at  the  present  time  enable  our  health  boards  and  quarantine  officers  to  protect  the  com- 
munitv  without  materially  interfering  with  the  current  of  commercial  enterprise.'-' 

The  depopulation  of  the  city  of  Xew  Berne  in  IS'U  saved  many  of  its  garrison  and 
inhabitants  from  falling  victims  to  the  fever.  After  the  vlisease  had  fairly  broken  out  among 
the  troops  most  of  them  were  removed  from  the  town,  and  nearly  all  of  those  tlius  removed 
escaped.  This  experience  was  repeated  in  the  yellow  fever  epidemic  of  1867:  AVIiere  the 
troops  faced  the  pestilence,  as  at  Galveston,  Houston,  Hempstead,  New  Orleans  and  Fort 

*  I'litil  the  estnljlishment  of  tlie  National  Board  of  Hoaltb  in  1870  the  Unitod  States  had  no  competent  protective  system  against  yellow  fever. 
For  many  years  before  that  date  tlie  sanitarians  of  tlie  conntry  and  the  leading  pnldic  health  officials  were  well  aware  of  the  principles  wliich  nnderlie 
such  a  syi^ti-m.  The  meetings  and  transactions  of  the  American  I'nhlic  Health  Association  extended  the  knowledge  of  these  principles  and  prepared  the 
way  for  suliseipient  concert  uf  action  by  th"  ln-alth  officers  of  threatened  ports.  A  central  healtli  office,  which  shonld  co-ordinate  the  efforts  of  the 
various  rotate  and  municipal  health  authoritit-i,  was  rejrarded  by  all  as  essential  to  protection.  TIu-  (inarantine  powers  vested  in  the  State  and  local 
anth<>ritii-s  were  effectively  exercised  liy  some,  but  their  beneficial  results  were  counteraeted  by  the  i^rnorance  or  carelessness  of  others  or  the  imperfection 
of  tli'-ir  'piarantine  reirulatious.  At  tliat  time  the  National  Government  took  cognizance  of  tlie  danger  only  by  the  provisions  of  an  act  pas^i-tl  iu  17'J8 
authorizing  tlie  officials  of  the  revenue  service  to  aid  the  local  authorities,  when  reiiuested  by  them  to  do  so,  and  when  such  assistance  could  be  rendered 
without  int'-rftrhig  with  their  own  duties.  A^^s't  Surgeon  II.kuvkv  E.  Brown,  V.  S.  A.,  in  a  liiport  on  Qminnithi/',  submitted  to  Congress  in  1872,  exposed 
the  weakiK-ss  of  the  want  of  system  then  prevailing,  and  indicateil  the  general  character  of  the  needful  retnedial  measures.  Touching  national  super- 
vision, he  held  that  in  the  administration  of  the  AVar  Dejiartment  alone  is  found  that  freedom  from  i»olitical  influences  and  that  authoritative  manage- 
ment which,  wliile  demanding  absolnte  obedience,  gives  to  the  individual  the  largest  liberty  consistent  with  i)ublic  safety.  Hence  he  reconuneiided 
that  the  generil  management  of  affairs  Bhonhl  be  comlucted  by  the  Surgeon  General  of  the  Army,  aided  by  insjiectors  detailed  from  his  corps  of  officers. 
Tlie  Surgefpn  General,  in  forwarding  this  report  to  the  Secretary  of  ^Var  for  transmission  to  C'ongrd'fes,  objected  to  this  reconnnendation  on  the  ground 
that  the  Army  Medical  Corps  as  then  constituted  would  he  unable  to  furnish  officers  for  quarantine  duty  without  serious  interference  with  its  own  military 
duties  and  detriment  to  the  interests  of  the  service.  No  efficient  action  was  taken  by  Congress  until  187'.',  when  a  central  body,  the  National  BoAitn  or 
IIkai.th,  was  organized  to  advise  the  National  and  Stat"-  autln^rities  on  matters  pertaining  to  the  public  health,  and  to  co-ojierate  with  the  State  ami  local 
hiiitth  buanls  and  officials  iu  iireventing  the  importation  of  foreign  pestilence  and  in  restricting  its  spread  should  it  unfortunately  succeeil  in  effecting  a 
landing.  On  the  recommendation  of  this  board  ethcient  and  uniform  regulations  were  adoided  by  the  vari'ius  ports  exposed  to  tianger.  By  the  co-opera- 
tion <.if  the  Consvilar  Service  it  was  kept  informed  of  the  sanitary  condition  of  all  foreign  ports  having  commnniiation  with  this  country,  and  was  thus 
enabled  promptly  to  notify  the  local  authorities  when  danger  threatened.  It  endeavoi-ed,  by  medical  inspection  and  disinfection  at  foreign  ports,  to  have 
ail  vessels  bound  for  ports  of  this  conntry  in  a  .satisfactory  si\nitary  condition  before  beginning  their  voyag*-.  The  certificate  of  its  agent  at  the  j'ort  of 
departure  had  weight  with  the  authorities  at  the  port  of  entry,  who  granted  admission  if  the  vessel  was  said  to  be  entitled  to  free  jiratique  and  nothing 
had  occurred  during  the  voyage  to  change  her  status  in  this  resjicct.  The  movements  of  a  vessel  suspected  of  infection,  on  account  of  having  faiNd  to 
submit  to  inspection  prior  to  leaving  the  foreign  port,  were  conununicated  to  the  officers  of  the  port  of  destination,  who,  on  her  arrival  at  their  station, 
applied  such  nn-asures  of  disinfection  as  her  condition  reijuired.  Refuge  stations  were  established  at  certain  points  oii  the  coast  to  which  infected  vessels, 
ilenied  entrance  to  port,  were  sent  for  treatment.  These  fulfilled  the  role  of  quarantine  stations  for  many  snnill  ports  on  the  Gulf  and  .\tlantic  coasts,  the 
commerce  of  which,  although  as  dangerous  in  this  connection  as  that  of  the  larger  ports,  wa.s  inadequate  to  equip  and  maintain  the  requisite  quamntine 
establishment.  Here  the  iMissengers  and  crews  were  kept  under  observation  or  treated  in  liospital,  according  to  circumstances,  and  the  cargo  and  vessel 
submitted  to  a  thorough  cleansing  and  disinfection.  By  thiti  system  infected  vessels  only  were  delayed, — and  not  for  an  arbitrary  period  but  merely 
until  disinfection  was  satisfactorily  effecti-d.  Under  the  ausi>ices  of  the  National  Board  of  Health  the  jKithway  of  commerce  was  freed  from  vexatious 
TRstrictitms  and  unnecessary  obstacles,  while  the  country  was  jirotected  against  the  unanticiiMtt-d  arrival  of  the  disease  on  its  shores,  and  the  j)eople  of 
the  exjiosed  sections  realized  a  feeling  of  security  to  which  they  had  heretofore  been  unaccnstomed.  Its  experience  has  demoustrftted  that  protection 
may  b.>  obtained  without  a  recourse  to  non-intercourse  or  iudiscriminatiug  quarantines  of  detention. 


YELLOW    FKVKR. 


683 


JefFersoiL  the  great  portion  of  those  exposed  were  attaek-d.     Where,  en  the  other  hancl  as 
at  InJianola,  Mobile  and  Pass  Christiaiu  the  commauJs  were  removed  after  the  outbreak  of  ^ 
the  disease,  nearly  all  the  men  escaped.     Since  then  the  prompt  removal  of  trooi's  U\m 
points  threatened  with  infection  lias  lessened  the  ravages  of  yellow  fever  at  our  Southern 
UiiUtary  stations. '■' 


CHAPTEP.  VIIL— OX  ^^CUPVY. 


Prkvalexce,  etc. — According  to  the  statistics  of  this  office  tlie  average  annual  rate 
of  cases  reported  from  military  commands  under  the  heading  Scorhi/tu.s,  during  the  eighteen 
years  before  the  war,  was  26.3  per  tliousand  of  strength,  (tr.  as  will  be  seen  directly,  nearly 
twice  as  large  as  that  which  prevailed  amung  our  white  troops  dui'ing  tlie  years  ui  the  war. 
The  medical  officers  of  our  Regular  Army,  by  virtur  u(  i\uAv  e.xp«.-ri(.'nc<.'s  afivmotL'  li-untirr 
posts,  were  well  qualified  to  detect  the  exist(_*nce  cf  tliis  diseased  c«:nidili-'iL  Surg-u^.n 
Chakles  S.  Tkiplee,  U.  S.  A.,  who  was  j\Iedical  Ihrectnr  of  tlie  Army  of  the  I'olomac 
when  scorbutic  symptoms  were  discovered  in  it  during  its  opL-ratiuns  on  the  Penin>ula.  had 
ah^eady  placed  his  experience  and  views  on  record:'!*  and  manv  I'efereiices  to  seui'vy  are  lo 
be  found  in  the  published  reports  of  Army  Medical  Officers.?!;  although  deserijttiuns  of  the 
scorbutic  condition  itself  are  rare.  § 

*  In  more  receut  epult'inic!'  iiftVctiiij;  tin*  civil  population,  us  in  tho.-c  \vliii;li  iMMnn'>:'<l  >I<-riiplii>.  T>-iin.,  in  1>T.*>  ainl  1>7'.'.  i!'i-<i]'iitatii>ii.  I^v  the 
estublisliinent  uf  camps  iit  some  distiiiu-e  from  t)ic  city,  ctTtainly  suveil  innny  Iiw>.  At  Camii  Marks,  whidi  uas  f>talili>li''<l  .liity  i.'*  aii<i  t>rMkiii  up  *  tit. 
28,  l5>7it,  the  average  miinber  of  ratiuiis  drawn  wns  l,3(i4.  Nine  cases  of  Vl-Uow  fevt-r  occurn-tl,  <'l'  wliidi  imin-  wn-.'  fatal.  T\\-'  ••t'  ilu'  inlial.itiiui-  *jf 
this  camp  were  taken  witli  fever  aftiT  their  return  to  the  city  when  the  w'ttlement  wiis  lirok-ii  up.  At  ('amp  \\"illiaiii>.  «iiirli  \\;is  ili-iaut  mhIv  l.-ur 
auil  a  half  miles  from  Memphi-,  a  lar^re  number  of  cases  occurred,  but  invariably  in  pi'i>ons  «b"  had  viulati'il  tin-  rules  hy  vi>iiin;.''  tin-  riiy  ui-  in  vfu- 
gei'S  who  sungbt  the  camp  wliile  already  infi-itt-d.  As  many  as  seventeen  uf  the  luttir  diid  in  one  niirht :  yit  it  is  siid  that  in  no  ';)>••  \\a*  the  frver 
coniiuunicated  to  those  in  the  camp,  j^ro  paper  by  Col,  John  F.  Tamekon  uf  3k'in]diis,  in  li'junt'i  ami  Piqirif..  American  I'ublir  Il.-altb  A"i'riati"n.  y\ 
l.^T'.',  1'.  1-7.8,  iti  wliirh  the  author  strongly  urges  depopulation  as  a  saving  nn'asure  in  frvcr-stricki-n  citii's. 

I  In  the  riitcinnati  Lwcet  and  Ohsemr,  \o\.  I,  1S.>.  p.  l:il  ft  ."P./.  His  able  article  investigat«-<.  the  th'.-rii-^  nl"  .au-iitinii  an.)  mwh  <4  th.-  nT..rdi-d 
experience  on  pivventiuii  and  cure,  lie  concluded  that  ab-tin.  nc-  i'lmu  fresh  meat  and  vegetables,  by  <Iiniini>liing  the  uee.lful  pr-ipnrtions  i.f  put  ash  ami 
iron  in  the  bloud,  induces  scurvy;  and  that  in  tlie  i(h.senre  uf  a  propei-  dietary  the  disease  should  be  treat-d  I  y  ,-aIt^  -^f  Ibi-r  ]-:i-,-^,  ihe  pnta>%io-iartrate 
of  iri.iu  being  suggested  as  capable  of  fultilling  all  tlie  indications. 

:J:  A  scorbutic  tendency  was  developed  at  most  of  our  military  i>oA<  during  the  winter  seasMn.  iill-  r  the  tmnp.  Iii,d  1-een  i'<-y  f-unn'  t;).-nth-'  ri.nfined 
to  the  use  of  the  ordinary  ration  with  desiccated  vegetables.  The  latter  in  the  .jnantities  issued  failed  to  repre.w^  the  di>easf.  At  j.osts  which  could  be 
readily  supplied  with  potatoes  only  the  taint  was  manifested,  on  accpunt  uf  a  want  of  liberality  in  the  issues;  but  at  those  in  the  interior,  whlrh  were 
reaihed  by  a  tediotis  overland  journey,  the  disease  became  uni-  uf  the  first  inipurtaJiee.  The  capabilities  of  the  soil  harl  rioi  Ihth  testi-d  by  thi-  cnltiva- 
tion  uf  post  gardens,  but  in  the  sj'ring  and  sunnner  every  plant  of  assumed  anti-scorliutic  value'growitig  in  the  vicinity  was  larefully  gathered  fur  use. 
Till'  conditions  aflei-ting  the  dietary  of  the  men  at  these  stations  may  in-  appreijated  by  a  perusal  I'f  the  n-poits  ]iubli.<hed  by  Aps'I  Surg'-i-n  U.  H.  e"ML- 
iiKii:,  r.  S.  A.,  in  his  Me>U';tl  ,<la(i>'flr.-i  of  the  I'nit'd  Sttilts  Armn,  Is.M-Gn;  M'ii>hingtoti,  1».  ('.,  iM'rfi.  For  instance :— Ass' t  Surgeon  1>.  I..  -Ma'.rvI'Ku  stated, 
in  a  report  from  Fort  Lookout  on  the  Missouri  river,  in  Nebraska  Territory,  itrt<d.i-r,  Is.V.,  tliat  should  any  ac<ident  pre\ent  the  arrival  of  a  supply  uf 
flesh  vegetables  tliis  fall,  it  would  be  his  misfortune  to  witness  another  siorlmtic  epidemic  before  the  return  of  vegetation  in  the  siiring.  Surgeun  T.  C. 
5I.\i>isox  wrote  from  Fort  Itandall,  .Sei)ti'ndier,  1S57,  that  scurvy  was  the  only  disea-^c  about  which  the  slighte.>t  apjireheiisiun  A\as  felt.  iMiring  the  pre- 
vious winter  the  whole  command  was  more  or  less  affectc<l  before  the  arrival  of  a  supply  of  Irish  potatne-i  in  .lanuary  enabled  him  ijuiikly  and  vtte.tnally 
to  suppress  the  disease.  These  vegetables  had  been  shipped  from  .St.  Louis,  M<:i.,  in  the  full,  and  Inul  become  frozen  while  m  rutitf,  but  their  anti-scor- 
butic properties  had  not  been  destroyed.  They  were  used  raw  as  \vell  as  cooked.  At  this  post  linu'-juice,  iiickle>,  molasses  and  dried  fruits  were  issu  -d 
along  with  tlie  ration,  but  in  the  quantities  furnished  they  did  not  prevent  tlie  appearance  of  scurvy.  The  wild  artichoke,  edible  from  tlie  beginning  of 
April  to  the  middle  of  Mny,  was  eaten  raw,  grated  or  sliceil,  with  vinegar;  later  in  the  season  other  greens  were  usii!.  Ass't  Surge. m  K.  \V.  .Imhvs, 
^^  liting  from  Fort  Laramie,  December,  iSdS,  considered  that  there  was  little  uf  interest  to  ivjM>rt  ex<'ept  wlnit  related  to  senrbutic  di^ea-e.  I|,-  n-ed  the 
juice  uf  cart  us  plants,  which,  in  the  alM»ence  uf  any  other  curative  agent,  effected  a  wludesume  ihange  in  the  system,  as  i-uiupbte,  althougli  not  >o  rajtid, 
as  that  resulting  from  the  use  of  juitatoes.  Tlie  juice  was  ]»repared  by  broiling  the  thick  leaves  >lightly  over  a  fire  and  tin  n  slicing  and  digesting  th*  m 
in  water  until  a  tliick  grei-nisli-lirown  mucilaginous  mixture  was  obtaine<l.  .\  tnmbhrful  of  this  mixture^  with  twu  ounces  of  whi>key,  llavored  with 
essence  of  lemon,  was  given  as  a  dose.  At  this  post  stores  of  water-cresses  were  collected  and  used  at  tlie  mess  t;ibles  ;  and  so  highly  was  the  in  port  mce 
of  this  addition  to  the  diet  appreciated  that  the  colonel  commanding  suiM-rintended  the  .^ieanh  r>r  the  platit.  (Joing  back  to  earlier  times,  a  severe  out- 
break of  the  disease  occurred  in  IS'in  at  Council  Itlufts  and  St.  Peter's.  Th<'  strength  of  the  farmer  post  January  1  was  7iSS,  of  the  latter  22S,  making 
in  all  l,oir>.  The  total  of  cases  of  all  diseases  reported  at  these  two  i*osts  during  the  quarter  entling  JLirch  III  was  S'.t."».  (if  these  .^Q  were  of  a  scorbutic 
character;  and  the  number  of  deaths  from  this  cause  was  His,  uf  whicli  L'u  occurreil  at  Council  IllufTs.  Acconling  to  Surgeon  Mower,  neither  tsmall- 
pox  nor  Asiatic  cholera,  in  their  most  malignant  forms,  was  so  dreaillul  as  tliis  outbreak  of  st-urvy.  .See  Foitr.v — o,i  fyoihittits — American  Jon:  3[<;d. 
Sciences,  N.  S.,  Vol.  Ill,  Philadelphia,  1842,  p.  77. 

g  R.  S.  Holmes,  formerly  of  the  U.  S.  Army,  has  given  in  tin-  St.  J.uni-'  Mr.lir.t}  „uii  Sttrgl'ii!  J.nmiiil,  Vol.  V,  1M7-8,  p.  417  «/  «»;.,  some  account  t  f  the 
disease  as  it  occurred  among  the  troojis  iu  Florida.  He  also  saw  it  elsewhere  in  this  country  and  in  Mexico,  and  from  its  diversifi'-d  cliaracter  and  the 
absence  of  symptoms  commonly  considered  diagnostic,  he  is  convinced  that  tla-  disease  is  often  tiverlooked,  and  that  cases  of  true  scurvy  are  soau'time« 


6.S4 


SCURVY. 


jmning 


The  maj.irity  of  our  volunteer  medical  officers  had,  on  the  contrary,  at  the  Lesj; 
of  the  war  no  i>er>onal  familiarity  with  tiie  disease;  n._-vertlieless  few  of  thern  failoil  t 
recognize  the  pussibility  of  its  ..c.-urrenoe  or  to  lo.dv  closely  after  the  health  of  their  men  with 
the  view  of  detecting  its  earliest  manifestations.  In  fact,  the  first  intimation  of  a  scorbutic 
tendency  among  the  troops,  so  far  as  is  sliown  by  tlie  records,  came  from  a  volunteer  medical 
officer.  Surgeon  David  Woosteb,  5th  Cal.,  encamped  near  Sacramento,  Cal.  His  reference, 
which  is  dated  Jan.  !:->,  1S62,  is  as  iVjlIows; 

I  liave  foniul  chlorate  of  jiotash  iiivaluablo  in  tlie  first  .syniptouis  of  scurvy  :  Tender  j;uius  harden  as  if  by 
magic  under  the  use  of  a  dracliui  a  day  in  two  ounces  of  simple  syrup. 

The  figures  submitted  in  the  first  part  of  tliis  work  indicate  that  scurvy  was  present  in 
our  armies  from  the  first  month  for  which  reports  were  forwarded,  May,  1861,  to  the  close 
of  the  war.  In  the  month  stated  7  cases  were  reiiorted  in  a  streno-th  of  16,161  men.  These 
may  Ijo  regarded  as  a  contribution  from  the  conditions  that  were  in  existence  before  the  war. 
The  continuance  of  the  disease  after  the  cessation  of  hostilities  was  mainly  duo  to  a  recur- 
rence of  these  conditions. 

Among  the  white  troops  during  the  five  and  one-sixth  years  covered  by  the  statistics 
30,714  cases  of  scurvy  were  reported;  anil  383  deatlis  were  attributed  directly  to  that 
disease.  These  numbers  arc  equivalent  to  71.2  cases  and  ().S'2  deaths  in  every  thousand 
men  of  average  strength  present  during  the  period.  The  fatality  of  the  disease  was  not 
large,  1.25  per  cent,  or  one  fatal  case  in  eighty,  although  nearly  one-half  of  the  deaths  trom 
this  cause  occurred  in  general  hospitals  in  the  cases  of  men  received  from  Southern  prisrins 
and  not  recorded  in  the  list  of  those  taken  sick  with  scui-vy.  Tliis,  however,  may  be  con- 
siilered  offset  fiy  the  cases  of  diandio^a  winch  owed  tlieir  persistence  ani.l  fatal  ending,  perhajis 
also  their  orio-in,  to  the  scorbutic  cachexia. 

The  prevalence  indicated  by  these  statistics  might  be  regarded  as  suggesting  the  presence 
of  a  very  notable  scorbutic  taint  in  an  army,  but  it  must  be  remembered  that  these  numbers 
are  the  aggregate  of  a  series  of  vears.  and  that  the  average  annual  rate  of  cases  amounted 
onlv  to  13.8  jjer  thousand  ot  strength,  <;)r  to  the  development  of  scorbutic  symptoms  in  one 
man  in  every  company  of  72.5  men.  Moreover,  it  seems  probable  that  these  rates  greatly 
overestimate  the  extent  of  the  pervasion  of  our  white  regiments  by  the  scorbutic  taint.  It 
is  usually  considered  that  if  one  man  in  a  command  be  affected  with  well-developed  signs 
of  scurvy  many  other  men  in  that  command,  all  of  Avhom  have  been  subject  to  the  same 
dietary,  will  be  more  or  less  disabled,  although  they  may  not  lie  borne  on  the  sick-report. 
This  assumption  is  indisputable;  but  it  is  c|uestionable  if  all  the  cases  that  were  reported  as 
scurvy  by  our  medical  officers  actually  presented  the  characteristic  signs  of  the  disease. 
Medical  statistics  are  of  no  value  unless  all  the  circumstances  attending  their  collection  be 

mistakfii  t'l'i-  ntlu-r  tlisea.'^es  aii<l  trt-iitotl  as  sticli.  lie  hoUb  it  as  an  error  to  Huppusf  that  ilepression  of  j^jiirits,  luss  uf  ^treii-tli,  affoction  nf  tlio  irnuis, 
-allow  apiit-araiMt'  ainl  Uvid  jiatchi-'S  aro  prt'sont  in  every  case  of  scurvy.  lu  (Uiulitl'iil  aiitl  nl>>iiuv  ca.scs  the  only  well-niarkcl  proof  of  the  jirc^jcnce 
of  the  Hc.irl'Utic  taint  is  f.Mui'l  in  the  results  of  treatment :  If  an  ophtlialmia,  nr  an  nlcerati"n  ff  thu  U-iX  nceurring;  in  a  jier-^oii  whu  [ireviim.-^ly  •^iitisi^t'Mi 
ua  suite'!  I'ruvisions  without  vegetables,  shouM  t»ersi^t  uinler  urdinary  nietho'ls  uf  euro  anil  yielil  to  aci.l  drinks  and  a  diet  of  ves;etal'Ie.'^.  the  pn-sMMip- 
ti'tn  is  ptntu^  that  the  disease  was  connected  with  the  sc<frl»utic  taint.  The  syniptoins  n^o^t  cmiuionly  i,)ljserved  were  liver-colored  patdn  s  <»n  the  arni=?, 
leirs  aii'l  ehe>t,  and  a  imlTy  or  tender  and  bleeding  state  of  the  ;rnnis  with  a  tendency  of  the  teeth  to  become  h>ose.  A  fre«i«ent  »i)j;ii  of  the  disea.'ie  as 
observed  in  Fli;'rida  consiste<l  of  extensive  suiierficiul  nlcerations  following  the  rujiture  of  bulla?  on  the  feet,  ankles  and  between  the  toei*.  At  first  the 
origin  of  those  was  not  sur'iiectedj'anfl  case-i  were  borne  on  tlie  sick-list  for  three  month:*,  when  their  cure  was  broujj^ht  about  jirobably  by  the  anti  scor- 
butic diet  that  was  liabitnally  used  in  the  hospital  as  far  as  circuntstances  would  iiennit.  Subsequently  the  affection  was  curctl  in  a  few  days  l>y  drinks 
of  lemonade,  or  what  was  considi-rf]  better,  a  mixture  of  vinegar  and  nitiiite  of  potash  and  a  diet  of  vegetables.  Ulcers  on  the  legs,  suppunitive  inflani- 
matiuu  after  wounds,  a  f')ul  --tate  ..f  the  socket  after  the  extraction  of  a  tooth,  a  peculiar  suscejitibility  to  salivation  from  mercury  and  other  medicine^ 
Were  also  among  the  more  coninniu  elTects  of  *'urvy,  and  assoi.'iated  with  these  were  muscular  debility,  derangement  of  the  bowels,  dei)ressioM  of  spirits, 
a  eallow  countenance  and  bleeding  gTims.  Soldiers  suffering  from  intlammations  complicated  with  the  scorbutic  taint  formed  a  large  proportion  of  the 
ixitieiits  in  Florida.  These  w.-p-  pr<,»ne  to  relap-',— a  return  to  ttieir  fuiuu-r  di't  in  -juarters  was  fulluwed  in  a  week  or  ten  days  by  the  reaj. pea  ranee  of 
their  complaints. 


.•^CUKVY. 


685 


clearly  ajijireciatoil.  The  writci'  Kiiows,  t'ruin  ]i\-  Ljcal  rxjiurienco  in  tlio  Arniv  '■!'  t"^^'  Potomac, 
that  after  tiie  tirst  alarm  of  seurvv  in  the  I'anks  ni'  that  armv  mauv  incJieal  cflici'rs  coiitiiuiia 
on  the  alei't  fur  a  rceurrence,  and  ca.-e.s  whieh,  but  fur  that  alarm,  would  have  bt<.ii  rftunird 
as  diarrhoea  or  rheumatism,  found  place  on  tlie  Monthly  JiejKirts  as  vcritalile  f-eurvy. 

During  the  twenty-seven  months.  April,  1854,  to  June,  ISoO,  inelusive,  tlie  French  army 
m  the  CVimea.  averaging  86,740  men,  reported  23.250  cases  of  seurvy  and  615  deaths  trom 
that  disease  irrL'Sjieetive  of  those  that  occurred  among  the  large  numlirr  of  cases  sent  home 
for  treatment.'''  These  nundjers  are  equal  to  268  cases.  t)f  which  2.S  per  cent,  were  fatai  in 
c-very  thousand  of  average  strength  present.  The  annual  rate  of  prevah-nce  amounted  to 
119  cases  per  thousand,  or  to  one  man  with  characteristic  scurvv  in  ivei'v  sipiad  ot  8.1  men. 

To  judge  from  the  statistics  of  tuicoinplicated  scurvy  the  J'higlish  army  \vas  I'dinjiara- 
tively  iVee  from  the  disease,  as  onlv  2.0!'6  cases  and  ITS  deaths  were  rrpi'rted  during  the 
whole  period  of  twenty-seven  months.-j-  Most  of  these  occui'reil  dui'ing  the  seven  months, 
K^ovember,  1851,  to  May,  1855,  inclusive,  giving  a  rate  of  55  cases  per  tlmu.sand  men  lur 
this  period,  or  an  annual  rate  of  94.3.  erpuvalent  tocjne  man  with  marked  seoi-butic  symptoms 
in  every  squad  of  10.6  men. 

During  the  early  months  of  the  campaign  in  the  Crimea  both  ai'mies  remained  tree  li'om 
scurvy,  a  result  attributed  to  the  quantities  (<(  grapes  and  ealiba-es  gathered  by  the  s<ildiers 
■\vhile  on  the  march  from  Ivalamita  liay  to  lialaklava.  lUu  in  November,  1854,  the  disease 
appearetl  in  the  ranks  and  increased  rapidly  in  the  Knglish  armv  mitil  the  following  Feb- 
ruarv,  after  which,  under  the  free  use  of  lime-juice  ami  issue.-  of  potat<;es,  its  threatening 
aspect  was  immediately  subdued.  It  continui'd,  howevei',  to  furni.~h  a  few  cases  monthly 
until  the  end  of  the  campaign.  In  Januarv,  185(\  these  munbered  58  an\l  Were  equal  to 
one  per  thousand;  in  the  other  months  they  did  not  reach  this  rate  and  were  not  recorded  in 
the  official  table  of  sick-rates.  In  the  French  army,  on  the  contrarv,  the  disease  was  piomi- 
neut  throughout  the  war. 

The  death-rate  among  the  English  cases  shows  decidedly  that  tlie  same  methods  of 
recordinii-  the  statistics  of  scurvv  did  not  hold  L:'<-'od  in  the  idlied  armies:  lor  whih-  in  both 
the  disease  was  clinically  identical,  a  death-rate  of  S.4  per  cent,  jirevailed  in  the  Knglish 
hospitals  as  compared  with  2.8  per  cent,  among  the  French  troo])s.  English  inedical  officers 
have  reported  that  although  comparatively  few  cases  of  pure  scurvy  were  noted  in  the  returns 
nearly  ever}'  admission  into  hospital  for  other  diseases  exhibited  unequivocal  signs  of  the 
scorbutic  taint.  Apjiarently  French  military  surgeons  sent  their  men  to  ho.-pital  when  pre- 
senting signs  of  scurvy,  l)Ut  in  the  English  camp  such  cases  were  not  taken  on  sick  report 
until  the  disease  was  in  an  advanced  stage  unless  some  intercurrent  attack,  to  which  the 
morbid  condition  of  the  blood  rendered  the  men  peculiarly  susceptible,  called  imiieratively 
for  treatment.  But  even  in  the  French  practice,  as  stated  by  ]\I.  Baudexs,  soldiers  were 
rarely  sent  to  hospital  during  the  first  stage  of  the  scorbutic  malady  wlnii  the  characteristics 
were  a  hemorrhagic  disposition,  great  muscular  lassitude  and  pains,  particularly  in  the  legs 
and  feet,  weakness  of  pulse,  loss  of  appetite,  a  notable  discoloration  of  the  skin  and  a  remark- 
able dilatation  of  the  pupil;  yet  most  of  the  men  admitted  for  other  maladies  had  these  con- 
stitutional evidences  of  the  scorbutic  aft'eotion. 

*  ■'^"J'i"*'*'  ^t^'Uco-Chirtu'jk'tl  Sitr  la  Ctiiiipd'jnt  l>'  Oi'iml,  juir  J,  ('.  Cnr.Nr.  i'ltri*.  I^^Vi.  S-t-  lii"  Flfpoxltioti  S^imitniire  tits  /•iif»  principaHJ'  ih  It  cnt.ij'H'jiie, 
IK  13  etseq.  ami  Tuble  3;i,  p.  5t;5. 

t  M'ffVnd  and  Sinijiral  Uistorii  of  the  liriU^h  Ar,„i/  i„  (ht  i'l-imta. — Ojirial  livport  ^-  Varlinnnut,  LuiuluU,  Ibijt.  JSee  article  oil  i^ain-fi,  Vol.  II,  j..  171  et 
8eq.  aiul  Tiitik-s  A  ami  B. 


686 


■UKVV. 


Our  mcM.Iical  officers,  perhaps  from  tlieir  luit'ainiliaritv  with  tlie  disease,  paii.l  much 
attention  to  the  early  symptoms;  ami  oertainlv  of  the  30.714  cases  reported  by  them  a  harge 
majority  were  never  admitted  into  hospitah  but  were  excused  from  duty  and  treated  in 
quarters  until  the  symptoms  of  the  first  stage,  which  gave  them  a  [dace  on  the  sick-report, 
had  subsided.  In  fact,  a  comparison  of  the  records  of  our  armies  witli  those  of  the  allied 
forces  in  the  Crimea  shows  that  our  Medical  and  Supply  Departments  have  reason  to  feel 
gratified  with  the  success  of  their  efforts  to  banish  scurvy  from  our  ranks. 

Ass't  Surgeon  E.  S.  Dunster,  U.  S.  A.,  on  sjiecial  duty  as  an  inspector  of  liospitals 
and  camps,  was  the  first  to  call  attention  to  the  probable  pi'esence  of  a  scorbutic  taint  among 
the  troops  operating  in  the  East.     His  report  is  dated  New  Creek,  Va.,  April  27,  1S62. 

The  8tli,  just  from  Parkerslmrs,  is  uikU'V  orders  to  proceed  to  Moorefteld.  I  am  decidedly  of  the  oiiiuion  that 
this  regiment  should  lie  aUowed  iiioro  time  to  recover  from  the  dehiUtating  condition  that  ensued  from  the  winter's 
residence  in  Jiuti'alo.  You  wiU  remember  in  my  rejiort  that  I  referred  to  the  (as  I  called  it )  latent  scorliutic  condition 
of  the  men;  its  effects  are  still  visilde,  though  there  has  already  lieen  a  manifedt  improvement;  and  I  tliink  a  fiw 
weeks  camping  in  some  healtliy  place  like  this  would  put  the  men  iu  line  condition. 

Shortly  after  this  time  rumors  were  current  of  the  existence  of  scurvy  in  the  Army  of 
the  Potomac.  These  ultimatelv  took  official  form,  and  indicated  two  Ijrigades,  one  of  wliich 
consisted  of  regular  troops,  as  tlie  commands  specially  affected.  Medical  Director  Tkiplkr, 
who  was  well  informed  concerning  the  dietary  of  tlie  regular  brigade,  could  scarcely  believe 
that  these  men  should  be  the  first  to  manifest  scorbutic  svmptom>.  Nevertheless  he  [iro- 
cured  suitable  supplies  and,  proceeding  to  the  front  on  May  22,  investigated  the  condition 
of  the  suspected  regiments.  The  men  were  found  free  from  taint.  Dr.  Tiuplkk  reported 
to  the  Surgeon  General  as  follows  concerning  this  reported  outlireak: 

I  received  a  telegram  while  I  was  at  White  House  engaged  in  organizing  a  general  hospital,  informing  me  of 
the  appearence  of  scurvy  iu  two  brigades  and  directing  me  to  send  for  Hnie-juice,  etc.  I  telegraphed  you,  May  21, 
for  lemons,  in  obedience  to  that  order,  expressing  at  the  same  time  my  doubt  of  the  accuracy  of  that  report.  This 
doubt  was  based  on  the  fact  that  one  of  the  lirigades  was  that  of  the  regular  infantry.  I  knew  that  these  troops  had 
Ijeeu  furnished  with  desiccated  vegetables  and  that  some  of  them  had  used  them  regularly.  Orders  for  this  issue  had 
been  pronuilgated  long  before,  with  instructions  as  to  the  method  of  cooking  to  be  adopted  by  the  troops.  I  called 
upon  the  Chief  Commissary  and  learned  that  the  meu  very  generally  refused  to  use  the  desiccated  vegetables;  that 
he  had  abundance  of  them  and  could  not  get  rid  of  them.  Even  potatoes  had  been  sutfered  to  rot  upon  his  hands  and 
in  the  camps.  A  general  order  was  again  applied  for,  aud  issued  on  the  23d  of  May,  requiring  the  troops  to  draw  and 
use  the  desiccated  vegetables  iu  soup  daily,  unless  prevented  by  lieing  actually  on  the  march,  prohibiting  the  frying 
of  meat  and  commanding  it  to  lie  always  roasted  or  boiled.  Upon  my  arrival  at  headquarters  1  inciuired  into  the 
grounds  of  the  report,  and  learned  that  it  had  been  made  by  the  Medical  Director  of  (Jeneral  Fitz-Jcdm  Porter's  Corps, 
Dr.  Geohue  H.  Lymax.  This  gentleman,  one  of  our  ablest  and  most  energetic  officers  in  the  volunteer  service, 
informed  me  that  he  had  not  seen  any  cases,  but  he  had  considered  it  his  duty  to  nuike  known,  for  prudential  reasons, 
as  soon  as  it  was  mentioned  to  him,  that  it  had  been  reported  to  him  by  Brigade  Surgeon  Wateks  and  by  some  young 
assistant  surgeon  of  the  Regular  service.  I  sent  for  Dr.  Waters  and  found  he  had  seen  no  cases;  that  it  had  been 
reported  to  him  by  some  volunteer  regimental  surgeon.  I  directed  him  to  have  the  men  brought  to  me  immediately 
for  inspection.  He  subsequently  reported  to  me  that  the  patients  had  been  sent  to  the  general  hospital  at  the  White 
House.  A  short  time  afterwards  I  visited  this  hospital  and  then  found  two  cases  set  down  as  scurvy.  I  examined 
these:  one  had  no  sign  of  scurvy,  and  the  other  was  a  robust  man  with  an  erythematous  patch  upon  one  shin,  swell- 
ing of  the  leg  and  knee,  disc<doration  of  the  ham  without  hardness,  and  no  swelling  or  sponginess  of  the  gums.  The 
artection  came  on,  according  to  the  account  of  the  patient,  in  one  night  from  sleeping  without  shelter  after  a  hard 
day's  march  through  deep  mud.  I  could  not  consider  this  case  scorbutic  under  the  circumstances,  aud  accordingly, 
feeling  relieved  as  to  the  fact,  I  reported  that  no  scurvy  existed  iu  this  army.  About  that  time  the  lemons  arrived 
and  were  distributed  among  the  several  corps. 

But  three  weeks  later,  on  June  14,  there  were  discovered  in  the  19th  and  20th  Mass. 
six  men  showing  symptoms  of  scurvy  and  others  "acquiring  a  predisposition  to  the  disease." 
Surgeon  J.  F.  Hammoxd,  U.  S.  A.,  Medical  Director  of  Sumner's  Corps,  to  which  these  reg- 
iments belonged,  stated  that  the  19th  had  become  generally,  indeed  almost  universally, 
affected  with  scorbutic  symptoms,  and  reported  on  medical  authority  that  similar  cases  had 
been  observed  in  another  brigade  of  the  corps.     As  explanatory  of  the  outbreak  he  was 


SCURVY.  637 

informed  that  the  desiccated  vegetables  were  so  disagreeable  to  tlie  taste  that  the  men  would 
not  cat  them.  Ass't  Surgeon  A.  K.  Smith,  U.  8.  A.,  was  immediately  despatched  by  Med- 
ical Director  Tripled  to  inspect  the  men  said  to  be  aftected.  lie  confirmed  the  truth  of 
the  report,  whereupon  the  commissary  of  subsistence  at  White  House  was  telegraphed  to 
send  potatoes,  dried  apples  and  pickles  to  Sumner's  Corps.  At  the  end  of  the  month  Sur- 
geon J.  P.  Dyer,  19th  Mass.,  furnished  a  report  of  the  condition  of  his  command,  showing 
IS  cases  of  pronounced  scurvy,  1(J0  uf  the  scorbutic  taint,  and  rnanv  of  diarrhcta  which  he 
attributed  to  the  causes  of  scurvy,  inasmuch  as  it  was  controlled  when  the  patients  had 
access  to  a  free  supply  of  vegetables. 

Dnring  the  quarter  just  ended  the  regiment  has  l>een  (in  the  peninsula  before  Yorktown  and  Kieliniond.  The 
labor  of  the  men  has  been  arduous  and  their  exposure  jireat,  Tliese  eauses,  with  an  almost  total  deprivation  of  fresh 
veftetables  aiut  fruits  for  three  months,  have  in  my  opinion  laid  the  foundation  for  serious  disi-ase,  which  has  in  many 
cases  made  its  appearance  in  the  form  of  scorbutus.  Kij;lite<'n  cases  of  this  disease,  in  the  form  of  ulcerations,  hem- 
orrhages and  eruptions,  have  lieen  noticed  during  the  jiast  month,  and  nearly  one  hundred  have  been  found  with 
sponjry  and  bleedinjj;  i;ums.  Diarrluea  has  also  been  ajiparent.  di'in'iidin^;.  it  ajijicars  to  me.  uiioii  the  same  cause, 
and  disappearing  whenever  the  patient  could  have  access  to  vegetables  in  any  considerable  (|Uantity. 

Surgeon  Nathan  Haywarp,  20th  Mass.,  rendered  a  similar  report: 

In  addition  to  the  number  of  eases  reported  as  taken  sick  during  the  month,  some  two  hundred  and  forty  men 
of  the  regiment  showed  more  or  less  decided  marks  of  scorlmtic  disease,  and  were  treated  as  far  as  practicable  by  the 
ailministration  of  raw  potatoes  and  vinegar.  These  cases  were  in  most  instances  too  slight  to  warrant  jiutting  the 
men  in  fiuarters,  and  hence  they  do  not  appear  in  the  report.  In  nnmy  other  instances  the  scurvy  taint  was  only 
a]iparent  in  its  modification  of  other  diseases.  Thus  a  large  number  of  the  diarrlueas  were  characterized  by  passive 
hemorrhage  and  a  peculiar  intractability  when  treated  by  ordinary  methods,  yet  they  yieldi-d  readily  to  vegetable 
acids  and  anti-scorbutics  when  they  could  be  procured. 

The  usual  marks  of  the  disease — swollen  and  ulcerated  gums,  painful  swellings  of  the  muscles.  langu(U'.  nos- 
talgia, petechial  eruptions  and  ecehymoses — were  observed.  The  cause  of  its  ajipearance  can  readily  be  found  in  the 
exposure  of  the  regiment  to  the  deiiressing  influences  of  cold,  wet,  hunger  and  niiasnnt  during  the  ten  or  twelve  days 
following  the  battle  of  Fair  Oaks,  combined  with  the  absence  of  vegetables.  The  dithcnlty  of  obtaining  even  the 
usual  ration  of  fresh  vegetables  has  placed  an  insurmountable  obstacle  in  the  way  of  the  cflVnts  of  the  medical  otticers 
to  arrest  the  spread  of  this  disease,  and  unless  potatoes,  onions  and  other  vegetables  are  soon  sn]>i)lied  in  lilieral 
(juantities  there  is  reason  to  apprehend  its  manifestation  in  more  serious  forms. 

Various  other  medical  ofhcers  noted  in  their  reports  for  .Tune  the  |iresence  of  a  scorbutio 
taint,  which  in  some  instances  in  Julv  became  developed  into  unmistakable  scurvy.''' 

Surgeon  H.  F.  V.\x  Dekveei:.  .">//(  X  J.,  Cump  near  .llexan<Jri<i,  Vu..  Oct.  21,  lxG2. — Scurvy  connuenced  in  the  reg- 
iment towards  the  close  of  June.  Tlie  causes  of  this  epidemic  were — 1st,  a  want  of  vegetable  food;  2d,  exposure  to 
■wet  ami  cold  at  night;  3d,  an  impure  atmosphere,  and  4  th,  the  aggravation  of  all  these  causes  by  mental  deinession. 
The  disease  exhiliited  its  usual  symptoms — sjionginess  of  gums  and  s]iots  of  purpura;  contraction  of  joints  and  stitt- 
ness  and  pain  of  limbs  were  especially  freijuent  and  severe.  Xo  fatal  case  occurred.  The  epidemic  reacheil  its  height 
about  the  first  of  August.  During  its  prevalence  diarrlnea  and  all  other  diseases  were  complicated  w  itli  scorbutic 
symptoms.  The  means  employed  to  combat  the  disease  were  fresh  vegetables,  a  free  su]i]ily  of  lemons,  the  salts  of 
potassa  and  tincture  of  the  chloride  of  iron.  The  use  of  the.se  remedial  agents  was  attended  with  considerable  ben- 
efit, and  the  disease  was  diminishing  when,  on  the  l.")th,  we  imtrched  out  of  camp  on  tin'  way  to  YorUtowii.  The 
change  of  air,  the  exercise  of  marching  and  foraging  on  the  cornfields  and  orchards  soon  put  an  end  to  the  epidemic. 

Surgeon  A.  J.  JIcKelw.a.v,  8*/i  X.  J.,  Cnmp  nenr  AUrtindria.  V(i.,  Oct.  20,  18C2. — In  addition  to  the  diseases  speci- 
fied as  having  aftected  the  men  of  this  regiment  since  their  laudiugat  Yorktown  scorbutus  made  its  appearance.  Few 
escaped  without  showing  some  manifestation  of  the  disease.  The  general  symiitoins  were  feelings  of  languor  and 
debility:  fatigue  on  the  slightest  exertion;  the  face  presented  a  putty  ap]iearanee  in  many  instances;  the  gums  were 
spongy  and  swollen,  the  breath  ofi'ensive,  the  legs  in  many  cases  mottled  with  purpuric  spots:  cases  not  so  well 
developed  nor  so  distinctly  marked  were  attended  with  wandering  neuralgic  p;iins,  at  times  attacking  the  spine  and 
at  other  times  producing  pain  or  constriction  of  the  chest  with  difticulty  of  breathing.  One  well-marked  symptom 
in  some  cases,  where  the  di.sease  did  not  manifest  itself  in  jiurplish  spots,  was  rigidity  of  the  muscles  of  the  leg,  spoken 
of  as  chronic  rheumatism  in  the  description  of  their  feelings  given  by  the  sufferers.  In  some  of  these  cases  purpura 
shortly  appeared,  but  in  others  who  suft'ered  precisely  in  the  same  way,  malaise  and  debility  included,  tlie.,e  spots 
were  never  exhibited.     The  exciting  causes  can  be  easily  found  in  the  continued  deprivation  of  proper  vegetable 

*  Dr.  Francis  K.  Lvma.n,  liouse  iihysiciuii,  Bellevue  hospital,  New  York,  reniarkp  in  tlie  .iiiterU^an  Meiticnt  Timen.  Vol.  V,  1862,  p.  125,  that  of  at>oat 
one  hundred  soldiers  of  the  Army  of  the  Potomac  admittctl  during  July  and  Anpu^t,  1S<;2,  thirty-five  iier  cent,  were  alTected  with  scurvy.  Snme  of  tht-t^ 
men  had  been  in  Uichnuind  hoj^pitals.  Debility  and  wandering  shooting  pjuns  were  sonielinies  the  only  groinul;*  for  a  diagno^^is.  The  diarrloea,  fre- 
quently present  in  these  cases,  abated  as  the  general  health  became  restored.  Many  after  gaining  in  tlesh,  strength,  appetite  and  spirit^  continued  to 
BUIfer  from  sore  gums,  excniciating  jiains  and  stitfuess  and  st,  citing  of  the  lim!»s. 


6SS  >cui:vy. 

food  imdt.T  wliicli  tlie  men  hail  suti't'icil  since  their  huidinij;- on  the  Peniiisnhi.  Doulitless  other  causes  contrilmted  to 
its  production. — ex]>osnre.  fatigue.  exh;iustioii  and  otlier  lU'pressini;'  intlnences:  hut  the^vallt  of  fresh  vcLjotahU's  and 
meat  and  tlie  use  of  salt  meat  for  months  no(hiuht  gave  orinin  to  the  disease. 

Asfi't  Suryvoii  C.  !>.  Wooii,  iiiitli  X.  )'.,  Sipi.  30.  l!Sl)2. — At  tliis  time  scurvy  manifested  itself  in  the  most  unmis- 
takalde  manner.  Xearly  one-half  of  the  regiment  suftered  from  itduringtlu-  month  of  June.  Fresh  vegetables  were 
ordered,  hut,  owing  to  the  want  of  tran.sportation,  the  qtiantity  received  wa.s  so  snnill  that  its  eft'eet  was  hariUy  per- 
ceptihle.     Lemons,  however,  of  which  we  .soon  had  an  abundance,  controlled  the  di-sease. 

SitniKHi  Hkni:y  McLk.\x.  2d  X.  1'.,  Caiiq)  mar  Ahxinidriii.  V<(.,  Oct.  30,  18(;'J. —  The  water  was  impure  and  the 
men  for  the  greater  portion  of  the  time  [at  Harrison's  Lauding]  scantily  supplied  «ith  fre.sh  vegetables.  .Symptoms 
of  scurvy  made  their  appearance.  These  cases,  as  well  as  those  of  associated  diarrho-a,  were  benetited  by  the  exhi- 
bition of  dilute  sulphuric  acid. 

Hui-ijtmi  A.  I'.  FiilCK.  103(/  Pa.,  Xitv  Binic,  X.  C,  Fth.  2.^,  1863.— At  this  place  [Harrison's  Landing]  scorbnt::s 
made  its  appearance,  liut  this  was  speedily  repressed  by  the  liberal  irse  of  fresh  vegetables,  lenums,  etc. 

During  tilt;  uJvanco  on  Riclimond  aiiJ  the  retreat  to  Harrison's  Landing  tlicre  had 
been  a  constant  strain  on  tlie  mental  and  plivsieal  energies  of  tlie  men,  lor  their  excitement 
had  heeii  as  intense  as  their  labors  were  severe.  IS'o  fresh  vegetables  had  been  supplied.  The 
desiccated  vegetables  were  not  liked,  and  there  was  seldom  time  to  prepare  them  properly. 
Even  the  ordinary  components  of  the  ration  were  not  always  fully  supplied,  nor  was  time 
allowed  for  cooking.  The  men  frequently  ate  their  rain-soaked  hai'd  bread  while  under 
arms  awaiting  orders.  Sleep  was  obtained  by  snatches  on  the  muddy  roads  and  fields  and 
was  broken  Ijy  the  call  to  arms.  The  troops  inarched  by  night,  manceuvered  and  fought  \^\ 
day,  and  they  were  gloomy  and  despondent  withal,  becaii.se  en  roati'  to  the  landing  a  series 
of  harassing  and  deadlv  conflicts  served  onlv  to  secure  the  safetv  of  the  armv.  The  hard- 
ships,  privations  and  exposures  of  the  seven-davs'  fight,  added  to  those  of  a  campaign  which 
had  already  produced  scurvy  in  .some  of  the  regiments,  sufficed  for  a  more  extensive  devel- 
opment of  this  disease.  One  of  the  first  cares  of  Surgeon  Jxo.  Lettekmax,  U.  S.  A.,  who 
relieved  Surgeon  Teipler  as  Medical  Director  on  the  arrival  of  the  army,  July  4,  at  Har- 
rison's Landing,  was  to  promote  its  recuperation  by  eradicating  the  scorbutic  disease.  Rer^ui- 
sition  was  made  for  large  supplies  of  potatoes,  onions,  cabbage,  tomatoes,  squash,  beets  and 
fresh  bread.  The  first  shipment  of  anti-scorbutics  was  received  on  the  7th;  potatoes  and 
onions  reached  the  Landing  on  the  20th,  and  thereafter  supplies  were  so  abundant  that  they 
rotted  at  tlie  wharf  for  Avant  of  some  one  to  take  them  away.  In  addition  to  the  vegetables 
and  liread  issued  by  the  Subsistence  Department,  fifteen  hundred  boxes  of  lemons  were 
procured  bv  tlie  Medical  Purveyor  for  the  various  regimental  hospitals.  The  beneficial 
effects  of  these  issues  .soon  became  perceptible  in  the  improved  health  of  the  men.  and  when 
the  army  left  the  Landing,  August  16,  scurvy  had  disappeared  from  its  ranks.  According 
to  Lettermax  a  true  idea  of  the  improvement  that  took  place  could  not  be  conveyed  in 
writing,  as  there  was  so  much  in  the  appearance,  in  the  life  and  vivacity  exhibited  by  the 
men  in  their  slightest  actions,  even  in  the  tone  of  the  voice,  which  conveyed  to  one's  mind 
the  impression  of  health  and  .spirits,  of  recovered  tonicitv  of  mind  and  body  and  of  the  jires- 
ence  of  viwrous  and  manlv  courage. 

After  this  scurvy  was  no  more  seen  in  the  Army  of  the  Potomac  except  in  isolated 
cases,  although  at  times,  especially  after  the  conditions  of  an  active  campaign  had  prevented 
the  issue  of  fresh  vegetaldes  and  soft  bread,  a  scorbutic  complication  of  other  diseases  was 
considered  l)y  some  observers  as  noticeable,  and  by  others  the  increased  danger  attending 
diarrhceal  attacks  was  attributed  to  the  same  cause.  Thus  Ass't  Surgeon  JoHX  S.  Billixgs, 
L'.  S.  A.,  in  his  account  of  the  condition  of  the  army  in  June,  1864,  the  second  month  of 
its  advance  from  the  Rapidan  to  Peterslnirg,  Ya.,  reported  the  existence  of  several  cases  of 


f^CUKVY.  6S9 

well-iiiarkeJ  S(?urvy  aiul  of  a  sccrbutic  elcUKTiL  cDinpli eating  oiIkt  diseases;*  and  llie  iii'esent 
writi.i',  when  rcporung  tlie  cunJitiou  of  llie  Srcmi]  Arniv  Chirps  in  ^[ai'.-ii  aiiil  A]>ril,  18(35, 
attributed  tlie  olistinancv  of  the  diarrlicvas  wliicli  wi-i'e  then  ]n'evading,  and  the  great  and 
ra|ndly-inci'easiug  jirustration  Avitli  wiiieh  tliov  wore  assoeiated,  to  tiie  alisenee  of  fresh  veg- 
otahl(.'s  from  tlie  diet  of  the  conimanih  aUiiougli  the  onlv  well-marlved  ca«es  of  scurvy  jtresent 
in  camp  -were  known  to  have  contracted  the  cachexia  wliile  in  S'>nilifrn  pi'ison>."j'  The 
t-tatistics  of  tlie  army  sliow  that  during  tlie  month  of  Juta',  ISiil.  v.'h'ii  ]h\  J5il.LiXi.is  made 
liis  oh>ervation>,  only  22  casi-s  of  t-curvv  were  jvportcd.  i,v  .22  pi^r  thousand  of  strength  for 
the  inontli;  and  in  March  and  April,  LS().3,  when  a  pussihji'  scorhutie  condition  of  the  Second 
Armv  Corps  was  suggested,  there  were  rcjiorted  from  the  whdh'  army  only  o6  and  20  casvs, 
or  .33  and  .26  cases  per  thousand  respectivi.'ly  for  each  monlh.  Pi'actically  that  army  was 
])reserved  from  the  scorbutic  influence  fmm  the  sujipression  of  llie  outbreak  in  June  and 
Julv,  1862,  to  the  conclusion  of  its  historv.  IMedical  Inspectcn'  Joiix  AVii.sox,  U.  S.  A., 
refers  thus  to  its  freedom  from  scurvy  during  the  siege  of  Petersbui'g: 

The  am])le  sui)i>l,v  of  fresh  audnomishing  vefjetaliles  had  an  oxceUeiit  efl'ert  in  triianlinf;  I  lie  men  from  soorlmtic 
taint.  Xever  was  so  large  an  arni.v  so  entirely  exenijit  from  this  form  of  disease.  This  fact  increases  in  sanitary  sig- 
nificance when  we  consider  that  the  depressinj;  anil  exhausting  inlluenee  of  life  in  tlie  trenches  pre.itly  favors  the 
develoiunent  of  adynamic  diseases.  The  demorali  zing  tendency  of  an  almost  unremitting  shari)shoi)tiiigfire  iirodvices 
under  any  circumstances  more  or  less  of  that  moral  depression  and  ])hysical  dejiravation  so  faviuiilile  to  dyscratic 
disease:  yet  notwithstanding  this  the  most  niarUed  exemption  from  scorhutic  disease  has  bi'cn  en.joyed,  ami  thn 
health  of  the  Army  of  the  I'otomac,  during  the  months  of  Se]iteml>er  and  (Ictober,  has  Uecn  of  a  most  gratifying 
character. 

About  the  time  of  the  suppression  of  the  e[>idemic  in  the  Eastern  army  scurvy  was 
observed  in  other  portions  of  the  U.  S.  forces.  Brigade  Surgeon  Ch.vrles  H.  li.vwsox,  5th 
Iowa.  Acting  Medical  Inspector  of  the  left  wing  of  General  Pope's  command,  adverts  to  a 
species  of  land  scurvv  as  the  most  irregular  and  insidious  of  the  diseases  aflecting  the  troops, 
and  as,  in  his  opinion,  complicating  many  other  complaints. J  The  following  rejiorts  indicate 
its  jiresence  in  detached  commands; 

Siiryion  B.  F.  Stkvexsox,  22,1  h';/..  J'ii)-tUi)i(h  Ohio.  Ocl.  8,  l«liL'.— I)nriiig  the  month  of , Inly  we  had  .-i  niimUer  of 
well-n\arked  cases  of  scorbutus.  They  were  sent  to  hos]iital  without  tlie  lines,  where  a  vegctalile  diet  could  be  pro- 
cured. Under  this  regimen  they  rapidly  )m])roved  and  were  returned  to  duty.  The  prevalent  ojiinion  tliat  attributes 
scurvv  solelv  to  the  absence  of  vegetable  nutriment  will  derive  but  little  supjiort  from  a  histoiy  of  the  cases  that 
occurred  in  this  regiment  :*  We  had  in  all  eleven  cases  of  scurvy;  ten  of  these  were  men  of  foreign  birth,  wlio  indulge 
niorefrcely  in  vegetable  diet  than  do  our  native  Americans.  As  these  had  for  years  been  addicted  to  a  fice  indiilgence 
iu  spirituous  liquors,  may  not  the  withdrawal  of  the  long-accustomed  stimulus  have  had  a  material  innnence  in  pre- 
paring the  system  for  the  inroads  of  the  disease?  ■ 

.Stirgcon  .ToHX  W.  Scott,  in(7i  /uniw.— During  the  month  of  July,  ISlil'.  the  legiuient  was,  with  other  troops,  in 
the  Cherokee  country,  and,  owing  to  the  absence  of  fresh  vegetables,  was.comjiellcd  to  subsist  mainly  upon  the  army 
ration,  in  consequence  of  which  a  scorbutic  tendency  began  to  manifest  itself  in  the  shajie  of  cutaneous  eruptions 
and  iu'tractable  ulcers  in  the  mouth:  but,  owing  to  the  juoniptuess  of  the  commanding  oliicer  in  carrying  out  the 
recommendations  of  the  medical  ofticers,  a  supply  of  desiccated  vegetables  was  inocured  and  the  unfavorabis 
symptoms  S2>eedily  disappeared. 

Ass't  Simjcon  Jos.  V.  B.vILY,  ;'.  S.  J.,  raralta,  X.  Mix.,  Od.  6,  lsC.2.— An  abundance  of  grapes,  green  corr., 
beans  aud  onions  were  immediately  furnished  the  troops,  with  sneh  good  etfect  that  by  September  not  a  sign  of  scurvy 
remained.     Chlorate  of  potash  was  prescribed  iuterually  for  the  worst  cases  with  unmistakable  benelit. 

Surgeon  B.\sil  Norkis,  V.  S.  A.,  Fort  Craig,  X.  Mtx.,  Sept.  6,  18(2.— The  character  of  the  pain  in  incipient 
scurvy  is  so  like  that  in  rlieumatism  as  I  have  seen  it  in  this  Territory,  that  I  am  inclined  to  the  opinion  that  a  fair 


*  See  Ills  Il'iinrl,  imac  I'.W,  r.irt  Fii-st  of  tliis  worli.  t  H)'"!.  V'S"  21'.i. 

X  111  11  li-ttiT  (lim-.I  Corinth,  3Ii^s.,  June  il,  18<-,2,— Imericaii  Med.  Tmf>,  Vol.  V,  1402,  p.  42 :    Suim-  uf  the  niMi  affwtud  liii.l  lale,  was.v,  [.uffy  and 

aiift-mic  faces  •  iucrca^in-  dehilitr;  soreness,  ccchvmosis  and  swelling  of  tlie  feet  and  legs ;  jiaiiis  in  the  Ijones,  nmsoles  or  any  and  ever.v  portion  of  tho 

ho.'l V  diarihcea  or  irresular  howels  and  capricious  appetite  ;  comparatively  few  ha.l  the  gnnis  ulcerated.    Su.ldeii  death  in  men  apjiarently  healthy  was, 

I.y  i)r.  E.1WS0S,  attributed  to  an  insidious  scorbutic  taint.    He  liad  no  opportunity  of  making  a  j...«(-.....rf.»,  examination  in  any  of  tliese  suddenly-fatal 

.  cases  but  was  satisfji-d  that  death  did  not  result  from  heart  diseas.-. 

g  Surgeon  Stf.vexsos  does  not  api«ar  to  have  noticed  the  support  given  to  the  prevalent  opinion  I.y  the  rapid  improvement  of  his  ca-.'s  uiul.r  a 

Tegetable  regimen. 

Med.  Hist.,  Pt.  Ill— 87 


690  SCURVY. 

l)i'Oi)Oi'tion  iif  all  tlu' cases  nf  ilu-uiiiatisin  (icouniiii;  in  ihis  (lc]iaitMi(iit   may  lio  s    .■ces.sl'ully  ticatiMl  liy  fresh  vej;e- 
tables,  fruits,  lime-juice  and  otlier  leniedics  adajited  lo  the  cure  (il'senivy. 

Subsequent  to  this  period  (ircusional  ivfcri^'UCcs  to  >cur\'}'  wrw  maile  liy  variuus  dllicfi-.s; 

Ass't  Surgeon  A.  R.  Rice,  lut  Muss.  Cm-  ,  Hc(iiiJ'iirt,  .*>'.  C.  (hi.  2.  isdi'. — In  Si'iitemliei-  %ve  wen'  nnuli  troiilded 
■5\ith  seorlmtus:  but  with  an  abundance  nf  fVesh  vej^etables,  I  aui  liajiiiy  lo  say.  the  disease  is  deelininLT.  I  liave 
found  that  painting  the  sores  with  tincture  of  uniriate  of  iron  promoted  a  healthy  action. 

Ags't  SurijcDii  A.  A.  Wooniifi.t,,  V.  S.  ./.,  '2d  tind  lOtli  ['.S.  Inf..  Ciiiiij'  mtii'  iSlicplienl>:l(in-)i  Ford,  Md.,  Oct.  i), 
18C2. — I  have  observed,  not  so  uiueh  in  niy  own  command  as  in  otlier  rei,'iMU'Mts  with  which  I  have  been  casiuilly  con- 
nected, the  signs  of  latent  scorbutus.  That  diathesis  in  a  niimlier  cd'  cases,  especially  after  long-continued  fatigno, 
was  exhibited  veiling  itself  chielly  under  the  garb  of  obstinate  chronic  rheumatism.  I  attribute  it  to  dejiressing 
influences  at  work  upon  systems  that  had  been  more  or  less  didiilitati'd  by  the  privations  of  life  on  the  frontier. 

Suryvon  W.  W.  Bro\vx,  Ith  X.  II..  St.  AtKjusiine,  FJa.,  May  1, 18G3. — When  the  regiment  left  Fort  Jefferson  many 
of  the  men  were  beginning  to  manifest  symptoms  of  scorbutic  disease,  such  as  spongy  and  bleeding  gums  and  ulcera- 
tions of  the  legs.  Slight  scratches  of  the  skin  became,  in  some  eases,  ulcers,  showing  a  cachectic  condition,  which 
no  doubt  would  have  assumed  an  alarming  aspect  had  we  continued  as  destitute  of  fresh  vegetables  as  while  at  that 
post.  [The  regiment  had  been  stationed  at  Fort  Jeil'ersou  for  three  and  a  half  months,  and  this  service  had  been 
preceded  by  a  sea  voyage  lasting  nearly  a  month.]  Ou  our  arrival  at  ISeaufort,  S.  C,  corn,  watermelons,  sweet 
potatoes  and  other  garden  vegetables  soon  arrested  the  jn'ogress  of  the  disease,  and  its  removal  was  completed  by  the 
oranges,  lemons  and  limes  which  we  obtained  in  abundance  on  reaching  .St.  Augustine. 

Surgeon  Cu.^ules  T.  Soutiiwohtii,  ISth  Mich.,  XaslieUlc,  Tenn.,  June  8,  1803. — Notwithstanding  the  advantages 
derived  from  rest,  a  clean  and  desirably  situated  camp,  well-cooked  rations,  good  tents,  etc.,  I  daily  found  the  men. 
becoming  less  susceptible  to  the  action  of  remedial  agents.  "With  few  exceptions  all  wore  suffering  froiu  scorbutic 
disease.  Vesicants  were  surely  followed  by  erysipelatous  inflammation;  scarifying  and  cupping  had  similar  conse- 
cjuences,  and  in  many  cases  a  peculiar  eruption  existed.  I  innncdiately  substituted  fresh  beef,  soft  bread  and  corn 
meal  for  the  salt  ration,  beans  and  hard  bread:  vinegar,  j'cpper  aiul  a  few  vegetables  were  also  used.  From  that 
time  to  the  jirescnt  but  little  medicine  has  been  employed.  Now  we  have  less  than  thirty  sick  in  iiuarters.  Ko  dis- 
ease assumes  a  malignant  form,  medicine  has  a  happy  etfect,  and  the  men  are  in  good  si)irits,  instead  of  being  torpid 
and  sluggish.  *  »  -  j  eonsUler  beans  the  most  indigcEtible  of  all  vegetables,  and  if  this  be  true  they  are  of  course 
the  most  injurious.  The  bean,  let  it  be  cooked  as  it  may.  fermeuts  in  the  stomach  before  it  is  digested,  and  an  irri- 
tated alimentary  canal  is  the  necessary  consequence;  it  akso  gives  to  the  system  a  vast  amount  of  carbon,  which  is 
not  rcriuired  in  this  warm  clnnate,  nor  in  any  climate  with  the  thermometer  at  ilO°  Fahr.  Corn  meal,  on  the  contrary, 
is  generally  grateful  to  the  stomach,  atfects  the  bowels  suflicieutly  to  maintain  them  solvent  and  thereby  prevents 
the  accunuilation  of  irritating  substances.  It  has  as  much  nutriment  as  the  system  requires,  and  it  can  be  prepared 
in  many  different  ways.  I  have  known  7,000  men  nuirch  for  twelve  successive  days  (in  the  Mexican  army  in  1852) 
with  no  other  ration  than  one  quart  of  parched  corn  daily,  and  without  five  sick  in  the  whole  division  to  which  I 
belonged.  Scurvy  is  a  disease  almost  unknown  in  that  army;  and  corn  is  at  all  times  the  principal  article  of  food 
and  at  many  times  the  only  one  the  soldiers  can  obtain. 

I.'kuI.  Cid.  F.  II.  Hamilton,  Mcdiciil  Ini<i>ector,  U.  S.  .).,  ./in.c,  1803:  Inspection  of  iruojis  at  XaxhviUe  and  Mnrfnes- 
lioro',  Teini.* — The  ith  Edi^t  Tenn.  Inf.,  nearly  800  strung,  is  composed  almost  entirely  of  refugees  from  Eastern  Tennes- 
see. Nearly  all  of  these  nuai  have  been  hunted  by  their  enemies  and  have  lived  for  a  time  among  the  mountains 
befoi'e  they  were  able  to  get  within  our  lines,  subsisting  by  chance,  and  in  most  cases  unable  to  procure  vegetables  or 
indeed  food  of  any  kind  excejit  in  sumll  (|iiantities.  The  regiment  has  been  organizing  for  several  months  by  com- 
panies which  were  filled  up  gradually  as  the  men  came  in.  Since  their  enlistnuMit  until  recently  they  have  had  no 
fresh  vegetables.  »  *  •  They  need  esi)ecially  fresh  vegetables  and  water-i)roof  blankets.  *  »  *  Vaccination, 
whidi  has  been  practiced  pretty  generally  among  the  men,  has  in  most  cases  made  large  and  tmhealthy  ulcers,  caus- 
ing swelling  and  suppuration  of  the  axillary  glands.  Several  of  the  cases  were  brought  to  my  notice.  There  have 
also  been  some  cases  of  idiopathic  erysipelas.  It  will  be  fortunate  if,  in  this  condition,  the  men  are  not  called  into  aii 
engagement;  their  wounds  would  generally  no  doubt  prove  fatal. 

Ttte  ith  E<(st  Tenn.  Caw;  600  nu>n  :  refugees.  F''ive  companies  have  been  organized  since  the  middle  of  Decem- 
ber, 1802.  Up  to  the  first  of  April  last  they  had  received  almost  no  fresh  vegetables, — since  that  date  about  one  ration 
of  potatoes  every  two  weeks.  From  April  2.'5  to  May  10  more  than  one  hundred  men  were  vaccinated,  of  whom  many 
are  still  suffering  from  ugly  ulcers  and  suppuration  of  the  axillary  glands.  About  seven  cases  of  idiopatliic  erysip- 
elas have  occurred.     These  men  need  vegetable  food. 

The  Igt  Middle  Tenn.  Inf.  was  organized  in  April,  1802.  The  regiment  has  been  in  no  battle  and  has  not  done 
much  marching.  It  was  recruited  mostly  from  Nashville  and  its  vicinity.  The  men  have  had  very  few  fresh  vege- 
tables since  their  entry  into  the  service.  A  good  many  cases  of  scurvy  have  aiqioared,  and  slight  wounds  have  not 
healed  kindly.  The  whole  regiment  was  vaccinated  four  weeks  since,  and  about  one-third  became  affected  with 
intractable  ulcers, — many  not  yet  healed.  In  several  cases  the  axillary  glands  suiipurated.  There  have  been  several 
cases  of  idiopathic  erysipelas  lately,  with  diarrluea.     This  regiment  is  still  sufiering  for  want  of  vegetable  food. 

The  22d  Mich.  Inf.;  640  men ;  organized  July  31, 1862.  F'p  to  April  1  almost  no  issues  of  fresh  vegetables  were 
made:  since  then  about  one  ration  of  potatoes  every  two  weeks.  Vaccination  has  left  large  and  obstinate  sores  in 
a  great  numy  cases.     These  men  need  more  fresh  vegetables. 

*  Dr.  Hajiiltun  refers  at  some  leugtli  to  these  e.vij.rieuces  in  his  Ti-vatise  on  Militunj  Sttnjt'i-ij  and  Hfjtjivne,  New  Yurti,  ItfOo,  p.  80  H  aaj. 


SCURVY.  C)91 

Till'  \>^th  Mich.  Inf.;  43t>  nifii.  This  roi,'imoiit  bus  lieeii  in  sorvicc  for  alioiit  nine  niontlis;  iliiiinft  tlio  liist  seven 
months  it  reecived  almost  no  I'resli  ve^etahles,  hut  since  April  1  live  lull  rations  of  potatoes  ]ier  man  liave  lieen 
issued.  [Here  Insiiector  lI.vMil.rON  ijuotes  at  length  from  a  report  hy  the  sur|j;eou  of  this  regiment,  the  suhstanee  of 
which,  as  relating  to  scurvy,  lias  already  been  suljmitted.] 

'flic  Will  III.  Inf.;  54li  men.  Tliis  regiment  lias  been  in  ser\iee  nearly  two  years,  anil  nntil  April  1  last  the 
colonel  does  not  recollect  that  an  issue  of  fresh  vegetables  was  ever  made.  Tliere  has  been  a  great  deal  of  scurvy  but 
it  is  now  disappearing. 

'/Vic  85(//  111.  Inf.:  ISO  men.  Tlie  regiment  has  lieeu  in  service  about  nine  months;  it  received  almost  no  fresh 
vegetables  until  April,  1803.     The  men  have  been  scorbutic  but  are  now  improving. 

Thc><i>tli  III.  Inf.;  (iOD  men;  in  service  nine  nmntlis:  first  vegetables  received  April  1,  lsii3.  Scurvy,  w  hieh  was 
present,  is  disappearing  and  all  diseases  are  becoming  milder. 

The  125t]i  III.  Inf.:  in  service  eight  nuniths;  first  issue  of  fresh  vegetables  Ajiril,  LsIm.  The  men  have  been 
scorbutic  but  are  now  improving. 

The  60th  III.  Inf.;  588  men  ;  mustered  into  service  Feb.  17,  18(U.  The  cidonel  says  he  has  received  for  his  men 
more  fresh  vegetables  from  the  Sanitary  Commission  than  he  ever  received  I'roiu  the  Commissary,  and  that  he  does  not 
know  what  he  should  have  done  without  that  aid. 

The  52(1  Ohio  Inf.;  .">32  men;  in  service  nine  monJlis.  Fresh  vegetables  received  in  .April  and  May,  but  very 
seldom  before  that. 

The  5th  Ki/.  Cai;.;  397 men.  Tliere  is  a  slight  tendency  to  scurvy  among  the  men,  and  a  little  intermittent  fever. 
They  are  now  receiving  about  one  ration  of  jxitafocs  ]ier  week.  They  were  mustered  into  service  eighteen  mouths 
since,  but  until  w-ithin  the  last  i'cw  months  liave  had  very  few  fresh  vegetables. 

Tilt  Idth  III,  Inf.;  583  men.  The  regiment  is  encamped  on  the  north  side  of  the  Cumberland  river,  opposite 
Nashville,  on  rather  low  sandy  soil.  The  health  of  the  comniand  is  excellent.  There  is  not  a  man  in  this  regiment 
but  can  read  and  write;  one  liundred  and  sixty  are  members  of  a  temperance  society;  they  have  a  sehoolniaster  and 
a  gymnasium.  The  colonel  assures  me  that  his  men  all  use  desiccated  vegetables  when  they  can  get  them,  but  they 
cannot  draw  tlienr  at  present.  Until  late  in  April  they  bad  drawn  but  one  ration  of  fresh  potatoes  in  sixteen  months; 
since  then  they  have  draw  n  four  full  rations.  They  have  only  15  men  sick  in  hospital  and  quarters  :  not  mie  in  hos- 
pital in  Nashville,  and  only  about  15  men  absent  in  any  hospital,  and  these  are  mostly  detained  as  nurses.  The  good 
health  of  this  regiment  1  ascribe  to  their  good  habits  and  discipline  and  to  their  free  nse  of  desiccated  vegetables. 

The  tronps  at  Mmfrceshoro'. — The  scorbutic  taint  continues  slowly  to  disajipear:  but  ;i  good  many  well-marked 
cases  remain  in  the  field  and  general  hosjiitals.  Potatoes  continue  to  arrive,  arid  the  commissary  has  been  able  during 
the  month  to  issue  three  full  rations  per  Aveek,  and  lately  one  full  ration  jier  day;  but  the  enlisted  men  do  not  gen- 
erally get  more  than  one-half  or  one-third  of  the  rations  issued.  The  last  arrivals  of  ])otatoes  are  all  sprouted  and 
many  are  decayed;  it  is  probable,  therefore,  that  very  few  more  w  ill  Vie  received  in  a  c<nidition  jiroper  to  issue.  Suf- 
ficient attention  is  not  paid  by  the  buying  and  shipping  commissaries  to  the  ventilatiiui  of  the  barrels.  A  subsistence 
officer  at  J[urfreesl)oro'  informed  Surgeon  I'kkin  and  mysidf  that  he  liad  to  open  the  sides  of  all  the  barrels  after 
their  arrival.  The  conse(|nence  is  that  when  oiiencd  they  are  already  decayed  or  mouldy.  Those  forwarded  by  the 
Sanitary  Commission  are  opened  liel'orc  being  sliip]ied,  and  they  arrive  in  .-i  iiiueh  belter  condition  than  (ioveiiiment 
potatoes.     *     '  The  sick  at  this  post,  with  the  exception  of  t  hose  al'ferted  with  siiiall-]iox.  are  now  gathered  into 

the  (jeneral  F^ield  Hospital,  where  30tJ  hospital  tents  have  been  pitched,  giving  a  cajiacity  of  2,(l75  lieds.  The  hos- 
pital garden  is  already  beginning  to  supply  onions,  lettuce  and  other  early  vegetables  in  great  alpundance.  The 
Invalid  Camp,  established  also  in  tents  inside  the  fortilicatious,  is  a  model  of  neatness  and  order.  To  Medical 
Director  I'ElilN'  too  much  credit  cannot  be  given  for  his  increasing  vigilance  ami  attention  to  the  wants  of  all 
Jiortions  of  this  command,  bnt  especially  for  what  he  has  accomplished  for  the  troo]is  both  in  hos]iitals  and  in  the 
field  in  and  about  JIurfreesboro'. 

Ajipeiuletl  to  Dr.  Hamilton's  Iiispfclion  lU'port  aiv  two  s|icci;il  i\|iort<.  uuf  by  k^ur- 
geon  R.  J.  Parquhaeson,  4tli  Etist  Tenii.,  ami  tlie  otlicr  by  Ass't  Sui-gcou  X.  ]>.  SissoN, 
92d  Ohio,  to  illu.stmte  the  conditions  that  elev(.'h)ped  the  scoi'l)Utic  taint  in  tliese  conimands. 

Surgeon  F.vhquii.vhsox  says: — The  men  are  almost  entirety  refugees  from  East  Tennessee,  and  for  some  time 
previous  to  their  enlistment  were  subject  to  many  hardships  from  exposure  to  the  weather,  scanty  clothing  and  imper- 
fect, meagre  and  monotonous  diet.  Indeed,  after  having  subsisted  for  periods  varying  from  a  few  months  to  a  year 
upon  corn  bread  and  bacon,  they  entered  the  regiment  during  the  past  winter  and  have  since  been  upon  the  army 
ration  for  a  longer  or  shorter  period.  The  most  immediate  and  obvious  eonsequeuce  of  this  has  been  the  development 
of  that  scourge  of  armies,  scurvy,  in  some  of  its  protean  forms.  To  account  for  its  production  one  needs  bnt  consider 
the  composition  of  the  army  ration,  abuudairt  in  carlioniferons  and  nitrogenous  principles  but  almost  entirely  defi- 
cient in  any  manifestly  anti-soorbntic  agent.  Three  items  of  the  ration  only  jiartake  of  this  nature,  viz;  vinegar, 
molasses  and  potatoes;  of  these  the  first,  to  be  efficacious  as  a  preventative  of  scurvy,  would  have  to  be  issued  iu 
larger  quantity,  and  to  be  cider  or  wine  vinegar  instead  of  that  prepared  from  spirits  by  the  German  method;  the 
second  is  iu  small  quantity  and  of  doubtful  virtue:  the  third  would  be  of  much  importance  if  it  were  issued  regularly) 
and  also  if  the  men  could  be  induced  to  eat  it  iu  its  most  powerful  anti-scorbutic  state,  viz;  raw. 

Some  two  or  three  months  before  I  joined  the  regiment,  in  June,  many  of  the  men  were  vaccinated  in  Louis- 


692  scriivv. 

villc.  Ky.,  liy  llii'  ;i>sistii:it  .surircoM,  with  iiiaitci-  I'liinisliiMl  l.y  iiiithi.  ily.  niid  \vlii'.-.>  in  a  ti  w  casrs  iiioiIiu'imI  tlie 
Old  in  illy  eti'ecl.s,  leavinj;  Ijcliiiiil  tlir  ;i|i|irii\"i'il  scar:  In  it  of  il>  >I  ranur  and  iliri'  r  tin' Is  in  tlu-  ureal  niajoi  ily  nl'  cases 
I  can  best  give  an  idea  Uy  stating  tin'  ciMiditiim  cd'  i  licsc  nun  wlu'ii  I  Juiiicd.  11  le  scar  was.  in  mhuc  instances.  l>i(iad. 
.siiiDoth  and  flat,  without  the  ,slij,'htest  ii|i|ieai:ince  id'  pits:  in  olhcis  ii  was  raised  al>i>\c  tlm  sitilaee  and  lacerated, 
jiresenting  tbe  appea  ranee  of  a  hirge  wart.  A  he  nit  the  period  id"  cieairi/at  inn  1  w  o  sc(iiiehe  generally  appeared,  sonie- 
tinios  separately,  Init  (d'leii  in  the  same  patient :  a  iiartieiihir  eruption,  resenilding  eetliynia,  in  the  iniiiiediate  vicinity 
of  the  sear,  and  an  iulhininiation  of  the  lymidnitic  glands  of  the  axilla,  tliose  of  the  lower  part  of  the  neek  just  above 
the  clavicle  being  in  a  few  instances  also  affected.  These  enlargenienis  were,  as  a  rule,  cold  and  indolent,  ending  li.v 
resolution  in  most  cases,  in  a  few  liy  snppniation  and  o]ieii  abscess.  In  other  eases  the  arm  presented  two  or  three 
sores,  corresponding  to  the  points  of  vaccination,  covered  by  thick  si  abs  id'  a  dirty-white  or  yellowish  color,  with 
dark  pus  oozing  from  breaks  in  the  crust  at  the  edges  or  on  the  sniface.  In  some  persons  the  sores  coalesced,  form- 
ing an  ulcer  embracing  all  the  points  of  vaccination.  When  these  scabs  came  away  or  were  renio\cd  by  poultices 
the  well-defined  scorbutic  ulcer  presented  itself,  with  raised  edges,  smooth  or  jagged,  and  the  ciip-like  cavity  lilled 
with  dirty  sanies  when  the  ulcer  is  phagedenic  or  extending,  or  with  large  lUibby  granulations  when  showing  a  dis- 
jiosition  to  remain  station.-iry  or  to  heal.  These  ulcers  were  indolent  or  irritalde  in  diiferent  patients.  Ulcers  of  this 
kind  resulted  not  only  from  vaccination  but  from  slight  abrasions  of  the  skin  ;  examples  may  be  instanced  as  result- 
ing severally  from  a  slight  burn  of  the  llngi'i-.  from  a  scratch  of  the  forearm  by  a  pin  and  from  a  wound  id'  the  hand 
by  a  thorn. 

I'pon  a  general  examinatiou  of  the  men  the  following  conditions  were  observed:  In  most  cases  a  com]ilaint  of 
malaise  or  debility,  which  jirevailed  to  such  an  extent  and  in  so  marked  a  degree  as  to  present  to  a  casual  observer 
the  appearance  of  coniirnied  laziness,  the  men  sitting  dowu  even  when  you  were  talking  to  them,  and  exhibiting, 
when  apparently  well,  the  greatest  lassitude  and  indisposition  to  duty,  indeed  to  exercise  of  any  kind.  They  were 
not  aiia'iuic,  but  ratlier  dark  and  ruddy.  Headaclie  was  common,  as  were  also  dyspeptic  symptoms,  loss  of  appetite, 
gastnilgia,  vomiting  and  eructation  of  food.  The  pulse  was  smaller  and  more  rapid  than  in  health.  The  tongue  in 
almost  all  cases  presented  the  same  appearance — broad,  flabl)y,  smooth  and  without  the  slightest  appearance  of  fur 
tio  matter  what  might  have  been  the  immediate  disease  for  which  the  patient  presented  himself;  in  a  few  cases  in 
which  the  stomach  was  imidicated  the  tip  was  red  and  papilhe  prominent.  The  gnnis  were  preternaturally  red,  and 
in  most  instances  retracted  from  the  teeth  and  inclined  to  ooze  Idood  iijiou  pressure.  Though  in  many  cases  there 
was  complaint  of  paiu  in  the  bones,  in  none  have  nodes  or  the  llatness  and  hardness  of  the  muscles  of  the  calf  of  the 
leg,  so  ofteu  described  as  a  peculiarity  of  marine  scurvy,  been  observed. 

Finally,  attention  should  be  called  to  the  most  prevalent  and  the  most  important  consequences  of  the  cachexia 
luesent,  viz.,  dysentery.  Three  causes  may  bo  assigned,  and  probably  all  had  an  agency  in  the  production  of  this 
disease:  exposure  to  rain,  with  imperfect  protection  and  sleeping  on  the  wet  ground;  the  use  of  hard  limestone  water 
from  a  well  near  liy, and,  lastly,  the  scorbutic  taint.  This  dysentery  is  of  an  acute  cliaracter,  with  liloody  stools  from 
the  beginning,  but  no  typhoid  symptoms;  it  seems  to  be  more  of  the  nature  of  bloody  <liarrlia'a,  easily  checked  by  a 
laxative  followed  by  an  opiate,  but  soon  returning,  as  might  be  expected,  the  causes  remaining  in  full  force. 

Ass't  Surgeon  N.  B.  Sissox  reports: — The  regiment  was  moved  from  the  mouth  of  Coal,  on  the  Kanawha  river, 
in  West  Virginia,  to  Carthage,  Tenu.,  by  way  of  Nashville,  aliout  the  2.jth  of  January,  18C3.  It  consisted  of  855 
jtrivates  and  35  oflieers,  and  although  it  had  been  in  the  service  a  little  over  five  months  the  health  of  the  men  had 
been  such  that  we  had  lost  but  one  nnin  from  disease;  and  yet  we  had  been  much  exposed,  had  ofteu  bivouacked  in 
moving  from  Marietta,  Ohio,  to  the  month  of  Xew  Kiver,  in  West  Virgiuia,  and  had  done  much  hard  work  in  build- 
ing, llooring,  rooting,  bimking  and  completing  about  tiO  houses  for  winter  barracks  which  we  had  occasion  to  use. 
At  the  time  we  moved  measles  and  mumps  were  making  their  appearance  in  tlie  regiment.  We  were  transported  in 
three  small  steamers,  the  '"Cottage,"  •'  Victor  No.  2"  and  '■  Leslie  Coombs,"  with  one  comp.any  on  the  '•Odd-Fellow." 
These  were  all  old  steamers,  narrow  keels,  nanow  guards,  old  models,  fueled  to  run  from  the  mouth  of  the  Kanawha 
to  Nashville  and  back  to  Fort  Donelson,  and  carrying  ordnance  stores,  regimental  horses  and  a  full  supply  of  tents 
and  camp  and  garrison  e(|uipage.  During  the  two  weeks  occupied  in  moving  to  Nashville  the  soldiers  were  so  much 
crowded  that  food  could  not  be  well  cooked  nor  clothing  washed  or  changed;  personal  cleanliness  was  impracticable, 
and  the  air  was  impure  and  poisonous.  These  insanitary  conditions  so  undermined  and  debilitated  the  constitutions 
of  the  soldiers  that  they  could  not  resist  or  sustain  future  severe  attacks  of  disease. 

Having  reached  Nashville,  the  regiment  encamped  three  miles  south  of  the  city,  during  rainy  weather,  in  old 
and  leaky  tents,  with  cases  of  measles  occurring  daily  until  the  number  ran  up  to  80.  These  were  left  in  hosjiital 
at  Nashville  after  having  remained  iu  camp  thirteen  days. 

After  this  we  were  placed  on  the  steamers  '•  Fitzhugh''  and  ''Gleuwood"  for  transportation  to  Carthage,  Tenn. 
Ou  these  vessels  we  were  more  extremely  crowded,  for,  in  addition  to  the  troops,  they  carried  ordnance  stores,  fuel, 
tents,  camp  and  garrison  ecjuipage  and  forty  mules.  Six  days  were  occupied  in  reachingCarthage,  and  the  crowding 
was  such  that  some  of  the  companiew  were  compelled  to  sleep  in  the  hold  of  the  "Fitzhugh.''  Ou  February  28  the 
regiment  disemliarked  and  marched  to  a  camp  two  miles  south  of  the  Cumberland  river  and  the  same  distance  from 
Carthage,  a  sloping  piece  of  ground  covered  with  a  large  growth  of  beech  trees  and  apparently  a  healthy  location. 

At  this  time  the  ration  was  very  defective  in  variety,  there  being  no  potatoes,  mixed  vegetables,  salt,  acids, 
subacid  fruits  or  fresh  meat.  The  ration  in  the  early  part  of  March  consisted  of  hard  bread,  poor  bacon,  beaus, 
coHee  and  sugar:  but  in  a  few  days  rice,  salt,  tea  and  molasses  were  added.  Medical  Director  F.  S.\i.TER,  U.  S.  A'ols., 
was  informed  of  the  necessity  of  having  the  regiment  supplied  at  once  with  fresh  meat,  jiotatoes,  etc.,  and  was 
urgently  reciiiested  to  use  his  iutlueiice  iu  having  these  articles  furnished.  From  day  to  day  and  week  to  week  I 
u-ged  the  necessity  of  fresh  meat  and  a  vegetable  and  anti-scorbutic  diet.     I  stated  that  the  present  camp  w  as  healthy 


and  well  selected,  and  that  dm'  dilijjoiico  wa.s  jjivfu  to  cntbrco  the  laws  of  military  Iiy},nene,  as  far  as  in  my  power, 
to  I'ladicati'  the  scorliiitic  and  typhoid  elements  of  disease  from  tlie  oonimand.  Thoroii^'h  cocdiinj;,  eleanliness,  ven- 
tilation nifi'ht  and  day,  strikinj;  tents  twice  a  week  and  oftencr  when  practieable,  cffieient  ditcdiinu;  and  diaininif  of 
lents  and  eani)>  and  daily  disinlectinj;  of  kit(dien-sinks  and  latrines  have  hei'n  recommended  and  in  a  f;reat  measure 
carried  into  etfeet.  I  am  informed  liy  the  C'onnnissary  that  during  the  period  Jan.  2~t,  lsti:{,  to  Jnne  3  following, 
li(!  issued  ahont  twfilve  ralicjns  of  flesh  beef.  Xo  fresh  or  desiccated  potatoes,  mixed  vegetables  or  subacid  iVuits 
were  issued  to  the  comniaiul  until  the  close  of  JIay.  As  soon  as  weeds  an<l  grass  bci^an  to  grow  the  men  were  enconr- 
age<l  to  procure,  cook  and  use  them. 

Tlicse  numerous  debilitating  causes  and  elements  of  disease  operating  on  a  regiment  unscasoiu'd  to  the  service 
has  made  a  largo  sick-list  and  mortality  report.  Ty]dioid  fever  was  develojicd  by  crowded  transportation  and  made 
malignant  by  the  long  absenjo  of  vegetable  diet  and  the  presence  of  scurvy  among  tlii'  S(ddii'rs  thus  di'prived  for  a 
long  period  of  projier  rations.  The  scorbutic  taint  increased  the  number  of  diarrlueal  cas<>s  and  made  the  disease 
intractable.  Aljoiit  12U  casi's  cd'  measles  occurred  in  the  regiment,  of  \\hich  'Xi  diccl  duriuir  the  disi-a^'C  vv  from  its 
effects.     There  were  about  l.M)  eases  of  typhoid  fevei',  of  which  l:>  died. 

This  hasty  statenu'nt  is,  T  believe,  correct,  and  covers  most  (d'  the  caus(<s  that  ha\e  so  si'vi'icly  arili<'ted  the  regi- 
moiit  and  destroyed  so  many  valuable  lives.  To  what  extent  these  caus<-s  were  avoidable  I  am  md  )ii'ei>ared  to  say; 
yet  it  is  a  great  misfortnne  that  scurvy  should  have  alfected  Anu'rican  troops  and  given  a  malignant  character  to 
other  diseases. 

Si(rf/('(iii  Jamks  ])HYa\',  r.  S.  Tols.jOjijtnxilr  I'ldxliiirii,  Jiiiu  I'T.  ISi!:!. — Scorbutic  diseases  in  their  several  forms, 
without  much  external  ilevelojiment,  were  not  uncounuon  both  anion;;  our  jiatienls  and  convalescents.  'J'he  IVee  use 
of  I'resli  aninnil  food,  together  with  vegetable  acids,  acetic,  citric  and  tartaric,  wa.s  resorted  to  with  advanla<;e  in 
these  ea.ses.     Spongincssof  the  gums  would  sometimes  continue  a  long  time  after  the  other  sym|>t(uus  had  disaiipeared. 

Siirijvitn  \.  \\' .  l.i-:i(;iiio.\,  ITIlr/  X.  )'. .  Fniiikliii,  l.ii..  I'lh.  VI.  iMll. — Nnmer(His  cases  of  boils  and  cutaneous  crn|i- 
tions  have  improved  under  an! i-scorbut ic  remedies. 

.I.s.w"/  SunjiOii  IllONUV  JI.VNti;Kli,  '22(1  Jii/.,  Jitiluii  Hoikj,  ,  I.ti.,  Munli  '2'J.  l.-sill. — Sever.il  ca>es  of  scorbutus  oi-iiii  led 
from  a  deficient  supply  of  vegetables  and  fresh  meat.  Eveiy  eti'ort  was  made  by  tin'  medical  ollicers  to  remeily  thesi- 
deliciencies.     Kecoveiy  under  improveil  diet  antl  appro]iriate  medical  treatment  was  spee<lily  efl'ected. 

S Ill-fit  II II  A.  W.  (;i;.VY.  2Mh  fuel..  Moryanzn.  Lii.,  Sipt.  17,  INiil. — The  surgeons  of  the  aHected  regiments  arc  unani- 
motis  in  the  belief  thi»t  this  scorbutic  condition  is  owing  to  the  inhalation  for  a  leir;;lliened  jieriod  of  an  atnios])here 
strongly  impregnated  with  salt,  and  the  entire  absence  of  fresh  meat  and  vegetables  from  tlie  diet  of  the  men  while 
mucli  e>:;:o.-,ed  to  tile  heat  of  the  sun  and  doing  excessive  fatigue  duty. 

Ill  Julv  ari'l  August.  ISiU.  the  lino  of  pivvalouee  ol' scoi-lnitii'  ili.-.'aso  ainuiiL;  llic  wliito 
troops  ln-'oaine  sonicwhat  jiroruiiiiMit,  altliougli  it  I'ailctl  to  reach  tlio  k'Vi-l  ot'  liic  omlavak  iu 
tlu.'  Ariiiy  of  tlio  Putciiuac.  Tiiis  incroaso  chiefly  aflected  the  iV,i'ci,':s  ojieratiiig  a^-ainst 
Atlanta,  (ia.  Tlic?e  ti'uop.-  cinisiituUil  only  20  pc-r  cent,  oi'  the-  arniirs  ihiai  iu  the  iii/ld.  hut 
thev  furnisheJ  o~)  per  cent,  of  the  scorbutic  cases.  Their  rate  fur  July  amounted  to  G.6 
case.s  per  thousand  of  strength,  i^urgeou  Jl.  Iv  (ioouMAN,  U.  S.  \'ol<.,  2d  J'ivision.  2Uth 
Corps,  iu  liis  report  on  the  condition  of  his  couunand  during  the  Atlanta  campaign,  slates 
that  1-30  itiarked  cases  were  admitted  to  division  hospital  during  the  mouths  of  Julv  and 
August,  and  that  during  the  cain}iaign  fil'ty  per, cent,  of  the  divi-ion,  which  numhered  7.'"K) 
iiieii,  had  been  sent  to  the  rear  sick,  two-thirds  of  whom  were,  iu  his  opinion,  sull'ering  from 
scorbutic  affections. '■"  .But,  ou  the  other  hand,  Stirgeon  W.  (tUIXstkaii,  U.  S.  Vols.,  of  the 
3d  Division  of  the  same  Corps,  states  that  his  comntand  did  not  sud'er  itiui-h,  although  there 
was  ail  insuificiencv  of  vegetables."!"  The  number  of  cases  in  the  I)e|iartmeut  of  Arkansas 
was  at  tlie  same  time  above  the  average;  and  a  similar  increase  in  tln'  lte[>artment  of  the 
Gulf  prolouw'd  the  increased  jnvvaleuce  iu  the  armv  as  a  whole  into  Septemlier  of  that  year. 

Towards  the  close  of  the  year  ending  June  30,  ISGo,  a  slight  increase  in  the  number 
of  scorbiutic  cases  was  rnainly  due  to  conditions  affecting  the  diet  of  the  troops  in  the  Central 
region.     Xt)  sjiecial  reports  relating  to  tlie.so  outljreaks  are  cu  file. 

The  annual  rates  of  prevalence,  calculated  iVoni  the  cases  rej)orted  bv  medical  officers 
of  white  troops  during  the  four  }-ears  of  the  war  and  the  year  following  the  war,  were: 


■'  Seo  his  ll.jinrl.  i>.  ^iiT,  rnrt  First  of  this  wurk.  1 1''"',  iwt'i'  WO. 


694  SCURVY. 

r.T  1,1111(1  ,,f  ftivii^'th. 

Fell'  the  year  fudinj;  .Iiiiio  ?.n.  1802 .1.7 

For  tlie  year  cihUiiji  June  30,  lxV>:'i 12.  (1 

For  the  year  eudiiij?  June  30,  IMOl _ li.ii 

I'or  the  year  euiling  June  30,  18(i.") lii'.  4 

For  the  year  ending  June  .SO,  1X()(! L'S.  ."> 

Avera.ije  annual  rate  from  the  statistics  of  the  live  years _ V.i.x 

But  tlie  prevak'neo  of  llie  disease  among  tliese  troops  will  be  better  appreciated  by  a 
reference  to  the  diagram  facing  tliis  page,  on  Avliicli  it  is  rejjresenleil  liv  tlie  light  red  line. 
The  maximum  during  the  war,  4.0  per  1 ,0l)0  in  Julv,  l.^fil*,  was  occasioned  bv  the  outbreak 
in  the  Army  of  the  Potomac.  At  that  time  this  army,  which  constituted  only  25  per  cent, 
of  the  forces  iu  the  field,  furnished  6S  per  cent,  of  the  reported  cases.  The  maximum 
monthly  rate,  shown  by  its  reports,  was  10.7  per  l.OUO  men. 

The  unexpected  diMnonstration  of  a  more  extensivdv  dill'usi'd  scoi-butic  taint  among 
the  white  troops  in  the  year  following  the  war  than  at  anv  time  during  its  progress  must 
be  referred  to  the  conditions  attending  the  disl^anding  of  lai'ge  masses  of  men,  and  especially 
to  carelessness  on  the  part  of  ofhcers  and  luiai  whoso  thoughts  were  perhaps  engaged  on 
their  own  futuri'  plans  rather  than  on  current  allaii's.  The  monthlv  rate  of  5.6  was  recorded 
towards  the  end  of  the  snring  of  1866,  when  the  return  of  vegetation  retiressed  the  epidemic 
tendency.''' 

The  same  diagram  illustrates,  by  means  of  the  heavy  red  line,  the  prevalence  of  the 
disease  among  the  colored  troops  of  the  army,  while  the  orange  and  green  lines  submit  lor 
comparison  the  monthly  rates  tliat  pi-evailed  in  the  J5i'iti-li  and  Frencli  armies  in  lS54-5<i. 
during  the  Crimean  campai--n. 

Scurvv  Jiad  a  much  gi-eater  prevalence  and  fatalitv  among  the  colored  than  among  the 
white  troops.  During  the  three  years  covered  by  tlie  statistics  16,217  cases  and  338  deaths 
were  recorded, — equivalent  to  an  annual  average  rate  of  88.8  per  thousand  of  strength,  with 
2.08  per  cent,  of  the  cases  terminating  fatally.      The  rates  were: 

Pit  l,Oi:iO  (.f  strentrtli. 

For  the  year  ending  June  30,  1S61 _ 68.  0 

For  the  year  endin<;  June  3l>,  lSt).5 - (m.  1 

For  the  year  ending  June  30,  ISGG 141.  6 

The  causes  which  increased  the  prevalence  among  the  white  troops  in  tlie  suinmer  of 
l8(5-l  and  in  the  summer  and  autumn  of  1865  appear  to  have  operated  with  great  intensitv 
on  the  colored  troops.  In  August  of  the  latter  year  the  monthly  rate,  33.9,  was  higher 
than  the  maximum  attained  by  the  disease  in  the  French  ranks,  32.9,  in  February,  1856. 
Even  in  July,  1863,  the  first  month  for  whicli  returns  were  received,  and  when  only  12,000 

*  During  the  fisral  yt*ars  ISCitl-OT  ami  lSOT-r.8  tho  rate  of  scurvy  cniitimu-il  liijrhir  in  thi>  V.  S.  Army  than  it  luu}  bi'rn  during  tlif  years  of  the  vrar. 
In  tlic  furmor  year  thi'  nito  was  25. 0 — in  tho  latter  21.1— among  the  white  truojis  per  tlionsand  of  strength.  This  wuh  nndonhtedly  owing  to  tlie  ri--est;ib- 
lishnient  of  thoj^e  cumlitions  alreinly  iinlieatfl  as  having  heeu  in  exi.-st*'iice  before  the  war, — the  garrisoning  of  military  post.s  in  luealitiea  remote  from 
vi-getul'le  Diarki-ta  ami  otln-r  si>urced  of  fooil  supplies.  The  following,  from  a  report  ou  the  romlition  of  F(prt  Stevens- m,  I)akota,  hy  Ass" t  Surgeon  ^VASH- 
iKGToN  Mattiiewsj,  I'.  S.  A.,  puhHriheil  in  rireular  No.  4,  AVar  iJepartnieiit,  Surgeon  CJeneral's  Othce,  Washington,  It,  C,  December,  1^70,  p.  30r.,  sh>.w- 
tho  prevaleno^  of  S4urvy  at  that  post,  ami,  ha  thi.s  is  not  an  isolated  instane*',  tlie  high  rate  of  &:urvy  in  the  army  ilnring  those  years  is  readily  under- 
Sjtootl : — "During  the  summer  of  1807  the  Sii>ux  made  three  raid.s  on  the  ramp  in  ftm-o  and  one  attac-k  in  u  small  jiarty.  Tho  troop.s  were  compelled  to 
labor  very  hanl  aft'T  tho  building  of  t!ie  post  was  conimeuced,  and  a.s  tlii'ir  food  was  defieient  in  variety,  and  Indng  lodged  in  tents  during  the  severest 
weather,  they  sutTt-red  grejitly  in  health.  Aeutc  dysentery  was  the  first  prevailing  disease.  Tliis  reached  its  height  in  Sejitember,  18*17,  wlien  tliere  were 
honiM  fifty-five  cases  on  the  rf|t«>rt,  besides  a  number  of  mild  attaeks  not  recorded.  After  this  si-urvy  prevailed.  Tliis  reached  its  beiglit  in  .Vpi'il,  ISiiS, 
during  which  month  there  were  eixty-oue  cases  reporti-d  among  the  enlisted  men  aloin-,  besides  forty  or  fifty  at)le  to  perform  light  or  jHirtial  duty,  whoso 
names  were  n<it  taken  upon  the  aick-Ust.  The  scurbutic  taint  was,  however,  even  more  w  idespread  than  these  numbers  would  stem  to  indicate.  The 
men  were  jirone  to  contnict  diseases,  slow  to  recover  and  little  abb.*  to  bear  their  hard  labors  an<l  tho  rigors  of  tho  climate- ;  frost-bites  were  ronmnm. 
The  trtM'ps  were  iii)t  comj)ktel3'  liouse<l  until  Jan.  3,  ISOS."  In  the  mean  time  the  lessens  of  tli«'  war  were  not  forgotten  by  medical  and  company 
officers  and  post  commanders.  EflForts  were  made  to  raise  such  vegetables  as  were  rtdajited  to  gr<jw  in  the  poil  of  the  garrisoned  localiti4*s ;  ami  at  posts 
wliore  the  soil  was  ari"i  and  sterile  a  larger  allowance  of  ilour  or  liread  was  anthorized  to  admit  of  the  purchase  <if  articles  to  vary  the  diet  by  nuans  of 
the  money-value  of  the  unconsunied  portions  of  the  ration.  In  Se])temher,  1807,  tho  Subr-istenee  Depaitment  was  recjuired  to  keep  on  hand  liberal  sui^- 
plios  of  canned  fruits  ami  vegetables  for  sale  to  officers  for  their  jKTsonal  use  and  company  messes.  Tho  effect  of  these  measures  was  s<n-n  in  the  year 
18f*-*'>0  in  the  rexlmtiou  uf  the  annual  rate  of  scuny  to  4.8  per  thousand  of  strength.     Since  tliat  time  the  disease  lias  ln-en  i)ractically  excluded  from 


SCURVY. 


60.3 


men  had  been  enrolled,  tlie  rate  of  scurvy  was  7.7  ]<>-v  lliou.-and,  or  nearly  double  tlie  rate 
of  the  white  troops  when  tin.'  (-pi'lrnue  in  the  Army  of  the  pMimnac  raisril  it  to  its  niaxirnum. 
From  this  a  cachectic  condition  must  he  inferred  as  liavinu'  l.ircn  in  existence  at  the  time  of 
their  eidistmcut;  and  this  seems  the  more  likely  when  it  is  considered  that  mo<t  of  them 
had  endtu'ed  manv  hardships  in  those  disturbed  times  before  their  adnussion  into  tlie  service 
uave  them  a  position  and  resources.  The  tendencv  of  the  colored  men  to  succumli  under 
morljitlc  influences,  a  reference  to  which  has  already  lieen  made;-=  min-ht  be  sui^'crested  in 
explanation  of  the  extension  of  scorbutic  disease  among  them,  and  the  I'emarks  of  Surgi'on 
H.  AY.  IjKowk,  -ith  Corps  ],)'Afri(]ue,  submitted  below,  might  be  cited  in  suppoi't  of  this  view: 
but  this  is  manifestly  inconsistent  with  the  fact  that  during  the  last  half  of  \]io  yi^ar  ending 
June  30,  1866,  the  number  of  scorbutics  in  the  colored  ranks  was  relatively  less  than  among 
the  white  troops.  The  very  great  prevalence  at  the  jteriod  mentioned  must  therefore  l.ie 
attributed  to  a  deficient  dietary  operating  on  the  system  of  a  rac(>  having  pe!-ha])s  a  special 
predisposition  to  be  harmfully  affected  by  the  delicieney.  Unfortunately  the  only  special 
reports  on  this  subject,  two  in  number,  relate  to  a  period  when  the  general  rate  of  scurvy 
was  nearly  at  its  minimum. 

Surgeon  H.  W.  Buowx,  ith  Corps  ly.ifriqiw,  Port  Hudson,  I.a.,  April  "i,  isiil. — 'riicic  is  a  kind  (if  .scdi Initio  Uiiut. 
a  want  of  vitality,  wliicli  sconis  to  belong  to  the  iio};i'o,  ami  is  olisi-ived  in  liiui  l>otli  in  and  on  t  of  llio  military  scivici'. 
It  nianif(>stn  it.se]f  in  soft  and  swollen  fjunis,  tnmid  bellies  and  offensive  breath.  The  swelled  belly  is  foniid  mostly 
among  the  contraliands  and  in  their  ehildven  :  tint  the  negro  soldier  is  eonstantly  apjilying  to  the  surgeon  for  alum 
for  asoremoutli.  These  ajuiearances  are  frei]Ucnt  wlieii  senrvy  eannot  be  said  to  exist  as  a  di.sease.  Diet — that  is  to 
say,  a  proper  diet  and  constantly  snpplicd — wonld,  perhaps,  remedy  this :  as  it  is.  the  tendency  no  donbt  has  a  great 
influence  upon  the  canse  and  termination  of  intlammatory  complaints. 

Surijeon  Joiix  Fisii,  \lth  Corps  D'Jfriijiu,  Port  Ilitdsou,  La.,  Fcli.  2.5.  18l)4. — Senrvy  eerlainly  exists,  but  is  gen- 
erally associated  witli  and  masked  by  other  diseases.  It  works  insidiously,  and  while  few  are  attacked  with  uncom- 
plicated scurvy,  tin?  constitutions  of  niany  are  so  iinderniincd  that  they  yield  with  .scarcely  a  struggle  to  the  i|uick 
onset  of  more  open  foes,  such  as  pneumonia  and  other  acute  diseases.  My  slender  experience  inclines  me  to  think 
that  scurvy  often  ]ialins  itself  off  upon  the  surgeon  for  clironi<'  rheumatism.  At  any  rate  I  am  treating  some  cases 
of  chronic  rheumatism  (?)  with  chlorate  of  potash,  iron  and  Irish  ]iotatoes. 

Surgeon  S.  IIemexway,  41st  Colored  Troops,  has  placed  on  record  some  interesting 
partictdars  concerning  the  epidemic  in  the  25tli  Army  Corps.t  which,  in  the  months  of  July, 
August  and  September,  1S65,  raised  the  rate  of  prevalence  of  scurvy  among  the  colored 
troops  to  19,7,  33,9  and  18.3  per  thousand  of  strength.  These  troops  had  been  engaged 
during  the  previous  winter  in  the  operations  against  llichmond  and  rcterslan-g,  Va.  Sup- 
plies of  fresh  vegetables  had  been  exceedingly  limited,  and  it  is  said  that  the  articles  of  the 
regular  ration — the  pork,  hard  bread,  beans  and  rice — had  not  always  lie-en  in  good  condition 
when  issued.  Fatigue  duty  was  arduous  and  continued,  fuel  insufficient,  and  the  quarters  of 
the  men  dark,  damp  and  cold.  Many  became  despondent  and  would  not  exert  themselves 
to  improve  their  condition.  Distinctly  marked  cases  of  scurvy  had  already  appeared  in 
May,  1865,  wdiile  the  corps  was  at  City  Point,  Va,,  and  many  medical  officers,  in  reviewing 
their  practice  at  this  time  by  the  light  of  their  subsequent  experience  in  Texas,  concluded 
that  cast's  which  they  had  reported  as  rheumatism  had  been  in  fact  manitVstations  of  scor- 

thosc  wliirli  tin'  iiriny  surf^coii  lius  Itcni  rsiHfil  uiKiii  Xn  treat.  Exceiitiniiiil  ciisi-s  have  m-i-iirri'il  in  iii.-'taiifi^  i-f  initiviiliial  itrivatioii,  suim-tinifii  thf  n'sult 
of  all  iiuiisjuL-itioii  on  thi'  part  of  tho  man  to  inaki-  us.'  of  tUo  availaliU*  vcirrtaltlc  siiiiplir-.  TIi.-  i-xtuii^ion  of  railmail  tralisjiortatioa  anil  tiie  niaterial 
iniTi'asc  of  tlio  canned-gooiis  tratli-  liavi*  coiitrilnitt..d  largt'l.v  to  iTinovo  the  taint  of  srurvv  fr-.m  tin-  inilitaty  s'Tvici-  .>f  the  I'nited  Stat'/S.  The  intro- 
duction of  Kteam  into  tlio  navy,  I»y  Kliortrning  tlif  voyagr  from  port  to  port,  the  usi'  of  frrsli  provisions  wliilt.-  in  port  and  tlie  issue  of  a  ratitm  of  six 
ounces  of  canned  vegetaliles  twice  a  week  when  fresli  vegetables  are  not  availahle,  have  hanislied  .scurvy  fri'in  tlie  navy  under  the  ordinary  conditions 
of  service.  The  disease  was  observed  by  Dr.  GinoN  in  IsfiS  on  tlie  Lhthf  iluriu;:  a  voyaire  which  lasted  two  hniulreil  .lays.  Few  ^.f  the  men  sought  excuse 
from  duty,  but  their  general  comlition  was  below  jiar  ;  they  performed  their  duties  listlessly;  they  lo>t  strength  and  appetite  ;  their  bcHiies  were  covered 
with  nmrked  discolorations  ;  their  gums  were  tender  and  bled  easily,  causing  those  who  chewed  to  attribute  it  to  the  tobacco,  for  which  they  lost  taste; 
scratches,  woun.ls  and  bruises  healed  slowly  or  not  at  all :  an<l  ni.-n,  often  of  th.'  fiiie>t  physi.jue,  succuinbe.l  readily  to  trifling  causes  of  disease,  (See 
Pruflkttl  Sii'j>j*.''fi"ns  nn  Xm-al  li'j'jiene,  by  .\lbert  L.  Ginox,  Surgeon,  I'.  S.  Navy.  \Va>liingt<>n,  P.  (',.  IsTl,  p.  74.) 

*Slij)ra,  page  14.  t  Clikmjo  Medial  Emminer,  Vol.  VII,  ISliO,  page  5S2  .(  seq. 


<;i'0  srUKVY. 

butic  disease.  Duriim;  tlic  voyao-e  tVoiu  (?ity  roint,  Va..  to  Brazos  f^t.  la-v.,  'i\xas,  scurvy 
iiiade  rapid  progress.  As  >uou  as  ilu,.  tivi.ip<  c'lTrcti'd  a  landing  at  t!io  l;iUer  place  llie  worst 
cases  were  sent  to  the  }io>t  hospital,  at  whii/Ii,  williin  a  wr-ck,  live  liuiidrcd  ca<cs  liad  accu- 
luulated.  Two  or  tnri.-i-  lanidrcd,  for  wliuni  no  ]i(i>]iiial  acconnnndatioii  cnuld  be  procured, 
were  sent  to  Xcw  Orleans,  La.,  but  this  rdict  was  only  t^niporarv,  i'or  within  ibri'c  tlavs  ihe 
patients  at  the  post  hn~pit;d  a-aiu  largc/lv  cxcrdlrd  the  aoeominodations.  Ab^tit  sixtvinr 
cent,  ot'  the  cordis  sutlb're.l  fi'iaa  the  disease.  ^lust  of  thf  cases  had  to  bo  treated  in  quarters. 
As  souu,  however,  as  the  truii[is  niuved  into  the  interior  and  fresh  vegetables,  even  in  limited 
quantities,  wC're  obtained,  the  disease  began  to  decline. 

A  deliilitated  state  of  the  .system  with  ciuaciaticm  i-hMractei'ize-d  the  disease,  jiarticuLarly  in  cases  accoinpanled 
b.y  dianlid'al  or  dysentorie  disclutiges.  Extensive  nU'evations  of  the  gnnis  with  frequent  hleedinj;  vrere  nniversally 
present.  Tlie  s\viilli.-n  j;unis  iiro.jeeted  in  tlie  furni  of  liiillxnis  enlavgeuients  of  r«  darli-ved  or  purplisli  ami  often  of  a 
lierfectly  tdaclc  eohjr.  These  sometimes  completely  liid  the  lateral  view  of  tlie  molar,  liieuspid  and  eanine  teeth. 
Extensive  ecchynioses  on  the  extremitie.s  and  other  portions  of  the  hod}' and  ,i  dr(iii.>ieal  Cdiidltiun  of  the  feet  anllle^s 
were  atteudeil  with  severe  ])ains  in  the  joints  and  hones  of  tlie  lower  extremities.  A'esieatioiis  and  foul  nleerations 
were  also  freijuently  present.  The  nuiscles  of  the  ealf  and  tlii,i;h  were  often  indurated,  anil  the  joints,  particularly 
the  knee  and  ankle,  anchylosed.  The  patients  were  nsuiilly  uiiteh  dejected,  and  death  ensued  after  muscular  exertion, 
from  heiiiorrhajie  during  the  process  of  digestion  and  sometimes  from  pulmonary  O'denia.  Dr.  Tti'MKXWAY  used  with 
smile  degree  of  satisfaction  the  juiee  of  the  .lijiirc  Aiiii'ririuiii ;  hnt  he  did  not  feel  warranted  in  allirming  tlnit  the  good 
results  depended  entirely  upon  this  renieily,  for  most  of  tlie  scdihutie  iiatienis  were  siijiplied  at  the  .same  time  \\  itli 
small  allowances  of  raw  potaine-^  and  onions  sliced  in  \  inegar,  and  pickled  calil>age — and  when  thus  supplied  iiiiprove- 
iiicnt  was  always  more  rapidly  eliected. 

The  greater  prev;deni;-e  of  scurvv  anumg  the  sciLliers  of  the  Cont'ederate  tirniies  tinii  the 
prisoin.'rs  of  war  on  bioth  sides  than  among  the  Uniteil  States  troops  in  active  service  litis 
alretidv  been  indii.'ttt'.'d."" 

The  CLixrcAL  in-j.onDs  of  scurvy  are  exceeilingly  niCMgre.  The  ctisedjooks  of  the  gen- 
end  hospitals  contain  notes  (.if  only  seventeen  casc's  in  which  the  disease  occurred  in  United 
Sttites  soldiers  while  on  duty  with  their  eomniands;  1-11  are  from  the  records  of  the  hos- 
pital at  Quincy,  111.: 

(,'.\SK  1. — Private  John  Ceishithler,  Co.  11,  S2il  111.;  age  38;  was  admitted  .July  H,  ISOl,  from  .Jeli'efson  llairacks, 
Mo.,  having  suffered  more  or  less  from  .scurvy  for  live  months.  He  was  emaciated  and  had  jiurple  spots  on  the  right 
leg.  Ciave  nitric  acid,  sour  krout,  fresh  vegetables  and  full  diet.  He  improved  fur  the  lirst  few  weeks  of  his  stay, 
Imt  after  this  there  was  only  a  very  gradual  change  in  the  swollen  limh.  On  Octotier  1  it  was  still  ci.insideralily 
enlarged  and  the  patient  had  lost  some  teeth.     He  was  discharged  from  the  service  Feb.  8,  l8(i'). 

C.\s!-:  2. — Priv.'ite  Peter  IJeymdds.  Co.  H.  Slth  111.:  age  I'T  :  was  admitted  .Tuly  27,  1S(il,  from  Jefterson  I'arraeks, 
Mo.,  wliere  he  had  been  treated  tbr  a  month  for  seiirvy.  He  «as  feebh^  and  his  legs  were  swollen  and  covered  with 
livid  splits.  Gave  eimdioni.  stilphate  of  iron  and  anti-scorbutic  diet,  liiiiirovemeiil  was  slowly  eft'ected.  He  was 
discharged  JIarcli  2!t,  ISll.'i. 

C.vsK  3. — Private  Dennis  Crowley,  Co.  I,  S)6th  111.;  age  I'l  ;  admitted  .July  27,  18(!1,  fiom  .Jefferson  Parracks, 
Mo.,  having  been  somewhat  troubled  with  scurvy  for  two  months.  His  left  foot  and  h'g  were  swollen,  discolored 
and  ulcerated.  He  was  treated  with  special  diet  an<l  vegetable  acids,  but  improvement  was  not  rapid.  In  Xovemlier 
there  was  still  some  swelling  of  the  leg,  although  the  patient  was  able  to  do  duty  not  requiring  activity  or  strength. 
He  sutfered  from  palpitation  in  going  up  stairs  or  in  making  any  special  exertion.  On  Kef).  VA,  18G5,  he  was  trans- 
ferred to  the  Veteran  Reserve  Corps. 

Cask  I. — Private  .James  ISIair,  Co.  A,  o4th  111.;  age  2-;  was  admitted  -Vtig.  17,  ISOl,  from  .Jetferson  liarracks, 
Mo.,  with  chronic  rheumatism.  He  had  pain  in  all  the  large  joints;  the  gums  were  almost  totally  destroyed  and  the 
roots  of  the  teeth  carious.  Colehicum  was  given  with  a  nunith-wasli  of  chlorate  of  Jiotash.  In  aliont  three  months, 
during  half  of  which  period  he  was  on  furlough,  the  rheumatic  pains  were  relieved,  but,  as  he  was  unable  to  eat  solid 
food,  he  was  discharged  from  the  service  Jan.  26,  1865. 

Cask  .j. — Corp'I  Thomas  Leiuiard,  Co.  I,  39th  Iowa;  age  10;  was  admitted  Sept.  2.'),  180:!,  with  scurvy.  Body 
emaciated;  skin  livid;  purplish  spots  on  legs;  gums  spongy  and  bleeding;  feet  and  ankles  somewhat  ledematous: 
pulse  and  appetite  normal,  tiave  lemonaile  and  fresh  vegetables.  Octolier  20:  Constant  pain  in  largo  joints. 
yovember20:  Gave  gnaiacum  and  iodide  of  potassium.  Scurvy  better;  rheumatism  better.  Decemt)er  2.j:  .Skin  free 
from  discoloration;  pains  in  hip  and  knee  joints.  Jan.  10,  1861:  Scorbutic  symptoms  returning;  gums  swollen  iind 
bleeding;  severe  pain  in  back;  appetite  poor, — inability  to  eat  animal  food.     2.3:  Iodide  of  potassium  discontinued. 

■'  Sri-  snj.i.i,  \.\K  :i",  40,  4;i,  51,  .".li,  .')4,  u'l,  58,  00,  01,  04  and  07  cl  s,.^. 


s.TKvv.  697 

(iuvc  nitric  iiciil  tliroi^  tiiiios  a  day.  Kt'luiiaiy  10:  No  iiiipriiN ciiiciit  :  jiatii'iu  i-aiiiuit  walk  wiilmut  ciMtilu-s.  Ili.>- 
cliaijivd  I'roni  sfiviee  (in  tlic  LTith. 

Case  (!. — Seri;'!  Audicw  Allen,  ('(i.  II.  :11st  Wis.:  ai;i-  :il :  was  adiiiiitr.l  Nnv,  L'-'i.  IMjI.  liaxin;;  ln-cii  sicdi  since 
the  1st  ■with  .scuivy  and  diariliuM.  lie  was  wi'ak  aii<l  emaciate<l  and  had  pains  i]i  his  le^'s,  -wliieli  were  ronjrh  and 
eiivi'ied  with  reddish  spots.  He  was  ti-eated  with  citvic  acid.  ve;;etalde  diet  and,  siilisciitienily.  a  l'nil(>iie;li.  and  was 
letnined  lo  duty  Fe'i.  ti,  iMiy. 

(.'a>i:  7. — Private  Henry  1'.  llrnsh.  to.  II,  .'iOlh  Wis.:  ai;e  :\'.> :  was  adniitticl  Nov.  2''.  iMil,  wiili  senrvy.  havii.;; 
liad  chills  and  li  ver  alnint  the  1st,  I'olhiwed  in  a  lew  days  iiy  le\er  and  ]iain  in  licit  li  le^s,  the  skin  of  wliieh  was  dry 
anil  showed  some  yelliiw  spots.  The  ]iat  lent  w.as  \M'nk  anil  emaeiated  ;  his  ^niiis  sjioniiy:  a]i['etite  Inoilerale.  'I'lmics, 
\e;;etalile  diet  and  a  l'iui()nj,'h  enabled  him  Id  he  returned  lo  duly  Feh.  d.  ISlTi. 

Ca.'-ie  8. — I'rivato  Kohcrt  11.  Davidson,  Co.  11,  :50th  Wis.;  ai;c  I.':  was  admilled  Nov.  L'."i.  iMll,  with  Jiain  in  ihe 
U'lTs  and  swollen  gnnrs,  loss  of  appetite  and  dehilit.-itin,!,;  iiiL,'ht-Kweats.  I'nder  the  nse  ot'  ttinics  and  a  iilenlil'nl  \  ei;e- 
tahle  diet  ho  gradually  gained  strength  and  was  relurucd  to  duty  Feh.  L'll.  l.^il."">. 

Case  0.— Private  Chester  Tnttlc,  Co.  II,  :i()th  Wis.:  aire  l."i;  was  admilled  \o\  .  L'."..  IHII,  w  iih  sein\y.  He  li.id 
lieeii  attacked  with  diaiiiiiea,  soreness  of  the  glims  and  |iaiiis  in  the  legs  almnl  three  nioiiihs  hi-rore  .'idmission.  His 
gums  Avere  spongy  and  the  siirl'aeo  of  his  legs  hoi .  dry  and  pur)  dish.  He  was  nluinid  lo  duty  .\piil  I.  allei  a  coiuse 
of  tonics,  vegetable  acids  and  ajipropriato  diet. 

Case  10. — Private  Xelsou  Peterson.  Co.  D.  HOth  \\'is.:  age  :!X:  was  adniilled  N'm  .  I'd,  1,K(1I,  with  senrvy.  lie 
had  sulfercd  occasion:illy  from  fever  and  diairlnea  for  .six  monllis  jirnir  lo  admission.  His  legs  were  painl'iil  and 
spotted  and  liis  gums  red  and  spongy.  Vegetable  acids  and  .t  suil.able  did  w  eie  |ireseiibed.  .s^iibsi  qinni  ly  he  w  as 
furlonghed  and  had  an  attack  of  pneniiKMiia  while  at  home.     On  April  :>  he  w:is  i  i.insfeired  lo  .Madison,  ^^■is. 

Case  11.— Corp'l  .lacob  Siotts.  Co.  K,  Isl  Mo.  Eng'is;  age  'Ml;  :iilinilled  Hee.s.  Isi'd.  His  legs  were  painlnl, 
tender  and  covered  with  purplish  spots;  his  gums  temler  and  swollen.  He  was  emaeialed  and  weak  and  had  a 
diarrlnea  of  three  or  four  stools  daily.  Vegetable  acids,  chlorate  ol'  potass.i.  t  mpenl  ine  emulsion  and  |iills  of  nitrate 
of  silver  and  opium  were  prescribed;  suljdiate  of  copjier  and  opium  were  snbsei|nenl  1\  em]iloyed.  but  iiiijirovement 
\vas  slow  and  the  ])atient  was  discharged  Ajnal  I,  lN;."i. 

Case  12. — Private  Lewis  H.'irry,  Co.  1.  1  ITlli  Pa.:  age  iM  ;  w:is  admitted  May  I!'.  Isdl.  w  iih  seur\  y.  His  mouth 
was  mm-h  iidlamed.  .lellies,  )iotato  salad  ami  lemoiKide  were  )ircserilved  :  al-o  a  leas]iooiirnl  e\  ery  I  liree  hours  of  a 
solution  eontaiiiing  foity  grains  of  chlorate  of  potash  in  an  on  nee  of  water.  A  garijle  of  chlorate  of  j.oi  ash,  i  inciuri- 
of  myrrh  and  water  was  used  at  first,  and  afterwards  a  lotion  containing  six  grains  of  niliate  of  sih  i  r  in  an  mi  nee  of 
water.     He  was  returned  to  duty  July  !(•. — South  SImt  Jfunpilal,  J'liilailtlpjdn.  !'■!. 

Case  13. — Private  Knimaiiuel  Piro(d<s,  Co.  A,  122d  I'a.,  was  admitted  <>et.  ."..  isiy.  h:i\  iiig  been  siidc  for  a  month 
ill  camp  with  scurvy.  Ho  had  jiaiu  in  his  back,  which  was  habitually  benl  forward:  the  joiiiis  of  his  exiiemiiies 
were  painful  but  not  tender,  red  nor  swollen:  the  muscles,  esjieeially  of  the  lower  limbs.  weri>  tender,  painful  and 
affected  with  frequent  cramps.  He  had  no  fever:  his  apjietile  w  .is  good  and  bowels  regular.  He  w  as  di^rharged 
Feb.  12,  1.SG3,  on  account  of  disease  of  the  sjiine. —  [.(ul'un'  Iluiin-  llosjiilnlj  Sin-  I'or/,'. 

Casi-.  11. — Private  F.dwin  1!.  .Tell'ries,  Co.  A,  122d  Pa.,  was  adinil.ted  r)et.  .".  ISi;2.  He  had  enlisted  .\ugusl  II 
and  served  with  the  Army  ot  the  Potomac,  but  after  the  latter  part  of  this  monlli  lie  was  lakeii  with  a  fe\  <-r  w  hich 
lasted  about  eight  da\  s.  Follow  ing  this  he  had  pain  in  the  li:i(dv  and  the  exi  remit ies,  ]i:irliciihuly  on  boili  sides  of 
the  spinous  processes  and  in  the  liuiscles  of  the  lower  extreniilies.  His  :ippct it e  was  good,  bowels  regiilar  and  ho  had 
no  fever.  His  liod>'  w  as  habitually  bent  forward.  Sul]ihale  of  i|iiiiiine  in  small  doses  and  aflcrw;irds  cii  r.-ite  of  iron 
and  i|ninia  w  ere  administered,  with  ilry  cups  to  the  back  and  slimiilat  ing  linamcnts  to  the  limbs.  He  was  discharged 
from  service  Feh.  12,  IHiii,  because  of  dise.-ise  of  the  spine. — l.itil'Ks    IIiiiik   ILixjiitnl.  Xi  ir   \'orl\ 

Case  1."i. — Sergeant  David  V.  Whiirry,  Co.  (I,  23d  Ohio,  had  been  confined  to  bed  with  feviu'  for  a  week  about 
the  middle  of  Seideiuher,  1SU2,  in  Washington,  D,  C'.,  prior  to  which  he  had  sniVered  froiii  ]iain  in  the  back,  but  liad 
been  able  to  do  duty.  Subseiiueiitly  hehad  four  interiiiittent  jiaroxysmsof  the  ipmiian  tyjie.  He  was  admitted  I  ictober 
"i  with  marked  teudenicss over  the  dorsal  and  lumbar  vertebra'  and  tenderness  oi'  the  muscles  of  the  extremities,  l.mt 
Avith  no  cramps,  swelling  or  tenderness  of  the  joints  and  no  fever:  his  appetite  and  digesiion  were  good.  He 
iai]u-oved  somewhat  under  the  treatment  pur.sued  in  the  two  cases  Just  recorded,  and  was  discharged  from  service 
March  21,  1!<03,  because  of  anterior  spinal  curvature. — LadUs'  Ilumr  JIu>ipital,  Scir  )\<;/..* 

Ca.se  1G. — Corporal  William  A.  Morris,  Co.  H,  29th  Mo.:  age  32;  had  a  severe  alla(d<  of  seui\  y  in  .\ugnst.  ISiil, 
by  w  hich  he  lost  seventeen  teeth.  On  admission  from  lialtinioiv,  Md..  Feb.  23.  lMi.">.  he  was  convaleseent.  ( (n  March 
13  he  was  reported  cured;  hut  on  April  1  ho  was  taken  with  small-l>ox  and  w;is  leit  much  debiliiated  and  ananiie. 
He  was  jnustered  out  of  service  Juno  11. — Sattcrhe  Iloxpitul,  rkUadiliih'in,  I'a. 

Case  17.— Private  Elihu  E.  Gillet,  Co.  D,  37th  Wis.;  ago  3X;  was  admilled  .Inly  21,  iHil,  with  diddlity  from 
miasmatic  disease  and  scurvy.  He  had  a  cachectic  appearance;  jnilsc  SMI  and  weak:  skin  somewhat  yellow;  tongue 
furred  and  moist  and  bowels  constipated.  On  the  right  side  of  Lis  mouth  w  as  ii  small  hard  tumor,  which  the  patient 
said  had  existed  there  for  over  six  months;  his  gums  were  livid  and  swollen.  He  was  treated  with  rhubarb  and 
magnesia,  tincture  of  iron,  stimulants  and  fresh  vegetables.    In  a  day  or  two  the  tumor  ulcerated  and  by  sloughing 


*The  Pinirular  coiucidoiiroof  thrfc  cii^e^  trciitfil  in  IIi,'  Mtiiie  linsi.itiil  jit  tlu-  r-iiiii*'  tiiiii'.  two  ef  llifiii  frmji  I  he  Kum-  ceniitaiiy  nf  die  panli'  r'-;:imi'iit, 
auil  all  lu-esi-uriiig  the  t^anie  syiii]ittinis,  whicli  wi-r-'  gincrally  iii'gatiVL-  in  cliuracli.-i-,  .■,iii:^^'>1'i  llmt  i-ruliaMy  Iliu  disease  in  tlll•^t■  iustanccs  was  Uuftalgiii 
Djauifestin.i;  itsflf  activ^-ly  in  a  lif.-irc  f-ir  iliM.ljargi.'.  ^ 

Med.  Hist.,  Pt.  Ill— S8 


69S  SCURVY. 

foriiiiMi  ii  sore  an  inoh  in  diiimotor.  The  aiipiication  of  bromine  caused  the  surface  of  the  ulcer  to  assume  a  healthier 
aii)iearan(i',  but  the  general  eon<litii.n  of  the  patient  did  not  improve:  he  became  weak,  restless  and  ultimately 
delirious,  lie  died  August  In.  In  a  note  a])iiended  to  tlii.s  case  Ass't  .Surgeon  II.MtuiSOX  Ali.kn,  U.  S.  A.,  says: — I 
believe  this  to  have  been  a  scnrbuiic  ulcer  sulisecjuently  complicated  by  phagedenic  sloughing.  Hroniine  did  not 
have  the  sanu'  beneficial  effect  oliserved  in  its  ai>i)lication  upon  the  phagedena  of  wounds.  The  fauces  and  jiharynx 
were  free  from  ulceration.  The  body  decomposed  so  rai>idly  that  no  examination  was  made  after  death. — Fairfiix 
Seiiiiniii'ij  Iloi<pit{d,  la. 

Thr  ease-books  present  in  addition  ten  cases  in  which  tlie  patients  were  either  rebel 
prisoners  or  Union  soldiers  wlio  had  contracted  the  disease  wliile  in  the  hands  of  the  enemy; 

Cask  18. — Private  John  S.  Farthing,  Co.  C,  37tli  N.  C,  was  admitted  .July  21,  1801?,  with  scurvy.  He  was 
■weal; :  his  gums  swollen,  spongy  and  bleeding:  teeth  denuded;  compli'xiou  sallow:  pulse  slow  and  feeble;  bowels 
loose.  I'nder  the  use  of  two  lemons  daily,  a  teaspoouful  of  lemon-Juice  and  ten  grains  of  iodide  of  potassium  three 
times  a  day  and  pills  of  opium  and  camphor,  he  was  much  improved  by  the  end  of  two  weeks,  and  on  August  8  was 
transferred  to  the  Provost  Marshal's  bureau. —  Wtti  IVahiut  Street  JlofintaJ,  niirrinhiirij,  I'd. 

Ca.se  19. — During  the  invasion  of  Pennsylvania  in  1863  private  Joseph  King,  Co.  C.  11th  iS.  ('.,  was  in  the 
AVinder  hospital,  Kichmond,  under  treatment  for  scorbutic  dlarrlnea.  When  jiartially  recovered  he  was  ordered 
with  four  Inuidred  convalescents  to, join  his  regiment  at  Ilagerstown,  JId.  He  was  transported  by  rail  to  Staunton, 
Va..  niarclied  thence  to  Hagerstown,  and  was  placed  in  liosiiital  at  Chainbcrsburg,  where  he  was  captured.  On 
August  4,  when  he  reached  this  hosi)ital,  he  was  much  debilitated,  having  fever  every  evening  and  an  exhausting 
diarrho'a.  The  fever  was  controlled  by  tifteen  grains  of  quinine  every  morning  for  three  days  and  brandy,  nu)rphine, 
camphor  and  veratriira  viride  at  intervals.  He  convalesced  rapidly  under  tonics,  anti-scorljutics  and  a  suitable  diet, 
aud  was  returned  to  the  Provost  Marshal's  care  October  28. —  TT'csi  Wiihiut  Street  Uvxjiital,  Harrishury ,  Va. 

C.KSK  20. — Private  John  Haggerty,  Co.  A.  173d  N.  Y.;  age  40:  contracted  scurvy  while  in  a  rebel  prison,  and 
several  months  afterwards,  .June  17,  18G.'>,  was  admitted  into  hospital.  His  joints  were  stiff  and  his  gums  spongy 
and  bleeding.  He  was  treated  with  vegetable  diet  aud  strong  lemonade.  He  was  discharged  from  service  Septem- 
ber 12. — Satterlee  Huxjiital,  I'hilailelphia,  J'a. 

Q.s.i<¥.  21. — Private  Nathan  Raynor,  Co.  C,  ICDth  X.  Y.:  age  33:  was  admitted  June  17,  1865,  having  suffered 
more  or  less  from  scurvy  since  April,  1864,  when  he  was  a  prisoner  in  Texas.  His  gums  were  swollen  aud  painful 
aud  he  had  a  scorbutic  ulcer  on  the  left  leg,  but  his  health  was  otherwise  good.  He  was  treated  with  kMuonade.  On 
the  2t)th  he  was  transferred  to  McDougall  hosjiital  in  New  Y'ork  City. — Sutterlee  HospiluJ,  DiUadelpkia,  I'a. 

Cask  22. — Private  J.  J.  Snyder,  Co.  I,  97th  N.  Y.;  age  37;  was  struck  on  the  liack  with  a  musket  at  the  battle 
«f  the  l{ai)idan,  Oct.  15,  1863.  This  paralyzed  his  lower  limbs  aud  caused  him  to  be  taken  prisoner.  He  w  as  carried 
to  Kichmoud,  where,  in  the  course  of  a  week,  he  began  to  be  aft'ected  with  incontinence  of  urine,  luenuituria  and 
pain  in  the  back  aud  left  side.  At  a  later  date  he  contracted  scurvj-.  On  April  18,  1864,  ho  was  admitted  to  Jarvis 
hospital,  Baltimore, — diagnosis,  quinsy;  furloughed  June  15;  returned  July  9;  transferred  to  hosjiital,  Annapolis, 
Md.,  on  the  12th, — diagnosis,  bronchitis;  sent  to  Camp  Parole  hospital,  near  Alexandria,  on  the  18th, — diagnosis, 
gangrenous  ulcer;  returned  to  Jarvis  hospital  Octoberl2;  transferred  to  this  hospital  on  the  22d;  furloughed  Novem- 
ber 4.  returned  on  the  24th;  transferred  to  Invalid  Corps  becau.se  of  debility  from  scurvy  May  6,  1865.  On  November 
24  he  was  free  from  all  trace  of  scurvy  and  aide  to  dispense  with  the  use  of  crutches. — Chester  Hospital,  I'a. 

Ca.se  23.— Private  Jacob  Strickler,  Co.  H,  25th  Va.  (rebel),  was  admitted  Aug.  10,  1863.  On  the  18th  he  was 
in  a  low  condition  with  feeble  pulse,  blood  oozing  from  the  gums  and  a  diarrhoea  of  twenty  to  thirty  stools  daily. 
He  was  treated  with  aromatic  sulphuric  acid  and  raw  onions.  At  the  end  of  two  weeks  the  diarrlnra  was  checked 
and  the  patient  transferred  to  Point  Lookout,  Md.,  where  he  arrived  on  October  4, — diagnosis,  chronic  diarrhcea. 
He  was  exchanged  March  17,  1864. — Chester  Hospital,  I'a. 

Case  24. — Private  Isaac  Eosa,  Co.  G,  89th  111.:  age  35;  was  eajitured  at  Chickamauga,  (ia.,  Sept.  20,  1863, 
confined  two  months  at  Richmond  and  five  months  at  Danville,  where  he  c<intracted  scurvy.  On  admission  to  hos- 
pital, June  7,  1864,  he  had  (edema  of  the  left  foot,  leg  and  thigh ;  his  gums  bled  easily  and  his  teeth  were  (]uite  loose. 
Small  doses  of  citric  acid  and  (juinine  were  given  frequently,  with  a  free  supply  of  grated  raw  potatoes,  and  afterwards 
two  ounces  of  lime-juice  three  times  a  day.  He  was  improving  when,  on  July  12,  he  was  transferred  to  hospital  at 
Annapolis,  Md. — Aniuqiolis  Junction  Jlospital,  Md. 

Cask  25. — Sergeant  Charles  Bramfels,  Co.  F.  Kith  111.  Cav.:  age  30:  was  ca|itured  at  Jonesville,  Va.,  Jan.  3, 
1864,  and  carried  to  Belle  Isle,  Va.  He  was  paroled  May  2  and  admitted  to  hospital  June  7.  He  had  lieeu  under 
treatment  in  Kichmond  for  ten  weeks  on  account  of  scorbutic  ulcers  which  yet  remained  unhealed.  They  persisted 
notwithstanding  the  use  of  various  local  applications — stimulating,  astringent  and  soothing.  He  was  furloughed 
August  8,  the  ulcers  still  unhealed.  He  returned  September  3  aud  was  transferred  to  Quincy,  111.,  on  the  26th. — 
A)niapt)lis  Junction  Hosxntal,  Mil. 

Cask  26. — Private  O.  C.  Babcock,  Co.  E,  18th  U.  S.  Inf.;  age  35;  was  captured  at  Chickamauga  Sept.  20,  1863, 
jind  eonlined  for  six  weeks  at  Richmond  and  for  six  months  at  Danville,  where  he  contracted  scurvy  through  star- 
vation and  exi)osuro.  It  was  jireceiled  by  diarrhna,  pleurisy  aud  rhcuniatism.  Scorl)utic  ulcers  appeared  upon  the 
limbs  in  many  places.  He  was  paroled  May  2,  1864,  and  when  admitted  to  hospital,  June  7,  was  so  weak  as  to  bo 
unable  to  walk.  Diarrhcea  was  easily  controlled  and  his  improvement  was  rapid.  On  the  28th  he  was  emidoyed  on 
light  duty  as  a  nurse  and  was  returned  to  duty  July  19. — Annapolis  Junction  Hospital,  Md. 


scuKVY.  699 

Case  27.— Private  Joshua  Ilc'lrun,  Co.  1),  54tli  Va.,  admitted  \ov.  L'().  1W31:  returned  to  barraek.s  Feb.  2."),  1S|!5. 
Ife  stated  on  admission  tliat  he  ha<l  lieen  a  prisoner  of  war  at  this  ]daee  I'or  six  inontlis.  dnrinji  wliieli  lie  never  had 
ven;etat)k-s.  Two  weeks  before  admission  he  experienced  arnte  jiaiii  on  moviiifitlie  liirht  h'j;.  whieli  speedily  became 
swollen  from  the  kuee  to  the  heel  and  spotted  with  dark-piiride  jiatehes;  the  tliiiih  also  was  slifjlitly  swollen  and 
discolored  on  its  inner  aspect:  the  gums  were  somewhat  tender  and  coated  with  aeenmulated  tartar.  'I'he  resjiira- 
tory  and  digestive  organs  appeared  to  be  sound. — /I'oci-  Ixjiiiiil  Jloxpital.  111. 

Uf  12,000  medical  descriptive  lists  (iii  lilc  in  tlii>  oiHce  unly  lOG  n-ll'i'  to  scorlditic 
attacks.  One  linndred  and  sixteen  of  tlifse  were  forwarded  from  two  liosjiitals  in  ]\Iai'v- 
laiid. — 58  each  i'mm  the  general  hosjiital  at  Annapulis  and  tlie  Hammond  lajspital  at  WAwi 
Lcrokoiit.  The  patients  treati.'d  in  the  lormer  were  Union  soldii'Vs  transferred  fmm  rrliel 
prisons  In'  parole  or  exchanu;e:  19  of  these  died  and  39  recoven'd.  Thusc  treated  in  the 
latter  establishment  were  mostly  Confederate  soldiers  from  the  iieiohhoriiiL;-  prison  camp;  of 
these  21  died  and  37  recovered.  The  followiiiu-  selections  are  submitted  as  illustratinii'  I'ully 
the  general  character  of  the  information  furnislie.l  bv  ihe.-e  i-eporls: 

Cask  28. — Private  Thomas  W.  Travis,  Co.  II,  41th  111.:  age  21:  was  admitted  Hec.  17.  181! I,  with  scurvy,  direct 
from  Savannah.  Ga.  He  iiiii)roved  rajiidly  on  a  vegetable  diet,  and  in  the  couise  of  a  week  was  placed  upon  light 
duty  as  a  nurse.     He  was  returned  to  duty  Jan.  17,  lWir>. 

Cask  2!I. — Private  Andrew  Brown.  Co.  li,  77th  \.  Y.:  age  2(l:  was  admitte<l  Pee.  I.  lSi;i,  with  scurvy  contracted 
while  a  prisoner  at  Andcrsonville.     He  recovered  under  jiroper  diet  and  was  finlouglieil  .Ian.  2(1.  ISti.'i. 

Ca.se  30. — Corporal  Hansom  Dodge,  Co.  K,  11th  N.  Y.  Cav.:  age  lid:  was  admitted  .\]iril  !•.  1S(!I,  with  scurvy 
contracted  while  in  prison  at  liclle  Isle.  Va..  after  his  capture  at  Edwards  Kerry,  Aug  2S,  lh(i:i.  He  was  ninch  debil- 
itated, his  respiration  labored  on  account  of  j)eritoneal  effusion  and  the  action  of  the  heai  t  also  .somewhat  alfecte<I. 
In  addition  he  had  a  jiersistent  and  weakening  relaxation  of  the  bowels,  which  were  generally  nM)ved  three  times 
daily.  Citric  acid,  lemons,  lime-Jniee  and  onions  were  freely  used  in  his  treatment,  with  fall  diet  and  jiortci.  For 
a  few  days  bitartrate  of  jiotash  was  tried,  but  its  actioti  was  considered  too  debilitating.  He  was  improving  and  in 
a  fair  way  to  recovery  w  hen,  on  August  G.  lie  was  transferred  to  New  Voik  city. 

Case  31 — Private  John  Fisher.  Co.  A,  74tli  Pa.:  age  2',t:  was  admitted  Xov.  18.  1803.  His  skin  was  dry  and 
rough,  feet  (edematmis,  legs  painful,  knee-joints  stift",  gums  tender,  apiielite  lost,  bowels  relaxeil  and  mind  deiiressed. 
He  was  sjionged  with  vinegar  and  water  and  directed  to  take  thirty  drops  of  tinctnre  of  iron  three  times  a  day,  with 
milk-punch,  lemonade  for  a  drink  and  special  diet.  Later  he  was  directed  to  have  pickles,  and  camphor  and  ojiinm 
was  called  for  on  account  of  the  diarrlueal  tendency,  but  w  itlial  his  condition  improved  and  on  Jan.  31,  I.hOI.  he 
was  considered  convalescent.  Meanwhile,  however,  he  began  to  com|dain  of  rhenmatie  pains  in  his  legs  and  feet, 
which  were  still  somewhat  aHlematous.  Ten  grains  of  iodide  of  potassium  were  givi'ii  three  times  daily,  and  a  liui- 
luent  containing  chloroform  and  tincture  of  capsicum  was  em])loyed.     He  was  retnined  to  dnty  Febiuary  2."). 

Case  32. — Private  Anderson  (a-een.  Co.  H,  4tb  Ky.  Mounted  Inf..  a  ]iaroled  prisoner;  age  2ii:  was  admitted 
Dec.  17,  18l)l,  with  scurvy  and  chronic  diarrlnea.  His  lower  limbs  weri'  di<ipsi<'al  and  he  w  as  so  weak  as  to  be  unabk- 
to  rise  from  bed;  he  had  a  frecment  diarrlnea,  light-c(dore(l  and  frothy.  H<'  was  treated  with  astringents,  generous 
diet  and  brandy,  but  the  diarrluea  jiersisted  and  on  Jan.  Ill,  18(i5.  the  stools  were  jiassed  in\(>lnntarily.  He  died  on 
the  21st. 

Case  33.— Corporal  William  K.ed,  Co.  K,  l(i2d  X.  Y.:  age  31:  was  admitted  Oct.  29.  lxt;3,  from  lielle  Isl.'.  Va., 
where  he  Lad  been  imprisoned  from  the  time  of  his  capture  at  Springtield  Landing,  July  2. 1«li3.  He  was  much  ema- 
ciated and  weakened  by  diarrluea  and  had  several  large  ulcers  on  dili'erent  parts  of  the  body;  his  pulse  was  feeble 
and  frequent  and  he  had  little  or  no  appetite.  Charcoal  and  yeast  poultices  were  a]>]ilied  to  the  ulcers  and  stimulants 
and  tonics  were  administered,  with  a  free  vegetable  diet,  but  the  jiatient  gradually  failed,  dying  November  22. 

Case  34. — Private  Fdward  Dwyer,  Co.  F,  104th  N.  Y.;  age  3."):  was  admitted  March  11.  lsi!."i.  w  ith  scurvy  and 
general  debility.  Chlorinated  washes  were  jirescribed  for  the  mouth  and  throat :  tonics  and  stimulants  were  admin- 
istered with  an  appropriate  diet;  but  the  patient  was  in  a  hopeless  condition.     He  died  on  the  17tli. 

Case  3.5. — Private  M.  ^V.  White,  Co.  I,  2.5th  111.,  a  paroled  prisoner  from  Andersonville:  age  24;  was  admitted 
Dec.  4,  1864,  much  emaciated  and  weak  from  scurvy  and  a  diarrluva  of  twelve  or  fifteen  jiassages  daily.  Astringents 
and  antiscorbutics  were  freely  used,  but  for  a  week  the  jiatieiit's  condition  reniaini'd  unchang<Ml  exce)pt  for  the  devel- 
opment of  a  chill  and  fever  every  afternoon.  t,|iiininc  and  stimulants  were  administered.  On  the  11th  the  alvine 
discharges  became  increased  in  frecniency,  mixed  with  blood  ;ind  associated  with  great  thiist,  increasing  )irostration 
and  much  abdominal  pain.     The  stools  were  jiasscd  involuntarily  on  the  lilth,  and  death  took  i>laee  next  day. 

Cask  3t). — Private  A.  J.  (Ireen,  Co.  I.  51st  Oa.:  age  28;  was  admitted  tict.  2ti.  lX(i3.  from  the  hospital  at  the  pris- 
oners' camp,  complaining  of  weakness  and  soreness  in  the  legs  from  scurvy,  although  otherw  ise  in  fair  condition.  He 
improved  rapidly  on  tincture  of  irim  and  full  diet.  On  November  5  he  w  as  considered  cured.  He  was  transferred  for 
exchange  March  17,  1864. 

Case  37.— Private  J.  M.  (iallava.  Co.  A,  Pith  S.  C;  age  22;  was  admitted  Oct.  4,  18<j3,  as  a  scorbutic  w  ho  had 
suffered  more  or  less  with  diarrluea  since  May.  On  October  20  he  was  reported  much  improved,  having  been  taking 
diluted  sulphuric  aeid  and  special  diet.     He  was  returned  to  prisoners'  camp  Jan.  12,  1864. 


700  pcur;vY. 

Case  38.— Private  A.  RoU.iisiiii,  Co.  C.  30th  X.  ('.:  iiS''  --'■  ^'''•^^  adiiiitttMl  witlumt  :\  rocoid  nl'  liis  ]>!i'\  icjiis  his- 
tory, Xov.  8,  iNio.  The  ]iostcri(ir  and  inner  aspect  of  the  riglit  thigli  and  the  calfot'  th<'  rij;lit  li'n'  were  extensively 
discolored  with  purple  .>*pots.  Tinotiire  of  iodine  was  ajiplied  externally  and  chlorate  of  potash  )ireseril)ed  for  internal 
use;  full  diet  was  ordered.  On  the  2tith  thesjiotshad  disappeared  and  tlie  patient  was  nearly  well,  but  there  tenia ineil 
some  dropsical  swelling  of  the  foot  and  leu;  for  which  a  mixture  of  siiiiiU.  huchu  and  sweet  spirit  of  nitre  was  admin- 
istered.    On  March  3,  18t)4,  he  was  sent  to  City  Point  for  exclianLce. 

Cask  39. — Private  Jacob  Jenkins,  Co.  A,  11th  X.  ('.:  aj^e  I'd:  was  admitted  Oct.  27,  ]8t)3,  with  an  acute  Iiron- 
cliitic  attack,  but  he  had  been  scorbutic  forseveral  months,  lie  was  treated  w  ith  tartar  emetic  and  opium,  blue-pill 
and  Dover's  i>owder,  with  blisters  to  the  chest,  whiskey,  eitralc  of  iron  and  (|uinine  and  sjiecial  diet.  liy  IJccemlier 
lii  the  chest  aft'ection  was  entirely  reliev<'tl.  lint  there  was  much  debility  and  occasional  diarrhiea  fronr  the  scorbutic 
oouditiou.     Xo  decided  improvement  in  this  res]iect  was  maiiifesied  up  to  rlie  tinu'  of  his  e>cchauj;c.  March  17,  18tii. 

Cask  40. — Private  D.  F.  Eddleman,  Co.  It,  ."i^d  X.  C.:  ajj;e  3:;:  was  admitted  i  >ct.  27,  lsii3,  having  been  aft'eeted 
for  live  months  with  scurvy  and  fieiiuent  attacks  of  dianlicea.  Ciider  Ireatiiii'iit  and  extra  diet  the  diarrluea  was 
controlled,  but  the  gums  and  teeth  lemaiued  in  an  unhealthy  condition,  the  former  swidlen  and  disposed  to  Ideed, 
the  latter  decayed  and  loose  in  their  sockets;  one  loose  tooth  had  to  be  removed.  He  continued,  however,  to  improve 
slow  ly  and  on  Jan.  12,  18(jl,  was  returned  to  camp. 

Cask  H. — I'rixate  Forney  Avery,  Co.  E,  4tli  X*.  C;  age  38;  was  admitted  Xov.  (i,  I8ti3.  witli  chronic  diarrlnea. 
His  gums  were  of  a  deep  dark-red  color  and  spongy,  but  there  were  no  scorbutic  ecchymoses  or  ulcerations.  He  was 
treated  with  vegetable  diet,  lemonade,  jiotato  sa'ad  and  astringeuts.  The  diarrhcea  persisted,  causing  seven  oreight 
stools  daily,  until  death  took  place  on  the  21st. 

Cask  42. — Private  \V.  H.  Criekmau,  Co.  C,  1st  X.  C.;  age  28;  was  admitted  Oct.  22,  1803,  with  scurvy.  He  was 
jilaced  on  tincture  of  iron  and  ajipropriate  diet,  and  was  show  ing  signs  of  improvement  when,  cm  X'ovember  3,  an 
active  and  exhausting  diarrhiea  superveucil.  This  was  somewhat  controlled  by  the  8tli,  but  iIk;  patient  was  very 
weak  and  had  no  appetite.     Pneumonic  symptoms  were  noted  on  the  20th,  and  death  took  place  on  the  2:i(l. 

Cask  43. — Private  D.  Dukes,  Co.  H,  (list  \i\.:  age  22:  was  admitted  Xov.  10,  18t)3,  with  a  diairlKca  (d'  four 
months'  continuance  and  scurvy  manifested  in  his  swollen  and  tender  gum's.  He  was  w  eak  and  much  emaciated  but 
had  no  cutaneous  discidorations.  Special  diet  w  as  )irescribed.  with  sulphate  of  iron,  o]iium  and  alcidiolic  stimulants. 
The  diarrhoea  became  aggravated  and  the  patient  pKijiortioiiati'Iy  dcbiiitati'd  :  ten  to  lifleen  passages  from  the  bow  els 
were  recorded  daily,  until  he  ilied  on  the  21st. 

Case  44. — I'rivate  Thomas  Logan.  Co.  I,  117th  X.  Y.:  age  21:  was  admitted  March  13,  l8t'i."i.  with  ly]dioid  fever, 
and  died  on  the  2ltli.  He  ha<l  been  conl'ined  in  Soutliern  prisons  and  fed  on  corn  meal  and  singliiini  molasses.  He 
was  very  scorbutic  and  had  sufl'ered  from  chronic  dysentery  before  the  supervention  of  the  fever.  Turpentine  emul- 
sion, sweet  spirit  of  nitre,  morphia  occasionally  and  persulphate  of  iron  were  prescribed.  Creat  care  was  exercised 
iu  giving  suitable  noirrishment  and  in  having  perfect  ventilation  of  the  tent-ward  in  w  liicli  he  was  treated.  Act. 
Ass't  Surgeon  Joiix  Fee  remarks  on  this  ease  as  follows:  It  was  a  noticeable  fact  that  all  the  returned  prisoners  wlio 
were  scorbutic  suffered  from  diarrluea.  and  tliat  tlu'  grave  condition  of  the  bowels  was  indicated  by  the  odor  and 
color  of  the  stools  and  the  iiresence  of  blood  and  mucus  in  them.  Typhoid  fever  supervening  in  these  cases  was  sure 
soon  to  terminate  fatally. 

PiisT-MOPvTEM  OB8i:rvatiox>. — Few  rocorJs  of  pn-^l-inorteni  examinations  in  ca.se3  of 
scurvy  iiaveboeu  preserved.  Scorbutic  svniptoms  wen-  present  in  twenty-one  of  the  cases 
already  submitted  as  illustrations  of  tlie  diarrliajal  diseases  tluit  prevailed  among  the  troops; 
but  twelve  of  these,  229,  232,  231,  ■l^~),  020,  038,  G4().  Oil,  0-j7,  003,  <307  and  (>S1,  occurred 
in  the  persons  of  rebel  prisoners  treated  in  the  hospitttls  at  Point  Lookout,  ^Id.,  and  Itock 
Island,  111.,  and  in  three,  222,  223  and  251,  the  patients  were  Union  soldiers  recently 
returned  from  Southern  prisons: — thus  iu  onlv  six  of  these  cases,  111,  11-1,  lOS,  100,  1S7 
and  798,  does  the  diseased  condition  appear  to  have  originated  in  men  while  on  active  service 
with  their  commands.  Two  of  the  cases  illustrating  theji'"4-^//("r/<'//^  a[ipearances  of  the  con- 
tinued-fever cases  were  associated  with  scurvy,  and  in  buth  of  these  the  jiatieiits  had  suilered 
imprisonment  in  the  South.  In  addition  to  these  the  following  have  been  gathered  from 
the  case-books  and  medical  descriptive  lists: 

Case  4.'). — Private  Christopher  Frey,  13tli  X'.  Y.  Pat'y,  was  admitted  Aug.  11,  18(U,  and  died  on  the  same  day. 
He  had  much  aching  in  the  bones  and  an  exhausting  diarrhira,  the  stools  occurring  every  twenty  minutes.  His  gums 
were  swollen  and  bled  on  the  slightest  pressure,  and  there  were  large  dark-colored  spots  on  his  lower  extremities; 
his  pulse  was  weak  but  not  frequent;  breathing  quick  and  somewhat  difficult;  tongue  dry  in  the  centre  but  moist 
at  the  edges.     Post-mortem  examination:  Congestion  of  the  entire  body. — Second  Division  Uospital,  Ttretitieth  Corjys. 

Case  46. — Private  Andrew  (iarrett,  Co.  A,  16th  Colored  Troops;  age  38;  was  admitted  Aug.  21,  1864,  from  the 
field  witli  scurvv  and  general   debiltv.     He  died  on  the  27th.     Post-muiicm  examination:  Lungs  much  congested; 


PcriivY.  70] 

left  lull?  aiUieipiit  niiiviTsally:  iicricardiiim  c;imniniii,i;  cii^lit  oiuu-cs  ofsoniin  ;  heart.  \v...i;:hiiij,' .■i-htn-ii  (Uiiicrs.  jinlo 
and  llalili.v:  aliclniiiinal  viscera  iimiiiul. — <'/iiiliini(ii>r/H  I'itJU  llonpilal.  Jiiiii. 

(.'ASK  IT.— I'livatc  I.saiah  Slmicr.  Cci.  II.  Kith  Colorod  Tiooji.s:  ajrr  21:  was  .■iduiittcd  .Viij;.  2'A.  ISIII,  I'loin  ihc 
lield  with  .scurvy.  I)if(l  Seiiteuilicr  11.  rosl-mnrtim  exainiiiatiiiii :  Thoiv  \vcr<-  idciuitic  adlicsidiis  on  Ixitli  sides: 
tlie  lower  lohe  of  the  rinht  liui,>:  was  f;aii,i;ieiioMs  and  tlie  other  lube.s  coiijiesteil :  the  left  liiiij;  wa.s  normal.  'Jlie 
reiiiaiiiin,U'  viscera  wne  lii-althy.— r/i,/»,/(,i"i(/((  FirUl  fluspitul.  Ttiiii. 

C.vsi:  IS.— l'ri\ali' t'.  11.  .^iiiilh.  Co,  (_■.  Itli  X.  IT.:  au'e  ,S1 :  \v;is  admitted  Scjit.  ^.'i.  l.s'ffl,  with  scurvy.  He  was 
emaciated.  ;rrcar!y  dehililat<<l  and  Imd  tiunors  and  ulcers  on  his  lei;s  and  liiiis:  liis  toiij;ne  was  moist  and  sliiilitly 
coated:  liowels  rcynlar.  Tincture  of  iron  and  sjiecial  diet  were  ]>reserilieil.  (in  Xovemlur  I  the  foUowini;  note  was 
made;  The  condition  of  the  blood  of  this  jiatieiit  is  improviiin;  since  his  niceis  ha\e  lie;ile(l,  l.nt  thi'ie  is  evidently 
(li.sease  of  the  lungs:  lie  has  a  dry  tensinu;  con;;h.  llatness.  jinerile  res]dration  and  liniiiiil  rales.  On  the  2(>tli  the 
Iniifj  troulde  was  reliorted  ai;gravated.  the  lejrs  (edemati)iis.  the  jtatieiit  aft'eeted  with  <liarih(ea  and  extremely  pros- 
trated, lie  died  on  tlie  2yth.  rost-iiKirliiii  examination:  Extensive  tnlierculons  disease  of  both  lung.s  in  all  stages, 
hard,  .soft  and  excavated. — Jet.  .l.ts't  Si(rij<vii  Chaihn  T.  Rilnr.  Gem  nil  Iloijiilul  Sa.  11,  lUiiufuvl,  S.  C. 

Qxsv.  -19. — Private  Enoch  Green,  Co.  I.  27th  Miss.,  was  admitte<l  Nov.  1.  IStil,  w  ith  scurvy,  and  ilied  .Ian.  27. 
18(^0.  I'nst-miJi-tcm  examination:  Both  lungs  were  adherent  and  tilled  with  tnberclo.  Tlie  liver  and  s]dcen  wi-w 
healthy  but  somewhat  enlarged.  The  bowels  were  slightly  congested  and  thi'  iiii'senleric  glands  enlarged.  Xo  other 
abuormal  appearance  was  observed. — Jet.  Ann' t  Siirgeou  II.  II.  liiiKxell,  HoeJ:  Ixlaiul.  III. 

C.^SE  50. — Private  Philo  li.  Weaver,  Co.  K,  ()7th  Ohio:  age  20:  was  adniittecl  from  IJicdinioiid,  \\\.,  Ajiril  Is. 
1864,  with  scurvy  and  dropsy,  and  died  May  7.  I'lmt-iitniii  ni  examin.ition  :  Tin'  right  lung  was  congested;  tin-  left 
tuberculous.  The  heart  was  small  ami  llabby.  The  perltonenm  containeil  tlin-e  <|iiarts  of  thin  pus  and  tln'  intes- 
tines were  extensively  congested.  The  spleen  was  soft  :  the  liver  liard  :  the  kidneys  natural. — .lei.  Anx't  .n'iov/mih  Ji. 
B.  Miles,  Jarris  Ho^pihd,  BiiUimorc,  Mil. 

C.-^SE  51. — Private  M.  11.  Kindred.  Co.  E,  1st  East  Ti'iiii.;  age  2S:  was  admitti-d  from  K'icbiiioiid,  \'a..  .\y\i]  is. 
1864,  with  a  contusion  of  the  left  lung,  and  died  May  11  of  jiurinira  hemorrhagica.  I'uKt-morlem  examination  :  The 
right  pleural  cavity  contained  a  ijuart  of  bloody  eti'tision  and  the  lung  was  intensely  congested  and  adherent  to  the 
parietes  by  shreds  of  soft  lymph.  The  pericardium  contained  effusion:  the  heart  was  Habby.  I'ho  liver  and  kidneys 
were  somewhat  enlarged  ami  congested:  the  sjileen  inteiisidy  congested  and  hard:  the  mucous  coat  of  the  stomach 
was  soft,  thickened  and  ecchyiiioscd:  that  of  the  intestine  spotted  with  dark-colored  extravasations.  The  blood  was 
tiiin,  dark-looking  and  did  not  coagulate. — Act.  AnD't  Siinjenn  li.  B.  Miles,  Jid'vis  Ilospitnl.  liultiiiiorc,  Mil. 

C\SE  52. — Private  \oah  Davis,  Co.  C,  8th  Colored  Troops,  was  admitted  (^ct.  20,  1x05.  He  became  scorbutic 
two  weeks  after  landing  at  Brazos,  but  accompanied  his  regiment  to  Ringgold  liarracks.  w  here  he  went  into  hospital 
and  took  pulijue  for  two  weeks,  but  be  did  tiot  get  well.  His  gums  were  red  and  bled  occasionally;  his  legs  became 
swollen  and  shortly  afterwards  ulcerated.  Later,  diarrhn-a  was  developed;  and  when,  in  October,  his  regiment  left 
to  be  mustered  out,  he  was  sent  by  sti'amer  to  this  hospital  for  treatment.  He  was  somewhat  emaciated  and  so  weak 
as  to  be  confined  to  bcil.  He  had  a  diarrluea  of  eight  to  twelve  evacuations  daily.  The  patient  failed,  and  died 
December  7.  rosl-ninrleni  examination:  liody  emaciated  and  showing  a  few  scars  where  the  sores  had  been.  The 
thoracic  viscera,  liver  and  pancreas  were  normal.  The  stomach  contained  aliout  ten  lluid  ounces  of  greenish  liijuid. 
The  gall-bladder  was  empty:  the  spleen  weighed  less  than  two  ounces  anil  was  of  a  red  color.  The  kidneys  were 
tough,  the  pyramids  contracted,  infiinilibula  and  caliees  enlarged  and  all  of  a  bright-red  color;  the  bl.iddcr  con- 
tained twelve  ounces  of  urine.  The  calibre  of  the  last  fifteen  inches  of  the  ileum  was  narrowed  to  threc-fourtlis  of 
an  inch;  the  mucous  coat  was  thickened  and  red.  The  caput  coli  was  pale :  the  ascending  colon  slightly  enlarged  : 
the  transverse  and  descending  colon,  sigmoid  flexure  and  rectum  were  contracted  to  about  one  inch  in  diameter  and 
were  of  a  bluish  tinge.  The  mucous  membrane  of  the  wluile  of  the  canal  was  examined  w  ithoiii  detecting  ulccr.ition 
or  even  much  congestion.  The  mesenteric  glands  were  enlarged, — one-half  to  two  inches  long,  one-foiiilh  to  tliree- 
fourths  of  an  inch  tliick  and  one-half  to  one  and  one-half  indies  liroad. — they  felt  somewhat  like  suet  to  the  touch. — 
Ans't  Surgeon  Ini  Firnj,  iUli  Colored  I'roops.  llospiinl,  llruii-iinrilh,  Te.i(is. 

Proli;\lj]y  some  of  tlic  deaths  ainoiiu'  iianilcil  |iri.-onri>,  .-ueh  as  the  t'ullowinu  at  the 
Jarvis  hospital,  were  in  a  uTeat  measure  iliie  to  the  iiiihiencc  of  defc'Ctive  alimentation. 

C.vsK  5S. — Corp'l  William  Snyder,  Co.  H,  IHth  Pa.  Cav.;  age  10;  was  admitted  from  Kichmoud,  Va.,  A|iril  18 
1861,  with  ascites  and  clironic  diarrhica.  He  died  .liiiiu  22,  I'o.'^t-iiinrteiii  examiuation :  There  was  much  etTusion  iu 
the  pleural  and  pericardial  cavities.  The  liver  w  as  of  a  liright-yellow  color.  The  w  hole  of  the  abdomiua]  viscera 
were  matted  together.     The  kidneys  were  small  and  contracted, 

C'.VSE  54. — Private  Frederick  Moore,  Co.  K,  llth  Conn.:  age  22:  was  admitted  from  Richmond.  Va.,  April  18 
1864,  with  chronic  diarrha'a,  and  died  June  2.  rost-mortviii  examination:  The  right  lung  was  atrophied  and  bound 
down  by  adhesions:  the  left  ideural  sac  contained  etfusion  and  the  lung  was  liepatized;  both  lungs  were  tilled  with 
crude  tubercle.  The  pericardium  was  distended  with  effusion;  the  heart,  large  and  flabby,  was  filled  with  fibrinous 
clots.  The  liver  and  spleen  w  ere  natural ;  the  kidneys  large  and  congested.  The  intestines  generally  were  inflamed 
and  the  ileum  ulcerated:  the  mesenteric  glands  tuberculous. 

C.\SE  55. — Private  Samuel  Robbins,  Co.  tJ,  16tli  Me.:  age  22;  was  admitted  from  Richmond,  Va.,  Ajiril  Is,  1864, 
with  chronic  diarrha'a,  and  died  April  27.     I'ost-mortem  examination:  Both  lungs  were  filled  with  miliary  tubercle; 


702  s^cunvY. 

the.  light  lun;;  contained  a  vomica  and  tlic  pleura  of  tliat  .■si<lu  was  tilled  wiili  seriiiii :  tin-  iicr  it-aid  in  in  also  cuntained 
seruni.     The  spleen  was  larjje  anil  tnliereulons:   the  kidneys  natural. 

Case  56. — I'rivate  Eli  llrown,  Co.  (i,  L'd  East  Tenn.:  ajje  !?.'>:  was  adinilted  I'roni  liichniond.  \'a..  .\iiiil  is.  IMU, 
with  phthisis,  and  died  Jlay  17.  rosi-iiiitrtdii  examination:  lioth  1mii_i;s  were  tulierenhuis  and  hei)ali/eil:  tlie  lel't 
pleural  cavity  contained  a  gallon  of  eti'iisioii.  TIk!  pericardium  was  distended  with  turliid  serum  and  tlie  aortic 
valves  thickeneil  with  ossitic  deposits.     The  spleen  was  .soft  and  friable  :  the  stomach,  intestines  and  kidneys  healtliy. 

C.v.sE  57. — I'rivate  John  (i.  Aldridge,  Co.  H,  5th  lud.  Cav.:  age  27:  was  admitted  from  Kichmoiid,  Va.,  April 
18,  IWU,  and  died  June  1.  roxt-mortcin  examination:  The  pleural  ca\  it  ies  c<intained  etrusion  and  the  lungs  were  tuber- 
culous, excavated  and  iiitiltrated  with  pus.  The  heart  wa.s  tlalihy  and  tilled  with  fihriuous  clot.'S.  The  liver  and 
kidneys  were  natural,  the  spleen  soft,  the  intestines  congeste<l  aiul  the  mesenteric  glands  tul)erculou.s. 

C.\t-K  5S. — Private  John  James,  Co.  (i,  loth  (_>hio;  age  25;  was  admitted  from  Kiclimoud,  ^'a.,  April  IS,  lb>G4, 
with  chronic  hronchiti.s,  and  died  April  28.  I'o>it-mortvin  examination:  The  lungs  were  extensively  conge,ste<l ;  the 
heart  hypertrophied  and  soft.  The  liver  was  enlarged  and  coiigeste<l:  the  gall-liladder  disteuded  :  the  spleen  enlarged 
and  softened;  the  kidueys  normal.  The  mucous  coat  of  the  stomach  and  intestines  was  thickened  and  softened; 
the  colon  small  and  much  thickened. 

As.s't  )SurgfOii  Ira  Perky,  9lh  Colored  Troops,  filed  a  series  of  41  pOHt-uiorteui  oLserva- 
tions  in  cases  of  .scurvy  in  tlio  25tli  Army  Cnrps  at  Bruwnsville,  Tt-xas.""-'  A  careful 
exaiuiiuitiuu  of  lliose  records  wtirraiits  the  following  statements: 

The  condition  of  the  brain  is  recorded  in  two  cases  only.  In  both  it  w.as  soft:  in  one  there  were  two  ounces 
of  serum  in  the  membranes,  in  the  other  the  ventricles  were  tilled  with  a  dingy  linuid,  a  small  cjuantity  of  which 
also  covered  the  surface  of  the  hemisphcies. 

The  lungs  were  mentioned  as  uormal  in  5  and  altered  in  2s  of  the  11  cases.  In  Hi  of  the  2^t  liotli  lungs  were 
affected,  while  in  8  the  right  and  in  4  the  left  lung  was  the  .scat  of  the  morbid  changes.  Of  the  1(1  cases  tlie  lungs 
were  pale  in  6,  atrophied  in  2,  congested  in  2  and  tuberculous  in  0.  one  of  whi(di  presented  hepatization  and  another 
gangrene.  Of  tJie  f<  cases  the  lung  was  congested  in  1,  hepatized  in  1.  carnified  in  .S,  tuberculous  in  2  and  in  1  so  dis- 
organized that  only  about  two  ounces  of  its  tissue  remained.  Of  the  4  cases  the  lung  was  tuberculous  in  :i  and 
atrophied  to  two  ounces  in  1. 

The  pleural  cavities  were  noted  as  abnormal  in  14.  (.)iie-lialf  of  these  wi-re  charactei  ize<l  by  adliesions  and  i-xii- 
dations  of  coagulable  layers,  the  other  liy  etfnsions  of  more  or  les.s  turbid  liijuid.  amounting  in  one  iustaiici'  on  the 
right  side  to  six  pints.     In  one  case  there  was  an  empyema  of  the  right  side. 

The  condition  of  the  pericardium  was  noted  in  20  cases.  In  one  there  was  adhesion,  in  the  others  cli'usioii, 
■which,  in  one  case,  was  associated  with  exuded  lymph  and  in  three  with  tubercle.  With  the  exception  of  six  pints 
in  one  instance,  the  largest  ([Uantity  of  effusion  was  eight  ounces,  present  in  three  cases. 

The  condition  of  the  heart  was  reported  in  19  cases,  In  3  of  w^hicli  it  was  normal.  It  was  small,  pale,  soft  or 
flaccid  in  one-half  of  the  remaining  Iti;  large  in  2,  dilated  in  all  its  cavities  in  3  and  in  its  right  auricle  in  1 :  covered 
with  a  red  fibrinous  coating  in  1  and  <lisplaced  to  tlie  right  by  a  pleuritic  effusion  in  1.  The  valves  of  the  heart 
were  reported  thin,  deficient  or  eriliriform  in  19  of  the  cases.  Fibrinous  clots  were  noted  in  8  cases,  and  in  11  it  is 
stated  that  there  were  no  clots. 

The  liver  was  noted  in  28  cases,  in  3  of  which  it  was  normal.  It  was  tuberculous  in  4;  small  iu  4,  in  (Uie  of 
which  it  was  yellow ;  large  in  11,  in  two  of  which  it  was  pale  and  yellow,  in  four  purple  or  dark,  in  two  mottled  and 
in  one  congested  and  friable.  Of  the  remaining  0  cises  it  was  tough  in  1,  nutmeg-colored  in  1,  mottled  in  1.  lirown 
and  hard  in  1,  dark,  with  tar-like  bile  iu  the  gall-bladder  iu  1  and  coated  with  a  layer  of  lymph  in  1. 

The  spleen  was  noted  iu  35  cases,  iu  14  of  which  it  was  normal.  It  was  tuberculons  iu  10,  one  of  which  was 
carnitie<l  and  three  enlarged;  it  was  large  in  5  cases,  in  two  to  three  times  the  healthy  size:  it  was  small,  pale  and 
wrinkled  in  4  cases;  of  the  remaining  2  cases  the  weight,  two  ounces,  only  is  given. 

The  pancreas  was  mentioned  11  times;  8  times  as  normal,  once  as  large,  once  as  small  and  ouce  as  tuberculous. 

The  condition  of  the  kidneys  was  noted  in  2(i  instances,  in  5  of  which  they  appeared  normal.  They  were  large 
in  7,  one  of  which  was  pale,  two  flaccid  and  one  friable;  pale  in  3;  congested  in  4;  fatty  in  2;  flaccid  in  3,  in  two  of 
which  they  were  also  tough;  in  1  they  were  small,  weighing  only  two  and  a  half  ounces  each,  and  in  another  they 
are  said  to  have  exhibited  a  change  of  structure  and  color. 

The  8Ui>rarenal  capsules  were  large  in  5  cases,  attaining  in  one  instance  to  three  times  the  natural  size;  in  1 
they  were  large  and  tulierculous  and  in  1  small. 

The  condition  of  the  miliary  bladder  was  noted  in  only  3  cases.  In  one  case  it  was  full;  in  a  second  it  con- 
tained four  ounces  of  urine  and  its  thickened  coats  were  so  bound  liy  adhesions  as  to  be  incapable  of  further  expau- 
sion;  in  the  third  it  was  contracted  into  a  small  hard  mass. 

The  stomach  was  noted  IG  times;  7  times  as  normal,  4  times  as  disteuded  with  flatus  or  li(iuid  and  once  as  the 
subject  of  hour-glass  contracture  by  a  baud  of  peritoneum.  Of  the  remaining  4  the  mucous  memlirane  was  pale  and 
softened  in  two  and  red  and  congested  iu  two. 

The  intestines  were  mentioned  iu  whole  or  in  jiart  in  30  cases,  in  5  of  which  they  were  normal  or  merely  dis- 
tended with  air.     They  were  recorded  as  pale  in  4,  in  one  of  which  the  colon  was  congested;  soft  and  thickened  in 

*  Iir.  Perrv  publislu'd  one  of  tbeae  cases,  by  way  of  illustrating  the  character  of  the  whole  number,  in  the  Boston  Medkal  and  Surgical  Journal, 
Vol.  LXXIV,  180G,  p.  \r,b. 


scrr;vY.  70i3 

2;  Miiisli  or  ilaik-colored  in  2;  eccliyniosed  in  1  and  cdiigobted  in  10,  in  four  of  which  tliP  cohm  was  ulcerated.  Of 
thu  I)  reiiiiiiniiiji cases  the  colon  alone  was  rejiorted  as  affected,  in  five  witli  mild  congestion  and  in  one  witli  ulceration. 

The  iieritoneuni  was  noted  in  2r>  easr>.  It  was  tuhcrculous  in  ."i,  in  four  of  which  there  was  adhesion  and  in 
one  effusion  ;  congested  in  2  and  adherent  in  '.'>.  in  one  of  wliich  there  was  a  small  (jiiantity  of  reddish  serum.  'I'here 
was  ertusion  in  0,  ill  four  of  wliieh  there  was  also exudat ion.  and  there  was  exudation  in  7  eases  associated  with  iiKjre 
or  less  of  congestion.     Lastly,  in  1  tlieri'  was  thickening  and  in  1  a  dark-slate  colcjr  ol'the  meiiiljiane. 

Tlie  condition  of  llie  mesenteric  glands  was  noted  in  27  cases,  in  all  of  which  there  was  more  or  less  enlarge- 
ment and  in  many  softi-ning:  in  2  the  glands  were  of  a  <lark  cohn-  and  in  7  tuherculous.  The  cervical  and  lininehial 
glainls  were  fre(iiiently  associated  in  the  tuorhid  conditions  of  enlargement,  softening,  darkening  or  tuliereiilar  degeu- 
eration.     In  one  case  there  was  suiipnration  of  the  cervical,  axillary  and  mammary  glands. 

In  one  of  the  41  cases  no  section  was  made:  tlw  pont-iiiurliiii  record  noted  only  the  condition  of  the  lymiihatics 
and  a  perforate  empyematous  thorax. 

Oa  rovicwinp;  tlie  liisuny  of  scurvv  in  our  arniie.s  it  is  fseen  tliat.  rXL-luJiiiu'  a  i'^w  local 
outlnvaks.  the  troojis  wvvc  kept  free  froiti  active  luaiiife.'^tations  o\  ilie  oaclie.xia.  Jn  fact  it 
may  be  said  tliat  as  a  wliole  the  United  States  Ai'inv  was  as  five  fi'Oia  tin'  scdi'lmtic  taint 
as  were  the  British  troojis  in  the  CViiaea  (luiiiiLi;  the  year  ending  June  oU,  ISoli.  -when, 
although  a  small  number  of  admissions  were  noted,  they  were  not  recorded  on  the  tabic  of 
sick-rates,  as  they  constituted  only  a  fi'action  of  a  monthly  ratr  of  one  case  per  thousand  of 
strength.  ^Nevertheless  scurvy,  in  the  gvnoral  o|iiuion  of  the  profrssion,  occupied  a  prom- 
inent jilace  among  army  diseases.  This  must  be  atli'ibulfd  to  the  fivijueiicv  of  cases  among 
the  rebel  pi'isoners  at  Xoiihei'u  depcds  and  the  gi-iicrallv  scorbulie  condition  of  our  own 
paroled  or  exchanged  men  rather  than  to  the  actual  presence  of  the  di.sease  among  our  troop.s 
in  the  field  and  garrison. 

A  few  reports  on  tile  indicate  that  although  cases  of  developed  scurvy  were  rare  the 
scorbutic  taint  complicated  other  diseases,  rendering  them  intractable  and  correspondingly 
dangerous.  Besides  reterences  to  such  comj)lieation3  in  rejiort^  already  submitted,  as  in 
those  of  BiLLlXGS  and  Bawso.x,  the  following  have  been  discovered :'-' 

Sui-inoii  H.  P.  Stroxg,  llth  If'ie.,  Dcs  Area,  Arlcansan,  June  30,  1^162. — Our  army,  composed  mostly  of  raw  recruits 
from  rural  districts,  suhjected  to  the  fatigues  of  long  marches,  uuii-^ed  to  the  bivouac  or  the  exposures  of  a  camp  and 
southern  climate,  andsuttering  more  or  less  from  want  of  projier  food  sniiplics,  has  not  been  exempt  frcun  the  diseases 
incident  to  the  service;  yet  I  was  a  little  stirpri.scd  during  the  latter  part  of  ilay  to  notice  scorbutic  symptoms  in 
several  cases  of  dyseutei-y  and  remittent  fever.  I  had  been  of  the  opinion  that  fresh  meat  ami  dried  vegetables  arc 
good  )ireventives  of  scurvy.  We  have  had  a  fair  proportion  of  these  issued,  but  the'  men  are  scorbutic.  There  has 
been  no  ease  of  scurvy  ]iroper:  but  many  eases  of  dysentery  and  remittent  fever  have  bi'cn  complicated  with  hem- 
orrhage from  the  mucous  membranes,  in  a  few  cases  to  an  alarming  extent.  Sonu-timcs  tlie  bleedingapjieared  to  conio 
from  the  entire  length  of  the  alimentary  canal,  while  fre(|uenlly  it  was  only  (diserved  fioni  the  nose,  nuuith  and  fauces. 
In  one  case  of  continued  fever  epistaxis  was  so  jiersistent  that  plugging  was  resorted  Xo  with  the  eflect  of  arresting 
it  there,  while  it  started  afresh  from  the  mouth  and  fauces.  When  last  seen  tliis  young  man  was  recovering  under  the 
use  of  large  doses  of  muriated  tincture  of  iron.  In  a  few  eases  I  have  observed  slight  purpuric  si)ots  on  the  legs  and 
chest.  1  have  not  noticed  spoiiginess  of  the  gums  exceiit  in  a  few  persou.s  that  had  been  taking  mercury  nearly  to 
ptyalism.  A  mess  which  has  been  kept  well  sujiplied  with  vinegar  has  not  furnisheil  me  a  scorlnitie  jiatieut.  It  lias 
been  impossible  to  provide  the  command  with  vinegar.  P^-esh  vegetables  cannot  be  obtained  in  any  iiuautity:  the 
enemy  destroys  them  rather  than  pernut  tlieni  to  fall  into  our  possession.  In  our  circumstances  I  believe  vinegar  to 
rank  among  the  best  antiscorbutic  remedies.  The  only  medication  of  any  advantage  is  the  liberal  use  of  mineral 
acids,  llnriated  tincture  and  proto-sulphate  of  iroir  are  particularly  applicable:  they  seem  to  arrest  Iiemorrhage 
and  impart  tone  and  vitality  to  the  capillary  vessels,  or,  as  the  case  may  be,  reinvigorate  their  nervous  distribution. 
Nitro-uiuriatic  acid  seems  appropriate  when  there  is  umeh  hepatic  derangement.  The  scorluitic  diathesis  would 
hardly  be  wortli  mentioning  in  this  connection  were  in  not  that  it  couiplieales  diseases  of  a  character  grave  enough, 
in  camp  life  and  at  this  seascui  of  the  year,  when  uucoiiiplicated.  A  tendency  to  congestion  is  characteristic  of  all 
our  diseases. 


*Tlii'  t'iik'iKiti  Mi'iU'itl  E.'-iniiinrr,  \<>\.  Ill,  Isivj.  p.  ,".;;!  it  n''/.,  in  what  inirptnl;?  to  Ik-  n-iuarkr*  ;uL-uiiipiinyiiifr  tlu-  monthly  rt-jiort  uf  Sxirgeuii  H.  C. 

Fiuptf..  2'Jtl  flhid,  for  August  of  tliut  yenr.  has  tlu-  following  :  *'Tlifr.'  liuvc  1 ii  no  c-asr.;  of  ;;cnrvy,  imif  anil  ^irripli'.  dniin:;  this  month,  and  s'-arce  any 

siiu>-  tlif  rciiimcnt  has  hn'ii  in  scrvii'*',  hnt  vory  many  of  thf  patii-nts  have  snffiToil  in  a  way  that  i-uulil  not  he  acronnti-il  fur  exi-opt  on  tin-  supposition 
Lif  some  scurhutic  taint.  In  varions  instances,  Imt  jrcnerally  in  cases  of  diarrlnea  and  dysentery,  there  was  niurked  tedema  of  the  Uiwer  extremities  and 
soiuetimes  of  the  face  al.so.  Partial  iiaraly.-is  of  one  or  more  limbs  lias  not  been  uiicouimon,  and  in  one  or  two  cases,  which  proved  fatal,  there  were 
ecchymosesi,  in  one  ease  quite  extensive.  The  treatment  most  successful  with  tlie.se  cases,  after  suhduinjr  the  active  disease,  was  the  admiiiistnitiou  uf 
iron,  acids  and  uourishiliK  diet."  G.  P.  II.vcHRNBEituF.it,  .\ss't  Sur;ieon,  '2sth  (.Ihio,  in  a  correspondence  published  in  the  Ohio  Meilical  nn<l  i^iir<jk-al  Joiivnal^ 
Vol.  XIV,  ls('i2,  p.  3SS,  dated  Cox's  Division,  West  Virginia,  Aug.  1,  lsi;2,  mentions  some  of  the  evils  unfavor-ably  affecting  the  health  of  the  division, 
and  among  them  the  ajipeanince  of  a  scorbutic  taint  on  account  of  a  deticieut  sujiply  of  vegetables.  lie  considers  that  the  existence  of  this  couditiua 
added  greatly  tu  the  ditliculties  of  treating  some  coniplaiuts,  particularly  dysentery,  ulc'-rations  and  cutaneous  diseases. 


704  SCURVY. 

Sid-iiroii  IIexky  f'ArEiiAi;T.  lyt  V(i.  Car..  J'lilliii  of  Virijinin .  Jmi'  ilO.  iMii'. —  Ihc  iiio^t  prominent  symptoms  of 
ilisease  iniionj;  tin-  iniai  of  my  n"j;inu>ut  con.s;>t  ot'  i^i'ni'ral  <li'bility  and  iiii  (■\  idcnt  Icnclcncy  to  sctiilintiis.  If  these 
are  neglecti'd  they  soon  iU'Vclo|)  intojauiidict'.  t  \  ]ihcji(l  fc\ci'  oi'  |iiii'iniionia.  lint  liy  the  free  ami  I  iiiicly  ii>e  of  a  c  ids. 
<juinine  and  aleohcjlic  stimulant^  this  •■iindition  is  remo\cd  and  tlie  jpatiint  ii'stoied  Ui  duty  in  fioni  two  to  lour 
<lays.  1  eannot  too  stron^rly  reeomniend  tlie  u>e  of  t(niies  and  sliniuhints  in  tlie  treatment  of  the  diseases  ineideiit 
to  cami>  life.  My  success  has  lieeii  so  uniform  in  tlu'  Ueatiuenl  of  aiiite  pneumonia  hy  this  plan  that  I  have  hren 
forced  to  entertain  serious  doubts  as  to  its  inliammator\  ehar.ieter. 

Altlinllull    SUell   !V  (adllJiliealRill     lli>   (Inlllit   t'xislril    ill     1,11111V    liicill     illstaiieOS    wliei'f    a   tl'Ur 

scorbutic  taint  liaJ  licrii  (,l(:'velo[)e(.l.  tlic  statistics  (.1'  the  war  di>  uut  pcriait  the  supposition 
that  this  was  at  any  time  a  general  ct.aiililinii.  (.'crtainlv  the  lianl  worl<.  loss  of  sleep.  ex[)()- 
sures  in  all  kin'ls  ot'  wi^'atlier,  and  the  iinju'riL-ct  dirtaiv  >ri  often  associated  with  active  tirltl 
service,  resulted  in  many  instances  in  a  dehilitatcd  cundiiicjii  oi'  the  system  which  rendered 
the  soldier  jteculiarly  prone  to  succumli  under  attacks  ul'  acute  disease:  hmt  it  is  doubtful  if 
in  all  such  cases  the  term  scorljutic  could  with  ]ir(:)priety  be  applied  to  the  cachcxia'developL'd. 
Even  the  improved  condition  which  trequeutly-attcndtal  the  tree  i.ssue  of  vegetable  Ibod  does 
not  establisji  the  scorbutic  nature  of  tjie  deterioration  ;  tVa-  such  issues  were  usually  associated 
with  a  temporarv  cessation  of  active  hold  work,  during  which  many  harmful  conditions 
were  rcphtced  bv  those  whi.-h  were  salutary.  The  constitutional  state  resulting  from  the 
deteriorating  influences  of  the  war  was  of  ;i.  ty}>luius  or  advnamic  nature  rather  than  siniplv 
scorbutic. 

Rymptom.s. — The  first  manifestations  of  the  scorbutic  condition  were  usually  languor, 
lassitude,  fatigue  on  the  sliglitest  exertion  and  dull  aching  |xiins  in  the  legs  and  feet ;  but  other- 
wise at  this  time  the  patient  was  in  his  usual  condition,  his  appetite  good  and  bowels  regular 
or  pei'haps  inclined  t(^  be  torpid.  In  a  short  time  the  pains  increased  in  severity,  aflect- 
ing  chietiv  the  inuscle.s  of  the  legs  and  in  some  cases  those  of  the  back  and  sujierior  extremi- 
ties. The  p;un  was  often  referred  to  the  liones  and  in  many  cases  to  the  larger  joints. 
Soldiers  reporting  at  sick-call  with  these  symptoms  were  at  first  regarded  as  affected  with 
rheumatism.  Tlie  insidious  character  of  the  disease  favored  its  unnoted  invasion.  Xo 
doubt  in  manv  instances  its  pains  have  fieen  regarded  as  rlieumatic.  its  debility  as  resulting 
from  malaria, and  even  its  manifestations  on  the  gums  as  a  local  afiection  induced  by  irritating 
chewing-tobacco,  accumulations  of  tartar,  carious  stum|'S  and  other  unhealthy  conditions; 
but  in  general  our  medical  otficers  appear  to  have  been  from  the  first,  and  particularly  after 
the  alarm  of  scurvv  in  the  Ai'iriy  of  the  Potomac,  on  the  alert  tbr  the  ajipearance  of  the 
disease,  and  to  have  formallv  announced  its  pi'eseiice  if.  in  a  ca.-e  of  delnhty  with  muscular 
pains,  the  gingival  margins  were  I'lAmd  slightly  tumid  or  to  Ijleed  easily  when  the  thumb-nail 
of  the  examiner  w^as  rasped  along  them,  although  the  calves  of  the  legs  might  not  present 
any  petechitd  discolorations.  The  want  of  correspondence,  to  be  noted  hereafter, "•■  between 
the  prevalence  of  scurvy  ami  of  the  rheumatic  aftections  shows  very  definitely  that  jiains 
in  the  muscles,  liones  or  joints,  due  to  the  scorbutic  cachexia,  were  not  (■rroiieously  rej)orted 
as  rheumatism,  but  met  with  j'l'ope'r  recognition  and  treatment  in  the  practice  of  our  medi- 
cal officers.  Sometimes  debility  and  wandering  pains  formed  the  only  grounds  for  a  diag-, 
nosis.f  As  AVooDHULL  has  expressed  it,  the  disease  veiled  itself  under  the  guise  of  chronic 
rheumatism.  This  view,  generally  accepted  by  our  medical  officers,  was  in  one  instance 
officially  jiromulgated: 

George  Sucki.ey,  Surgeon,  U.  S.  Vols.,  Medical  Director,  Eleventh  Army  Corps,  to  Surgeon  Gl'xkle,  in  charge 
of  the  Field  Honjiittil  of  the  Corjjs,  dated  June  9,  1863. — I  notice  that  there  Lave  been  many  cases  in  hospital  of  soldiers 


*  Scf  iti/ni,  iiay*'  s:i:i.  I  Si.-«--  riMiiurk.-^  uf  Di-.  Fkancis  R.  Lyman,  pagi;  G87,  ficjira. 


SCtTA'Y.  .       /I  I.) 

CDiuiilaiiiiiig  (it'i)uiiil'iil  aud  ''weak''  liacks.  with  painful  sensations  iu  tlio  hii)s,  thighs,  etc.  Some  ol'tlicst.'  siniiihite 
renal  attcetions,  while  others  are  looked  upon  as  rheimuitisni,  neuralgia  and  even  acute  or  chronic  spinal  meningitis, 
and  treated  accordingly.  I  wish  to  draw  the  attention  of  your  medical  oflicers  to  the  fact  that  the  data  in  the 
Surgeon  (ieneral's  office  liave  pretty  clearly  established  that  many  of  these  cases  are  purely  scorhiilii-  and  should  lie 
treated  accordingly.  I'lease  imjiress  also  upon  the  minds  of  your  officers  that  most  of  our  army  cases  of  chronic 
rheumatism  and  chronic  diarrho'a  are  attributable  to  the  same  cau.se.  Yon  are  respectfully  requested  to  furnish  your 
medical  officers  with  a  copy  of  this  letter. 

As  indicated  iu  tliis  conunuuication,  diarrhoea  al.-^o  was  considered  a  proiniiK'nt  syiuptoin 
ul'  incipient  scurvy.  Its  suljsidence  wlien  tlio  scorbutic  taint  \vas  eft'aced  by  an  appropriate 
diet  estaljlislied  in  the  minds  of  inanv  its  svnij>toinatif  cliaracter.  By  sonu'  tlic  intestinal 
aftection  was  regarded  as  an  accidental  association,  for  wliere  diarrhoea  was  s(;  prevalent  as 
to  occasion  711.46  cases  annual)}'  in  every  thousand  present,  the  chances  of  its  occurring 
iu  a  scorbutic  individual  were  very  great.  But  siuc(\  as  already  mentioned,  the  vegetable 
diet,  which  cured  botli  the  scurvy  and  the  diarrlia'a,  was  usually  associated  witli  the  removal 
of  many  conditions  known  to  occasion  and  aggravate  the  latter  affection,  it  seems  probable 
that  the  diarrhiX'a  was  neitlier  a  symptom  nor  a  })urely  acciilental  complication  of  the  scor- 
butic taint,  but  that  its  causes  were  intimately  connected  with  tlie  military  conditions  which 
gave  origin  to  the  cachexia  by  i:)reventing  the  issue  of  fresh  vegetables. 

When  more  fully  developed,  however,  the  scorbutic  disease  was  so  invariably  accom- 
panied by  diarrhoea  that  the  constitutional  state  must  lie  conceived  as  having  predisposed 
to  the  local  affection.  According  to  Act.  Ass't  iSurgeon  Fkk  of  the  Annapolis  hospital,  it 
was  a  noticeable  fact  that  all  our  returned  prisoners  who  were  scorbutic  suffered  from  diar- 
rhoea, and  that  the  grave  condition  of  the  bowels  was  indicated  by  the  color  aud  odor  of  the 
stools  and  their  admixture  with  blood  aud  mucus.'-'  Indeed,  iu  a  majority  of  the  fatal  cases 
an  exhausting  diarrhoea  or  dvsentery,  sometimes  of  twenty  to  tlurtv  stools  daily,  precij^itated 
tlie  issue;  and  in  cases  of  recovery  the  intestinal  disease  was  seldom  controlled  until  an 
improvement  was  manifested  in  the  general  health. 

Subsequent  to  the  rheumatic  or  diarrlioeal  stage  of  incipiency  the  gums  became  tumid, 
red,  spongy  and  disposed  to  bleed,  the  teeth  loose  iu  their  sockets  and  the  breath  exceed- 
ino'lv  offensive.  The  swollen  o;ums  assumed  a  darker  color,  risiuii;  to  the  level  of  the  dental 
crowns  aud  obscuring  the  lateral  view  of  the  molars,  bicuspids  and  canines.  After  this 
their  tissue  broke  down  or  sloughed  away,  leaving  the  necks  of  the  teeth  bare  and  frequently 
carious;  mastication  became  difficult  or  impossible  and  sometimes  the  teeth  dropped  out, — 
in  case  16,  treated  at  the  Satterlee  hospital,  seventeen  teeth  are  said  to  have  been  lost.  At 
the  same  time  the  appearance  of  the  patient  became  changed  tVoin  tlie  healthy  condition. 
His  skin  was  dry  and  rough;  his  slow  movements  and  mental  de.'^pondency,  proclaimed  his 
debility,  and  his  pale,  waxy,  puffV.  ansemic  aspect  indicated  the  grave  deterioration  that 
had  taken  place  in  the  blood.  This  was  further  manifested  by  the  indi.spositiou  of  wounds 
to  Ileal,  slight  scratches  becoming  converted  into  indolent  ulcers  or  affected  with  erysij^e- 
latous  or  gangrenous  iuffammation.  Individual  instances  of  tliis  kind  "were  observed  by 
medical  officers  in  the  field  during  the  local  outbreaks  already  uieutioned:  liut.  as  a  general 
dyscrasia  affecting  wounds,  it  has  been  noticed  only  by  Southern  writers.  Dr.  JoXES  refers 
to  the  ulcerations  induced  among  the  prisoners  at  Audersouville  by  slight  injuries,  as  the 

*  Si-e  ctise  44,  (tage  7U0.  Ill  an  articlo  by  ^V.  It.  Cornish,  Statii^tical  (tfficur,  Madras  Mt-dical  Deimrtnicut,  in  the  Matlm^  MonthJy  Jour,  ^^ell.  &i., 
Vol.  I,  ISTO,  l».  177, — Oil  Svoi-hiitic  jV(i/a»fic5  us  ej-ein}ill:icJ  m  the  MeilU'al  Ilistorif  of  llw  Iii>i/tih  in  Irnha  fij-ty  year.<  ajo, — in  wliith  tlio  autliur  attributed  the 
exces.sive  mortality  which  fornu'rly  ntti'nilod  tht-  arrival  of  British  rfgiiiients  in  India  Ic^ri  to  climatic  conditions  than  to  scurvy  devdoiic'd  by  tlio  confine- 
ment and  imperfect  dietary  of  the  long  voyage,  it  is  stated  that — "In  India,  according  to  my  own  observation,  the  stress  of  the  scorbutic  disease  ^'"iier- 
ally  falls  on  the  large  intestine.  In  cold  countries  tlie  spongy  gums,  u'dema  of  the  limbs  lunl  extnivasition  of  bUn-d  beneath  the  skin  are  the  more 
common  syniptonis;  but  here,  often  the  tii^t  iua!ufestuti(.n  of  the  diseas"  is  a  disordered  condition  of  the  bowels,  d.'iK-udiug  on  destructive  ulceration  of 
the  mucous  surface  of  the  large  intestine." 

llED.  Hist.,  Pt.  Ill— 1^0 


TOG  8CUKVY. 

prick  ol'  a  splinter  or  the  scratcliing  of  a  laosquito  bite/-'  an^l  Dr.  Paul  F.  Evk,  speaking 
of  si.'urvv  in  tlie  Confederate  Arniv.  savs;i- 

It  certainly  diil  complicate  wounds  and  seriously  interfered  with  sui'gical  operations,  and  was  itself  asgravated 
by  erysipelas,  sypliilis,  spurious  vaeciuation.  Secondary  lieiuorrliaf;e  liecanu'  uuicb  more  fvei|ueut  from  wounds  and 
operations  after  the  battle  of  Cliickamau.!j;a  and  Jlissiouary  Kidjje,  September  and  December,  1863,  attril)utable  justly 
to  the  increased  scorbutic  tendency  in  the  soldier  as  the  war  iirogressed.  In  proof  of  this  assertion  the  otticial  report 
of  nhuteeii  cases  of  secondary  heniorrliajic  occurring  in  the  (iate  City  hospital  after  the  battle  of  Chickamauga  might 
be  presented. 

Coincident  with  tlie  tumefaction  of  the  gurns  jtetecliial  .<pot.s  appeared  on  the  lower 
extremities,  generally  at  first  on  the  calves  of  the  legs.  Tliese  were  followed  l>y  larger 
hemorrhagic  discolorations,  varying  in  hue  from  a  dusky-yellow  to  a  dark-purple.  The  inner 
aspect  of  the  thighs  was  also  frequently  affected;  but  all  parts  of  the  superHcial  tissues  were 
liable  to  the  extravasation.  The  spots  varied  in  size  and  shape;  in  some  instances  a  con- 
tinuous discoloration  extended  along  the  trunk,  thigh  and  leg.  Meanwhile  the  affected 
limbs  became  cedematous,  pitting  on  pressure,  and  afterwards  more  resistant,  as  if  some 
degree  of  coagulation  had  taken  place  in  the  liquid  transuded  into  the  intercellular  spaces. 
Local  congestions  determined  the  formation  of  tumors,  whicli  subsequently  became  ulcers, 
presenting  swollen  margins  and  tlark-colored,  fungoid  and  fetid  granulations.  The  knee 
and  ankle  joints  in  some  instances  became  painful,  stiff' and  contracted.  Delnlity  increased, 
the  pulse  became  slow  and  feeble  or,  in  the  presence  of  the  diarrhreal  affection,  rapid  and 
weak;  occasionally  the  patient  suff"ered  from  exhausting  night-sweats.  EfFusions  into  the 
peritoneum,  pleui'a  or  pericardium  caused  oppression  of  the  breathing  and  interference  with 
the  circulation.  Death  occurred  from  the  intestin^d  alFection,  from  pulmonary  cedema  or 
other  etl'usions  causing  cardiac  oppression  or  coma,  or  suddenly  after  muscular  exertion 

In  the  majority  of  cases  presented  during  the  war  improvement  was  rapid  under  appro- 
priate diet  and  medication.  In  some,  however,  the  gums  remained  spongy  and  tender  long 
after  the  other  symptoms  had  disappeared.  !N"ot  unfrequently,  also,  in  cases  of  slow  improve- 
ment, the  patient  continued  weak  and  suffered  from  palpitation  on  exertion;  in  other  cases, 
notwithstanding  the  removal  of  the  characteristic  scorbutic  symptoms,  a  rlieuinatic  condition 
persisted,  necessitating  the  discharge  of  the  soldier, — in  one  of  the  cases  submitted  above  tlie 
patient,  after  five  months  of  treatment,  was  discharged  from  service  as  being  unable  to  walk 
without  crutches. 

Xvctalopia  as  a  symptom  of  scurvy  does  not  api)ear  to  have  been  olvserved  in  the  Union 
armies.  Sporadic  cases  occurred,  lait  no  general  tendency  to  night-ldindness  has  been 
recorded  as  connected  with  the  scorbutic  taint.  According  to  Surgeon  J.  C.  Xortox,  U.  S. 
Vols.,  who  reported  its  extensive  prevalence  during  the  summer  of  18(31:  in  the  3d  Division, 
4th  Army  Corps,  the  robust  and  plethoric  were  affected  rather  than  the  debilitated: 

As  far  as  my  personal  observation  extends  the  disease  occurs  more  frei|uently  in  robust,  plethoric  jiersous  than 
in  those  of  lax  and  feeble  habit.  The  fust  ease  I  saw  occurred  in  the  19th  V.  .S.  Inf.,  May  S,  1801,  after  a  hard  day's 
march  from  Einggold  to  Buzzard's  Koost,  Ga.,  in  the  hot  suu.  It  came  on  .suddenl.v.  After  this  several  other  cases 
occurred,  and  as  the  campaign  advanced  the  disease  appeared  to  rage  as  an  epidemic.  Some  regiments  had  to  lead 
thirty  or  forty  blind  men  every  night.  Surgeons  did  not  understand  the  disease  and  were  unable  to  treat  it  success- 
fully. It  is  very  common  for  medical  officers,  when  they  do  not  understand  the  disease,  to  accuse  the  soldier  of 
mnlunjt  riiiy ;  so,  in  regard  to  night-blindness,  many  considered  all  cases  feigned.  I  am  aware  that  when  a  disease 
becomes  popular  there  are  many  soldiers  who  will  take  advantage  of  it  and  feign  the  symptoms  to  avoid  duty.  At 
the  same  time  mj-  observation  has  taught  mo  that  there  is  not  one-half  as  nuich  malingering  iu  the  army  as  is  gen- 
erall.v  supposed.  That  mental  inlluences  liave  much  to  do  with  the  production  of  disease  there  can  be  no  doubt,  as 
chorea  lias  often  been  caused  by  witnessing  the  convulsive  umvements  of  a  patient,  and  it  is  likely  that  the  exjiecta- 
tiou  of  and  attention  to  any  disease  act  as  predisi>osing  cairses  of  the  disease  itself.     Nostalgia  manifests  itself  in  a 


*  See  Hij?rrt,  page  37.  t  Xw<Ja-iUe  Mediad  Jonru'd,  Vol.  I,  X.  S.,  1»0G,  p.  16. 


SCURVY.  707 

variety  of  \>-ay.s;  but  there  is  no  doubt  tliat  the  nervous  system  is  primarily  affected,  and  it  is  nut  unreasonable  to 
suppiise  that  tlie  irritability  of  the  nervous  centres  which  characterizes  nostalgia  is  in  sonic  instances  a  predisposini; 
cause  of  nyctalopia.  There  is  no  doubt  in  my  mind  that  tlie  exciting  cause  of  night-blindness  is  excessive  use  of  the 
eyes  and  exposure  to  bright  light  and  oppressive  heat,  causing  local  congestion  first  of  the  ciliary  vessels  supply- 
ing the  iris  and  tlien  of  tin;  vessels  of  the  retina.  The  impil  is  sometimes  found  contracted  and  sometimes  dilated, 
and  I  have  seen  several  instances  in  which  there  was  unei|ual  dilatation,  one  pupil  being  contracted,  tlie  otlier  dilated. 
In  general  the  only  reason  why  the  patient  cannot  see  at  niglit  is  because  the  pupil  does  not  dilate  surticiently  to  take 
in  the  requisite  number  of  rays  to  nuike  vision  distinct.  The  excitability  of  the  iris  is  exhausted  by  continual  irrita- 
tion, so  that  it  fails  to  respond  to  any  but  the  strongest  excitant.  I  do  not  believe  that  the  disease  is  a  form  of 
anniurosis,  as  is  taught  by  authors  generally,  but  it  may  be  combined  with  that  disease.  Tlie  distinctive  character 
of  nyctalojiia.  however,  is  congestion  and  jiartial  paralysis  of  the  muscular  tissue  of  the  iris.  It  should  be  reniem 
bered  that  the  connection  of  this  muscle  with  the  optic  nerve  or  the  retina  is  very  distant,  the  iris  being  supplied 
liy  the  ciliaiy  branches  of  the  oiihthalinic  artery  and  the  motor  oculi  nerve,  while  the  retina  is  supplied  by  the  arteria 
centralis  retina?  and  the  optic  nerve.  A  rational  treatment  consists  in  the  removal  of  the  exciting  cause,  giving  nature 
a  cliance  to  restore  the  proper  e(|uilibrium  of  the  circulation  and  nervous  functions. 

Di'.  Robert  J.  Hicks;  of  Williamsburg,  X.  C,  affirms  the  prevalence  of  night-blindness 
m  the  Confederate  Army  of  Northern  Virginia,  partieularly  at  the  period  of  the  occupation 
of  Fredericksburg.'^'  The  soldier  who  had  been  marching  all  day  complained  at  nightfall  ' 
that  he  could  not  see,  and,  like  a  blind  man,  walked,  holding  the  arm  of  a  comrade.  Xo 
constitutional  symptoms  were  manifested  and  the  eyes  appeared  perfeeUy  natural.  Fre- 
quently only  one  eye  was  affected.  At  first  the  complaint  was  looked  upon  as  a  trick  of 
the  malingerer;  but  the  continued  dilatation  of  the  pupil,  when  exposed  to  the  light  of  a 
candle,  demonstrated  tlie  morbid  condition.  It  was  considered  to  be  a  local  innervation  due 
to  meairro  diet,  the  want  of  vegetables  and  vegetable  acids  and  the  various  depressing  influ- 
ences  that  then  affected  the  soldier's  health.  Medication  was  of  little  avail.  Cases  fre- 
quently recovered  spontaneously  after  treatment  had  hoQn  discontinued.  According  to  Dr. 
AVm.  Hays  of  Covington,  Ky.,f  at  one  time  a  prisoner  of  war  at  Point  Lookout,  ]\Id.,  the 
disease  was  of  iVequent  occurrence  at  that  de|)ot.  His  account  does  not  differ  fi'om  that  of 
Dr.  Hicks.  In  some  cases  the  conjunctiva  was  injected  and  sometimes  the  liils  were  granu- 
lar and  the  corm.'a  ulcerated.  Innervation  from  exposure  to  jiowerlul  sunlight  is  mentioned 
as  thr'  excitinf  cause.  Scurvv  was  a  frequent  coinrilication.  Wlien  the  u'enei'al  health  was 
inqinived  the  sight  became  restored. 

Pt.'rhaps  the  llrst  mention  of  night-blindness  in  Amrrican  medical  literature,  as  a  symp- 
tum  of  the  scorbutic  dyscrasia,  was  made  by  Dr.  Edward  Coalk,  U.  8.  Navy,  in  his  account 
of  the  epidemic  of  scurvv  which  affected  the  crew  of  the  frigate  Columbia  in  her  cruise 
around  the  world,  1838-40. J  The  vessel  carried  450  men,  liut  so  many  became  affected 
with  inability  to  see  after  sundown  that  the  deck-work  could  not  be  carried  on  without  their 
assistance.  During  the  increase  of  these  cases  scorbutic  disease  became  distinctly  manifested. 
Eno-llsh  observers,  however,  connected  nyctalopia  with  scurvy  at  an  earlier  date,§  and  recent 
papers  appear  to  confirm  the  connection. || 

Xutwithstanding  the  intimate  association  witli  scurvy  demonstrated  by  the  history  of 
nio-ht-blindness,  it  is  questionable  if  this  constitutional  state  is  ntlier  than  one  »(  many  causes 
of  a  debilitating  character  that  predispose  to  the  local  affection.      Xight-blindness  may  occur 


*Sec  Ilkhilmid  3Ir,li,-nl  .r„«nml  Vol.  Ill,  18fi7,  Jiago  K.  f  rmcimmliJ''m-nHl  ■/ 3[,-,'.khi,'.  Vul.  I,  If'O;,  ,,a,CT  :U5. 

J  Aiic-rinm  J,:>inml  •■/  the  Medical  *ci<«c-c«,  Vul.  Ill,  N.  S.,  Is4.;,  ir.ijXL'  OS  li  »■../. 

f  Thus  ClLDEKT  Blank,  in  his  Ohm-ralhim  mi  the  biiemcs  of  ck-iiiiieii,  L.mduii,  ITMl,  p.  4S."i,  lias  tliL-  f.,Ilo\\  iiig  ]suagra|ili  ;  TIrtc  is  a  rfuiarkalj'.t-  syuili- 
tom  siimi'tinios  attciulaiit  on  this  disease,  wiiiih  has  escaped  the  notice  of  authuis.  This  is  the  Mjvfal„pi.i,  inentione.1  in  Jlr.TKLrORD's  report.  It  was  also 
rouimon  in  the  garrison  of  Gihraltar,  among  those  affeited  with  scurvy  duriuf.-  the  sieje,  as  I  was  infurmeii  l>y  Mr.  Cmrncro.ss,  surgeon  to  one  of  the 
battalions.  It  sometimes  takes  place  in  tliat  incipient  state  of  the  disease  which  does  not  show  itself  hy  any  visible  symptom,  hut  betniys  itself,  as  men- 
tioneil  above,  by  erchnaumi'  in  case  of  bruises  or  by  scorbutic  ulcers. 

Thus  of  fifty  prison  cases  treated  by  .V.  PouTEn,  31.  D.,  Civil  Surgeon,  .\koI^,  India,  and  reported  in  the  Madras  M"uthhj  Journal  of  Medicd  Science,, 
Vol.  V  1872,  p.  25:!,  nyctalopia  was  present  in  thirty-seven  cases  or  ~i  per  cent.,  and  was  the  earliest  symptom  in  thirty  cases  or  00  per  cent. 


708  SCURVY. 

in  tlie  absence  of  scurvy ;==  Lut  duuljtfnlly  in  the  absence  of  all  debilitating  causes.  Gen- 
erally, also,  there  is  a  iiotalile  rxposurr  [>>  ilirt-i-t  (.>r  I'eflcctfil  suiiliulit.  The  followinir  extracts 
illustrate  this: 

SurgeO)t  ,J.  V.  Ha.mmomi.  I'.  .S.  .1.,  Fuit  JcffiixMi,  I'Ut.,  ■Inn.  1,  isiil'. — Xyctaldiiia  occiineil  in  a  volunteer  and  was 
occasioned  liy  the  glare  of  liglit  reflected  from  the  water  or  from  the  wliite  sand.  It  was  treated  by  an  emetic,  calo- 
mel, .salts,  cups,  blisters,  bandages  to  the  eyes  excluding  the  light,  rest  and  low  diet.  He  \vas  perfectly  restored  in 
a  few  days.  After  the  lapse  of  a  month  or  two  the  di.sease  recurred,  caused  by  tlie  relli'ction  of  light  from  the  water. 
He  has  undergone  the  same  treatment  and  has  now  recovered. 

Act.  Ain't  Surgeon  W.  K.  S.mith,  Sioux  Cilij.  louu.  March  31,  ]t<62. — The  snow,  high  winds  and  occasionally  the 
reflection  of  a  bright  sun  explain  the  cases  of  nyctalopia  which  a])pear  in  my  (unirterly  report.  Exclusion  of  strong 
light,  rest  and  a  collyrium  composed  of  sulphate  of  zinc  and  morphia  constituted  the  means  effective  for  the  relief 
and  ultimate  cure  of  all  the  cases  that  occurred. 

Dr.  TrjPLEE,  in  liis  article  on  scurvy,  written  before  the  war,  says  that  iiyctiiloi>ia  was 
of  frequent  occurrence  among  our  troo|is  in  the  field,  particularly  in  Southern  climates,  and 
niuntTuus  cases,  totally  independent  of  scurvy,  were  observed  during  the  Florida  war.f  The 
views  of  Drs.  HiCKs  and  Hays,  referring  the  loss  of  sight  to  a  local  iiUK-rvation  in  constitu- 
tions enfeebled  by  hardships  and  exposures,  may,  therefore,  be  accepted  as  correct. 

The  MORBID  AN.\TOMY  of  scurvy  is  not  clearly  defined  by  the  post-mortem  notes  that 
have  been  preserved.  In  one  case  only,  51,  was  the  condition  of  the  blood  stated;  but  from 
the  invariable  presence  of  subcutaneous  and  intermuscular  exti-avasations,  noted  clinically, 
or  of  sanguineous  effusions  into  the  lungs  or  serous  cavities  observed  after  death,  the  abnor- 
mal  condition  of  the  blood  may  be  regarded  as  a  constant  lesion. J  The  brain  was  seldom 
examined  or  seldom  presented  any  noteworthy  changes.  The  lungs  were  usually  congested 
and  adherent,  often  tuberculous.  The  pleural  and  pericardial  cavities  frequently  contained 
effused  liquid.     The  heart  was  soft  and  flabby;  fibrinous  clots  were  sometimes  found  in  its 

*  .\ftpr  the  olosi'  of  the  war  the  writer  accompanied  four  comimnies  of  the  14th  V.  S.  Infantrj-  on  tlieir  niarcli  from  the  coast  of  t'aliforuia  into  the 
Territory  of  .\rizoiKi,  Three  men  hccanie  nij;lit-l>l!uil  in  crossini-  tlio  Carrizo  Desert  to  Yuma,  wIkto  the  siui-glare  on  tlie  sand  was  very  trying.  Tlicy 
were  not  scorliuties.  Tliey  had  heen  well  fed  on  the  short  voyage  to  California  hy  way  of  the  Isthmus,  and  hefori'  hegiiining  their  march  they  remained 
two  or  three  months  at  San  Francisco,  where  they  had  an  abundance  of  fresh  vegetables  and  fruits. 

t  Chieiumiti  hiiirel  awl  Ol-srrrer,  Vol.  I,  185S,  ]page  l:!2. 

I  The  QArlieT  pogl-iiwiiem  observations  in  cases  of  scurvy,  as  well  as  those  made  in  recent  years  with  the  microscoi)e  and  chemical  processes  as 
accessories,  give  prominence  to  the  condition  of  the  bhuHi.  During  the  second  voyage  of  Cartier  to  Newfoundlanil,  153'»,  liis  crew  of  110  men  became 
severely  affected.  "  This  malady  being  unknow  n  to  us,  the  body  of  one  of  our  men  was  opened  to  see  if  by  any  means  possible  the  occasion  of  it  miglit 
be  discovered  and  the  rest  of  us  preserved.  *  «  «  The  heart  was  found  white  and  putrid;  its  cavities  were  quite  full  of  corrupted  blood.  The 
lungs  were  blackish  and  putrid;  more  than  a  quart  of  n-ddish  water  was  found  in  the  thorax.  The  liver  was  pretty  sourul;  but  the  sjdeen  scjmewhat 
corrupted  and  rough,  as  if  it  had  tieen  rubbed  against  a  stone."— IIaki.ut's  C'oUetiirm  n/  Vniinijef,  Vol.  :i,  \i.  22"i,  quoted  by  James  Lino  in  his  IVc.idV 
OH  the  .St'io/;/,  Loudon,  1757,  p.  2'.pS.  Lord  Anson's  snrgeoTis,  1740-41,  observed  that  when  the  malady  was  well  advanced  the  hlocnl  ran  thin  and  seem- 
ingly very  black,  "and  after  standing  some  time  in  the  porringer  turned  thick,  of  a  dark  muddy  color,  the  surface  iti  many  places  of  a  greenish  hue, 
without  any  regular  si'paration  of  its  jiarts.  In  the  third  degree  of  the  disease  it  came  out  black  as  ink ;  and  thimgh  kept  stirring  in  the  vessel  many 
Ih.ui-s  its  fibri.ns  parts  had  only  the  appearance  of  a  ciuantity  of  wool  or  hair  tloating  in  a  muddy  substance.  U\  dissected  bodies  the  blood  in  tin'  veins 
was  so  entirely  broken  that  by  cutting  any  considerable  branch  yon  might  empty  the  part  b.  which  it  b.'b.nged  of  its  black  and  yellow  liquor ;  aiel  when 
found  extravasaterl  it  wiis  all  of  the  same  kind."— //.i./,  p.  iSo.  JI.  f'liAi.vET  examined  bl.iod  taken  in  .lUaiitities  of  2j  to  30  grams  from  the  small  veins 
of  the  forearm  in  si-orbutii-  cases  and  f..uud  it  fluid,  lale  and  watery.  The  clot  which  fi.nued  was  extremely  den.se  and  small  and  the  serum  in  unusual 
<inantity.  The  fliirin  of  the  clot  was  in  excess  of  that  found  in  normal  blood  ;  it  contained  4.5  parts  per  thousiind,  but  as  the  case  i)rogressed  the  qmmtity 
-limiuished,  .\  slight  im  rea.se  of  albumen  was  observed  in  the  serum— 72  parts  per  thousand  as  comisired  with  Oil  parts  in  nomml  bloo.1.  The  globules 
were  reduced  to  K)  parts  |kt  thousand  as  against  LIS  piirts  in  normal  blood  used  in  a  parallel  experinuuit.— See  Civile  ll,l,il„im,ihii,e  tie  Mulnhie  el  di- 
Chinirgie,  '1'  t-rie,  t.  VIII,  ls71,  p.  21'.i.  These  observations  are  essentially  similar  to  those  of  BlRK,  quote.!  from  the  Sydenham  Society's  clition  ..f 
Simnu'a  ClifiiiMni,  by  !>nrgeon  Tkipler  in  his  article  on  scurvy.     They  were  made  in  three  scorbutic  casi'S  that  occurred  in  the  Dreaduaught  Hospital 

ship  and  are  as  follows:  ..      ,  . 

Si-orbunc.  Ibaltliv 

, ■ ,        I1I.«h1.' 

Wgt,,r_     S4'.i.ii  SM.'.i  sli;.:;  7SS.S 

Solid  cousVituentsIIIIIIIIIIIIIIIIIlIIIIirilllll-.lIIIII-IJllII-lI'-I-IlI •■''"■1  l''*'  •■"'■<•■■*  211.2 

Fibrin  _._ <■■■•  l-^  ■>■■<  ■^■■'^ 

.\lbu.u.-u ^-l"  ''•■''  '*■■-  <"■"■- 

Ul.."d  corpuscles '■''>  '-■■'  '■'"■'  !■»•' 

.Salts....-! •■>■'■         n-^>  I"-'  '■> 

.\ciordiMg  t.i  the  Liiiiril,  Lund,,  V<d,  I,  ISsr.,  p.  11:!4,  the  blood  of  three  cases  of  uncomplicated  scurvy  under  the  car.'  of  F.  STAzKvr.  n,  In  the  mili- 
tary h...spital  at  M..S.-..W.  was  .lark  and  tiniil.  an.l  sli..we.l  irregular  nd  corjiuscdcs  and  mor.'  or  l.'ss  atn.phii'.l  .■.irpus.l.'s  coli.-riug  t..gethcr.  Aft.'r  r.'.'.iv- 
ering  this  irr.gnlarity  di.»<ipi»ar.-.l.  The  pI.Mira,  heart  and  aortic  valves  were  ecchynnjsed.  The  spl.'.'U  was  .-nlarg.'.!,  light-colorc-il  and  friabl.^ ;  tli.' 
liver  enlarg,-.l ;  tin-  .-..rt.^x  of  tin-  kidneys  thicken. -.1.  The  int.'stinal  mu.-..ns  m.-nibraue  was  soft,  sn.dl.^n  an.l  .■.■.liynn.si-.l,  tli.'  s.ililary  glan.ls  iMilargid 
in  one  cas.- ;  the  c.lon  ul.erate.l  in  one  case  ;  the  perit.m.-al  glands  eiilarg.d  in  all.  Th.'  brain  was  amemic.  Tin-  mi.Mle  glutei  mns.h-s  hail  extravasa- 
tions between  their  fas'-icnli.  The  livir-,-.  lis  w.t.'  enlarL-..!  an.i  cb.u.l.v.  as  were  also  th..se  of  the  epithelium  of  the  urimiry  i^ssig.^s.  The  alv.-,,li  of 
the  me3.-nteri.-  glands  w.  r.-  .nlarged  and  filled  with  round  c.dls  of  the  size  of  white  ctirj.uscles.  Th.'  nmc.ms  lining  of  the  small  int.-stiue  was  disorgan- 
ized, the  cotni:ieucemcnt  of  the  lymiJiatics  containing  finely  granutar  detritus  and  the  vessels  distended  and  surrounded  by  extravasatious. 


SCUKVY.  709 

chambers.  Tlie  alimentary  canal  from  the  stomach  downwanl  was  inorc  or  less  congested, 
occasionally  ecchymosed;  iiseudo-memltranous  dysenteiy  was  a  frequent  complication.  The 
mesenteric  glands  were  generally  affected,  even  in  the  absence  of  ulceration  or  much  conges- 
tion of  the  intestine.  The  peritoneum  contained  effused  liquid  and  the  viscera  were  some- 
times matted  by  adliesions.  Xo  constant  hepatic  or  splenic  lesion  was  observed.  The  kidneys 
were  sometimes  congested. 

PATiiOLOiiY,  Causation  and  Tkkatmext. — These,  in  the  case  of  scurvy,  are  so  inti- 
mately connected  that  it  is  impossible  to  speak  of  one  without  at  the  same  time  discussing 
the  others.  When  scurvy  was  first  observed  among  the  crews  of  the  earlv  ocean  navigators 
the  disease  was  regarded  as  a  contagious  malady.  The  same  view  was  taken  by  many  of 
our  soldiers  who  saw  it  for  the  first  time  during  their  confinement  at  Andersonville,  for 
Jones  informs  us  that  they  sedulously  guarded  their  wells  and  springs,  fearing  lest  some  one 
suffering  with  scurvy  might  use  the  water  and  thus  poison  them.  Aj)parentlv  the  wonder- 
ful recoveries  following  the  use  of  fresh  }>rovisions  when  a  vessel  reached  ]iort,  or  on  the 
return  of  spring  in  the  case  of  outbreaks  on  land,  should  have  demonstrated  that  the  disease 
was  connected  with  the  continuance  of  a  salt-meat  dietarv  or  the  alisence  of  trreens  and 
fresh  vegetables;  but  medical  men  continued  to  ascribe  it  to  bad  air,  dampness,  improper 
diet  and  mental  despondency,  while  prescribing  iid'usions  and  syrups  of  scurvy-grass,  w^ater- 
cresses  and  other  herbs  or  the  juice  of  oranges  and  lemons  as  medicaments.  At  this  time 
a  depraved  condition  of  the  blood  in  scurvy  was  generally  acknowledged,  the  causes  assigned 
being  the  imperfect  materials  from  which  this  important  fluid  was  elaborated  and  the  failure 
of  the  skin  and  kidneys  to  effect  its  purification.  Cockbukx,'-'  in  1696,  referred  the  origin 
of  the  disease  to  salt  provisions,  and  pointed  out  how  speedy  was  recovery  under  the  use  of 
coleworts,  carrots,  cabbages  and  turnips.  He  insisted  that  if  proper  care  was  taken  with 
their  diet  seamen  would  not  be  so  liable  to  the  disease.  BACK.STROM,f  in  1734,  contended 
that  the  primary  cause  of  the  disease  was  an  abstinence  from  fi'esh  vegetable  food  and  greens, 
and  that  although  other  secondary  causes  might  concur,  recent  vegetables  were  an  effectual 
preventive.  Keamee,^  Lind]!  and  ]^lane§  insisted  on  the  value  of  lime-juice  as  preserva- 
tive against  the  disease.  From  the  experiences  on  which  these  opinions  were  based  the 
abnormal  condition  of  the  blood  was  of  necessity  referred  to  a  lack  of  something  contributed 
to  the  system  by  fresh  vegetables  and  fruits;  and  as  the  acid  quality  of  many  of  these  was 
their  most  notable  characteristic,  the  pathology  of  the  disease  was  considered  unveiled. 

Not  until  1848  was  a  further  advance  made  in  our  knowledge  of  the  causes  and  pre- 
vention of  the  scorbutic  condition.  Then  ALFRtzD  B.  Gaerod  of  the  University  College 
Hospital  identified  the  particular  element  of  the  diet  which  appeared  by  its  absence  to  occa- 
sion the  disease. II  He  jJointed  out  that  although  fruits  containing  organic  acids  are  highly 
antiscorbutic  the  acids  themselves  are  not  so;  that  milk,  on  which  the  infant  thrives  during 
the  first  year  of  its  existence,  contains,  when  fresh,  no  organic  acid,  and  that  all  the  sub- 
stances noted  as  antiscorbutic  contained  larger  proportions  of  }iotasli  than  the  articles  of  a 
scorbutic  diet.  His  conclusions,  which  were  advanced  rather  as  hypothetical  than  as  proved 
bv  extended  experiments,  were  very  generally  accepted  by  the  profession.^y 

*  t^L-e  LiNTi's  excellent  gunimary  of  the  literature  of  this  subject,  i»age  3S1  uf  his  Treati^^f  on  the  ik-i'rnj^  Lomlou,  1757. 

t  Ihhl,  imgc  3M.  X  IliM,  page  412.  il  Tbid,  page  160  el  seq. 

i  Blane  regavdeil  tile  iiitruduction  of  lime-juice  iuto  the  navy  sujiiilies  as  an  era  in  naval  liistor.v.  It  \v!i.«  first  Lssued  on  his  reconiniendation  in 
17113,  hut  he  asirilies  the  credit  of  having  effected  its  acceiitance  to  the  earnest  writintr  uf  Lin:-.  The  ijuautity  tiven  daily  to  i-acli  man  was  at  first  three- 
.juarters  of  an  ounre  with  two  ounces  of  brown  sugar.— Cil/s<!ri<i(roiis  oh  tte  Di-'easef/  Seaiuiii,  by  (.u.uruT  IIlavk,  London,  ITy'.l,  ]>.  4W. 

ij  MouOibj  .Jminml  of  Medical  Science,  Vol.  VIII,  1848,  page  4.57. 

il  They  were  iis  follows :  1st.  That  in  all  seorbutie  diets  )>ot.ifli  exists  in  much  smaller  c|uantilies  tlian  in  those  which  are  capable  of  maintaining 
health.    2d.  That  all  sutetances  proved  to  lut  as  autiscorbuties  contain  a  large  ijuautity  of  p,>l,tiJi.    M.  That  in  scurvy  the  blooil  is  deflcieut  iu  polasli  and 


710 


SCURVY 


Meauwliilo,  in  this  country,  limr-juioe  as  a  substitute  for,  or  representative  of,  a  fresh 
vegetable  diet  became  so  intimately  associateil  in  the  professional  mind  witli  the  prevention 
and  cure  of  scurvy  tliat  it  seems  as  if  tlie  operation  of  predisposing  agencies  had  bi-come 
foraotten;  for  when  Ass't  Surireon  Johns  reiiorted  some  of  these  influences  as  havin'j;  con- 
duced  to  the  production  of  scurvy  at  Fort  Laramie,  Wyoming  Territory,  in  1858,  he  was 
called  upon  by  the  Surgeon  General's  Office  for  further  investigation  and  report. '■'  His  state- 
ment of  the  causes  was  fornniiated  as  follows: 

I.  That  the  primarij  cause  of  scurvy  is  the  absence  of  material  furnished  to  the  l)]ood  hy  fresli  vegetable  matter. 

II.  That  froni-the  primary  cause  the  disease  is  (h-nloptd  by — 1.  Hepression  from  exi)osuie  to  cold,  particularly 
during  guard  duty  at  night  and  the  long-continued  cold  of  winter:  2.  Depression  from  fatigue:  3.  Jn-tufficioif  V()itil<(- 
tioii  and  crowding  of  men  in  a  restricted  place,  whether  in  company  ijuarters  or  on  sliipboard:  4.  Too  great  a  pre- 
ponderance of  salted  food. 

This  brief  sketch  of  the  history  of  our  knowledge  of  scurvv  brings  us  to  the  [leriod  of 
the  war.  Tlie  disease  had  been  satisfactorilv  connecti'il  witli  a  deficient  dietary.  Its  preva- 
lence amon"  bodies  of  men  whose  only  constant  insanitary  factor  was  the  limitation  of  the 


the  quantity  of  that  substauce  thrown  out  hy  t!ie  kidneys  less  than  that  ^vlli^■h  occurs  in  Ip'jilth.  -itli.  That  scnrhiitir  patients  will  tccuvt'i-  w  lim  pni,i..-}i  is 
added  to  their  fuod,  thf  utlier  constituents  renniining  fus  hi'furc,  both  in  nuantity  and  iiuality,  and  without  tlic  use  of  siucnlcut  vcgctabh-s  ur  milk.  5th. 
That  the  theory  which  astTihci*  scurvy  to  a  deficiency  of  jiohtsh  in  the  food  is  also  cajiable  of  rationally  explainini;  many  syniiitinns  of  that  disease. 

*  The  report  of  Ass't  Surfjcon  JotiNS  wa.s  rof^iirdod  witli  interest  its  sujrfiestiny;  the  iiroduction  of  scurvy  jtt  I>ai'aniit'  from  local  causes,  some  df  which 
niiglit  b»'  determined  by  further  nhservation.  It  was  htdd  in  the  first  place  that  the  garrison  at  Fort  Laramie  wa-;  iirobabiy  provided  with  a  more  liberal 
antiscorbutic  iliet  than  certain  frontiersmen  and  quartermaster's  eniphiyO;*  in  the  ueighburhoud  of  the  post,  nitm-  of  whom  had  suffered  fnun  scurvy. 
The  immunity  of  tin'  luoiintalu  men  having  been  attributed  by  Dr.  Joiixs  to  their  living  chielly  on  fn-sh  meat,  Surgeon  K.  C.  M'iini>,  on  behalf  of  the 
Surgeon  tieneral's  Ottiee,  inquired  how  it  came  that,  as  regards  scurvy,  the  condition  of  these  men  could  be  considered  better  than  that  of  the  troops  at  a 
post  where,  as  at  Laramie  at  the  time  iu  question,  the  commissariat  had  on  hand,  besides  oi'd  Iiead  of  lieef  rattle,  7.1;>N  rations  of  mixeil  desiccated  vege- 
tables, 8,701.1  rations  of  desiccated  potatoes  and  large  riuantities  of  dried  apples,  pickles,  sugar  and  nudas^^es.  It  was  further  slmw n  l.y  a  reference  to  the 
attstracts  of  issues  of  a  formeryear  that  fresh  meat  was  supplied  to  the  <|uarternmster's  men  in  much  less  proitortiun  than  to  the  troo]is,  and  that  while  the 
latter  liad  what  might  be  considered  huge  quantities  of  desiccated  potatoes  and  niixetl  vegetables  the  former  had  nime  ;  nevirtheless  the  quartermaster's 
men  had  been  but  little  affected  by  the  siorbutic  taint.  Moreover,  contrasting  the  condition,  as  regards  scurvy,  of  the  garrison  of  Laramie  with  that  of 
the  troops  on  ai.tive  service  iu  Utah,  it  was  found  that  while  4'1  cases  wei-e  reported  from  the  fi>rmer  command,  averaging  o2o  ofhcers  and  men,  during 
the  five  niuulhs,  Nov.  1,  1857,  to  March  IU,  IS58,  only  17  cases  were  reported  from  the  latter,  averaging  l,8fH)  ullicers  and  men.  Ihiring  this  period  the 
troojis  in  Utah  were  much  exposed  in  tents,  were  w  itho'it  vegetables  aiul  did  not  have  tumw  of  the  component  parts  of  the  regular  ration  with  which  the 
conmiissariat  at  Laramie  was  fully  supplied.  Assuming  the  accuracy  of  these  data,  it  was  claimr-d  that  scurvy  at  Laramie  must  liave  been  due  less  to  a 
deficient  vegetable  supply  than  to  certain  other  conditions  which  affected  them  to  a  greater  e.xtent  than  tlie  other  classes  uf  men  jnentloned,  as  for 
instance:  1.  A  want  of  sutTicient  ventilation  of  the  quarters  allotted  to  the  troops;  2.  A  want  of  due  proportion  of  regiUar  exercise  in  the  open  air; 
3.  An  impropriety  in  the  manner  of  cooking  of  the  food.  Ass't  Surgeon  Johns  was,  in  this  connection,  requested  to  report  on  :  1st.  The  kind  of  build- 
ings occupied  by  the  troops  at  Laramie,  their  occupancy,  ventilation,  heating,  etc.;  2(1.  The  numner  of  cooking  the  food  ;  3d.  The  duties  of  the  troops, 
and,  4tli.  Shelter,  tiuties  and  habits  as  to  clothing,  exerci.se,  food,  etc.,  of  the  iiuarternuister's  employes.  In  reply  to  this  Dr.  Jotixs  dwelt  strongly  on 
t!ie  moindony  of  existence  as  a  cause  of  the  di.sease  in  the  soldiers.  Apparently  the  chief  jioiut  of  distinction  between  tiie  duties  perfornu-il  liy  the  quar- 
termaster's men  and  the  soldiers  consisted  of  the  guard  duty  required  of  tlie  latter  at  night.  The  quarternnister's  emidoyes  perfornu'd  more  labor  than 
the  soldier,  lait  it  was  of  a  ditferent  character  and  exercised  a  dillerent  intluence  on  the  mental  and  pliysical  condition  of  the  men.  A  certain  monotonous 
routine  and  confinement  hedged  the  soldier  on  all  sides.  His  guard,  drill  and  police  duties  were  unvarying,and  so  fatiguing  on  this  very  account  that 
wlien  left  to  llim^elf  at  their  conclusion  he  seemed  to  feel  little  inclination  to  do  aught  but  vegetate  in  his  bunk,  witli  some  occasional  spasmodic  effort 
at  foot-ball.  '*In  tlie  topography  of  a  sentiuerrt  post  the  cliief  characteristic  is  the  hf>-line.  This  is  the  straight  and  narrow  patli, — from  it  there  is 
turning  neither  to  the  right  liand  nor  the  left.  Longitudinally  'thus  far  and  no  farther'  is  tlie  fiat ;  and  tiiu.<,  for  two  mortal  hours,  or  any  given  nujre 
or  less  mortal  time,  according  to  the  exigencies  of  the  service  or  thermometer,  the  military  pendulum  vilirates  his  monotonous  existence  until  the  twice 
blesst'd  'relief  releases  liim  from  the  efl'ort  to  keep  liis  falx  cerebri  iu  and  parallel  to  the  same  plane  of  direction  as  that  of  his  post.  Thus  there  is 
necessjirily  a  monotony  of  mental  action,  depressing  in  its  character,  too,  from  this  verj'  monotony,  afibrding  no  stimulus  to  n-sist  the  nnirbific  effect  of 
exposure.  Of  course  I  particularly  refer  to  the  garrison  duty  of  a  peace  estiiblishment,  when  tliere  is  little  to  put  the  soldier  ou  the  qui  lire  of  mental 
and  physical  vivacity, — and  in  ten  years  I  liave  never  known  a  sentinel  to  have  a  good  excuMc  even  to  cry  *fire.'  Js'ow,  add  to  this  hopeless  nn_*ntal 
monotony  the  effects  of  depressing  cold,  imrticularly  at  nigiit,  after  a  day  of  monotonous  pemhilisfic  fatigue,  and  it  would  seem  that  no  better  reagent 
could  be  desire<l  for  either  iiroducing  diseases  characterized  by  debility  or  for  developing  studi  a  disease  from  a  germ  derived  from  other  causes.  *  *  * 
Drill  is  also  another  efTurt  to  keep  the  falx  in  the  plane  of  certain  directions  and  to  produce  i>antograi>hic  results  with  iiodies,  lindisand  inuski'ts  or  other 
weapons.  Police  duty  is  a  daily  funeral  proi-ession  around  the  garrison  with  twig-brushes  instead  of  cy]iress  lioughs  for  the  mourners.''  lint  tlie  worl; 
of  the  employes  of  the  Quartermaster's  Dei«irtnu'ut  afforded  healthy  occuiuition  for  the  mind  as  well  Jis  for  the  body.  As  carju-nters,  blacksmiths,  etc.. 
they  preserved  their  individuality;  even  the  teamsters,  having  the  management  of  tiieir  animals  and  a  wholesome  variety  in  their  work,  were  unalTected 
!iy  the  mental  depression  resulting  from  a  monotonous  existence.  The  niuiintain  nn'U  of  the  country,  being  their  own  masters,  were  even  in  better 
circumstances  in  this  respect.  Thej'  hunted,  fished  and  were  idle  at  their  jdeasure.  As  to  fresh  meat  and  sujiplies  of  desiccated  veg*'tables,  Dr.  Johns 
suggested  that  the  <|uantities  issued  to  tin.'  trooi)s,  not  those  on  hand  in  tlie  ciimmissariat.  must  be  used  in  the  argument.  Carefully  stored  in  Injxes  and 
issued  honKetqiathically,  the  vegetables  had  i^o  efiect  in  raising  a  command  from  a  scorlmtic  condition.  Ou  the  other  hand,  the  higher  pay  of  the  quar- 
termaster's men  enabled  them  to  purchase  from  the  sutler  a  variety  in  their  diet,  inchnling  fresli  canned  fruits,  oysters  and  other  luxuries,  whii  h  was 
beyond  tlie  reach  of  tlie  soldiers;  nevertheless  scurvy  did  occasionally  aiijieur  among  them.  The  frontiersmen,  as  to  diet,  liad  facilities  for  procuring 
.sucli  antiscorbutics  as  could  not  beobtainetl  by  tlie  soldiers.  In  jdace  of  the  tough  and  stringy  beef  cattle  of  the  post  they  liad  juicy  venison  from  the  hills. 
In  jdace  of  the  salt-junk  of  the  soldier,  which  had  transferred  to  the  lirine  it.s  i)liospliates,  acids,  kreatine,  etc.,  necessiiry  to  tlie  formation  of  blood,  they 
used  a  dried  meat  which  had  lost  none  of  its  nutritive  essentials  in  parting  with  its  water.  Keferring  to  the  freeihim  of  the  troops  in  L'tah  from  scurvy, 
Dr.  Joiixs  consideretl  it  siitficiently  exphiined  by  the  mental  influences.  They  went  into  winter  iiuarters  after  a  wholesome  inarch  across  the  plains,  and 
they  were  in  lively  antiiipation  of  something  like  active  service  to  vary  tlie  monotony  of  the  previous  condition  of  peace.  In  concluding,  he  held  to  the 
proposition  that  scurvy  rer-ults  primarily  from  imperfect  supply  t>r  ratio  of  supply  of  the  three  kinds  of  material  for  the  body — azotized,  non-nzotized  and 
earthy,  the  point  of  departure  being  the  want  of  fresh  vegi-table  matter. 


SCURVY.  711 

food-supply  to  a  certain  issue  sufficiently  proved  tliis  point.  Salt  meat,  as  Ibnning  the 
staple  of  the  scorbutic  diet,  had  home  for  a  long  time  the  opproljrium  of  its  production;  but 
this  view  was  not  entertained  in  our  camps, — occasionally  the  continued  use  of  the  salted 
ration  was  mentioned  among  the  causes  of  an  outfireak,  Init  from  the  context  in  most  cases 
ot  this  kind  it  is  evident  that  the  consequent  deprivation  of  fresh  food  supplies  was  the 
expression  intended.  The  theory  entertained  acknowledged  certain  of  the  constituents  of 
fresh  vegetables  as  essential  to  the  perfect  nutrition  of  the  tissui'S  and  to  the  prevention  of 
the  scorbutic  condition,  many  of  the  reports  indicating  the  salts  of  potassa  as  the  salutary 
principles. 

But  other  so-called  causes  are  frecjuentlv  mentioned.  These  include  every  inilucnce 
tliat  tended  to  lower  the  vital  powers  of  the  soldier, — sueh  as  over-fatigue,  loss  of  sleej), 
exposure  to  cold  and  wet,  particularly  at  night,  over-crowding  in  rpiarters  and  the  diseases 
to  which  these  influences  predisposed.  Evideiillv  the  belief  was  entertained  that  all  con- 
ditions and  circumstances  causing  waste  of  tissue  i-eipiired  an  increased  ingestion  of  the 
speciid  material  supplied  by  the  fresh  vegetables  as  well  as  the  albuminoids  and  carbei- 
hydrates  that  formed  the  bulk  of  the  mitritive  supply,  and  that  the  i>roportion  of  the  former 
which  would  preserve  the  l)alance  of  health  under  certain  conditiuns  would  incline  fo  scurvy 
when  these  became  more  exhausting.  Chief  among  the  adynamic  inflnencfs  was  dejiression 
of  spirits  i'rom  whatever  cause, — in  the  individual  from  nostalgia  and  private  or  personal 
trouf>les  and  anxieties,  and  in  the  command  from  ennui,  tla^  endomie  prevalrn.ce  of  disease 
or  the  gloom  and  despondency  attending  disaster  to  the  flag, — among  the  jtrisoners  of  war 
this  was  no  doubt  a  powerful  predisposing  agency. 

Prior  to  the  outbreak  of  the  llebellion  the  L",  S.  Arinv  ration  consisted  ot' — 

Thvei'-fourtlis  ofii  iiuniid  of  pDik  or  l)acon  or  oue  and  a  iVmrtU  poniuls  of  fre.sli  or  salt  1icef:  cif;liti'i'n  ounces  of 
l)read  or  tloiir  or  twelve  onuces  of  hard  broad,  or  one  and  a  fonrtli  jionnd.s  corn-meal :  and  at  the  rate,  to  one  hnndreil 
rations,  of  eijj;ht  (jnarts  of  Uean.s,  or  in  lieu  thereof,  ten  i)onnds  of  rice,  or  in  lieu  thereof,  twice  ])er  week,  one  hunilM-d 
and  fifty  ounces  of  desiccated  potatoes  and  one  hundred  ounces  of  mixed  vej;etaliles:  ten  iiounds  of  colVec,  or  in  Ii<-u 
thereof,  one  and  a  half  pounds  of  tea;  fifteen  ))oiiiiils  of  sui^ar:  four  (|iiarts  of  vineirar:  one  iiound  of  sperm  candles 
or  one  and  one-fourth  pounds  of  adamantine  candles  or  one  and  one-half  poll  mis  of  tallow  candles;  four  jiounds  of  soap 
and  two  <iuarts  of  salt. 

But  the  act  of  Congress,  ajiproved  August  3,  bSiil,  providod  lor  an  increase  during  the 
continuance  of  the  war: 

Section  13,  And  be  it  J'lirlhir  euadid.  That  the  army  ration  shall  lie  increased  as  follows,  viz;  Twenty-two  ounces 
of  bread  or  tlour,  or  one  pound  of  hard  bread,  instead  of  the  present  issue:  fresh  beef  shall  be  issued  as  often  as  the 
commanding  otMcer  of  any  detachment  or  regiment  shall  re(iuire  it.  when  jiractieable,  in  [dace  of  salt  meat ;  beans 
and  rice  or  hominy  shall  be  issued  in  the  same  ration  in  the  jiroportion  now  ]inividcd  in  the  regulation,  and  one  pound 
of  potatoes  per  man  shall  be  issued  at  least  three  times  a  week,  if  practicable,  and  wlicn  these  articles  cannot  be  i.ssued 
in  these  proportions,  an  e(|uivalent  in  value  shall  be  issued  in  some  other  projier  food,  aud  a  ration  of  tea  may  be  sub- 
stituted for  a  ration  of  cotfee  upon  the  re(|uisition  of  the  )iroper  othcer;  Proridvd,  That  after  the  present  insurrectiou 
shall  cease,  the  ration  shall  lie  as  provided  by  law  and  regulations  on  the  first  day  of  .July,  eighteen  hundred  and  sixty- 
one. 

The  Heriscd licf/HJafions  for  tin:  Armi/  in  force  during  tlic  war  formulat(?d  this  increased 
ration  as  lollows  : — 

A  ration  is  the  established  daily  allowance  of  food  for  one  jierson.  For  the  fnited  States  .'Vrmy  it  is  comiiosed 
as  follows:  Twelve  ounces  of  pork  or  bacon,  or  one  pound  and  four  ounces  of  salt  or  fresh  beef:  one  jiound  ami  six 
ounces  of  soft  bread  or  llour.  or  one  pound  of  hard  bread,  or  one  jiouud  and  four  <iuuces  of  corn-meal  :'and  to  every 
one  hundred  rations,  lifteen  pounds  of  beans  or  jieas,'  niid  ten  pounds  of  rice  or  hominy:  ten  jiounds  of  green  c<ift'ee. 
or  eight  pounds  of  roasted  (or  roasted  and  ground)  cotfee,  or  one  ]iounit  and  eight  ounces  of  tea:  fifteen  pounds  of 
sugar;  four  quarts  of  vinegar;  one  jionud  and  four  ounces  of  adamantine  or  star  candles;  four  pounds  of  soap;  three 


«  Beans,  iieas,  Kilt  nnil  imtatoc's  (fri-sli)  slia.ll  lio  inurliusnl  iiii.l  issiir.l  aiul  s.'M  I'.v  «.i;;lit.  iiii.l  llii-  l.ushrl  i.f  uarli  shall  l.i-  I'^tiiiiat.-.!  at  turlij  jmmiii. 
Thus  lew  rations  of  Ix-ans  or  iwas  will  I...'  fiftwn  pounils.  the-  f.|uivalclit  of  .-i^lit  .|iiarts:  li«l  rations  of  salt  will  !..■  thr.c-  |i..un.N  and  tiwlvo  ounces,  the 
equivalent  of  two  (luails;  and  100  rations  of  piftatoes  ^fresh)  will  he  thirt.v  pouuils,  tin-  e.iui^alenl  of  half  a  liuj-hel. 


712  scunvv. 

jvouiids  and  t  wi'lveounoes  of  salt:  fimr  duiiiis  of  peiiiici  :  thirty  iiouLiils  of  potatoes,  when  iiiacticalilo,  and  one  (|iiart 
of  molasses.  The  Snlisistenec  I'ejiaitiiieiit.  a~  may  In-  most  convenient  or  h-ast  exjiensive  to  it,  and  aeeoi'diu}^  to  the 
eondition  aiid  ainonnt  of  its  supplies,  shall  detennine  whcthet  soft  liread  nv  tloiir,  ;iii(l  what  other  eoniponeiit  jiart  of 
the  ration,  as  eijiiivalents.  shall  he  issued.  Ilesir-eatcd  eouipressed  potatoes,  or  desieeated  compressed  mixi'd  vef^eta- 
hles,  at  the  rate  of  one  ounce  and  a  half  of  the  foinier  and  on<'  ounce  of  the  latiei.  to  the  ration,  may  lie  «iih«lilutal 
for  beans,  jieas,  rice,  hominy  or  fresh  iiotatoes. 

The  desiccated  }>otatoes  and  mixed  vegetables  of  tiie  ration  before  the  war  were  insuf- 
ficient of  themselves,  in  the  quantities  issued,  to  ]>i-evciu  liie  ajijiearance  of  scurvy.  It  was 
supposed,  however,  tliat  the  other  articles  (..f  the  ration  were  in  excess  of  the  needs  of  the 
men,  and  provision  w;is  made  for  creditine-  each  conipanv  with  the  inonev  vtdue  of  that 
portion  which  was  not  drawn  from  the  commisstiritit  for  consumption.  This  credit  consti- 
tuted the  basis  of  a  company  fun<l,  which  was  disbursed  bv  the  captain  for  tlie  benefit  of  tlie 
enlisted  men  of  his  company,  pursuant  to  the  resolves  of  a  council  consisting  of  all  the  com- 
pany otHcers  present.  A  comptuiy  commander  by  exercising  due  supervision  over  the  nK'ssing 
of  his  men  was  enabled  to  save  money  for  the  purchase  of  vegetables.  Practically  the  com- 
pany officers  in  council  were  authorized,  if  they  found  it  for  the  benefit  of  tlieir  men.  to  let 
any  jiart  or  the  whole  of  the  ration  remain  undrawn  and  purchase  food  supplies  in  open 
market  with  its  money  value.  Generally,  however,  the  troops  were  stationed  where  there 
were  no  supplies  other  than  those  retailed  bv  the  sutler  at  exorbitant  prices.  Hence  the 
existence  of  scurvy  during  tlie  winter  and  early  spring  months  at  posts  unfavorably  situated. 

The  considerable  additions  made  to  the  ration  at  the  beginning  of  the  war  would  liave 
enabled  experienced  company  officers  to  have  accumulated  a  largo  fund  for  use  in  varving 
the  diet  of  the  men  and  preventing  the  scorbutic  taint;  but  volunteer  officers  were  in  general 
ignorant  of  their  duties  in  relation  to  the  domestic  economv  of  military  I'ommands,  and  any 
excess  of  iood  that  was  not  wasted  by  improvident  cooking  was  thrown  away.  Subsistence 
ofHcers  also  frequently  discountenanced  the  attempt  of  company  officers  to  improve  the  diet 
of  their  men  by  ]iieans  of  a  company  fund,  as  it  complicated  their  accounts  wdien  sometimes 
all  their  energies  were  required  to  suppl}-  the  ordinary  issues.  Of  course  there  were  many 
notable  exceptions,  especially  in  camps  of  some  permanence,  where,  through  the  good  man- 
agement of  the  officers,  company  I'unds  were  accumulated  and  used  to  advantage;  and  as  in 
these  instances  the  company  cooking  was  usually  of  a  superior  order  and  the  men  well  cared 
for  in  other  respects,  these  commands  presented  a  marked  contrast  to  those  less  efficiently 
officered. 

But  Congress  made  a  liberal  provision  for  the  volunteer  soldiers  of  the  war.  The  issue- 
of  an  abundance  of  the  albuminoids,  fats  and  starclies  w;is  authorized;  and  to  ward  off  the 
scorbutic  taint,  whether  dependent  on  the  continued  use  of  salt  provisions  oi'  on  an  absti- 
nence from  vegetables,  the  Subsistence  Department  was  required,  if  practicable,  to  issue  fresh 
meat  on  the  order  of  a  commanding  officer  of  a  military  command  and  to  furnish  one  pound 
of  fresh  potatoes  three  times  a  week  to  every  man.  Unfortunately,  the  clause  //  practicable 
defeated  in  a  number  of  instances  the  intent  of  the  legislators;  and  cases  occurred,  as 
reported  by  Medical  Inspector  Hamilton,  of  regiments  which  for  months  at  a  time  received 
not  a  single  issue  of  fresh  potatoes  and  were  thus,  but  for  somewhat  better  facilities  for  pur- 
chases, in  no  better  condition  as  regards  the  prevention  of  scurvy  than  the  soldiers  that  gar- 
risoned Laramie  and  other  Western  posts  before  the  war;  but  when  these  cases  were  brought 
to  notice  liy  the  reports  of  the  medical  officer  or  medical  inspector  special  efforts  were  made 
and  the  practicability  of  the  distribution  demonstrated. 

In  the  treatment  of  the  developed  disease  a  fresh  vegetable  diet,  fresh  meat,  acids,  salts. 


SCUEVV.  713 

of  potash  and  tincture  of  iron  were  employed.  From  thi.s  the  theories  of  causation  adopted 
hy  our  medical  ofRcers  may  be  inferred.  Fresh  vegetables,  meat  and  milk  forme<l  the 
staples  of  cure  as  well  as  of  prevention.  Among  the  vegetables  ust^d  were  potatoes,  onions, 
tresli  or  pickled  cabbage  or  sour-kro>it.  lemons,  oranges,  limes,  sweet  potatoes,  watermelons, 
green  corn,  etc.  Corn-meal  is  highly  lauded  by  one  officer,  and  its  use  by  Mexican  troops 
is  suggested  as  the  cause  of  their  freedom  from  scurvy;  but  the  scorbutic  condition  of  the 
Confederate  armies  on  a  corn-meal  ration  disjiroves  his  conclusions.'-' 

The  vegetable  acids — acetic,  citric  and  tartaric — were  frerjueiitl  v  emploved,  and,  according 
to  some,  with  advantage;  but  in  these  cases  an  improvement  in  tlic  diet  was  alwavs  cuincident. 
Others  regarded  these  acids' used  alone  as  of  no  value.  Vinegar,  which  has  been  a  recog- 
nized antiscorbutic  since  the  days  of  the  early  navigators,  was  highly  valued  and  much 
used;"!"  but  there  is  no  ground  for  assuming  that  a  diluted  acetic  acid  possesses  any  value. 
Vinetfar,  in  addition  to  its  volatile  acid,  contains  solid  matter  of  veo;etable  derivation.  In 
exceptional  cases  the  mineral  acids — diluted  nitric  and  sul])huric — were  prescribed. 

Of  the  potash  salts  the  bicarbonate  was  p>referred,  given  in  conjunction  with  the  vege- 
table acids;  sometimes  the  bitartrate  was  used;  occasionally  the  nitrate;  but  as  fresh  vege.- 
tables  were  invariably  added  to  the  diet  it  is  impossible  to  determine  the  amount  of  benefit 
derived  from  the  medication.  The  chlorate  of  potash  was  in  gimeral  use  as  a  local  applica- 
tion to  the  gums;  several  officers  testify  to  its  value  when  used  internally  in  doses  of  twenty 
to  sixty  grains  daily.  Weak  solutions  of  nitrate  of  silver  were  also  prescribed  as  topical 
applications. 

Iron  was  supplied  to  the  patient  in  the  form  of  the  tinctura  ferri  chloridi  in  doses  of 
fifteen  or  twenty  drops  three  times  a  day.  Sometimes  this  acid  tincture  was  used  locally 
to  promote  a  healthy  action  in  the  scorbutic  sores. 

Diarrhoea  was  treated  by  opiates  and  astringents,  irrespective  of  the  general  antiscor- 
butic cause;  but  special  medication  was  not  employed  on  behalf  of  the  pains  unless  they 
persisted  after  the  scorbutic  condition  was  apparently  removed,  when  colchicum,  guaiacuiu 
and  iodide  of  potassium  were  tried. 

Tonics,  stimulants  and  change  of  air,  occupation  and  mental  impressions,  the  last  often 
effected  by  a  visit  home  on  furlough  and  at  other  times  l)y  the  opening  of  a  campaign,  were 
the  means  adopted  to  perfect  the  cure. 

The  danger  of  mereurializino-  the  scorbutic  patient  was  occasionallv  noted:  but  lew 
instances  have  been  placed  on  record. J 

It  cannot  be  said  that  the  history  of  scurvy  in  our  armies  has  added  much  to  our  knowl- 
edge. It  shows  how  readily  the  disease  may  be  controlled  by  the  adoption  of  appropriate 
measures;  but  this  had  already  been  repeatedly  illustrated.  It  shows  the  powerfully  pre- 
disposing influence  of  all  the  causes  of  adynamia;  but  this  was  also  already  well  known. 
It  shows  that  although  the  law  may  provide  adequate  means  for  the  prevention  of  the  dis- 
ease, the  desired  and  anticipated  results  may  not  always  follow  on  account  of  difficulty  in 
procuring  or  transporting  the  supplies  needful  for  large  bodies  of  men  under  the  changeful 
conditions  of  active  military  service.     Perhaps  this  is  its  most  instructive  lesson.     From  it 

*  Pr.  .losKPH  Jones  attriViiiteil  tlic  I'xUti'iicc  of  scurvy  at  AnilersoUTille  to  the  ofil-cts  of  salt  meat  ami  an  unvarj-ing  ilii-t  of  corn-meal,  with  hut  few 
vegetables  and  imperfect  supplies  of  vinegar  and  syrujt ;  to  these  he  added  the  intlueuce  of  the  foul  animal  emanations  from  the  crowded  and  pestilential 
stockade. — Report  No.  4o,  Fortieth  Congress,  ;id  Session,  AVashington,  ISilVi.  p.  110. 

t  Surgeon  51eBRinK,  4<ith  Ohii),  called  attention  to  the  value  of  vinegar  in  an  article  in  the  Ciiiciintnti  Laitcel  ami  Ohserier,  Vol.  V,  1SG"2,  page  300. 

t  .\n  instance  of  violent  salivation  resulting  from  tie'  apidication  of  a  small  quantity  of  mercurial  ointment,  intended  for  the  destruction  of  lice, 
is  mentioned  in  the  Cliicmjo  Meiliml  Joiinuit,  Vol,  XIX,  18i'.2,  p.  -174. 

Med.  Hist.,  Pt.  Ill— 90 


714  scri;vY. 

may  be  foreseen  the  occasional  apjiearance  of  tlie  cli>rase  in  time  of  war,  unless  the  anti- 
scorbutic principle  be  meanwhile  oljtained  in  a  form  in  whit-h  its  issue  to  the  troops  will  be 
more  frequently  practivahlc  than  when  assooiateJ  with  fresh  bt'cf  on  tlie  hoof  and  potatoes 
in  barrels. 

Although  Garrod's  theory,  indicating  a  deficiency  of  potash  in  the  blood,  lias  been 
before  the  profession  for  many  years,  accurate  quantitative  determinations  of  the  salts  of 
scorbutic  blood  have  yet  to  be  made.  Shortly  after  this  theory  was  suggested  the  nitrate  of 
potash  was  shown  to  jiossess  no  antiscorbutic  virtues.*  It  was  also  generallv  ol>served  that 
although  fresh  beef  and  nuitton  contained,  according  to  Gaerod's  own  analyses,  very  notable 
quantities  of  potash,  their  antiscorbutic  cpialities  were  not  proportionately  manifested.  Dr. 
Buzzard*}"  pointed  this  out,  and  suggested  in  explanation  that  the  form  in  which  the  organic 
salts  of  potash  exist  in  vegetable  substances  renders  them  more  easily  absorbed  and  decom- 
posed by  the  digestive  sys'tem  than  the  potash  salts  of  animal  tissues.  Somewhat  later 
ChalvetJ  suggested  that  the  chemical  combination  of  the  potash  in  fresh  meat  and  dried 
leguminous  vegetables  prevents  its  assimilation  by  the  human  system.  The  phosphates  of 
dried  peas  and  beans,  and  the  chlorides,  phosphates  and  nitrates  found  in  meat  are  too  stable 
to  be  decomposed  in  the  economy  and  are  passed  from  the  body  for  the  uiost  part  unchanged ; 
but  the  potash  of  fresh  vegetables  exists  in  the  form  of  easily  decomposed  salts  of  the  organic 
acids,  as  citrates,  tartrates,  malates,  etc.,  which,  when  ingested,  are  transformeil  into  carbon- 
ate,— and  this  salt,  when  in  excess,  gives  an  alkalinity  to  the  urine  and  at  all  times  presents 
the  base  to  the  tissues  in  an  assimilable  form;  the  acid  being  removed  by  the  circulating 
current  and  the  potash  fixed  in  the  tissues  by  the  luitritive  processes  as  phosphates,  chlorides, 
etc.  This  explains  the  want  of  relation  between  the  quantity  of  potasli  in  certain  articles 
of  diet  and  their  anti^coi'butic  value. 

Much  evidence  miirht  be  adduced  on  behalf  of  the  efficiency  of  fresh  meat  as  an  anti- 
scorbutic. §  The  preservation  of  hunters,  trappers  and  mountain  men  from  the  disease  has 
been  frequently  ascribed  to  their  constant  use  of  fresh  meat  or  meat  dried  with  all  its  salts 
intact.  The  Indians  also  have  been  frequently  quoted  in  this  connection. ||  But  in  all  these 
instances  the  absolute  exclusion  of  vegetable  substances  is  not  positively  determined.^     On 

*  It  was  trii'il  lij-  (iiiliT  (if  tho  Dirpctnr  General  of  the  British  Xavy  ou  scorlnitic  convicts  en  ronle  to  Xew  Zi'alaml,  Tlie  nitrate  at  the  end  of  two 
weeks  was  foimil  to  act  so  injuriously  and  to  he  taken  with  so  much  reluctance  that  its  use  on  one  vessel  was  aliaiidoued.  In  anotlier  set  of  cases  it  caused 
irritability  of  the  stoniacli  and  relaxation  of  the  bowels  to  such  adcjiree  that  it  was  uecessary  to  combine  oiiiuni  with  it.  In  a  third  set  it  seemed  to  impair 
the  jiowcrs  of  digestion  and  iissiniilatiou  aud  wa.s  therefore  considered  injurious.  Alkxasiieu  Keysox— who  reported  the  results  of  these  exiieriniouts— 
thought  it  would  be  worse  than  cruelty,  under  any  circumstauces,  to  iiersist  iu  the  exhibition  of  this  salt  either  as  a  proiihylactic  or  means  of  cure.— See 
Medical  Times,  Vol.  XXI,  London,  1S50,  i>.  213. 

t  IteijurMs'.HijtIem  of  Medicine,  Vol.  I,  Loudon,  1800,  i>age  740. 

X  (ia-.elte  lIcMomwlmie  de  Mnleciue  cl  de  rl,inii;jie,  2'  S.,  t.  VIII  (ISTl),  page  21'J, 

§Thu3,  in  tlie  outbreak  at  Couin-il  Bluffs— see  note,  siqirn,  page  0S3— tiie  men  detailed  as  hunters,  who  resided  in  the  w  ,iods  aud  subsisted  .m  game, 
were  iu  no  instance  unhealthy;  and  an  (»utlying  detachment,  under  tho  command  of  an  officer  who  fed  bis  men  entirely  upon  IVesli  no'at  from  the  woods, 
experienced  no  sickness  of  any  kind. — roltnv,  iu  Americuu  Joiirnid  of  the  Medical  S<--ienceK,  X.  S.,  A'ol.  Ill,  1S42,  ]t.  80, 

II  Ass" t  Surgeon  Wasiiixgtox  JIatthews,  U.  S.  A.,  in  his  lidmoijropliii  and  I'Inlolopii  of  the  Hiidasia  Indians,  Wasliingtou,  I),  f'.,  1S77,  p.  2.5,  says: 
"Formerly  they  lived  largely  upon  meat ;  when  out  on  their  liunts  and  war-paths  they  ofti'n  lived  exclusively  on  it.  There  were  many  nomadic  tribes 
around  them  who  seldom  tasted  vegetable  matter,  often  living  for  seven  or  eight  months  in  the  year  exclusively  on  meat  and  jircserving  perfect  health. 
I  have  seen  white  men  who  had  lived  for  years  among  the  Indians,  and  during  such  resilience  for  six  months  of  every  year  lived  on  nothing  hut  meat 
(and  water  of  course),  'buffalo  straight,'  as  they  expressed  it,  and  who,  in  the  summers  only,  occasionally  varied  their  diet  with  a  mess  of  roots  or 
berries,— not  seeking  such  vegetaljlc  fooil  with  any  jiarticular  longing  or  avidity.  In  various  books  of  Western  travel  these  statements  are  corroborated  : 
yet  there  are  modern  physiologists  who  would  try  to  persuade  us  that  an  animal  diet  is  inadequate  to  the  sustaining  of  human  life  in  a  healthy  condition." 

1^  Surgeon  T.  C.  JIadisox,  V.  S.  A.,  already  cited  in  note,  siipi-a,  page  OS:i,  attributed  the  healthy  condition  of  the  Fur  ('iini]iauy's  men  and  the 
Indians  not  solely  to  the  fresh  game  or  dried  buffalo  meat  on  which  they  subsisted,  but  to  this  and  tlie  i|uantities  of  dried  plums,  bnffiilo  and  clioke 
berries  which  they  imt  up  for  winter  use.  ,\nd  even  llr.  JIatthkws,  in  the  paragraph  succeeding  that  just  ipioted,  has  the  following:  "A  portion  of 
tlieir  corn  they  boil  when  uearly  ripe  ;  they  then  dry  and  shell  it  and  lay  it  by  for  winter  use  ;  when  boiled  again  it  tastes  like  green  corn.  This  is  often 
boiled  with  dried  beans  to  make  a  succotash.  Their  hcaus  are  not  usually  eaten  until  ripe.  Sfjuashes  arc  cut  in  thin  slices  and  dried  ;  the  dried  squash 
is  usually  cooked  by  boiling.  Sunflower  seeds  are  dried,  slightly  scorched  iu  pots  or  pansover  the  Are  and  then  powdered.  The  meal  is  boiled  or  made 
into  cakes  with  grease.  The  sunflower  cakes  are  often  taken  on  war-paths,  and  are  said,  when  eaten  even  sparingly,  to  sustain  the  consumer  against 
fatigue  more  than  any  other  fond.  They  gather  all  manner  of  dried  roots  and  berries  that  are  eaten  by  the  nomadic  tribes  of  the  same  region;  but  they 
do  not  consume  them  to  the  extent  that  the  wilder  tribes  do.*' 


DISEASES    ATTRIP.UTEU    TO    NON-MIASMATIC    EXPOSURES.  715 

the  other  hand,  many  instances  might  be  cited  from  the  literature  of  the  suijject  where,  in 
the  })resence  of  more  powerful  predisposing  factors,  fresh  meat,  in  the  absence  of  vegetables, 
has  failed  to  protect  from  scurvv/-'  i>ucli  testimonv  indicates  that  although  fresh  meat 
possesses  an  antiscorbutic  value  which  may  be  preservative  under  favorable  conditions,  its 
qualities  in  this  respect  are  by  no  means  equivalent  to  those  manifested  by  a  similar  inges- 
tion oi'  potash  salts  as  furnished  by  fresh  vegetaljles. 

By  comparing  the  analysis  of  scorbutic  and  healthy  urine,  Dr.  PiALFE.f  of  the  Seamen's 
hospital,  Greenwich,  England,  has  inferred  that  in  the  diseased  condition  there  is  a  dimin- 
ished alkalinity  of  the  blood;  and  as  the  home-service  diet  of  the  British  soldier,  which 
includes  potatoes  and  other  vegetables,  contains  a  much  larger  proportion  of  salts  susceptible 
of  conversion  into  alkaline  carbonates,  that  the  diminished  alkalinity  must  be  attributed 
mainly  to  the  withdrawal  of  these  readily  decomposable  salts  from  the  diet.  The  potential 
alkalinity  of  the  soldier's  ration,  which  is  regarded  as  a  typical  antiscorbutic  diet,  is  equiv- 
alent to  10.3  grams  of  bicarbonate  of  potash,  while  that  of  the  sailor  is  equal  to  only  5.9 
grams.  He  points  out  that  under  no  condition  has  the  blood  ever  been  observed  to  become 
acid,  and  that  its  normal  degree  of  alkalescence  cannot  be  reduced  without  causing  disturb- 
ances of  nutrition,  citing  in  evidence  the  ex}>eriments  of  Ley])EN  and  Mtnk  and  F.  Hoff- 
mann, which  show  that  attempts  to  reduce  the  alkalinity  of  the  blood  in  animals  terminate 
in  death  with  chano-es  in  the  blood  and  tissues  identical  with  those  found  in  the  bodies  of 
jaersons  who  have  died  of  scurvv.  It  would  seem,  tlierefore,  that  the  disease  is  due  to  a 
chemical  alteration  in  the  qualitv  of  the  blood  which  interferes  with  the  processes  of  nutrition. 

But,  whether  scurvy  is  caused  by  a  deficiency  of  p(:itash  in  a  readily  assimilable  form 
or  by  a  change  in  the  blood  from  a  want  of  the  alkaline  salts  that  are  best  supplied  by  the 
vegetable  kingdom,  it  is  evident  that  soldiers  in  the  field  may  easily  extract  materials  from 
the  ashes  of  their  camp-fires  to  sujiplement  a  defective  diet.  It  must  be  remembered,  how- 
ever, that  the  antiscorbutic  virtues  of  the  salts  in  question  have  not  been  satisfactorily 
demonstrated. 


CHAP.  IX.— OX  DISEASES  ATTRIBUTED  TO  XOX-.MIASMATIC  EXPOSURES. 

Apart  from  miasmatic  influences  the  exposures  incident  to  active  service  in  our  armies 
were  credited  with  the  development  of  acute  diseases  of  the  urgans  cf  respiration,  tonsillitis, 
diphtheria,  rheumatic  affections,  consunqjtioli,  etc.  Tlie  continuance  of  cold  rainy  weather 
durin^'-  a  campaign  was  productive  of  an  access  of  such  cases.  The  active  occupations  of 
the  camp  or  inarch  protected  the  men  during  the  day  from  the  injurious  effects  of  the  weather; 
but  at  niiiht  they  were  fully  exposed  to  its  influence,  whether  standing  guard  in  camp  or  on 
picket,  or  endeavoring  to  gather  warmth  enough  amid  the  all-pervading  moisture  to  enable 
them  to  pass  a  few  hours  in  sleep.  Fresh  levies  were  especially  prone  to  suffer  under  such 
conditions.  A  tedious  railwav  journey  in  bad  weather,  with  a  bivouac  in  the  streets  at  its 
conclusion  or  temporary  quarters  in  some  unwarmed  building,  was  often  as  disastrous  to  a 

«FKEDEKirK  iRVixo  Df.  LiSLK,  Medical  Times  and  Gazette,  Vol.  II,  Londi.u,  IfiTT,  |..  3111,  st.iti's  tli.it  the  dUc-ase  ajiin-arcii  am.iiii:  the  s.iuattcrs  in 
Queensland  dtiring  the  droughts  .if  ISGii  an.1 18C8,  when,  during  the  ilearth  uf  vegetables,  they  lived  upon  leau  mutton  and  baked  flour  :  also,  that  during 
the  war  in  New  Zealand  in  iMKi-T"  a  scorlmtie  taint  wa.<  developed  among  the  troops,  wli.ise  rations  consisted  of  lean  mutton  and  hisenit.  Many  instances 
are  citi'd  hv  liuzZARU,  in  his  artii.le  on  fycnrnj  in  Reinwl'f'  l<ilftem  ';f  Jledkinr,  Vol.  I,  Loudon,  ISWl,  pp.  737  el  se,i. 

■\Iiiqiiinj  into  the  Geiiend  Vuth.Aogti  of  Seumj,  by  Cu.lKLES  Ursrv  EALrr.,  hmret,  Loudou,  1877.  Vol.  I,  p-  fTC  and  Vol.  II,  ]..  81. 


716  DISKASKS    ATTr.inUTEI)    TO    XOX-MIASM ATIC    KXPO>n;K>. 

new  ivw-iment,  en  roufo  to  tlie  front,  as  some  of  its  subsequent  liattles.  Xotable  variations  iu 
temperature  were  injurious  even  wlien  the  degree  was  not  absolutely  low.  The  specific 
poison  of  measles  rendiTfJ  new  ti-oo])s  particularlv  susceptible  to  catarrhal  attacks  from 
trifling  exposures. 

Cold  and  dampness  manifested  their  combined  effects  even  in  winter  cpiartcrs,  when  the 
men  were  supposed  to  have  made  themselves  as  conrfortable  as  possible.  Sometimes  this 
was  due  to  insulEcient  supplies  of  clothiufr  and  blankets.  Fror|uen(ly  the  camp  soil  was  so 
retentive  of  moisture  that  no  system  of  trenching  sufficed  to  give  the  troops  dry  huts  and 
protect  their  feet  from  the  dampness  and  discomfort  of  the  mud  of  tlieir  camp-ground. 
Catarrhs,  sore  throats  and  rheumatism  were  endemic  in  these  undesirable  locations. 

The  difficulty  of  heating  the  tent  or  hut  was,  at  first,  a  cause  of  much  sickness.  Camp- 
stoves,  furnished  by  the  supply  department  or  purchased  by  the  men,  were  small  and  of 
thin  metal.  A  few  pieces  of  wood,  which  were  consumed  in  as  many  minutes,  rendered  the 
air  of  the  confined  space  oppressively  hot,  but  if  the  tent  liad  any  ventilation  the  teraperatui'e 
fell  immediately  until  again  raised  by  fresh  supplies  of  fuel.  Hence,  to  avoid  excessive  over- 
heating and  the  labor  of  constant  attention  to  the  stove,  an  attempt  was  usually  made  to 
prevent  the  escape  of  the  warm  air  from  the  tent.  Every  aperture  by  which  the  foul  air  of 
the  interior  might  be  replaced  by  cold  streams  from  without  was  carefully  chinked.  But 
the  endeavor  to  retain  the  foul  air  led  to  greater  hygienic  errors:  It  converted  the  hut  into 
a  cellar  by  excavation  and  the  banking  up  of  the  excavated  earth  against  the  outer  aspect 
of  the  walls.  It  led  also  to  overcrowding  for  the  sake  of  warmth,  and  to  permit  of  the 
clubbing  of  blankets,  overcoats,  shelter-canvas,  rubber  blankets  and  other  available  bedding. 
From  crowded  holes  of  this  kind  tvphoid  pneumonias  and  diphtherias  were  reported  instead 
of  the  catarrhs  and  cpiinsies  of  simple  exposure  to  cold. 

Medical  officers  condemned  these  attempts  at  comfort,  and  in  subsequent  winters  a  better 
style  of  log  and  canvas  hut  was  constructed  by  the  troops.  Men  who  knew  nothing  of  this 
kind  of  work  took  hints  in  l)uilding  from  the  backwoodsmen  of  Maine  and  Michigan.  The 
new  huts  were  trenched  on  the  outside  to  secure  dryness  of  site;  they  were  floored  with  split 
logs  and  provided  with  a  roomy  fireplace.  A  more  equable  temperature  was  secured,  espe- 
cially at  night;  but  ventilation  was  defective  and  the  space  overcrowded. 

In  the  hastily-constructed  pavilion  barrack-rooms  of  permanent  quarters  the  heating 
arrangements  for  winter  occupation  were  generally  insufficient.  Men  whose  bunks  were 
near  the  stove  or  fireplace  were  usually  overheated,  while  those  at  a  distance  were  exposed 
to  cold  from  the  pervious  character  of  the  walls.  Unequable  heating  was  associated  with 
defective  ventilation  and  overcrowding. 

Although  generally  attributed  to  cold  and  dampness,  bronchitic  attacks  are  in  some  of 
the  reports  regarded  as  originating  in  the  inhalation  of  dust  and  irritant  sandy  particles. 

The  followinsj  extracts  are  submitted: 

Surgeon  Isaac  F.  (Jalloitk,  l~th  Mass.,  Xcw  Berne,  X.  C,  April  1,  1862. — The  only  prevailing  disease  has  been 
bronchitis,  and  the  cause  of  its  prevalence  was  long-continued  exposure  to  moisture  consequent  upon  leaky  quarters 
and  insufficient  protection  of  the  feet  against  wet. 

Sitryeon  J.  A.  Wolf,  2i>th  Pa.,  Frederick,  Md.,  Dec.  31,  1801. — Since  our  return  to  Camp  Carniel  the  prevailing 
complaints  have  been  mild  catarrhal  aSections,  yielding  readily  to  ordinary  expectorant  mixtures  and  other  mild 
remedies.     This  is  rather  renuirkable,  since  many  of  the  men  had  wet  feet  during  almost  the  entire  march. 

Surgeon  Jxo.  S.  Jamison,  86//i  .Y.  F.,  Good  Hope,  Md.,  Dec.  31,  1861. — The  regiment  has  changed  its  location  three 
times.  These  changes  have  haiqiened  in  inclement  weather,  and  before  the  tents  of  the  men  could  be  made  comfort- 
able at  each  new  location  many  cases  of  catarrh  were  developed.  Three  cases  of  pneumonia  have  grown  out  of  these 
cases  of  catarrh. 


DISKASKS    ATTKIIU'TKI)    TO    XON-M  I  A.-.M  ATIt '    K.\  PO.-L'RKS.  717 

Suri/foii  J.  M.  Bates,  VMh  Mi.,  Slii2)  ^»'"»''.  Mixt..  April  2.  \XyVl. — My  iiiiiiressiou  is  that  iiuiiiy  liui;;  iliseascs  were 
iiidiiceil  by  overheateil  and  iiiadc(|Matrly  vi'iitilated  tents,  anil  .snihlrn  exposure  tip  I'lild  on  t;i''"S  ""'  "liili"  in  a  state 
of  jK'ispiratiuii  with  insiil'ticient  clothing. 

Axti't  Surijcon  A.  J.  Dickkhihifk.  2~lli  1 II.,  Londnn.  Tiiiii.,  I'lh.  28.  1865. — The  roijiniPiit  was  on  tlie  move  dnring 
the  greater  part  of  the  month,  generally  in  a  rolling  country  in  the  region  of  the  Holston  and  Frencli  Uroad  rivers, 
above  Knoxville.  The  weather  was  changeable  and  at  times  very  inclement,  with  cold  rains  and  one  snow-fall.  The 
roads  were  muddy  and  as  the  shoes  of  many  of  the  men  were  worn  out  their  feet  were  generally  wet;  the  clothing  of 
many  was  inaileqnate  and  their  shelter  insutticient,  Vutt  this  latter  was  in  part  remedied  by  their  energy  and  their 
exi)erience  as  old  soldiers.  Some  of  the  inarches  were  difficult;  some  forced:  some  nnule  by  night.  There  was  an 
unusual  number  of  rjcumatic  cases,  luost  of  them,  however,  not  reiiniring  excuse  from  duty;  many  of  these  seemed 
to  be  the  result  of  soreness  or  sprain  from  hard  nuireliing  in  addition  to  the  rheumatic  tendency.  Ca.ses  of  respiratory 
disease  were  not  so  numerous  as  might  have  l>een  expected  under  the  circumstances.  The  symptoms  in  the  more 
serious  cases  were  active  but  not  severe.  Treatment  was  at  first  moderately  antiplilogistic,  including  the  use  of 
quinine  if,  as  was  usual,  malarial  symptoms  were  also  present;  afterwards  diaphoretics  and  expectorants  were  used. 
I  infer  that  for  the  prevention  of  this  class  of  diseases  troops  in  field  service  should  not  be  too  warndy  or  closely 
Iioitsed,  as  catarrhal  attacks  depend  more  on  sudden  or  marked  changes  in  temperature  than  on  its  degree  or  contin- 
uance. The  troops  should  be  adequately  clothed,  including  good  shoes  and  socks,  blankets,  overcoats  for  inchuneut 
weather,  sudden  changes  and  night  duty,  and  rubber  blankets  against  rain  and  for  shelter  by  day  and  night. 

Surgeon  LoriS  W.vTSOX,  lG(7i  /;/.,  Pout  Surgeon,  St.  Joseph.  Mo.,  Dec.  81,  18til. — Much  of  the  bronchitis  and  pneu- 
monia which  has  prevailed  nuiy  be  attributed  to  the  discomfort  which  the  men  have  experienced  in  gcdng  to  sleep  in 
heated  quarters  without  suitable  covering  to  guard  against  the  low  temperature  occurring  after  the  extinguishment 
of  their  tires. 

Surgeon  JcSEril  P.  Coi.G.vx,  oO/Zi  X.  Y.,  Fort  Good  Hope,  J).  C,  Jan.  'J.  18(12. — The  weather  for  the  season  of  the 
year  has  been  favorable;  yet  the  temperature  has  been  variable  and  the  transitions  quick.  This  has  produced  per- 
haps more  sickness  from  diseases  of  the  respiratory  system  than  a  colder  and  less  variable  season  might  have  caused. 
Catarrhal  affections  have  prevailed  to  a  considerable  extent.  Another  cause  of  the  prevalence  of  such  comiilaints  is 
to  be  found  in  the  fact  that  the  tents  in  which  the  men  sleep  are  furnished  with  small  sheet-iron  stoves  of  poor  quality, 
easily  and  quickly  heated  and  as  (luickly  cooled  again.  Unless  these  stoves  are  constantly  supplied  with  fuel  the 
temperature  quickly  falls  to  a  low  range,  so  that  the  men's  quarters  are  all  the  time  either  too  hot  or  too  cold.  Just 
before  the  Vireak  of  day,  when  the  tnercury  ordinarily  falls  many  degrees  lower  than  at  any  other  hour,  the  men  from 
fatigue  being  all  asleep,  the  stoves  go  quickly  out.  aiul,  as  the  top  of  the  tent  is  open  to  the  atmos]iliere,  dew,  frost, 
snow  or  rain,  as  the  case  may  be.  descends  on  the  men.  who  appear  at  surgeon's  call  with  complaints  of  pains,  coughs, 
colds,  fevers,  etc. 

Ass^t  Surgeon  T.  AV.  McAuTiiUB,  39th  Ohio,  Palmyra,  Mo.,  Dee.  31,  1861. — During  Xovend)er  there  were  several 
cases  of  diphtheria  and  pneumonia.  The  weather  was  cold,  with  snow,  and  in  nu)st  of  the  tents  some  form  of  heating 
apparatus  was  constructed,  usually  furnaces.  I  doubt  not  these  furnaces  had  much  to  do  in  producing  disease. 
I  may  here  mention  au  interesting  incident:  At  midnight  I  was  called  to  see  a  man  who  was  said  to  be  dying.  On 
arriving  at  the  tent  I  found  two  men  in  slight  spasms  while  a  third  was  wild  with  delirium.  In  the  centre  of  the 
tent  was  an  open  vessel  filled  with  coals.  The  canvas  had  been  rendered  almost  impervious  to  air  by  a  coating  of 
snow  on  its  surface.     I  lost  no  time  in  dragging  the  smothering  men  into  the  open  air.     They  all  recovered. 

Surgeon  E.  P.  MonON'G,  2i?  Md.,  Dec.  31,  1861. — The  regiment  is  quartered  in  the  common  wedge  or  servants' 
tent.  Eight  of  the  companies  were  supplied  with  tents  so  worn  by  previous  service  as  to  be  unfit  for  the  protection 
of  soldiers,  especially  at  this  season  of  the  yea'-.  Straw  has  been  supplied,  but  most  of  the  men  refuse  to  use  it, 
believing  it  to  be  a  fruitful  source  of  vermin.  The  tents  are  all  heated  by  small  sheet-iron  stoves  or  by  trenches  ])ass- 
ing  l>eneath  the  llooring,  in  one  end  of  which  a  fire  is  built.  An  aiiartment  so  small  is  (juickly  overheated,  and  the 
sudden  change  of  temperature  to  which  the  men  are  exposed  in  jiassing  in  and  out  of  the  tent  is  a  constant  source  of 
catarrhal  complaints.  Moreover,  as  there  is  no  nu-ans  of  ventilation  except  by  leaving  the  tlap  ojien.  which  no  soldier 
will  do  at  this  season,  the  atmosphere  of  the  tent  is  constantly  more  or  less  vitiated.  The  men  are  generally  clean 
and  orderly  in  their  habits.  Their  clothing  is  of  poor  material  and  they  have  been  suiiplied  with  but  one  blanket 
each,  many  of  which  are  made  of  two  thin  sheets  of  cotton  and  woolen  material  machine-stitched  together. 

Surgeon  ,Txo.  Letteum.\n,  U.  S.  A.,  Medical  Director,  Armgof  the  Potomac,  to  the  Adjutant  (ieneral  of  that  armi/, 
March  9.  18liS. — I  have  the  honor  to  invite  the  attention  of  the  Commanding  (icneral  to  a  jiractice  quite  prevalent  in 
tliis  army,  that  of  excavating  the  earth,  building  a  hut  over  the  hole  and  covering  it  over  with  brush  aiul  dirt  or 
canvas.  This  systenv  is  exceedingly  pernicious  and  must  have  a  deleterious  effect  on  the  health  of  troops  occu])yiiig 
these  abominable  habitations.  They  are  hot-lieds  for  \ow  forms  of  fever,  and  when  not  productive  of  such  diseases 
the  health  of  the  men  is  niulernnned,  even  if  they  are  not  compelled  to  report  sick.  I  strongly  reconnuend  that  all 
troops  that  are  using  such  huts  be  directed  at  once  to  discontinue  their  use,  and  that  they  be  removed  to  new  ground 
and  either  build  log  huts  above  the  ground  or  live  in  tents.  I  also  recommend  that  in  huts  covered  by  canvas  the 
covering  be  removed  at  least  twice  a  week,  if  the  weather  will  permit,  and  that  the  men  throughout  the  army  l)e 
compelled  to  hang  their  liedding  in  the  open  air  every  clear  day.  In  huts  not  liuilt  over  an  excavation,  Imt  covered 
with  brush  and  dirt  or  other  materials  which  cannot  Vic  removed,  such  apertures  as  the  Medical  Director  of  the  corps 
may  deem  necessary  should  be  made  to  allow  light  and  ventilation.  I  am  convinced  of  the  propriety  of  these  sug- 
gestions as  well  from  my  own  observations  as  from  the  information  which  I  have  derived  from  reports  of  inspections 
made  by  my  orders  within  the  past  few  weeks. 


718  DTSEASKS    ATTRinUTED    TO    XOX-MIA.-MATIt  ■    KXTOsUKE?. 

AHiiuVnuj  Siii-iicdii  Hkxuy  K.  'I'ruxr.K,  I'oii  Jdiuns,  ynvjitirt.  /.'.  r...tj»il  1,  Isi;:;. — A  l;iri;o  ]iioiiortioii  of  the  cases 
have  been  coughs,  sure  thinats  ami  rhcMiiuUic  ali'ectiims.  'Jlu'sr  \\i_-yr  yciK'iiilly  nm  scvoie.  the  iiieii  usually  return- 
ing to  duty  after  two  or  tlin'c  dnys.  The  lualadies  lV(i]ii  whicli  iln-  miniMUi  li;i>  suti. nd  liavc  bren  such  as  are  iuci- 
<leut  to  damp  (juarters  aud  a  varial.ile  climate  in  a  rcuiarkaMy  ojicii  w  inter. 

J«is't  SiirijiO)!  J.  F.  Day,  Jn.,  l(l//i  ^f^^.,  lUhni  Hoiixc.  Md..  Die.  -il.  If^til. — We  were  encamped  in  a  low.  dani)>  pieei' 
of  ground,  and  the  great  increase  of  bronchial  diseases  during  that  tim<>  indicates  that  their  prevalence  was  due  to 
the  location;  another  cause  was  the  sudden  changes  of  weather  finm  warm  to  cold  and  rice  ro'sii.  These  causes  also 
produced  the  few  eases  of  pneumonia  and  pleurisy  which  we  have  had. 

SiD-f/con  J.  Pascal  S.mitii,  G'Jtk  X.  )'.,  7u<iv  .lli.raiuJriii.  J'<t.,  Die.  31, 18G1. — The  qnarters  of  our  soldiers  are  the 
common  A  tent,  in  each  of  which  seven  or  eight  men  are  crowded.  As  these  tents  are  wholly  unsiipplied  witli  boards 
or  straw;  and  the  men  have  but  one  Idanket  each  to  separate  them  from  the  damp  ground  and  cover  themselves,  the 
predominance  of  catarrhal  ami  rheunuitic  affections  is  easily  explained. 

Siirfjeon  Ciiahi.es  A.  Dkax.  S!I//i  Cdi-jix  iV .tl'riijtic.  Fort  HikIxoii.  La.,  Fch.  19,  1864. — Pneumonia  has  been  and  is 
now  the  prevailing  disease.  It  is  caused.  I  think,  by  living  in  tents  without  lire  ami  sleeping  vvithont  sufficient  lied- 
tling  during  the  recent  cold  weather. 

Act.  JksV  Siij-f/eo)!  Cai.vi.x  0.  Pack.  11//i  U.  S.  Inf.,  Fort  Independi ticc,  Maas.,  Oci.  5,  18G1. — T'here  has  been  one 
other  cause  of  bronchial  troulile.  which  still  continues.  The  men  are  furnished  with  woollen  shirts  without  collars, 
and  there  is  a  space,  varying  according  to  the  conformation  of  the  num.  of  from  one  to  two  inches  between  tlu'  upper 
edge  of  the  flannel  shirt  aud  the  lower  edge  of  the  leather  neck-stock  entirely  Ijare  and  unprotected  by  clothing. 

Sin-fU'on  J.  E.  Saxi.ohx,  27th  loini,  Jticlsoii,  Tiiiii.,  April  'M,  1803. — Most  of  the  resjiiratory  diseases  have  been 
bronchial  coughs  merely,  the  result  of  exposure  to  spring  cold  aud  wet,  together  with  an  enfeebled  condition  of  the 
puhuonary  capillaries,  a  sequel  of  measles.  Our  limited  supply  of  expectorants  has  left  ns  little  choice  in  the  treat- 
ment of  these  diseases.  We  have  used  exteriuil  remedies  largely  and  internally  small  doses  of  ipecacuanlia.  but  par- 
ticularly a  solution  of  tartar  emetic  with  sulphate  of  morphia. 

Surgeon  Exos  G.  Chase,  104//i  X.  Y.,  June  30,  1862. — The  regiment  was  at  Kalorama,  near  Washington,  during 
the  first  half  of  April,  when  diseases  of  the  respiratory  system  prevailed  to  a  considerable  extent  owing,  I  suppose,  to 
smlden  changes  of  temperature  and  to  the  fact  that  hundreds  of  men  had  recently  recovered  from  measles  and  were 
therefore  peculiarly  susceptible  to  these  changes. 

Snrijivn  F.  11.  PkcivIIam,  '3d  J!.  /.,  Fort  If'ells,  Hilton  Head.  S.  C,  Jan.  1,  1862. — lironchitis  has  Ijccn  somewhat 
prevalent  among  the  officers  as  well  as  the  men.  This,  I  think,  is  due  in  a  large  degree  to  the  inhalation  of  dust  and 
nunute  particles  of  sand.  Owing  to  the  absenceof  rain  forsometime  past  the  surfaceof  the  ground  has  Ijeeomo  very 
dry,  aud  the  constant  nioveuuMit  of  trooiis  aud  teams  has  kept  the  atmosphere  charged  with  dust  and  line  sand, 

Siiri/eon  Pal'L  M,  Fisheu,  Stii  Me.,  Hilton  Head,  S.  C,  Dec.  81,  18G1. — Catarrhs,  bronchitis  aud  tonsillitis  have 
been  caused  by  a  deficiency  of  straw  to  protect  the  men  when  sleeping  ou  a  soil  which  has  the  subsoil  water-level 
within  three  feet  of  the  surface,  lint  other  causes  have  had  their  share  in  their  production:  The  men  have  not  had 
sufticient  clothing  day  or  night;  the  niidille  of  the  day  is  very  warm  and  the  evenings  aud  nights  cold;  the  soil  here 
is  sand,  and  when  dry  the  least  wind  or  nujtion  of  men  or  auinuils  creates  a  cloud  of  dust,  which  induces  and  aggra- 
vates all  diseases  of  the  air-passages, 

Snr/jeun  Joiix  MuKl'ilY,  92(?  Corps  d'Jfriqite,  I'urt  JIad«on,  La..  I'eh.  I'J,  1861, — On  Jan,  7,  1861,  we  were  ordered 
to  Port  Hudson,  During  a  severe  storm  the  nu'n  were  jdaced  in  open  cars  from  Brashear  to  Algiers.  Some  fifty  or 
si.xty  of  them  had  their  feet  frost-bitten.  The  regiment  was  (juartered  in  a  macliine  slio]!  without  any  conveniences 
for  building  fires,  and  as  a  result  many  were  severely  chilled.  From  that  date  imeumonia  has  prevailed,  assuming 
at  an  early  stage  a  typhoid  character  and  atlemlcd  with  great  mortality.  We  remained  at  Algiers  from  the  evening 
of  January  7  until  the  12th:  we  then  embarked  for  Port  Hudson,  arriving  on  the  11th,  The  weather  continued  cold 
aud  wet,  increasing  our  sick  report.  From  that  time  to  the  present  we  have  lost  fifteen  men :  Xumber  of  cases  of 
pneumouia  treated  during  this  period  forty-nine;  deaths  eight, 

Snrijeon  RofiERT  K,  Reih,  3(/  Cal.,  Salt  Lake  Cilij,  Utah,  March  31,  ISC:!. — lironchitis  and  catarrhs,  pleurisy  and 
pneumonia  follow  exposure  and  are  persistent  and  troublesome, 

Snrijeon  AV,  M,  S.mitii,  S'lth  X.  ¥.,  Xew  Heme,  X.  C,  Feb,  22,  1S63. — Sickness  was  greatly  increased  witliin  ten 
days  after  leaving  Elmira,  [Dee,  3,  1861,]  pneumonia,  bronchitis  and  rheumatism  being  the  prevailing  diseases. 
Many  of  the  men  had  suffered  from  measles  at  Elnura,  and  while  in  transit  to  Washington  were  nuich  exposed  in  cars 
destitute  of  stoves  or  other  warming  arrangements.  To  these  cau.ses  and  the  exposed  condition  of  the  men  for  several 
days  after  reaching  Washington,  being  unable  to  procure  straw  to  protect  them  from  the  ground  at  night,  is  undoubt- 
edly due  much  of  the  increase  of  si(  kness,  '  '  *  A  comparison  nuide  at  the  time  [shortly  after  Jan.  2il,  1862, 
when  the  camp  was  on  Meridian  Hill,  Washington,  D,  C,J  of  the  prevailing  diseases  of  regiments  that  occupied 
barracks  with  those  that  wintered  in  tents  convinced  me  that  while  fever  was  the  prevailing  and  most  serious  disease 
of  the  former,  pneumonia  was  most  freijuent  and  fatal  in  the  latter.  It  appeared  to  me  that  the  prevalence  of  pneu- 
monia was  greatly  encouraged  by  the  arrangenu'uts  adopted  for  warming  tlie  Sililey  tents.  The  sheet-iron  stove  in 
general  use  for  that  jiurpose  (iuickly  heats  the  atmosidiere  of  a  tent  to  a  high  temperature,  which  falls  rapidly  when 
the  lire  in  the  stove  goes  out.  This  fluctuation  in  the  atmosphere  cannot  but  greatly  contribute  to  the  deseloiunent 
of  pneumonia.  A  great  majority  assumeil  a  typhoid  condition.  An  early  and  vigorous  supporting  tre;itment  was 
adopted  with  gratifying  results.  Stimulants  were  generally  found  useful  and  often  used  very  freely  in  c(tnuection 
with  beef-cisence. 


DISEAS]-;s    OF    THE    IIKSI'IKATOKY    UK(.;A.\> 


719 


Siirf/con  M.  R.  G.viiE,  2.")?/i  JVi^..  Camp  UandaU,  Win..  Die  ol.lSO-'. — IJheiiiii.'itism  haslieeii  nt' ciiniiiuin  iiccunciioi' 
and  miiny  of  the  casfs  serious.  Lyiiij;  uiiou  the  damp  ground  is  no  donlit  tlio  cliiof  cause,  and  is  nearly  certain  to 
cause  a  recurrence  of  tlie  disease  in  those  who  liave  at  any  tinio  previously  suti'ered  from  its  attacks.  To  tlu'se  cases, 
if  fever  lie  a  donunant  symptom,  we  j;ivc  liist  an  active  purj^ative  of  which  calomel  is  an  important  constituent; 
then  follow  with  sucli  doses  of  opium  as  will  ijuiet  the  sntVering.  in  coniliination  with  calomel  as  an  alterative.  When 
the  gums  liave  sliown  the  mercurial  trace  that  remedy  is  dropped,  continuing  tlie  opium  as  liefore,  with  snmll  quanti- 
ties of  ipecacmuiha,  opening  the  bowels  at  occasional  intervals.  When  the  more  acute  symptoms  have  disappeared 
colchicum  is  found  serviceable,  in  proper  doses,  continued  with  the  opiate  treatment  already  instituted.  ^Ve  pay 
little  attention  to  topical  applications  in  the  acute  form  of  rheumatism,  believing  them  to  be  in  fact  of  no  service. 

I.— DISEASES  OF  THE  RESPIRATORY  ORGAXS. 

From  wliat  luis  been  subuiittod  in  the  preceding  panignipli.'^  it  is  evident  that  these 
disease.s  were  due  to  conditions  of  exjwsuro  that  were  avoidable  so  long  as  they  were 
uncalled  for  by  the  military  necessity.  Fresh  troops  had  a  greater  susceptibility  to  atmos- 
pheric influences  than  those  whose  experience  enabled  them  to  avoid  needless  dangers  and 
discomforts  and  to  protect  themselves  more  or  less  when  the  exposure  was  unavoidable. 
As  might  be  expected,  therefore,  the  prevalence  and  fatality  of  these  diseases  were  greatest 
during  the  first  year  of  the  war,  after  which  they  became  progressively  diminished.  This, 
with  the  greater  iatality  of  the  cases  among  the  colored  troops,  is  shown  by  tlie  following 
series  of  rates  : 

Table  LIV, 
Shoicing  '.he  annual  and  average  annual  rates  of  Sickness  and  Death  from  Diseases  of  the  Bespiratory 
Or'jans,  as  also  the  percentage  of  Fatcditij  of  these  diseases  among  the  U.  S.  Troops  for  the  periods 
stated,  e.vpressed  in  ratios  per  1,000  of  strength. 

WHITE  TROOPS. 


Discasi.'s  of  tho  Rosiiiratury 

Uri-'iUl:^. 


("'.at.irrli"-= 

El'i'li-niic  ciiturrli  ._ 
Aeiiti'  l.roiii'liitis__. 
Cliruiiic  hrulU'hiti.s_ 

LaryliL'itis 

I'lii'iMii  iiiiia 

IM.iiiUy 

Othi'l-di>paSL-s_ 


T..t.i! 


Yi'ar  cuiiiiii;  .Juiu-  3il — 


ISOi. 


Cases.     PiMtlis.      Casi'S.     IVaths,     I'ascs,     Iliatlis.      Caws.   ;  Heaths. 


Avera^:c  annual 
ratiu  lit — 


Pcatlis.      Ca-rs.     Ilrath 


1:1.0 

'.1. 3 

:v.t,  (1 

IS,  2 


.:« 

•M.  0 

.12 

l.'i.T 

.12 

o.n 

7.45 

34.3 

.2!! 

17.3 

.  '.ir. 

40.2 

'.!.:« 

:;iis.4 

.31 


.15 
7.23 


01-,,  1 
111,  4 
10.2 
7,4 
2*1,  It 
12,7 


.III 

!2il 


■■"1.4 

i;2. 1 


211.3 
12.11 

17.!l 


2ll'.1. 5 
111.4 


5.  .14 
.24 
.411 


.s.  1 
4.1 
9.3 
!M 
14.2 


.111 
.11) 

l.~r< 
.(« 

.IS 


.02 

.(il 


12 


12.  .3 

■(■> 

7. !' 

.111 

27.8 

(1.21 

14.  -< 

.  V< 

211. 1 

.4!l 

- 

.no 

.11-2 

.39 

1.117 

1.3.') 

24.IPK 

l.S.ii 

COLORED  TROOPS. 


I 


.18.4 


Eiiidomic  catarrh 

Afiite  liroiichitis Is.l.  3 

Chroiiii-  iiiunchitis ^ 2<i.  s 

Laryii-itis ]i;.:i 

Put'unuiuift '  Is  1.3 

Pleurisy I  nil.  1 

Other  lUseases :  47.1 


.52.11(1 
3.411 
1.112 


.01 

27.4 

1.32 

(111.  11 

.21 

s.s 

5,  si 

31.7 

1.1(1 

24.  7 

1..54 

S.."' 

53.  S 

.03 

.0.5 

.42 

123.5 

1.33 

1.12 

.^12 

U.li 

.7S 

.5.45 

.  (Ill 

1 1. 11 

.21 

1.40 

S.  SI) 

SS.II 

27.  21) 

32.44 

.74 

311. 1 

1..511 

4.24 

.  "iS 

2(1.5 

1.13 

5. 77 

T  .tal . 


Among  the  Confederate  troops  these  diseases,  as  shown  liy  TaliJe  XIY,t  '^^■'-'i'*^  of 
more  frequent  occurrence  than  aiiKmg  the  Federal  suldiers.  no  diMiljt  liecause  of  the  com- 
parative scarcity  of  clothing,  blankets  and  shelter-canvas  in  their  blockaded  territory,  and 
of  the  greater  susceptibility  of  men  moved  northward  from  a  warmer  climate.  Pneumonia, 
tor  instance,  annually  affected  103  men  of  every  thousand,  while  the  corresponding  rate  for 
our  white  troops  was  but  34,  and  the  cases  repented  as  acute  bronchitis  and  catarrhs  num- 
bered 415  yearly  per  thouisand  of  strength  as  against  192  in  the  Union  ranks. 


*  Catarrh  was  reinuveii  from  tlio  H 


St  (.f  (lis.^ases  on  tWe  Montlilv  Siek  U.-n.irts  ,hine  30,  18C2, 


t.^'ij"-'!,  race  32. 


^20 


DISKAS]-;s    OK    THE    RK^PIKATOEV    ORuAXS. 


It  appears  probable,  also,  that  o-eiierally  tliesij  diseases  wt_'re  of  as  grave  a  diameter  as 
ainoiiq  the  Federal  troops.  Joskpif.  .Iuxks  lias  jmblished  many  statistical  tallies  I'elating  to 
the  ratio  of  deaths  to  eases  in  his  article  on  the  prevalence  and  fatality  of  |ineunionia  in  the 
Confederate  armies:'-'  hut  in  most  of  these  some  factor  essential  to  accuracv  is  wanting. 
When  the  calcttlations  are  ntade  from  the  Held  reports  the  deaths  that  occurred  after  transfer 
to  the  general  hospitals  are  omitted;  when  made  from  the  hospital  reports  the  frequent 
duplication  of  cases  by  the  custom  of  entering  every  transfer  as  a  now  case  is  an  clement  of 
fallacy.  But  among  his  tables  are  two  which  give  the  needful  data:  The  troops  operating 
in  South  Carolina,  Georgia  and  Florida  during  the  nineteen  months,  January,  1862,  to  July, 
1863,  inclusive,  reported  2,220  cases,  of  wdiicli  127  terminated  fatally  in  the  field  and  370 
in  the  hospitals,  making  a  total  of  497  deaths,  ccjuivalent  to  22.4  per  cent,  of  the  whole 
number  of  cases.  During  the  eight  months,  June  to  December,  1862.  and  May,  1863,  there 
Were  repiorted  in  the  Army  of  the  AVest  and  of  Tennessee  3,023  cases  of  pneumonia,  548 
of  which  proved  fatal  in  tlie  field  and  495  after  their  transfer  to  general  hospitals,  making 
a  total  of  1,043  fatal  cases  or  34.5  per  cent,  of  the  whole  number.  These  percentages  are 
higher  than  the  actual  rates,  inasmuch  as  the  cases  tluvt  occurred  in  the  floating  population 
of  the  hospitals  are  not  included  in  the  number  of  cases  used  in  their  calculation;  but  com- 
j5arisons  are  admissible,  as  tlie  Union  rates  are  similarly  aflected. 

The  registers  of  the  Chimborazo  hospital,  which  have  been  freed  from  duplication  ot 
cases,  show  that  in  the  wards  of  this  institution  37.18  per  cent,  of  the  cases  of  pneumonia 
and  pleurisy  proved  fatal. f 

The  mortalitv  of  these  diseases  per  thousand  of  the  Confederate  strength  cannot  l;e 
obtained,  except  doubtfully  in  the  instance  of  pneumonia.  Ky  consolidating  the  various 
tables  published  by  Jones  the  deaths  caused  by  this  disease  during  a  period  of  fourteen 
months  in  an  aggregate  strength  of  72,617  men  maybe  obtained.  In  view  of  the  greater 
frequency  of  the  disease  among  the  Confederate  troops  and  the  general  gravity  of  the  cases, 
a  higher  death-rate  per  thousand  would  be  anticipated  among  them  than  among  the  v\-hite 
troops  of  the  United  States  armies. 

Table  LV, 

Contrast inr/  the  Mortality  from  Pneumonia  in  rates  per  thousand  of  strength  in  certain  of  the  Confederate 

armies  and  the  ichite  commands  of  the  Union  army. 


Conuiiaiuls. 


Streiiirtli- 


Departmpiit  of  South  Carolina,  (Jeoisia  and  Florida,  .Tanuarv,  1802,  to  July,  ' 

IWiS— 19  months .' "...■  25,7.32 

C'onfederatij  forces  at  Mobile,  Ala.,  January,  18t)2,  to  .luly,  l^G^ — 1!)  months-.  6,752 

DepartuuMit  of  Tennessee,  .June  to  December,  18C2.  and  Ma.v,  ISIB — S  months..  30, 452 

Army  of  the  Valley  of  \'irginia,  January  to  October.  18ti2 — Id  months 15,582 


3J    -^ 


O         I  Q 


P  z 


497 

151 

1,043 

50 


If).  3  12.  2 

22.  4  ;     14. 1 

34.2  i     51.3 

3.2  3.8 


Average  strength  of  the  above  forces  for  the  average  period  of  14  months       72,617 
Union  white  troops,  year  ending  June  30,  1863 '     614,325 


1,741 
4,  769 


24.0 
7.8 


20.6 

7.8 


This  table  shows  a  Confederate  death-rate  of  20.6  per  thousand  of  strength  as  compared 
v/ith  a  Union  rate  of  7.8;  but  the  difference  between  the  rates  was  actually  greater,  for  the 


^  In  tlie  Medical  Volume,  C.  S.  Sauil'iri/  Commi^ion  Memoirs,  New  York,  18G7. 


t  Sec  Table  XII,  siipm,  page  30. 


DISEASE?   OF    THE    KESPIKATORY    ORGANS.  721 

mortality  returns  fi'oni  tlio  Ariiiv  of  the  Valley  of  Vir^-inia  aio  incoinploto:  During  tlio  ton 
months  covered  ly  tlio  jnililislied  statistics  of  tins  army  lA'ol  cases  of  ]>neumonia  were 
reporteil,  witli  onlv  •")•)  ileatlis  or  4.<'-!  per  cent,  of  the  cases;  hut  t"  this  mortality  should  have 
been  added  imu/h  nf  that  which  was  caused  hy  this  disease  during  llie  period  in  question  at 
the  Staunton  hospital,  Va.,  where  the  ordinary  rates  of  fatality  prevailed. 

The  statistics  show  also  that  diseases  of  exposure  were  more  prevalent  and  fatal  among 
the  PRISON EKS  OF  WAR  than  even  among  the  colored  troops.  This  was  to  have  Ijcen  expected, 
in  view  of  the  nrany  hardships  and  exposures  which  attended  the  capture  of  these  men  and 
their  transmission  to  the  prison  depots,  their  Avant  of  clothing  and  blankets  and  the  imper- 
fection of  the  arrangements  for  their  well-being  during  confmemmt.  The  fnllowing  tabular 
.statement  summarizes  the  information  derived  from  the  records  df  the  prnicipal  prison  depots. 
Tonsillitis  and  diphtheria  have  been  embodied  in  this  talde  as  diseases  allied  to  the  acute 
infiammatory  affections  of  the  respiratoi'v  tract: 

Table  I.VI, 

Showing  the  Prevalence  and  Mortal ity  from  certain  diseases  attributed  to  atmosjiherie  erposurcs  amove/  tlie 
Confederate  prisoners  held  at  the  principal  prison  dejmts  in  the  United  States.  Aeerage  period 
covered  hy  the  observations  two  years;  average  strength  present  40,SIo  men. 


.,,  .   ,           ,  AveraRo  iimiuiil 

lotalm.M.her  ,a„,V,  i.,,,,,, 

ot —  •     ■ 
Diseases. 


stivM;;!!]. 


k,    X 


Ca.se-s.    Deatlis.    Cases.     Deaths. 


Catanli.  o|)i(leniic  ratarrh  and  acMito  liidiichitis _ 17,7(>S  '>X  217. (i 

Chronic  liidiichitis ., _.  1,27X  H2  1.").  7 

Pneuniouia lL',L'l(l  |  i.HXH  W.H\ 

rieuiisy 2,109,  V<\,  S^.H 

Larvniiitis __ WI2  I  21)  !».  K 

Ton'siuiiis __ :i,.ii:i  y.i  4i.s 

Dililithoria .riO  4!t  ">.  0 


0.7 

0.32 

1.0 

(!.  4 

lO.lt 

40.  0 

i.;t 

7.8 

0.2 

2. .-) 

0.2 

0.  :w 

O.ti 

10.  9 

Total _- 38,030  i     r),2(;4        4(i."..9         64..")  i     13.9 


The  average  annual  number  of  deaths  from  these  diseases  was  (U..")  per  thousand  pi-is- 
oners  as  against  32.35  among  our  colored  troops  and  T.oG  among  our  white  soldiers.  J'lieu- 
monia  was  the  fatal  disease  to  which  so  many  of  these  men  fell  victims.  Its  annual  death- 
rate  per  thousand  men  was  59.9  as  compared  with  27.29  among  our  colored  and  (i.21  among 
our  white  troops.  Of  every  hundred  reported  cases  of  pneumonia  in  tliese  prisons  40.0  were 
fatal  as  against  32.44  among  the  coloreil  men  and  24.08  among  the  white  troops.  The 
conditions  that  contributed  to  these  results  have  alreadv  been  explained.'-' 

The  annual  death-rate  from  pneumonia  and  jihrnrisv  ]K-r  thousand  pri.soners  at  A.nder- 
sonvillo  was  seen  by  Table  XYI  to  have  been  27.4.  This  number  is  small  compared  with 
the  rates  that  prevailed  in  Northern  j>risons,  and  mav  lie  regarded  as  indicating  climatic 
differenci;s;  Imt  the  accuracy  of  the  diagnosis  mav  well  be  questioned  at  a  prison  where  so 
many  died  in  the  enclosure  unknown  to  the  medical  officers. f 

The  diagram  facing  page  722  shows  the  seasonal  character  of  the  catarrhal  and  pneu- 
monic diseases  that  have  been  ascribed  to  cold  and  moisture.     Their  waves  of  prevalence 

*  St'o  expni,  pape  TO.  j-  See  sirjira,  page  39. 

Med.  Hist.,  Pt.  Ill— 91 


722 


DI>:EASKS    of    Till-:    EEsriEATOEY    OPv<;ANS. 


aoTce  in  their  general  outliiio.  Tlieir  iniiiima  con\'S|><*inl  witii  tlic  wanner,  tlieir  maxima 
with  the  colder  months  of  tlie  vear. 

The  remarkahle  prominence  of  simjile  catarrli  'lurint;'  tlie  only  year  in  which  cases  were 
reported  under  that  title  was  associated  witli  an  epidemic  of  measles.  IW  comparing  the 
rise  and  fall  of  its  monthly  rate  with  those  of  the  specitlc  disease,  as  shown  in  the  diagram 
facing  page  650,  this  catarrh  will  be  recognized  as  having  been  a  sequel  of  the  eruptive  fever: 
The  latter  was  of  frequent  occurrence  among  the  new  levies  during  the  sumnier  and  autumn, 
but  in  Xovember  its  influence  became  largelv  extended,  and  in  Decemljcr  it  attained  its 
maximum;  catarrh  followed,  reaching  its  maximum  in  January.  The  eruptive  fever  declined 
to  average  rates  in  February,  but  these  rates  were  not  reached  by  catarrli  until  April  or  May. 
The  less  extensive  epidemic  of  measles  in  November  and  December,  1862,  may  be  regarded 
as  corresponding  with  a  p)rominrnce  in  the  line  of  c])idemic  catarrh  and  tlie  epidemic  of 
March,  ](S64.  as  connected  with  a  trivial  elevation  of  the  same  line. 

The  regularity  of  the  seasonal  waves  of  prevalence  of  acute  bronchitis  is  broken,  on  the 
diagram,  only  by  a  sudden  elevation  in  July,  1862.  This  is  evidently  due  to  the  change 
then  adopted  in  the  manner  of  reporting  cases  of  catarrhal  inflammation  of  the  respiratory 
mucous  membrane.  The  rate  of  catarrli  for  June  was  8.0,  of  acute  bronchitis  2.2 — making 
a  total  of  10.2:  and  in  July,  corresponding  with  the  exclusion  of  catarrh  from  the  re})orts, 
the  rate  of  acute  bronchitis  rose  from  2.2  to  8.8.  The  progressive  decrease  in  the  size  of 
the  waves  of  pneumonia  and  pleurisy  is  well  shown  in  the  diagram. 

The  line  indicating  the  prevalence  of  tonsillitis,  as  seen  on  the  diagram  facing  page  738, 
presents  seasonal  elevations  corresponding  with  those  already  observed  in  the  purely  respi- 
ratory diseases.  Diphtheria,  however,  had  no  such  marked  seasonal  accessions.  This  will 
be  referred  to  hereafter. 

The  season  of  increased  prevalence  of  the  diseases  mentioned  extended  from  October 
or  November  to  March  or  Ai)ril.  Observations  on  their  frequency  in  civil  life  in  this  country 
have  given  similar  seasonal  results.'-' 

The  following  tabular  statement,  constructed  fron^  data  in  Dr  JoxKs'  article,  already 
cited,  shows  the  relation  of  season  to  the  prevalence  of  pneumonia  in  the  Confederate  armies. 
The  disease  decreased  with  the  advent  of  warm  weather.     The  month  of  Julv,  18()2.  lur- 


*  The  following  tracing  was  mailc 
from  statistics  covering  the  period  frnni 
January,  1880,  to  May,  1882,  pul.Iisli.d 
in  the  Bnllelhi  of  the  National  lioard  "J 
Health.  Tlie  facts  were  derivetl  from  tlic 
weekly  reports  of  health  officers.  Tin' 
populatitiri  represented  was  mostly  nr- 
han  and  averaged  abont  eight  millions. 
The  monthly  rates  in  the  tracing  are  ex- 
pressed in  their  eqnivaleiit  annmil  rates 
I>er  thousand  of  population.  The  un- 
broken line  inilicates  thellnctuation.siu 
the  prevalence  of  all  acute  diseases  of 
the  respiratory  organs,  the  broken  lino 
the  corresponding  fluctuations  of  pneu- 
nioniii,  which  was  reporteil  specially 
only  during  the  twelve  months,  .June, 
1881,  to  .May,  18ji2.  So  far  as  the.se  sta- 
tistics go  they  imlicate  just  such  a  i  ar- 
allelisni,  as  regards  prevalence,  between 
pneumonia  and  the  other  acute  diseases 
of  the  organs  of  resitiration  as  h.as  been 
shown  to  have  existed  among  the  troops 
daring  the  war. 


188  0. 

18  5  1. 

18  82. 

s  t  ^  ^  J^  1  T  a"  &■  ■!:  J  c$ 

■^t^^-^-^  -^-^  'l'^  ^^  f:' 

llUf   ! 

4.00 

4.00  1 

3.7S 

.-- 

■— 

N^ 

J.75 

3.  SO 

^ 

tr 

/ 

V 

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3.50 
3.25 

3.25 

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2,75 

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2,75 

2.50 

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■■     '','« 

7  7S 

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11.26 

2.00 

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1.75 

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1,50 

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— 

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Aug. 
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Oct. 
Nov. 
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Feb. 

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Oct. 
Nov. 
Dec. 
Jan. 
Feb 
Mar. 
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Sep. 
Oct. 
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Jan. 
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May 
June 

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j4ug. 
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Jan. 

m. 

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Nov. 
JJec. 
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03 

DISKxVSES    OK    TJIK    ItEsniiATOKY    OKOANS. 


723 


nislieel  an  exceptionally  liigli  rate.  This  was  noticed  by  Jones,  who,  however,  failed  to  give 
a  satisfactory  explanation  of  the  anomaly.  The  monthly  I'ates  in  this  table  may  be  com- 
])ared  with  the  lines  indicating  monthly  prevalence  in  the  Union  Army  as  shown  by  the 
diagram  facinii'  i>ai;'o  GolJ. 


Mrull  -7  = 

stn-iiirtli.      £  ; 


18i;2:— .Tiiiiiiiirv 2:!2,  l:i8 

Ki'liniii'rv 2111, 0l» 

.Miinli ll'H'i,(l47 

.\]iril t>S,'AIH 

Miiv _.  .18,  li'.in 

.Itiiic l:i(i,  3fi2 

.riilv "11,  Ml'.) 

Aii-ii.st ll:i,  4117 

.•<ilitiniliiT 12."i,4IF8 

Octubcr 150,734 


3,  OfiO 
2,041 
1,84!) 
8;il 
3fi0 
881 
82() 
4:io 
1711 
384 


2 

If 

! 

Month. 

Minn 
:-tn'njrtli. 

2,  282 
2, 11.-^5 
2,  (■i7li 
1,11117 
2,81li 
1,7711 
1,. 511.3 

T  ^ 

17.0.i 
u.:il 

11.20 
\-,.  28 
(i.  13 

18G2 
18C3 

— Xov(^iiilior 

Ili'CcniliiT 

— lanuiiry 

Fi'linmrv 

Miir.li  ^ -_ 

270,  480 
172,800 
1112,  77li 
21.^1,  4.-.8 
313.848 
1110,518 
1113,711 
107,  l.-i:i 
72,  31lCi 

8.43 
17.27 
13.88 

11.  -11) 

8. 117 

fi.  4l> 

11.33 

10.32 

May  

11.73 
2.411  ! 

1.42 
2.45  j 

.July 

1.1  iti 

The  Well  defined  connection  between  ]ineinnonia  and  Lav  tmipcratures  leads  to  the 
expectation  that  regionic  intluences  would  be  inainly  climatic;  but  the  diversity  of  the  cli- 
matic conditions  ]:iresented  by  the  immense  rcgion.s — the  Atlantic,  Central  and  I'ac-ilic — into 
which  the  medical  statistics  of  tlie  war  were  originally  consolidated,  renders  the  C(ins(jlida- 
tions  valueless  from  the  medico-topographical  point  of  view.  The  table  on  page  7-4  ])rcsents 
the  prevalence  of  catarrhal  and  pneumonic  affections  in  the  several  military  dujiartmeiits  of 
the  regions  in  figures  which  admit  of  comparison. 

The  average  annual  number  of  cases  of  catarrhal  inflammation  of  the  respiratorv  mucous 
membrane  per  thousand  of  strength  did  not  differ  materially  in  any  of  the  rcgiuns.  The 
rates  in  the  Atlantic  and  Central  regions  were  verv  similar,  and  diminished  progressively 
year  by  year  from  44.^.  i  in  the  former  and  42U.G  in  the  latter  during  the  year  ending  Juno 
'M),  LS62,  to  114.9  and  1U9.(3  respectively  during  the  year  ending  June  i-JO,  1865;  but  the 
rate  in  the  Pacific  region,  altlmugh  lower  in  the  first  year,  owing  to  the  cumiiai'ative  immu- 
nity ol  the  troops  from  measles,  was  so  much  higher  than  those  of  the  (Ulicr  i-rgions  during 
the  remaining  years  as  to  raise  its  average  rate  to  a  somewhat  higher  figure  than  the  a\-ei'age 
of  the  regions. 

W  ithin  each  region  the  proportion  of  catarrhal  cases  depended  in  general  terms  on 
latitude.  In  the  Atlantic  region  durino;  the  first  year  the  statistics  were  disturbed  bv  the 
great  prevalence  of  measles  in  the  Middle  Department,  which,  at  that  time,  was  tlie  ramp- 
ing ground  of  the  new  regiments  awaiting  absor|)tion  into  the  army;  but  durmg  tlie  remain- 
ing years  the  departments  which  lay  north  of  A\  ashingtuii  had,  as  a  rule,  larger  rates  than 
those  which  were  south  of  it.  hi  the  Central  region  the  I*epartment  of  the  Xorthwest 
and  the  Xorthern  Department  had  generally  larger  rates  than  the  Southern  eummands.  In 
the  Pacific  region  catarrhal  affections  were  more  common  in  the  Dejiartnient  uf  the  Pacific, 
which  extended  to  the  Canadian  border,  than  in  Coloradci.  Xew  Mexieo  and  Arizona,  which 
constituted  the  Department  of  Xew  Mexico. 

But  pneumonia,  although  parallel  with  the  catarrhal  affections  in  its  monthly  jireva- 
leuce,  divero;ed  from  them  in  its  reo-ionic  distribution.     The  rates  in  the  Central  reolon 

'  O  CD  O 

greatly  exceeded  those  that  prevailed  on  its  Pacific  and  Atlantic  sides.  Latitude  was  an 
important  factor,  for  in  the  Atlantic  region  the  disease,  like  the  catarrhal  affections,  was 
more  common  in  northern  than  in  southern  commands,  and  in  the  Central  region  the  troops 


724 


DISEASES    OF    THE    KESPIKATuIIV    OKGAN.s. 
Tai;i.e    LVll. 


ShowiiKj  htj  ratios  per  thousand  of  strength  the  relative  freijiwney  of  Catarrh  of  the  Respiratory  3Iucous 
Membrane  eiml  Pneumonia  among  tlie  ichite  troops  of  the  several  Departments  and  liegions  during 

the  four  years  of  war  serriee,  July  1,  ISGl,  to  June  -10,  Ib'O'o. 


Dopaitmeuts  aud  Ke<;ions. 


Catanli,  EiiuleiMio  Cntmili  anil  ,,  ■      i      ■       .i 

.      ,1,         ,■.•       1  .1  Pnennionia  (iinii":  t lie  years 

,•  ,  „,,  ■  <'ll(llH";  .llllle  0(1 — 

ye:  r  ciul  ii<r  .linic  oO —  " 


18G2.    '    1W3.        18G4. 


DepartnienT  of  the  East  .- _. 

Middle  Deiiartnient 

Department  of  the  .Shenandoali 

Middh'  .Military  Division 

Deiiaitnii'nt  of  Washinf^ton 

Army  of  the  I'otomae 

Department  of  the  Ivappahannoek 

Department  of  Virfiini.-i 

Department  of  North  Carolina 

Department  of  the  South 

Atlantic  Kegiou 


2.''>5.9 
tW.'i.  2  2M.  it 
390.1  1 


2.")0.  ti 
19.'..  2 


Diih). 


210. 1 
132.2 


1862.    I    18G3,    i    1804.       1865. 


33.  9 
33* 


22.5 
35. 1 


46.7 
24.  5 


26.9 

20.8 


476 

9 

218. 

t 

399 

0 

376 

s 

463. 

0 

234.5 
189.  2 

199.  6 
266.  3 
100.  7 


204.6 
96.0 

'i33!'9" 
141.1 
170.  9 


123.  ( 
9(1.1 


102 
117 

135, 


448.4  I     205.6  I    142.4       114.9 


Department  of  the  North we.st 

Northern  Department 

Department  of  Wi>st  Virginia 

Department  of  Mi.s,souri 

Dci)artnient  of  the  Ohio 

Department  of  the  Cumberland 

Department  of  the  Tennessee 

Military  Division  Mississippi,  I'art  I.. 
Military  Division  Miiisissippi,  Part  11. 

Departnient  of  Arkansa.s 

Department  of  t  he  Gulf 

Central  EeRion 


526.6 


512.2 

482.  2 


4X3.  0 
200.  () 


381.2 
419.  8 
208. 1 
1XS.3 
171.1 
172.7 
159.  0 


172.7 
300.  2 
111.3 
220. 1 
119.3 
SO.  2 
73.  5 


15.5 
19.4 

12.8 

28.  0 
20.5 

34.1 
18.3 

30.0 
12.9 

12.7 
2(1.2 
10.1 

10.  () 

11.7 

.5.  5 

13.  S 
20.5 
10.1 

9.4 
27.5 
13.9 

20.0 

20.7 

18.0 

15.  7 

125. 0 
311.1 

100.  5 


80.6 

.'iS.  6 
120.  7 


00.0 
50.  3 


121. 1 

64.1 
46.7 
57.  2 
TiX.  7 
45.7 
4().  7 


235.5  I     IIS.  4 


132.  1 
07.9 


127.4 
.39.  1 

137.9 
sii.o 


19.0 


11.7 


420.0 


176.4  i     105.6       109.6 


64.7 


47.1 


39.3 

lU.S 
10.  2 
09.  1 
37.7 
19.  5 
25.9 


40.4 
14.4 


34.1 

09.  0 

30  i 


27.8 

9.4 

20.3 

13.  5 


30.  4 


23.  4 


Department  of  Xe\v  Mexico. 
Department  of  the  Pacitic  .. 


Pacific  Region 


109.0 
398. 3 

254.1 

234.8 

197.  7 
222.  2 

91.1 
200.4 

11.3 
21.  1 

20.7 
8.9 

14.9 
17.1 

27.4 
27.4 

258.  5 

242.  0 

212.  3 

205.1  j; 

1(>.  3 

13.7 

10.2 

27.4 

Total ,     433.  0 


191.0  I     120.5        113.8 


39.  6 


34.3 


26.0       20.3 


in  the  Department  of  the  Gulf  enjoyed  an  immunity  from  the  disease  as  compared  with 
those  in  the  Korthern  departments.  Apparently  the  principal  cause  of  tlie  high  rates  of 
the  Central  region  was  the  great  frequency  of  pneumonic  cases  in  the  Departments  of  the 
Missouri,  Ohio,  Tennessee  and  Cumberland,  particularly  during  the  first  and  second  years. 
These  cases  were  probably  the  effects  of  the  continued  exposure  to  cold  and  wet  necessitated 
by  the  military  operations  which  opened  up  the  Mississippi  river.  Later,  as  when  the 
armies  were  operating  against  Atlanta  or  crossing  the  country  to  the  Atlantic  coast,  the 
pneumonic  rate  became  much  reduced;  but  as  the  troops  under  General  Sherman,  in  their 
march  across  Georgia,  had  a  rate  of  only  9.4  per  thousand,  while  those  left  with  General 
Thomas  continued  to  have  a  rate  similar  to  those  of  the  Departments  of  the  Missouri  and 
Arkansas,  it  seems  as  if  along  the  great  lines  of  drainage  of  this  vast  central  region  the 
•causes  of  pneumonia  had  been  more  potent  than  on  the  ocean  slopes  or  western  prairie  lands. 
The  Confederate  statistics  appear  to  confirm  this  deduction,  for  while  the  Army  of  the 
'Tennessee,  which  served  in  the  States  of  Tennessee,  Kentucky,  Alabama  and  Mississippi, 


EPIDEMIC   CATATJUI.  725 

liaJ  an  averau'e  annual  rate  of  ITo.l  nneuuionic  cases  per  tliousanJ  of  strenolli.  as  calculated 
Ironi  tlic  statistics  submitted  by  Dr.  JoxEs,  the  troops  in  South  Carolina,  Georgia  and  Florida 
had  but  54.5,  those  In  tlie  Valley  of  Virginia  79. G  and  those  around  ^Mobile,  Ala.,  lOS.G. 

I— CATARRH. 

During  tin-  fourteen  nionths.  May,  '1S61,  to  June,  1862,  inclusive.  80.G77  cases  of 
catarrli,  six  of  whicli  terminated  fatallv,  were  reported  among  the  white  troojjs.  Xo  par- 
ticulars ot  these  cases  have  been  recorded.  On  the  dat(>  last  mentioned  the'  term  vKtarrli 
was  dropped  from  the  ^Montldy  Reports  of  »Sick  and  AVuunded.  k^ubserpiently  cases  which, 
according  to  custom,  would  liave  been  reported  under  this  title,  appear,  from  the  diagram 
lacino-  I'laa'e  722,  to  have  found  place  under  the  headinij;  (icujc  hroncJidiH. 

II.— EPIDEMIC  CATARRH. 

A  large  number  of  cases  were  reported  under  thi<  he'ading — D34,o'd7  among  tin'  white 
and  9,869  among  the  colored  troops.  Xevertheless,  as  these  cases  were  distributed  I'airly 
among  the  various  commands  and  throughout  the  srveral  ycai's  covered  I'V  the  statislies, 
giving  an  ainiual  average  rate  of  61.4  per  thousand  of  strength  among  thi;  wiiite  and  ^'■\.>^ 
among  the  colored  troojis,  it  mav  b(^  douljled  whetlier  the  disease  tlius  rcjiorted  was  in 
reality  that  for  which  the  heading  was  provided.  In  fact  the  cases  appear  tc)  have  been 
occasioned  by  local  rather  than  epidemic  influences.  During  the  winter-quarters  of  tlie 
Armv  of  the  Potomac,  1S63--1,  the  fortv-tlve  or  more  reiziments  of  the  Second  Armv  Corps 
were  hutted  near  Cole's  Hill,  Ptevensburgh,  Va.  Four  of  these  regiments  reported  the 
existence  of  epidemic  catarrli,  while  others  had  only  occasional  cases  of  acute  l>ronchitis,. 
and  a  few  belonging  to  the  Second  Division,  which  was  cpiartered  on  a  high  and  rather 
exposed  hill-side,  were  absolutely  free  from  sickness.  The  four  regiments  affected  with  the 
so-called  epidemic  catarrh  were  encanrpcd  on  low-lying  and  damp  ground.  The  principal 
sufferer,  the  IdStli  Pa.,  reported  bo  cases  in  January,  70  in  February  and  51  in  IMarch.  Its 
camp-ground  was  trampled  into  deep  mud  by  the  men  in  the  routine  of  their  daily  duties. 
Their  feet  were  constantly  damp  and  cold  and  their  .spirits  depressed.  The  regiment,  never- 
theless, labored  earnestly  to  improve  its  condition.  The  huts  were  floored  with  split  logs; 
sidewalks  of  the  same  material  were  built  on  the  company  streets  over  deep  trenches  which 
drained  the  building  sites,  and  pathways  ^vere  laid  to  keep  the  men  dry-shod  in  all  the 
ordinary  movements  of  the  regimental  domestic  economy.  In  fact  the  command  raised  itself 
above  the  mud  of  its  camp-site.  As.a  result  of  this  energetic  work  the  catarrhal  epidemic 
ceased;  no  case  was  reported  in  April.  In  May  of  the  same  year  tlie  2d  N.  Y.  Heavy 
Art'y  returned  150  cases  of  epidernic  catarrh,  or  nearly  one-half  of  the  total  of  322  cases 
reported  as  having  occurred  among  the  115,385  men  constituting  the  strength  of  the  Army 
of  the  Potomac;  and  in  June  this  regiment  returned  41  of  the  63  cases  reported  from  a 
strength  of  98,384.  Tlie  regiment  was  new  to  field  service.  During  the  previous  winter 
it  had  occupied  the  fortifications  of  Washington,  D.  C;  but  in  ]\[ay  it  was  relieved  and  sent 
to  the  front  when  the  battles  of  the  Wilderness,  Spottsylvania  and  Cold  Harbor  were  in 
progress.  Its  raw  material,  under  the  exposures  of  the  bivouac,  became  affected  with  catarrh 
associated  with  great  disturbance  of  the  system  and  unusual  prostration,  which  was  due 
rather  to  the  unaccustomed  fatigues  and  privations  undergone  by  the  men  than  to  any  epi- 
demic influence. 


726  ACUTE    J'.UOXCIIITIS. 

It  seems  probaLlo,  inilet.'(l,  that  most  of  tlic  rrjiorti'il  cases  were  of  a  cliaraoter  similar 
to  those  mt'iitioiici], — emlemics  of  simole  ciitai'i'h  criu-iiiatinij;  in  faultx'  camouiL;'  e-i'iMinds  or 
local  ejndemies  due  to  unwonted  exjiosurrs, 

Siinjin)!  Oiti'iiKTS  Evi:i!Ts.;?0//i  [nd.,  /'oo/cM-i/Zc.  JM.,  ()ct.2i,  ISiii'. — Soon  aftiT  caiiipiiii;  lit  Fort  less  Moiivop  [.Sci)t. 
2"),  18(51]  an  ciiiilcniic  of  iiilluciiza  ai)iieaii'(l  in  the  roginicnt,  which  1  h'avni'il  had  aticctcil  tlii'  1st  Del.,''  cncaniiu'd 
close  liy,  lioforc  our  arrival,  anil  from  which  Imt  1\'\y  cscajicd  licinij;  inoro  or  less  ailVcti'd.  The  conj;!!  was  violent  and 
very  persistent,  hut  attended  with  little  constitutional  distnrliauce.  'I'lie  men  sntieii'd  nuir<'  from  loss  of  sleej)  on 
ai'oount  of  the  annoyanei,'  of  the  eougli  and  muscular  soreness  from  the  violent  exercise  of  the  respiratory  muscdcs 
tlian  from  any  fehrilo  or  other  distnrhauce  of  the  system.  Kemcdies  administered  seemed  to  make  but  little  impres- 
sion on  the  cou^;h.     All  the  usual  foruiuhe  were  tried. 

Siin/coii  \).  Minis,  ixth  I'n.,  ('(oiip  Chirl-,  Vu..  Xor.  30.  1861. — Aliout  the  end  of  Octoher,  while  encamped  at  Camp 
Hamilton,  near  Fortress  Monroe,  an  epidemic  catarrh  made  its  ajipearance  amoiifist  ns.  Nearly  every  num  in  the 
regiment  was  more  or  less  ali'ected  by  it.  Jly  report  exhibits  Imt  a  limited  nuuiber  of  those  attacked,  only  those  cases 
of  grave  character  coming  under  our  ofticial  notice.  The  disease  was  characterized  by  severe  uehiiig.  throbbing  ]iaiiis 
in  the  head,  back  and  limbs,  bronchial  intlammation  iind  hepatic  disorder.  It  yielded  readily  to  moderately  large 
doses  of  sulphate  of  ((Miuia  ami  Dover's  powder  in  combination  :  but  in  all  its  severer  phases  was  lb  Ho  wed  by  unusual 
physical  debility  and  tedious  convalescence. 

Surf/con  EzR.v  Kkad,  21.s(  IihI.,  Fort  M(ir«liuU,  BuUimorc.  Mil.,  Jan.  11.  ISiii. — In  December  catarrh  prevailed  in 
an  epidemic  form  and  was  attended  with  great  irritation  of  the  pulmonary  mucous  surfaces,  headache  and  fever. 
Anodynes  and  aperients  were  the  remedies  relied  npini  and  ati'orded  as  much  relief  as  could  have  been  expected: 
deiileting  measures  were  not  indicated.  The  disease  prevailed  for  three  weeks  and  had  an  average  duration  of  about 
eight  days  in  eacdi  case.  Loss  of  ap|)etite.  lassitude,  debility,  headache,  pain  in  the  frontal  sinuses  and  cough  were 
its  prominent  symiitouis. 

,Siii-<iiiiii  Sami'KI.  Knkki.ani),  4."i//i  Mas^.,  A'cjc  Berne,  X.  C,  Fch.  19,  IXO'.i. — A  kind  of  inlluenza  iirevailed  in  Decem- 
ber among  the  officers  and  men,  rebellious  to  treatment  and  disappearing  spontaneously. 

!<iir!ieoii  L.  M.  Sloan.\kki!,  \9lh  Iowa,  Iirou-imrille,  Texan,  April  20,  18(U. — These  [cases  of  catarrh]  were  nncom- 
plicated  with  broncliitis  or  pneumonia,  and  may  all  be  cimsidered  dependent  upon  epidemic  influenza.  Many  were 
iliiite  tedious,  and  two  resulted  in  l>ermanent  i)artial  loss  of  s])eech.  'I'he  largest  number  occurri'd  in  March,  while 
the  regiment  was  at  Forsyth,  Mo.,  on  White  river, — a  location  which  is  low  and  damp  and  Iii'iice  favorable  to  catar- 
rhal att'ectious. 

Ill— ACUTE  BRONCHITIS. 

The  statistics  hold  this  disease  responsible  for  the  occuvrence  of  168,715  eases  of  sick- 
ness, of  which  650  terminated  fatally  among  the  white  troops.  This,  as  has  been  seen  in 
Table  LIV,  is  equivalent  to  an  average  annual  rate  of  76.8  cases  and  .27  deaths  per  thousand 
of  strength  and  to  .39  fatal  cases  in  every  hundred.  Among  the  colored  troops  22,648  cases 
and  255  deaths  are  reported,  giving  an  average  annual  rate  of  123.5  cases  and  1.33  deaths 
and  a  rate  of  fatality  amounting  to  1.12  per  cent,  of  the  cases. 

Only  six  cases  of  this  disease  appear  in  the  case-books.  Four  offer  no  points  of  interest ; 
the  two  others,  recorded  by  Act.  Ass't  Surgeon  PI.  C  Newkiek,  were  treated  at  Rock  Island 
hospital  and,  it  is  said,  with  benefit  by  inhalations  of  ether,  chloroform,  turpentine,  etc.,  with 
the  subsequent  occasional  use  of  an  expectorant  mixture  of  squill  and  senega. 

In  addition  to  these  cases,  which  recovered,  there  are  ten  deaths  in  the  progress  of  or 
subsequent  to  measles,  the  records  of  which  present  bronchitis  as  the  principal  abnormal 
condition.  The  brain  was  examined  in  but  one  of  these  cases;  the  weights  of  the  liver, 
spleen  and  kidneys  were  stated,  and  remarks  made  on  the  condition  of  the  intestines,  while 
the  thoracic  observations  were  recorded  briefly  as  having  shown  the  existence  of  bronchitis. 
Possibly,  in  some  of  these  instances,  the  infiuencc  of  the  specific  poison  destroyed  life  while 
the  lesions  within  the  chest  were  limited  to  the  bronchial  mucous  membrane;  but  as  nine 

*  D.  W'.  3lAri.L,  Snrixoon  1st  Del.,  haa  given  an  acrnnnt  nf  ttiis  oiiiiiemic  in  tlio  Mrdirdl  ami  Sm-tjiral  lifiporlrr^  Pliilaflclidiia,  Vol.  VII,  lSGl-(>2,  p. 
189. — While  the  affection  of  the  respiratory  piwsages  was  not  generally  severe,  altliongh  sometimes  attetiiled  hy  unetu^iueeB  in  the  clieHt  and  expectoration 
of  l)Iooil,  tlie  iliseaM'  was  marked  by  a  severe  and  almost  invariable  pain  in  tlie  frontal  region,  which  sonietinies  extended  over  the  whole  head,  by  pains 
in  the  loins,  aching  in  the  b»wer  extremities  and  [tain  in  the  neck  and  arms.  Intestinal  disorder  was  also  prominent,  evinced  by  severe  diarrhoea  with 
frequent  watery,  bloody  and  mixed  stools,  tenesmus  and  tr-udernesH  of  the  abdomen.  There  was  great  deljil'ty,  hat  the  febrile  disturbance  wa.s  not  great. 
Surgeon  Mavll  states  that  thirty-five  men  of  his  regiment  reported  for  treatment  in  one  day.     The  epidemic  continued  more  thau  two  weeks. 


ACl'TK    lillOXCHITIs.  727 

of  tliGin  occurred  at  tlie  saiuo  lio^piial  abnut  tin-  same  time,  aiiil  were  probal)ly  recorded  liv 
the  sanir  oi^icer.  it  is  not  unldcelv  tliat  in  tlir  overpressure  vl'  wnrk  tlic  lolailar  atelectasis 
and  coii^L:;estii)n  wliicii  would  have  j>laced  thom  amou^-  the  secondary  pneumonias  were  not 
recognized.  Cases  1-0  arr  I'roni  tlie  ivcnrds  ui'  .l[u>piml  Xc  1.  Xashville,  Tenn.:  case  10 
occurrei]  at  (Jliattanooga  hospital,  Tenn. 

Cask  1. — I'rivntc  I'lMkev  I'arliaiii.  Cn.  II.  2(1  7-",.-ist  "lY'iin.  (';iv.:  iidiiiittcd  Miiic/li  2,  isiil.  with  lnoncliiti.s  (■(lusocu- 
tivc  til  iiifn.sU's.  Hied  8(1.  roxt-mortiiii  exaniiiiatidii :  The  liniiu'hial  tuhi'.s  weri-  lii.iihly  inlhiiiicd  and  coiitaiiicil  nnico- 
pus.  The  heart  was  tilled  with  unii.siially  larfj;e  lifIht-yollo^v  clots  weiijhinj;  six  (luiu'os;  the  heart,  witlmiit  tlie  chits. 
weij;hed  fdurteeii  ounces.  The  liver  weighed  eight.v  ounces:  tlie  spleen  and  kidneys  weic  healthy.  The  nineoiKS 
membrane  oftlie  intestines  was  slii^htly  inllanu'd  thronghont. 

Cask  2. — Private  Samuel  Cowan,  Co.  K,  ITtli  Ohio:  aye  Is:  admitted  Mar(  h  (i.  Isill.  wiili  measles.  ])ied  lOtJi. 
PoKt-Dinrti'iii  examination:  There  was  extensive  broneliitis  on  Imth  sides.  J'lie  li\cr  was  tatty  and  weighed  seventy- 
four  ounces ;  the  spleen  ■weighed  ten  ounces.     Tlie  kidneys  and  intestines  were  liealihy. 

Ca.SE  3. — Private  Josejih  Stacey,  Co.  II,  5tli  Iowa  I'av.;  age  IS:  admitted  Mar(di  (i,  IStil,  w  itli  measles.  Died 
20th.  i'usf-mo)'?('»i  examination:  There  was  intense  broncliial  intlammation  on  botli  sides.  Tlie  pericardium  contained 
three  ounces  of  liquid,     Is'othing  else  unusual  was  (diserved  in  the  tlioiax  or  abdonieii. 

Case  4, — Private  Saniuel  R.  Davis,  Co.  E,  12tli  Tenn.  Cav.;  age  21:  admitted  Marcli  7,  ISlH,  willi  measles. 
Died  17th.  Poat-mortcm  examination,  Tlie  bronchial  nnicoiis  membrane  was  e\tensiv(dy  inllamed.  The  heart  coii- 
tained  large  light-colored  clots.  The  liver  weighed  seventy-two  ounces  :  the  spleen  I'ourleen  ounces,  I'lic  kidneys 
and  intestines  were  normal, 

Ca.se  5, — Private 'William  Taylor,  Co,  F,  2d  F.ast  Tenn,  Cav.;  age  HO:  admitted  Maridi  !•,  IMil.with  measles. 
Died  nth,  I'o.it-mortem  examination:  'I'liere  was  some  bronchitis,  luit  tin;  lungs  were  otherwise  healthy.  The  liver 
weighed  sixty-nine  ounces;  the  sjilccn  seven  ounces  and  a  half.  The  ascending  colon,  ca-cuiii  and  lower  third  of  tlie 
small  intestine  were  intlamcd  and  of  a  mahogany  color.     The  kidneys  a)>|ieared  normal. 

Case  G.— Private  Sylvanus  W,  Davis,  Co,  C,  7<ith  Ohio:  age  lit;  admitted  and  died  Mandi  21, 1S(U.  J\j.tl-iiiiirtrni 
examination:  Large  livid  spots  on  face,  neck  and  trunk.  .Seventy-two  ounces  of  .sero-bloody  tlniil  in  left  pleural 
cavity,  two  ounces  in  right :  lungs  much  congested  and  bronchial  mucous  membrane  highly  and  extensively  inllamed. 
Heart  nine  ounces;  liver  forty-nine  ounces:  sjilcen  seven  ounces:  kidneys,  each,  four  ounces — all  healthy.  Small 
intestine  slightly  inllamed. 

Case  7, — Private  Jacob  Eddleman,  Co,  D,  2d  Ind,  (';iv,:  admitted  March  21,  18t)l,  with  mi'asles,  I>ied  81st. 
rost-mortent  examination  :  The  bronchial  tubes  of  both  Inngs  were  inllamed.  The  liver  weighed  seventy-seven  ounces; 
the  spleen  eleven  ounces.     The  other  organs  appeared  normal. 

Cask  8,— Private  George  Carder,  Co,  I,  31st  Ohio;  age  17:  admitted  March  2,">,  IWII,  with  measles.  Died  2;ttli. 
I'oat-moriem  examination:  The  bronchial  tubes  of  the  lower  lobes  of  both  lungs  were  inllamed,  \o  other  marked 
lesion  was  observed  in  the  thorax  or  abdomen. 

Cask  9, — Private  Joseph  A,  (iraiiell,  Co,  H,  7th  Pa,  Cav.;  age  17;  admitted  March  27,  IWil,  with  measles.  Died 
April  2,  I'ost-mortcm  examination:  The  large  bronchial  tubes  on  both  sides  were  greatly  inllamed,  'i'here  were  linn 
clots  in  the  right  cavities  of  the  heart.  The  right  kidney  was  of  a  dark  coffee-color,  but  otherwise  the  abdominal 
viscera  were  healthy. 

Cask  10,— Private  J.  F,  (iensel,  Co,  I,  Kith  Ohio:  age  20;  was  admitted  March  10,  ISOI,  with  measles.  On  the 
disappearance  of  the  eruption,  (ui  the  21th,  cough  set  in  with  mnco-purulent  cxiiectoration.  On  the  27th  the  patient 
had  an  aphthous  month  and  diarrlnea,  accompanied  on  the  20th  by  a  good  deal  of  fever,  the  tongue  being  dry  and 
fissured;  mucous  rales  were  heard  on  both  sides  of  the  thorax.  Two  days  later  erysipelas  made  its  appearance  on  I  lie 
nose;  the  diarrhcea  had  ceased,  but  the  patient  was  nervous  and  anxious.  Delirium  supervened  on  Ajiril  1,  and  death 
by  coma  next  daj-.  I'ost-morttm  examiiuition:  Tlie  membranes  of  the  brain  were  injected.  The  iileura  and  the  paren- 
chyma of  the  lungs  were  normal;  tlie  mucous  membrane  of  the  broncliial  tubes  was  red  and  contained  a  f|Uantity  of 
mnco-purulent  secretion.  The  heart  was  normal.  The  mucous  membrane  of  the  stomach  was  mottled  w  ith  bright- 
red  spots.     The  colon  was  injected  and  presented  a  nnnibcr  of  ulcers,  most  numerous  toward  the  rectum. 

Among  the  j'^O'Sf-morfcui  records  ut"  pmeumonia  arc  a  numher  of  instances  of  acute  bron- 
<'liitis  fatal  by  the  .supervention  of  lobular  intlammation,'''  C)iie  instance  of  plastic  bronchitis 
has  been  found: 

Private  Daniel  Horen,  Co.  l\,!l()thPa,:  admitted  .Ian,  2,  1S0:>,  Diagnosis:  ]Icmi]ilegia,  Died  February  2,  /'()»(- 
inoyliiii  examination:  Kigor  mortis  well  marked;  emaciated:  veins  fullof  blood,  I'.rain,  forty-nine  ounces  and  a  half, 
full  of  blood;  choroid  plexus  pale,  but  its  largest  vessels  full  and  tortuous;  veins  of  pia  mater  injected;  veins  of  jions 
and  medulla  full  of  blood;  gray  matter  apparently  diminished  in  amount;  stria-  of  pons  marked.  Right  lung  forty- 
two  ounces;  pigment  deposit  on  pleura  in  intercostal  spaces;  coagulable  lymph  on  upper  and  middle  lobes,  which 
were  firmly  adherent  and  consolidated  in  the  vicinity  of  the  adhesions:  remainder  of  the  lung  much  congested;  in 
the  large  bronchial  tube  leading  to  the  consolidated  mass  was  a  fibrinous  plug  one  and  a  half  inches  long,  tilling  the 

*  See  in/ft,  page  78:1. 


(  26  CHKOXIC    KKOXCHITI^. 

hiincn  :  suifacc  of  tube  mottled  wiiite  ami  red.  Left  lung  liealtliy.  Heart,  seven  and  a  half  ounces,  firm;  small  clot 
in  caeli  vcntrielo.  I.iver,  forty-nine  ounces,  dark,  friable ;  spleen,  four  and  tliree-ijuarter  ounces,  much  coiif^ested, 
linn.     Colon  conjjested. — Lbuolu  Hospital,  M'litsJiiiiijInn,  1>.  V. 

The  oulv  paper  ivkTriiiL;  to  the  treatnifiit  of  ui-iitf  l>ronrhitis  is  a.s  folli^v-: 

Surgeon  M.  R.  (i.\(iK,  2.")//i  THv.,  Colmnhioi,  Kij.,  March  31,  lr<(13. — A  number  of  eases  of  acute  bionehitis  have 
occurred.  It  is  treated  in  severe  eases  liy  cuiijiinj;,  repeated,  if  necessary,  to  relieve  urgent  symptoms,  t'onnter- 
irritatiou  by  mustard  is  found  benelicial.  The  bowels  are  acted  upon  by  podopliyllin,  bicarbonate  of  soda  and  calo- 
mel, and  this  is  followed  by  tartar  emetic  ad  naumam,  as  in  pneumonia.  If  symptoms  of  debility  and  prostration 
ensue  resort  may  be  had  to  stimulating  expectorants  and  to  carlionate  of  aunnonia,  beef-tea,  wine,  etc. 

But  tlie  medical  descriptive  lists  iiulieate  that  JJovor's  }io\vJer,  spirit  of  nitre,  ueutml 
mixture  and  ipecacuanha  wiTe  the  remedies  generally  employed. 

IV.— CHRONIC  BRONCHITIS. 

There  were  reported  among  tln^  white  ti'oops  26,912  cases  of  chronic  bronchitis,  of  which 
529  or  1.97  per  cent,  liad  a  fatal  ending,  giving  the  annual  rtites  of  12, o  cases  and  ,22 
deaths  per  thousand  of  strength,  while  tlie  number  disposed  of  by  discharge  for  disability 
amounted  to  3,729  or  1;^9  jicr  cent,  of  the  cases.  Among  the  colored  troop.s  2,733  cases 
and  149  deaths  were  reported,  or  14.9  cases  and  .78  deaths  annually  per  thousand  of 
streugtli, — the  rate  of  fatality  amounting  to  ^.d-"!  }»;'r  cent,  of  the  cases;  discharges  among 
the  colored  troops,  as  already  explained,*  were  comparatively  rare. 

Xotwithstanding  the  prevalence  of  this  diseased  condition,  and  its  importance  as  a  cau.se 
of  disabilitv,  tweiitv-three  cases  only  have  been  discovered  in  the  Iiospital  case-books.  The 
frequency  of  the  affection  and  its  freedom  from  immediate  danger  to  life  probably  account 
for  the  want  of  interest  displayed  in  the  preservation  of  its  records.  From  the  meagre  data 
at  command  little  can  be  said  by  wav  of  gencralizati<jn,  Tito  symptoms  noted  arc  moi'e  or 
less  cough  with  an  expectoration  scanty  and  glairy,  whitish,  iVothy  ;uid  mucous,  sometimes 
streaked  witii  blood,  or,  more  profuse,  vellow  and  nnico-puruleiit ;  pain  in  the  chest,  but 
generally  only  on  coughing;  palpitation,  shortness  of  breath  and  paroxysmal  cough  on  exer- 
tion. The  tongue  was  usually  coated,  although  the  bowels  might  be  regular.  The  ptilse 
was  frequent  and  weak.  The  body  was  sometimes  fairly  nourished  and  the  appetite  good, 
but  more  frequently  tliere  was  some  emaciation  and  in  advanced  cases  hectic  fever.  The 
chest  resonance  was  normal  or  increased  ;  the  respiratory  murmur  was  sometimes  obscure, 
but  generally  harsh  and  prolonged  in  expiration;  mucous,  sonorous  and  sibilant  rales  were 
frecjuently  noted.  From  these  observations  the  condition  of  the  bronchial  mucous  membrane 
may  be  appreciated  as  congested  and  swollen,  with  more  or  less  hypersecretion  and  increased 
corpuscular  development,  occasional  obstruction  of  the  tubes  and  empihysematous  dilatation 
of  the  air-cells. 

Usually  these  cases  had  lasted  for  months  before  their  appearance  on  the  record.  Med- 
ication for  a  time  was  followed  by  no  marked  benefit.  Expectorants  were  given,  compound 
licjuorice  mixture,  squill,  senega,  ipecacuanha,  etc.;  chloride  of  ammonium  was  also  employed; 
wild-cherry  was  largely  used  as  a  tonic  and  to  allay  bronchial  irritation,  for  which  it  was 
given  with  morphine  and  chloroform.  In  addition  the  chest  was  blistered,  or  counter-irri- 
tation was  kept  up  by  emplastrum  picis  cum  cantharide,  croton  oil  or  iodine.  Extra  diet, 
quinine  and  iron,  cod-liver  oil,  porter  or  whiskey  were  also  generally  prescribed,  with  aro- 
matic sulphuric  acid  in  the  presence  of  hectic.  In  progress  of  time  an  improvement  was 
manifested,  the  patient  gaining  in  flesh  and  strength,  but  prone  to  dyspnoea  and  cough  on 
exertion  and  to  a  recurrence  of  his  trouble  on  slight  exposure.     Furloughs  enter  into  the 

*  See  supra,  page  28, 


ASTHMA.  729 

inei.lical  history  of  many  of  tlio.-o  rases,  wliile  otliurs  wore  ]i]ai"'i:'(.l  na  llu'lit  ilutv  in  tlio  wards 
or  kitchens  of  liosjiitals.  .Many  rocovrml  unJ  retui'iinl  t"  ilmv,  and  iludr  nanu's  Jn  not 
reappear  on  tlie  siek-rejiorts  from  this  cause.  ()ilii'rs  wi-rr  ultimalilv  tran^frrri'd  ui  the 
[nvaliJ  Corjis  or  discharLivil  as  until  for  servieu.  AltlinULi-li  tlie  stati>lics  >\\<,\v  that  a  notable 
percentage  of  tlieso  bronchitic  cases  died,  in  but  two  instances  do  llie  case-bonks  record  tlie 
progress  to  a  fatal  issue, — in  one  death  ajipears  tc.i  have  ri;'>ultcd  fr^ni  the  >Ui]ih'n  dcvclnji- 
ment  ef  pulnionaiy  congestion,  and  in  the  otlni'  fruiii  the  supi'rvcnti'>n  iitdai-vn^'ilis. 

C'.\tiE  1. — Private. I oscpli  Ilawkin.s,  Co.  K.  llUli  C'dloii'd  l'i(i(i]is  :  iiLTc  'Jl :  wa.-.  admitted  Si'iil.  2'.i,  Istll.  witli  i-lirniiic 
Ijriiiicliiti.s.  Cod-liver  oil,  iron,  stimulants,  cxpeotoraiits  and  dry  ciippinj;  ueii'  iLscd  in  the  treatment,  with  iodide  of 
potassium  and  volatile  liniment  when  eom]daint  was  made  at  times  of  ihenmalie  pains,  lie  seemed  to  !»■  improving 
steadily  when,  on  Jan.  IH,  1805,  he  was  taken  with  a  pain  in  the  left  .sidi'  of  the  ehe.st  and  syniptomatie  pyrexia; 
a  blister  was  apjilied.  Next  day  he  .said  he  felt  lielti'r;  he  j^ot  n]i  and  dressed  ;  he  died  within  an  hour  aft<'rward. 
Post-mortem  examination  :  The  left  Inii.i;  was  decidedly  enn^ested. — Sidiiiiiil  IIoii/h  Ilosjiitnl.  I'hiliuUlpliiii,  I'n, 

Case  2. — Private  Christoi)her  \\'af;ner,  Co.  F..  tilsi  N.  V.;  admitted  Aiiij;.  '.K  isiil',  Itrnnchilis.  ])ird  Sept.  7th. 
with  symptoms  of  acute  larynj^itis.  ro.sl-mnrlcm  exaniinal  imi  ;  llody  vifjorous:  aui- almut  :i."i.  .Xdhi-sinns  olihc  ij^hi 
]ung  throughout,  also  at  middle  ])oit  ion  of  uiijier  lolie  of  left  Iniij;:  both  lungs  somewhat  eoiigested  with  Idaek  Iilooil. 
Mncous  membrane  of  the  air-passages,  larynx  in  eluded,  inllami'd  and  the  erieoid  eartilagi'  ossilied  and  carious.  'I'lie 
heart  was  rather  large,  fatty  and  llabby;  left  veutriele  dilaled,  walls  about  half  an  inch  ihieU:  luie  of  the  aoitie 
valves  thickened  by  an  opa<|ue  yellowish-white  deposit,  .'spleen  large  and  softi'ued  :  the  remaining  abihmiinal  organ.s 
healthy. — .Id.  .t.-i.i'l  Sin-(jiiiH  J.  Liuiiv.  Sattirlci'  Ihi^ii'itul,  I'liilmh  Ipliin.  I'n. 

V.~ASTHMA. 

This  was,  coinjiarativelv,  an  infrerjuent  diseas.'.  Hui'lnL;'  tin/  live  and  idi<''-.-ixth  years 
covered  liv  the  statistics  x\\oyo  wt'i'e  rej^i.irted  1*. :>!)•")  cases  anning  tin'  whit''  tni"ps.  <iy  about 
four  cases  annuallv  in  cverv  thdusand  men:  but  as  unlv  l.l'l'n.  nr  abuut  cne-eighth  nf  the 
number,  were  discharged  from  the  service  as  unfit  f^r  dutv,  it  mav  be  inferred  that  in  general 
the  bronchial  spasm  was  amenable  to  treatment.  The  records,  Imwever,  throw  little  light 
on  this  subject.  They  are  few  and  meagre,  consisting  of  lait  >i.\  imperfeel  cases:  In  two  of 
these  the  origin  of  the  disease  is  ascribed  to  exposure  in  cold  and  rainy  weather.  A  slight 
attack  of  bronchitis  was  a.ssocitited  with  the  onsi't  in  two  cases,  while  in  one  every  ]iaroxysm 
Avas  jireceded  Ijv  a  chill.  In  one  case  the  patient  was  all'ected  with  lape-wonn,  but  its  expul- 
sion, l;)y  means  of  turpentine,  produced  no  beneficial  ellect  en  the  asthmatic  trouble.  In 
another  case  the  patient  had  been  subject  to  the  disease  from  childhood.  Treatment  was 
continued  in  four  of  the  cases  ibr  the  respective  periods  of  four,  seven,  nine  ami  luneteeii 
months,  but  without  notable  or  permanent  benefit  to  the  patients.  Tonics,  as  (piinine  and 
iron,  sedative  expectorants  and  counter-irritants  were  employe<l.  (Jhlorolorm  entered  Ire- 
Cjuently  into  the  prescriptions  given  to  prevent  or  cut  short  the  attacks, — three  ti:)  hve  di'ops 
in  mucilage  or  with  extract  of  wild-cherry  or  expectorants.  J)uring  an  attack  small  and 
repeated  doses  of  wine  of  ijiecacuanha  were  sometimes  administered.  Mustard  was  used  to 
produce  counter-irritation.  In  one  instance  iodide  of  potassium  and  extract  of  hyoscyamus 
appeared  to  exerci.sc  a  marked  influence  on  the  conditions  that  occasioned  the  broiu'liial  spasm  : 

Frederick  Wilkcsson,  Co.  C,  Slthlll,:  age  24;  was  admitted  Dec.  2,  18(!3,  with  a  gunshot  wound  of  the  left  hand 
and  asthma.  The  wound  was  received  at  Chickamauga  Sept.  20. 18G3,  and  was  healed  at  the  date  of  admission  ;  but 
the  patient  had  freriuent  attacks  or  paroxysms  of  asthma.  Ordered  iodide  of  potash  and  extract  of  hyoscyamus, 
with  thud  extract  of  cinchona,  three  times  a  day,  and  light  diet.  He  liad  no  paroxysm  after  he  commenced  taking 
this  preparation  and  was  sent  to  his  regiment  March  22,  1864. — Hospital,  (Juincy,  III. 

In  one  of  the  four  cases  that  were  continued  so  long;  under  treatment  a  mixture  con- 
taining  iodide  of  potassium,  liyoscyamus  and  lobelia  appeared  to  liave  a  good  effect  for  six 
or  seven  days,  but  the  patient  at  the  end  of  this  period  went  on  a  drunken  frolic  and  the 
asthma  became  thereafter  much  aggravated.     One  case  was  relieved  by  stramonium : 
Med.  Hist.,  Pt.  Ill— 92 


730  INFLAMMATION    OF    THE    LARYNX.  * 

Private  Thomas  L.  Rea,  C'li.  I.  2(1  IlL  Cav.:  airi'  -'.<:  «  as  ailniitlrd  Si'pt.  '_':!,  ISiili,  with  astliina,  with  wliich  ho 
had  been  ati'ectcd  sinci'  tlic  winrt-i'  nt'  INiil.  1  lis  n-st  at  niiilit  was  miiili  (listiiilicd  and  his  mind  di-|iiess('d  hy  lVtM|iiont 
paroxysms  of  nrj^fiit  dyspno-a  :  I  lis  ai'iictiti'  was  lair.  Hi'  liad  a  cdimli  Init  no  ex  ■,>(■(■  to  rat  ion.  (Javc  st  i  anion  in  m  to 
smoke;  full  diet.  Oct.  2it:  Patient  ri'sird  at  nisjhr  without  sitting  up  in  lied:  hi'  I'l-i'ls  bcttrr  ui'iii'iiilly.  Nov.  2.5: 
Transferred  to  Veteran  Reserve  Cor]is.  —  /lnspihiJ,  (Juiiicij.  III. 

VI,— INFLAMMATION  OF  THE  LARYNX, 

Altliougli  tlie  records  mako  tVoquoiit  moiitiou  of  larviio;i'al  inflammation  as  a  compri- 
cation  of  other  diseases,  tliere  are  but  eleven  cases  of  deatli  sjioeially  attributed  to  this  cause, 
concerning  wliicli  some  details  have  been  preserved.  11ie  17,318  cases  reported  as  having 
occurred  among  the  white  troops  consisted,  no  doubt,  l;u-gely  of  mild  catarrhal  attacks,  of 
chronic  thickening  marked  by  hotirseiiess  or  aphonia,  and  of  soitie  which  might  witli  pro- 
priety have  been  referred  to  syphilis  or  tuberculosis;  but  the  234  ftttal  ca.ses — a  mortality 
of  only  1.4  per  cent. — may  be  considered  as  fairlv  represented  l>y  these  eleven  cases.  The 
attack  was  generallv  sudden  and  indneed  bv  exposure  to  cold  and  damjiness,  especially  if 
the  individual  was  in  low  condition,  as  during  convalescence  from  some  serious  malady. 
The  throat  became  sore,  the  voice  hoarse  and  the  larynx,  trachea  and  cervical  glands  swollen 
and  tender.  There  was  much  jiain  and  difficulty  in  swallowing  and  a  rapidly  increasing 
dyspnoea,  with  inspiration  more  difficult  than  expiration.  The  patient  sat  up  in  bed  with  his 
heail  thrown  back,  and  in  his  struggle  for  breath  his  respiration  and  pulse  became  acceler- 
ated. Sometimes  a  chill,  followed  by  active  febrile  manifestations,  preceded  or  accompanied 
the  local  intlammation.  In  the  progress  of  the  case  the  imperfect  leration  of  the  blood  became 
indicated  by  the  dusky  complexion  and  blneness  of  the  lips  and  finger-nails;  the  anxious 
expression  disappeared  and  insensibility  deepened  into  coma  and  death,  or  the  fatal  termina- 
tion was  suddenly  reached  by  an  occlusion  of  the  glottis. 

The  rapidly  fatal  result  of  laryngeal  stenosis  is  seen  in  case  2,  in  which  tlie  interference 
with  respiration  was  due  to  the  presence  of  plastic  lymph,  whether  in  or  on  the  mucous 
membrane  is  uncertain.  The  conditions  in  5  and  6  are  equally  uncertain, — the  fibrinous 
exudation  is  said  to  have  been  under  the  folds  of  the  glottis.  In  1  cedema  is  assumed  as  the 
cause,  but  free  incisions  failed  to  collapse  the  swollen  membrane;  in  S-11  the  closure  was 
due  to  tt'dema;  in  7  the  larynx  appears  to  have  been  implicated  by  an  extension  of  the  dis- 
eased action  from  the  pharynx. 

So  long  as  the  dysjmcea  depended  mainly  on  narrowing  of  the  laryngeal  passage  an 
artificial  opening  gave  an  assurance  of  safety, — case  1  illustrates  the  rapid  improvement 
effected  by  the  entrance  of  air  into  the  lungs;  but,  when  the  pulmonarv  stasis  ended  in  an 
csdematous  permeation  of  the  tissues,  laryngotomy  was  obviously  of  no  avail.  Even  when 
the  lungs  were  free  from  effused  or  exuded  matters  the  operation  was  sometimes  unsuccessful 
if  delayed  until  the  nervous  centres  had  become  affected  by  the  depraved  quality  of  the  blood, 
as  in  cases  2  and  9.  In  case  3,  in  which  tracheotomy  failed  to  save  life,  although  the  lungs 
were  found  in  normal  condition  after  death,  we  are  probably  not  in  possession  of  all  the  cir- 
cumstances bearing  on  the  result. 

Treatment,  aside  from  opening  the  tube  below  the  constriction,  was  of  doubtful  value 
in  these  dangerous  cases.  Scarification  gave  temporary  relief  but  failed  to  cure.  Warm 
moist  inhalations  and  gargles  were  employed,  with  hot  fomentations  externally  or  counter- 
irritation,  as  by  iodine  or  cantharidal  collodion.  Active  cathartics  and  free  doses  of  iodide 
of  potassium  were  unavailing  in  case  4.  Chlorate  of  potash  was  administered  in  5,  proba- 
bly in  the  hope  of  supplying  oxygen  to  the  blood. 


INK  LA  MM  AT  lux    OK    TllK    LAKYXX.  T^'l 

Cask  1. — Private  Saiiiufl  I'rosli,  Co.  r,  1st  Pa.  Heavy  Art'y:  ajje  21 :  a  well-l'oniied,  liealtliy-lixikiiit;  yimiic;  man, 
was  ailiiiitted  ilareli  24.  l^<(il.  uiuler  ])r.  Joiix  II.  liAiiTlloi.K,  with  ]ili"nni-]nieuiiiiiiiia  iit'  tlie  Iclt  sidi'.  Dmiii^j  liis 
couvaleseenoi-  from  this  attack  lie  was  absent  without  leave  on  Ajuil  !•.  a  cliilly  rainy  day.  tin  the  lIUli  lie  had  sore 
throat  with  iiiiieh  dyspntea  and  oeeasioniil  straiifilinj;  in  atteni])tin;j  to  swallow:  the  larynx  and  traehea  were  tender 
and  there  was  slight  redness  in  the  tliroat.  A  garble  and  liot  foinentatious  were  ordered.  IL'lh:  He  slejit  hut  little 
thuing  the  night:  the  front  of  tlie  neek  was  swollen  and  tender  and  swallowing  caused  niueli  jiain:  there  was  no 
cough,  hnt  the  voiee  was  whispering,  the  respiration  difficult,  the  countenance  anxious  and  the  hea<l  thrown  hack. 
'Pile  fauces  were  reddened  and  the  epiglottis  cushiony,  yellowish-red  and  shining  as  if  from  elVused  si'runi.  The 
niiieous  menilirane  was  incised,  tile  vapor  of  waiiii  water  inliah-d  and  tincture  of  iodine  ajiplied  externally.  The 
incisions  gave  so  much  relief  that  the  jiatient  asked  to  have  them  repeated.  Kith;  At  midnight  he  had  a  seven'  par- 
oxysm of  dyspiift'a,  inspiration  lieing  more  dlMienlt  than  cxjiiration:  he  sat  n]i  in  lied  sucking  in  the  air.  with  an 
anxious  face  and  dull-colored  lips  and  linger  nails.  The  ajiex  of  the  i']iighittis  was  in  better  condition  than  on  tlu^ 
lireceding  day,  hut  the  remainder  of  the  organ  was  unchanged.  At  :i  a.  m.  incisions  wimv  made  in  tin'  swolh'ii  meni- 
hraue  and  repi'ated  many  times  until  daylight,  hut  they  did  not  give  satisfaetoiy  relief.  The  imlsi'  was  PJO.  Can- 
tharidal  collodion  was  applied  to  the  front  of  the  neck  anil  tliirty  drojis  of  laudaiiiim  given:  warm-water  vajior 
and  warm-water  gargles  were  used.  At  9  a.  m.  the  pulse  was  128 and  the  jiatient  we;ik.  .\i  11  a.  m.  he  w:is  worse.  A 
consultation  was  held;  a  strong  solution  of  nitrate  of  silver  was  aiiidied  to  the  larynx.  At  noon  he  was  nnicli  worse: 
his  pulse  13(5,  respiration  3o,  countenance  dusky,  nails  liliiish  and  his  muscular  jiower  so  all'ecteil  that  he  slijiped 
down  in  lied.  Dr.  H.  V.  Weir,  surgeon  in  charge,  made  an  incision  through  the  erico-tliyroid  mem  lira  ne.  tin-  cricoid 
cartilage  and  one  or  two  rings  of  the  trachea:  a  douhle  tracheal  tnlie  was  inserted  and  a  warm  ni<iist  sponge  with  a 
folded  piece  of  mosqnito  netting  placed  over  the  opening.  Two  teaspoonl'uls  of  hlood,  mostly  venous,  wen'  lost. 
The  dyspna'a  was  immediately  relieved  and  the  livid  color  lessened.  In  half  an  hour  the  luilse  fell  to  12(1,  the  resjii- 
ration  to  31,  and  soon  after  the  patient  dro]iped  into  a  doze  which  lasted  the  entire  altcniooii.     In  the  evening  he 

asked  for  food;  beef-tea  was  given.     At  (i  i>.  .M.  the  pulse  was  112.     IIi^  passed  a  g 1  night.     1  Itli;  The  pulse  was  !)2. 

Liijuid  food  was  given.  He  was  directed  to  use  the  larynx  as  much  as  jiossihle  in  respiration  by  putting  his  finger 
on  the  mouth  of  the  tube,  l.'ith:  He  passed  a  good  night  but  had  a  red  thish  on  his  cheeks  and  a  stitch  in  each  side, 
with  slight  cough;  pulse  100.  He  breathed  much  through  the  larynx  without  closing  the  tube.  Kith  :  The  thoracic 
symptoms  have  disappeared;  pulse  90;  appetite  good.  IStli:  The  tulie  was  removed.  19th:  The  orilicc  was  nearly 
closed,  no  air  escaping.  May  3:  He  was  still  somewhat  hoarse:  the  granulating  surface  at  the  site  of  I  hi'  incision 
was  nearly  cicatrized.  He  was  returned  to  liis  com]iany  to  receive  a  re-enlistnient  furlough,  .lune  !i:  He  called  at 
the  hospital.  His  voice  was  still  rough:  in  hallooing  the  note  was  not  clear:  in  shouting  there  was  :i  higli-|iit<died 
squeaking  noise:  he  was  otherwise  perfectly  healthy. — Hu^pital.  Fralcricl'.  Mil. 

Ca.se  2. — Samuel  Mitchell,  Co.  C,  12th  V.  S.  luf ,  was  affected  with  sore  throat  during  his  convalescence  from 
typhoid  fever.  On  Oct.  i,  18(52,  at  3  r.  M.  resiiiratioii  hecanie  embarrassed  and  he  grew  rapidly  worse:  at  1  n.  M.  the 
neck  was  swollen,  especially  on  the  right  side;  there  was  dyspntra,  coldness  of  extremities  and  insensibility.  I.aryii- 
gotomy  was  performed  and  respiration  through  the  artificial  ojiening  was  free,  but  in  about  fifteen  minutes  he  died. 
Post-mortem  examination:  Tonsils  deeply  eroded:  epiglottis  firm  from  effusion  of  jilastic  lymph,  which  effusion  was 
also  marked  about  the  vocal  chords,  esjiecially  on  the  right  side.     Lungs  congested. — //(/.yx'/ii/.  [■'ndcritk,  Mil. 

Case  3. — David  R.  Zimmerinan,  Co.  C,  7tli  S.  C;  age  30:  was  admitted  at  noon  \\t\\\  9.  IStil,  with  croii]iy 
breathing,  dusky  countenance  and  blue  lips.  .Sonorous  ami  siilicreiiitant  rales  were  heard  over  liotli  lungs:  the  c'pi- 
glottis,  tonsils  and  surrounding  parts  were  much  swollen.  Tracheotomy  w  as  jierformed  one  hour  after  admi.ssion 
and  a  quill  tube  was  inserted,  through  which  he  breathed  freely  and  w  itli  marked  ini]irovi'iiieiit  until  2  o'clock  of  the 
succeeding  night,  when  he  had  a  severe  cliill  and  rapidly  sank,  dying  at  8  a.  m.  .\pril  10.  I'lml-morliiii  examination: 
Thickening  and  enlargement  of  the  epiglottis  and  tonsils;  fibrinous  exudation  under  tlie  folds  of  the  glottis,  pro- 
ducing almost  complete  closure.     Lungs  normal. — Act,  Ass'l  Siirijcoii  M.  A'.  (Hciikoii,  Hork  IxJiuiiI  Uoxpitiil,  III. 

Case  4. — Marion  Evans,  Co.  G,  2d  Ark.  Cav.:  age  2G;  temperate  and  free  from  constitutional  taini  :  w  as  taken 
suddenly  with  a  violent  chill  while  attending  roll-call  on  the  evening  of  Sejit.  25,  18(i4.  High  febrile  excitement  fol- 
lowed, with  intense  headache  and  pain  in  the  back  and  limbs;  next  day  ho  had  sore  throat, enlarged  glands,  aiih<inia 
and  difliciilt  deglutition.  On  admission  on  the  27th  his  countenance  was  suffused  and  anxious,  breathing  loud  and 
distressingly  labored,  respiration  30;  he  ]ireferred  the  sitting  posture  and  kept  his  head  thrown  back.  His  cough 
was  dry  and  eroupy;  pulse  120,  hard  and  full;  tongue  coated;  skin  dry  and  hot;  throat  swollen  and  tender.  Croton 
oil  was  given  internally  and  applied  externally  to  free  pustulation.  The  pharynx  was  swabbed  w  ith  nitrate  <if  silver 
solution.  After  catharsis  ten  grains  of  iodide  of  potash  were  given  every  four  hours.  He  died  suddenly,  September 
28,  after  an  attempt  to  rise  from  bed.  Post-niortem  examination:  Parotid  and  submaxillary  glands  greatly  enlarged: 
epiglottis  swollen  and  exuding  pus  on  puncture:  three  drachms  of  sero-]iurulent  liquid  in  the  larynx,  the  cliink  firmly 
closed.     [S/>(ci«iCH  052,  Army  Medical  Museum.] — Art.  Ass't  Surgeon  M.  K.  Oleanon,  Hock  hhind  Hospital,  III. 

Case  ."). — James  B.  Lloyd,  Co.  C,  9th  Fla.;  a  plethoric  man;  age  35;  was  admitted  April  3,  18(il,  with  fever, 
crouiiy  breathing  and  pain  over  the  larynx;  the  fauces  were  inflamed  and  the  submaxillary  region  swdllen  and 
tender.  He  became  very  restless  and  delirious.  He  was  treated  with  catlnirtics,  chlorate  of  potash  internally  and 
iodine  externally.  He  died  April  5.  Poat-mortcm  examination:  Swollen  condition  of  glottis  from  fibrinous  exuda- 
tion.— Act.  Ass't  Surgeon  M.  K.  Gleaaon,  Hod-  Inland  UospHul,  111. 

Case  0. — Joshua  Watson,  Co.  C,  7th  Fla.;  age  40;  was  admitted  March  22, 18t>4,  in  a  very  debilitated  condition, 
having  been  sick  for  some  time  with  typhoid  fever;  his  tongue  was  dry,  teeth  covered  with  sordes,  countenance  dull 
and  expression  vacant.     On  March  25  ho  was  suddenly  attacked  with  acute  laryngitis  and  died  on  the  same  day. 


732  IXFI.AMMATIOX    OF    THE    LAEYXX.  ^ 

Post-iiiorltni  (.■xaiiiiiiation:  Peyer's  p.ifclifs  oongested,  tliiekcucd  iiiid  iilcciiiti'd.  Glottis  and  smroiindiiig  parts  con- 
gested and  swollen,  with  tibriiioiis  exudation. — Act.  A-tii't  Sunjcon  M.  K.  fllcii-sDii,  Hock  hliind  Ilo-^jiital,  II!. 

t'A.sE  7.— Private  Asa  C.  Wentwoitli.  Co.  II,  ISltli  Me.:  admitted  Xov.  L'l!,  181)3;  <lied  Jan.  12,  18(11.  ro«l-mortem 
examination:  The  velum  jialati  was  hard,  stiff  and  white  ;  thetoiisils  iniiormal  eondition.  Pliarvnf;itis  was  jiresent, 
especially  on  the  ritjUt  side.  0|)posite  the  right  arytenoid  cartilage  a  largo  ahscess.  witli  hard,  yellowish-white  walls, 
was  observed,  and  the  cartilage  itself  was  the  scat  of  a  large  protnheraiiee,  ]ir(dialdy  a  collection  of  jms.  This 
swelling  and  the  abscess  of  the  pharynx  cxi)laiiied  the  ditliculty  of  deij'lntition  observi'd  during  life.  A  small  col- 
lection of  pus  was  seen  on  the  opposite  side  of  this  region  innnediately  above  the  greater  horn  of  the  hyoid  bone. 
The  e]>igIottis  and  vocal  chords  were  (edematous  and  yellowish-white.  The  heart  was  soft  and  the.  liver  bronzed 
and  mottled  with  hard  lardaceous  spots.  [The  condition  of  the  lungs  is  not  stated.] — Asx't  Siin/ion  II.  AUcii.  U.  .*>'.  A., 
Lincoln  Ilo'^pitul,  Washinaion,  I).  C. 

Cask.  8.— Corporal  .Samuel  Dillingham,  Co.  II,  21tb  V.  R.  ('.:  age  •_'•_':  was  admitted  March  2it,  181)1.  He  bad 
been  taken  with  fever  and  sore  throat  on  the  )iie vious  day.  He  died  on  the  31st,  after  a  suddenly-developed  jiaroxysm 
of  dys])n(pa  which  lasted  thirty  minutes.  I'oxt-iiioiii  in  examiiuition ;  Inllammation  of  the  larynx  and  ledenia  of  the 
glottis, — Scconil  I)iri«ion  IT(isj>it<(I,  Ahxnntlrid,  Vk. 

Ca.sk  0. — Private  William  II.  Schlosser,  Co.  F,  lloth  Ind.:  age  13:  was  admitted  Feb.  3,  18(i."i,  having  been 
atl'ected  for  a  ^vc(d<  or  two  with  cou,!j;li.  He  had  an  abundant  exi)ectoration  and  well-nuirked  symptoms  of  bronchitis. 
On  the  12th  his  throat  became  slightly  sore,  the  fauces  somewhat  reddened,  tonsils  enlarged  and  cervical  glands 
swollen.  A  gargle  was  prescrilied.  Two  days  later  he  had  a  little  diarrluea  but  the  throat  was  better.  About  noon 
of  the  17th  be  was  suddenly  seized  with  great  dyspn(ea,  his  lips  becoming  quite  blue,  when,  on  examination,  the 
nvnla,  epiglottis  and  glottis  were  found  to  be  oedematous.  Scarification  gave  some  relief,  but  an  emetic,  which  was 
administered,  was  without  effect.  At  5  r.  si.  the  patient  again  became  threatened  with  suffocation,  which  scarilica- 
tion  and  inhalation  of  hot  vapor  and  of  acetic  acid  and  ether  failed  to  relieve.  Laryngotoniy  was  performed  at  7 
p.  M.  by  Ass't  Surgeon  Wir.i.lAM  X'ouiil.s,  U.  S.  A.,  the  incision  passing  in  the  mesial  line  througli  tlu^  crico-thyroid 
membrane  and  cricoid  cartilage.  After  the  operation  the  patient  took  two  or  three  inspirations,  coughed  up  a  few  drops 
of  blood,  and  died.  Po^t-niorlini  examination:  The  chink  of  the  glottis  was  completidy  closed  by  o'dema  of  the  sur- 
rounding tissue.  [S'jiccimcn  .51!t,  Med.  Sec,  Army  Jledical  Museum.]  The  epiglottis  was  O'dematons  and  much  thick- 
ened. The  trachea  and  bronchial  tubes  were  intlamed,  their  mucous  membrane  thickened  and  reddened  to  their 
minute  subdivisions;  no  false  membrane  was  found  in  any  part  of  the  air-|)assagcs.  A  small  ]i.itch  of  pneumonia 
was  discovered  in  the  lowerpart  of  the  left  lung.  The  otberorgans  were  healthy. — Act.  .Ixs't  .Siinji nn  liurid  L.  Ilnii/lit, 
Douijlan  JIuxpUut,  Washington,  D.  C. 

Cask  10. — Private  R.  I!.  Curtis,  Co.  C,  21th  Mich.,  was  admitted  Xov.  1,  18(;2,  with  laryngitis.  He  died  on  the 
8th.  I'ont-nwrtcm  examination:  Throat  swollen  and  bloodvessels  of  neck  engorited:  larynx  iiillamed  and  so  swollen 
from  serous  effusion  in  the  submucous  tissiu-  as  to  occlude  the  air-passage.  There  was  no  exudation  on  any  part  of 
the  respiratory  mucous  membrane. — Tloren'ooil  Hoapitnl,  Watjtinijton,  1).  C. 

Case  11. — Recruit  Henry  V.  White  died  of  acute  laryngitis  Feb.  13,  186-t.  X'o  history  recorded.  [Specimen 
570,  Med.  Sec,  Army  Medical  Museum,  shows  the  larynx  and  epii^lottis  of  this  case,  with  the  mucous  membrane  around 
the  orifice  of  the  glottis  thickened  from  (edema.] — Snrr/con  John  XeiU,  U.  S.  I'.,  JIa«pital  Ilroud  and  Cherry  streets, 
Philadelphia,  I'd. 

Lningrene  of  the  larynx  was  noted  by  two  medical  officers,  who  have  already  published 
their  observations.* 

VII.— INFLAMMATION  OP  THE  TONSILS. 

Inflammation  of  the  tonsils  was  reported  as  the  cause  of  59,911  cases  of  sickness  and 
97  deaths  among  the  white  troops,  equaling  an  average  annual  rate  of  26.9  cases  per  thousand 
of  strength,  .16  per  cent,  of  the  cases  ending  fatally;   and  of  6,754  cases  and  12  deaths  among 

*  W.  11.  Studley,  Act.  Ass't  .Siirseun — AmeyUau  Med.  Timc^,  Vol.  V,  T8G2,  p.  21.5 — gives  the  liistnry  of  a  case  uf  (liscasc  of  Itn'  tli|-nat  wlii<-li  ih-ciiitihI 
at  yort  Haniiltoti,  X.  Y.,  in  August,  18(>2 :  The  patient,  a  soldier,  convalescing  from  a  remittent  fever  which  had  deveIope<l  the  cliaracteri>tics  of  gen- 
uine typhus,  becan)o  afTected  with  sore  throat  considered  due  to  exptisnre  to  cold  and  damp  air.  Fever  sujie'rvened  with  co)isiderahle  debility,  and  after 
three  days  his  breathing  became  laburions  and  attended  with  an  inspiratory  whoop.  There  was  a  semitransjiarent  tnmor  below  and  anterior  to  the  left 
tonsil,  which  was  a  little  swollen  ;  the  epiglottis  and  glottis  were  very  ii'dematous.  Incisions  into  the  tnmor  and  the  diseased  parts  in  the  vicinity  of  the 
larynx  gave  temi)orary  rtdief.  Death  occurred  in  the  night,  but  whether  from  exhaustion  or  suff'x-ation  could  not  be  detern)ineil  from  the  imperfect 
account  given  by  the  attendant.  Pont-mitrtfm  examination  revealed  no  nn>rbid  apiM-arances  except  such  as  were  ftnuid  in  the  larynx.  The  mucous  mem- 
brane was  swollen  and  of  a  dark-green  coh)r  on  tlie  right  side,  the  tissues  being  affected  to  the  (b-pth  of  one-ftiurth  to  one-thinl  of  an  inch  ;  the  morbid 
condition  extended  over  the  ventricle  to  the  epiglottis  and  by  a  narrow  tract  to  the  left  tonsil.  Kerrs  Kisc,  Brown,  i^urgeon  l'.  S.  Vcds.,  has  described 
— AmerU-im  Med.  Time/*,  Vol.  V,  1S62,  p.  243 — a  gangrene  of  the  throat  that  appeared  in  the  geuenil  hospital  of  the  iJepartnient  of  the  Gulf  in  the  fall  of 
18(j2  :  The  disease  involved  the  root  of  the  tongue,  tlie  ventricles  and  cartilages  of  the  larynx.  Its  existence  during  life  was  not  at  first  known.  Out 
of  fourteen  cases  in  which  the  disease  was  discovered  after  death  only  three  jiresented  symptoms  that  might  have  directed  attention  to  the  seat  of  the 
affection  ;  in  one  there  was  marked  dyspncea  shortly  before  death  and  in  the  others  some  fetor  of  the  breatli.  It  attacked  the  sick  and  di.'bilitated ; 
nearly  all  affected  had  been  greatly  reduced  by  the  miasmatic  fever  of  the  Mississippi,  and  many  hail  suffered  long  from  chronic  diarrhoea.  Death  was 
sudden  and  apparently  from  sheer  debility.  Evidences  of  .the  disease  were  ftrst  observed  while  making  autopsies  to  find  some  lesion  or  morbid  state  of 
the  internal  organs  that  might  account  for  the  fatjil  result  in  these  cases.  The  diseased  parts  had  the  color  of  gangrene  of  pulmonary  tissue,  although 
free  from  tlie  strong  fetor  of  the  latter.  In  a  few  cases  there  was  (edema  of  the  glottis  and  serous  infiltration  in  the  vicinity  of  the  larynx.  The  heart 
was  flabby  and  the  blood  watery.    This  condition  of  the  throat  was  not  associated  with  scurvy. 


I^'FLAMMATIO^-    OK    TIIK    TONSILS.  '-^•-> 

the  colored  troops,  equaling  an  averago  annual  rate  of  Ziy.R  per  tliousaud  and  a  iatalitv  uf 
.18  per  cent,  of  the  cases. 

These  nunil)ers  probably  include  all  the  cases  of  quinsy  tiiat  came  und./r  oliservalion 
exce}iting  only  rare  instances  of  mistaken  diagnosis.  Thus  the  2d  ( 'al.  (  av.  appears  to  have 
suffered  at  one  time  from  inflammation  of  the  tonsils,  ^vhi(•h.  owing  to  the  violence  of  the 
symptoms,  and  particularly  the  suflbcative  feelings  exjierienced  by  those  afHictod,  was  regarded 
and  reported  as  an  epidemic  of  complicated  laryngitis. ■•■  It  seems  erpiallv  probable  that 
the  reported  cases  included  most  of  those  in  which  the  tonsils  were  involved  in  a  catarrhal 
inflammation  of  the  pharynx,  not  a  iew  of  those  in  which  the  inilammation  was  dljihtheritic, 
and  perhaps  some  in  which  the  tonsillitis  was  a  local  manifestation  of  a  constitutional  affec- 
tion. It  may  be  assumed  that  the  percentage  of  unfavorable  results  was  in  part  due  to 
diphtheritic  inflammation,  although  the  following  cases  indicate  that  some  at  least  were  fatal 
from  oedema  or  inflammatory  tumefaction  of  the  lining  membrane  of  the  larynx: 

Case  1. — Sergeant  Juliii  R.  Kurtz,  Co.  C.  llTtli  I'ii..  w.ts  uilmitted  Oct.  '2'>.  IKtiH.  with  secdiidary  Kypliilis. 
Slioitly  after  a(liiii».-jioii  lie  contracteil  s('al)ies,  whicli  ])revailiMl  to  .soiiu'  I'xtent  in  tlie  w.-ud  in  wliieli  lie  was  iilae<><l, 
lint  it  soon  yielded  to  treatment.  On  the  niornini;  of  Deeeniber  7  his  throat  was  son'  and  slightly  sw(illen,  lint  there 
■ivas  little  or  no  eonstitnt ional  distnrliance.  A  stimulating  liniment  was  aiijilied,  tlii'  throat  was  wrapiied  in  Ihiniiel, 
and  the  bowels  lieing  costive  were  moved  liy  Kiisoni  salt.  Next  day  the  right  tonsil  was  much  enlargi'd  and  Ihi'  jiulse 
a  little  (inicl<ened.  Chlorate  of  potassa  was  used  internally  and,  with  ca])sicuni,as  a  gargle;  stimulants  were  given, 
together  with  sneli  nutritious  articles  of  food  as  the  jiatient  could  swallow.  On  the  IHh  he  felt  easy:  the  right  tonsil 
was  discharging  freely  and  the  left  lint  little  swollen:  there  was  no  ditiicnlty  in  breathing.  His  condition  remained 
unaltered  until  midnight  of  the  lltli,  when  he  began  to  lie  restless  and  complained  of  inability  to  sice]),  for  which 
an  anodyne  was  prescribed.  The  symptoms  did  not  appear  alarming  at  this  time:  but  in  half  an  hour  the  patient 
expired.  I'ost-mortini  examination:  Holh  tonsils  were  much  enlarged  and  su]ipurating  freely.  The  epiglottis  and 
larynx  were  (edematous.  The  viscera  of  the  thorax  and  abdomen  appeared  healthy. — ict.  Ass't  Surgeon  K.M.Oiuvix, 
SdttcHee  J{ospit((l,  FliiltKhlpliin,  Pa. 

C'.\SE  2. — l^rivate  11.  Xelson  Young,  2d  lie.  liat'y:  age  L':!;  was  admitted  Oct.  ](>,  1802,  w  ith  a  slight  gunshot 
wound  received  at  Antietani.  On  October  29  the  right  tonsil  became  inflamed  and  suj)purateil.  Chlorate  of  ]>otasli 
was  used  as  a  gargle  and  tinetnre  of  iron  and  gnaiaciini  given  internally.  On  the  31st  the  patient  was  so  mueh  relieved 
by  the  escape  of  the  matter  that  in  the  afternoon  he  was  walking  about :  but  at  9  r.  .M.  he  was  seized  with  dysjiniea; 
the  veins  of  the  head  and  neck  became  turgid  and  the  pulse  feeble  and  too  rajiid  to  be  counted.  On  imlling  out  the 
tongue  by  a  pair  of  artery  forceiis  rcsiiirati<in  was  temporarily  relieved:  but  as  it  grew  more  urgent  an  inci.sion 
was  made  through  the  skin  and  the  crieo-tliyroi<l  ligament.  A  little  froth  issued  from  the  o]iening,  through  which 
the  patient  breathed  freely;  his  pulse  fell  iniimediately  to  about  9ti  and  his  lips  ajipeared  almost  natural  in  ajijicar- 
ance.  Finding  ies]iiratioii  thus  easy  no  tube  was  used.  At  11  r.  M.,  the  urgi'iit  symptoms  liavinir  reaiijiearcd  and  no 
tube  being  at  hand,  a  triangular  portion  of  the  cricoid  cartilage  was  removed,  but  the  resjiirations  diminished  in  fri'- 
(luency  and  the  patient  died  in  half  an  hour.  7'ws/-)»or/f»i  examination:  The  lungs  were  filled  with  serum.  The  heart 
w  as  normal.  The  right  tonsil  was  deeply  ulcerated  and  contained  some  ])us :  the  left  was  also  ulcerated.  The  uvula 
was  thickened  by  effusion  of  lymph  and  ulcerated  on  its  right  siile.  Tin-  ejiiglottis  was  erect,  hard  and  thickened  by 
effusion  of  lymph  beneath  the  mucous  membrane;  the  aryteno-epiglottidean  folds  were  mueh  thickened,  especially 
on  the  right  side:  the  chink  of  the  glottis  was  almost  entirely  closed  by  the  efi'usiou;  several  small  patches  of  false 
membrane  were  found  above  the  vocal  cords,  especially  on  the  right  side,  but  there  was  none  below.  The  mucous 
membrane  of  the  trachea  and  bronchial  tubes  was  deeply  congested,  but  without  ulceration,  eli'nsion  or  (le]iosit. — 
Act.  Asx't  Hiirycoii  W.  W.  Kekx,  Jr.,  Ceiilral  Iloapital,  FmUrick,  Mtl. 

Case  3. — Colonel .).  M.:  age  30:  of  sallow  coin]ilexion  and  having  the  ajiiiearanec  of  one  broken  clown  by  malarial 
disease,  was  attacked  Dec.  13.  ISG-i,  with  inflammation  of  the  left  tonsil,  followed  by  considerable  external  swelling. 
He  had  fever;  the  pulse  was  96,  full  and  hard.  Cathartics  and  antimonials  were  administered,  counter-irritants 
applied  to  the  throat  and  vapor  of  hot  water  directed  to  be  inhaled.  The  symptoms  were  relieved  for  a  time  under 
this  treatment :  but  on  the  fourth  day  the  jiatient  grew  hoarse  and  suft'eied  from  dyspiuea,  although  the  tonsillitis  had 
subsided  and  the  external  swelling  had  almost  disapjieared.  The  dyspmea  rapidly  increasing,  a  solution  of  nitrate 
of  silver  containing  sixty  grains  to  an  ounce  of  water  was  applied  to  the  root  of  the  tongue  and  fauces.  This  had 
little  eft'ecf,  and  in  an  hour  and  a  half  respiration  had  become  .so  difiicult  that  suffocation  was  imminent.  Kelief  was 
immediately  obtained  by  an  incision  through  the  crico-thyroid  membrane.  A  tracheotomy  tube  was  inserted  ami  in 
a  few  minutes  the  patient  was  able  to  lie  down.  Forty-eight  lionrs  after  the  operation  resjiiration  could  readily  be 
performed  througU  the  natural  passage.    The  tube  was  therefore  removed  and  the  wound  closed  with  adhesive  plaster. 


*St'c  S<iH  Fi-<ntci.tro  Mt'dUnl  P)rw,  Vol.  IV,  lsr>3,  ji.  14.  Aoronliiig  to  tlio  ri'itort  ('f  Charles  C.  Farley,  tho  curgooii  of  tlic  regiment,  tlie  disease 
was  Budiit'n  in  its  attack  ami  of  preat  severity,  lieinjr  diararti'ri/.eil  liy  high  fever  atel  preat  dysj-iHea  am!  (lysplinjria.  The  latter  Ryniptoms  were  jtrest-ut 
fruin  the  first  ami  soon  iurreased  to  an  alanning  dej^Tee.  In  two  nr  tliree  days  the  disease  usually  readied  a  crisis.  It  affected  alniust  exclusively  those 
who  had  lieen  exposed  to  cold  at  night.     No  ca.se  terminated  fatally. 


734  ixKr.AMNrATrox  of  tiif,  tonsils. 

Next  (lily  tlie  i)lasti'r  was  clKiiiiicd  fur  ii  tliick  Cdatiiifi  nf  cdUodioii.  Tlie  wduiul  luMlrd  in  a  few  daxs.  An  eivsipe- 
latous  rash  ai>lieareil  at  the  seat  of  the  ii)ieiatiiiii  and  spread  over  the  rij;lit  side  <jf  the  iu'(  1<.  seal]i  and  I'ljreliead.  It 
soon  disapjieared  under  tlie  ajiiilieation  <d'  iodine  and  the  use  of  internal  remedies. 

Sui'gciiu  A\  ii.sON,  l^tli  ()lii(i,  wlio  rc|ioi'teil  tlir  tliinl  case.'-'  coiisidoi-oil  il  one  ol'  crv- 
sipelatous  iulhunifialinii  which,  Ix'gi lining  at  tlio  ti")n.<ils.  invai.lcd  the  hirvn.x.  iuiil  fiuallv 
appeared  externally  at  the  wound  and  spread  over  tlie  surtace. 

A  few  extracts  relating  to  inflammation  of  the  tonsils  are  suhmitted  along  with  the 
records  that  afiord  any  information  in  addition  to  ditignosis  and  dates  of  attack  and  recovcrv: 

Sitrrjeiyn  Lot'is  Watson.  lfl//(  III.,  SI.  Joseph,  ^fo.,  Dee.  31,  1801, — Inliainination  of  the  istlinms  t'aneinm,  with 
tonsillitis,  prevailed  i'j)ideinieally.     The  tonsils  rarely  suppurated. 

Suryeon  II,  \V.  Kend.^i.i.,  .">0/7i  III.,  St.  Jusepli,  Mo.,  Dee.  31,  18(11. — The  seeond  epidemic,  one  of  tonsillitis,  fol- 
lowed closely  npon  I  he  decline  of  the  measles.  Consccnieiitl.v  most  of  the  debilitated  snlijectsof  rulieohi  were  attacked 
by  the  new  epidemic.  Tliis.  with  the  want  of  snfticient  hospital  accommodations,  reqnirinf;  a  hast.v  retnrn  of  conva- 
lescents to  qnarters,  lnoujjht  many  of  the  men  hack  ajjain  and  aj^ain  witli  relapses  and  complications  whicli  wonUl 
not  otherwise  have  occurred. 

Sitygeon  J.  M,  Allkx,  '>\lli  Pa.,  Sir  Joliii'ii  Ilitii,  J'a.,  Sept.  1,  18o2. — Malarial  fevers  and  tonsillitis  jirevailed  u.s 
epidemics  during  August.  The  latter  was  confiued  solel.v  to  one  company:  the  cause  could  not  be  ascertained.  This 
company  was  almost  exempt  from  fever  during  the  past  month.  The  disease  although  violeirt  was  in  no  instance 
fatal.  It  was  accompanied  with  more  or  less  constitutional  disturbance,  and  invariably  yielded  to  the  free  use  of 
nitrate  of  silver,  Neitlier  tonsillitis  noriliplitheria,  to  my  knowledge,  prevailed  in  the  surrounding  ni'ighborhocjd  at 
the  time, 

SiD-geon  KcFl'.s  KixG  Brown,  f.  .S',  Voln.,  Ship  Ixlaiid,  .Viw,,  Fehntnry,li<(M. — There  were  many  eases  df  inManima- 
tion  of  the  fauces.  The  seat  of  this  was  eircnmscribed  and  not  attended  with  exudutioii  or  destruction  df  any  iiart 
of  the  niendirane  involved. 

Act.  .isn't  Surgeon  Jokl  Sk.wkxs,  Fort  Ifeirrai,  Ho-ston,  Mu.^.t.,  April  1,  1H()3, — Tonsillitis  has  been  (|uite  prevalent, 
most  of  those  having  catarrh  or  bronchitis  having  at  some  time  during  its  course  been  a  fleeted  also  with  an  inllamma- 
tion  of  the  throat.  This  inthiniination  has  in  many  cases  iissumed  a  diiihtheritic  aspect.  ]ireseuting  exnde<l  lymph 
and  at  times  the  constitutional  symptoms  of  di[)litheria;  but  it  has  always  yielded  readily  to  appropriate  treatment. 

Cask  1. — Private  Augustus  lievens,  Co,  I',  2(lt  h  Me,,  w.as  a<lmitte(l  Dee,  18,  1802,  with  incout  ineneo  of  urine, 

*  *  *  Jan.  17,  1803:  Throatsore;  tonsils  enlarged,  (iave  a  gaigle  of  capsicum.  18tli:  Throat  l)etter,  21st:  (Jave 
ten  drops  of  tincture  of  iron  three  times  a  day  in  water,  2'Jt!i:  Omitted  iron,  February  SI:  Sore  throat:  great  jiain  in 
last  tooth  of  left  side  of  lower  jaw,  which  on  examination  was  found  overgrown  by  the  gum,  preventing  tlio  patient 
from  closing  his  moiitli.  Gave  capsicum  gargle.  lOth  :  Tonsils  much  swollen  and  painful ;  dysphagia.  Gave  a  gaiglo 
of  clilorate  of  potash.  11th:  Less  fever  ami  headache;  bowels  regular,  12th:  I'hroat  still  swollen;  dysphagia. 
Removed  redundancy  of  gum.  13th:  Continued  gargle  :  gave  milk  diet,  ITtli:  Applied  dried  alum  to  gum,  March 
23:  Returned  to  duty. — Satlerlec  Hospital.  I'ltiladelphid,  I'n. 

Case  2,— Private  liradbury  P,  Doc,  Co.  I,  1st  Me,  Cav,:  age  l!l;   was  admitted  Dec.  23,  1802,  with  debility. 

*  *  *  April  10,  1803:  Tonsils  very  large;  deglutition  painful,  Seurilied  tonsils.  Gave  extra  diet.  17th:  Ajiplied 
two  blisters  over  tonsils.  18th:  Full  diet.  May  14:  Applied  tincture  of  iodine  over  tonsils.  10th:  Tonsils  much 
swollen.     18th:  Gave  cod-liver  oil  three  times  a  day.     27th:  On  gtiard  duty. — Satterlee  Hospital,  rhihidelphia,  I'd. 

Case  3, — Private  Jerome  McLain,  Co,  K,  12tli  X,  J,;  age  2."j:  was  admitted  Dec.  12, 1802,  from  duty  as  a  mem- 
ber of  the  hospital  guard.  lie  had  a  mild  attackof  tonsilliti.s,  A  solution  of  nitrate  of  silver,  ten  grains  to  one  ounce 
of  water,  was  applied  to  the  throat  and  a  dose  of  Epsoiu  salt  administered.  22d:  Throat  better.  Repeat  the 
local  application.  23d:  Discovered  an  excavated  ulcer  on  each  tonsil,  that  on  the  right  lieiug  ])articnlarly  huge. 
Throat  to  be  swabbed  twice  with  the  caustic  solution  and  a  chlorate  of  i)ot:ish  gargle  to  b<;  used  in  addition.  21th: 
Continued  the  application  to  the  throat.  Ulcers  covered  witli  a  grayish  slough.  20th:  Throat  decidedly  lietter. 
Treatment  continued.  30th:  Patient  is  sitting  up.  Continue  gargle;  disuse  nitrate  of  silver.  Jan,  12, 1803:  Returned 
to  guard  duty. — Sattcrlee  Hospital,  I'hiladelpkia,  Pa. 

Ca.se  4, — Private  John  D.  Sargent,  Co,  K,  4th  X.  J,;  age  21 ;  was  admitted  from  guard  Feb,  10, 1803,  with  some 
fever  and  sore  throat.  The  right  tonsil  presented  an  ulcerated  patch  aliout  the  size  of  a  three-cent  jiiece  and  covered 
witli  a  grayish  pultaceous  slough ;  the  left  had  a  smaller  liut  similar  ulcer.  They  were  directed  to  be  swabbed  morn- 
ing and  evening  with  a  solution  of  nitrate  of  silver,  tifteen  grains  to  an  ounce  of  water;  a  chlorate  of  iiotash  and 
muriatic  acid  gargUi  was  also  prescribeil.  The  ulcers  continued  to  increase  in  size  tiiitil  the  22d  notwithstanding 
treatment.  After  this  the  general  and  local  symptoms  improved,  and  the  record  leaves  the  i)atient  on 'the  27th  doing 
well  and  taking  full  diet  with  eggs  for  breakfast  and  a  pint  of  milk  three  limits  a  day.  [In  connectioti  with  this  case 
the  previous  history  should  be  recorded:  Admitted  Xov.  7,  1802,  with  two  soft  chancres,  one  on  the  left  side  of  the 
glans,  the  other  on  the  frjennm.  Tlie.se  were  cauterized  with  nitrate  of  silver.  A  superlicial  gland  in  the  left  groin 
became  intlamcd  and  was  opened  December  11.  The  patient  was  cured  and  transferred  to  the  guard  for  duty  on  the 
30th.     Xo  symptoms  of  constitutional  syphilis  were  manifested.] — Satterlee  Hospital,  rhiladelrhii,  I'a. 


*  In  tlie  Amerii-uH  Junnud  »j  the  Metlkul  Sck'ncen,  Vol,  LII,  180fi,  page  •, 


DIPIITFIERITIC    INFLAMMATION    Ol-'    THK    KAl'CKS.   ETC.  735 

Cask  5. — Hospital  Slcwaid  John  J.  Maliaii.  l'.-<tli  Mass..  was  piMtoctly  wi-Il  luilil  almut  :i  A.  M.  of  .Ian.  L'S.  lS(i2, 
when,  having  got  uj)  to  put  coal  on  the  liii',  he  I'onnil  lie  had  lii-ailacho,  fever  and  son-  throat.  He  had  been  for  somo 
days  back  waiting  upon  a  jiatient  snlferinj;  from  sor<'  throat  and  submaxillary  swelling;-.  At  the  morning  visit  bis 
pulse  was  96,  full;  skin  warm  and  moist:  tliidat  and  uvula  very  r<'d  and  inllamed.  with  jntrulent  ap])earauces  upon 
the  tonsils;  pain  on  swallowing;  bowels  regular.  A  dose  of  Kjisom  salt  was  administered  and  blisters  applied  over 
the  tonsils.  '2iHh:  Spi'iit  the  day  yesterday  (inietly:  rested  well  during  the  night :  the  blister  rose  well ;  feels  Ijetter; 
pulse  slightly  accelerated  and  full;  throat  red  and  inllamed,  jiartienlarly  the  right  tonsil,  wliic'h  is  coated  with  a 
purulent  deposit.  Treatment  continued.  JWtli:  .Skin  hot  and  nu)ist ;  pnlseoverWl;  feels  pretty  well ;  throat  still  red, 
particularly  on  right  tonsil.  An  alum  gargle  was  )irescribed.  31st:  Attended  to  duty  yesterday;  rested  well  during 
the  night  and  now  feels  very  well,  but  throat  still  inllamed. — //e-vj/i/d/,  28(/(  J/(i.v».,  Ililluii  Head,  S.  C. 

('.\SE  (). — Private  Samuel  (J.  Williams,  Co.  G.  Kith  111.  Cav.:  age  45:  was  admitti'd  Ajuil  :>.  ISiil.  from  Kenton 
Barracks  with  dysphagia;  tonsils  swollen  and  touching  each  oilier:  uvula  elongated  and  swolh-n:  s<ift  palate 
inllamed:  ei'rvieal  glands  and  cellular  tissue  also  swollen  :  stillness  (d' Jaw  :  fcvei  :  full  jiulse:  beadaclie  :  anorexia; 
furred  tongue  and  constipation,  tiave  a  cathartic  and  apidii'd  a  scdnlion  of  nitrate  id' silver.  April  L'dtli:  Ifeturued 
to  duty. — Laifniin  Mospilttl,  St.  Louis,  ilu. 

VIir.-DIPHTHERITIC  INFLAMMATION  OF  THE  FAUCES,  ETC. 

Pkevalence,  etc. — DuriuLi,-  tliu  lirst  luurtifU  iiKHitlis  of  llio  war  no  spot-inl  ]irovision 
was  made  on  tlie  blank  forms  ot'  tlio  ]ic|H>rl  cl'Sicl-;  ami  Wouiulrd  i'ur  the  nunicriral  record 
of  diphtlieritic  cases.  A  form  issued  in  July.  iSlii'^  gave  diphtlieria  a  place  in  the  iniasniatic 
order  of  zymotic  diseases;  but  some  time  elajised  before  eases,  were  rejiorted  on  this  loim. 
i^one  appeared  during  the  months  of  .luly,  August  and  Seidemlier;  in  October  12.J  cas(\s 
were  reported;  in  Novemljer  217;  in  Deceinlier  ^o^^^.  and  in  January.  1S63,  43o.  This  did 
not  signify  a  rapid  increase  in  the  prevalence  of  dijtlitheritic  disease,  but  simply  that  month 
by  month  so  many  medical  othcers  recognized  that  the  new  form  differed  in  some  respects 
from  the  old,  and  reported  as  diplitheria  cases  wliich  had  formerly  lieeii  otherwise  returned 
as,  for  instance,  in  the  waste-basket  o{  otiicr  dixittsr^^  of  tlie  miasmatic  class. 

During  the  fortv-live  months,  Beptendjer,  1S()2,  tu  June,  lS(j(3,  there  wore  reported 
among  the  white  troops  7.277  cases,  equivalent  to  an  average  annual  rate  of  3.'.*2  per  tliou- 
sand  of  strength,  and  716  deaths,  a  mortality  (►!'*•. Si  pc-i-  cent,  of  ihe  ctises. 

Among  the  colored  troops,  during  the  three  years  of  their  service.  77*1  cases  and  (31 
deaths  were  recorded,  a  mort;ililv  of  7.''^()  per  cent.,  the  avi-rage  annual  rate  <if  c;ises  per 
thousand  of  strcno-th  bein"  4.25,  or  sliuhtlv  in  excess  of  the  rate  amomr  the  whites.  J/ioli- 
theria  appears  to  have  affected  the  white  men  almost  as  extensivelv  and  with  a  greater 
fatality  than  the  negroes.  Generally  the  latter  suffered  moi'e  from  camp  diseases  and  suc- 
cumbed to  morljiflc  influences  more  readily  tlian  the  whites, — cttscs  weiv  in  the  pro|iortion 
of  13(3  among  the  colored  men  to  100  among  the  while  men,  and  deaths  as  2(39  to  lOO;  but 
diphtheria  was  so  far  below  this  average  in  its  inlluence  on  the  colored  troops  that  the  operation 
of  some  saving  cause  fnust  be  assumed,  perhaps  a  racial  idio.syncracy,  as  suggested  by  some 
observers.'-'  Lines  indicating  the  monthly  rate  of  prevalence  among  the  white  and  colored 
troops  may  be  found  on  the  diagram  facing  page  73S. 

It  is  doubtful  if  the  diphtheria  of  our  camps  and  liospil;ils  was  in  every  inslance,  or 
even  generally,  a  constitutional  disease  occasioned  by  a  speciric  poison  and  manit'ested  by  a 
specific  local  lesion.     In  cases  1  and  2,  given  below,  the  disease  was  apparently  a  sloughing 


*  In  funniiiari/.iiit:  the  niortalit.v  :*tatistics  of  WiImiii;;tMn,  Pel.,  f.ir  ttii'  y.-ar  lss'2,  L.  P.  Hrsii,  iirosiiii'iit  iif  the  l),>anl  uf  hcaltli,  comnK'iits  upon  th^ 
fart  that  aItlM>u<rh  thirtei-n  tlcatli;,  from  iliiilithcria  (.K-currfd  itiiioiig  tlu'  wIiitL-  iMMi|ilf  no  fatal  cas*-  was  n'lKjrt.-ii  among  the  culured  poimlation.  "Tliii 
Btill  further  rontirms  the  (■I'iiiicui  of  the  frei'ilmn  cf  Ihe  Maetv  race  froniilil»litheria.  This  resistanee  i.f  that  clas;-  uf  people  to  the  eanse  of  lhi.s  liiseasi-  h&a 
been  ohsi-rved  ami  reeonh'il  in  the  .<tati>ties  of  Wilniiii;rtoii  since  tlie  tlii^e.a.'^e  ma.le  its  lirst  apl.i'aranee  among  us  in  ISliO."  The  Mfilini]  ,Veir«,  Vol.  XI, II, 
Philailelphia,  p.  .">7l',  referring  lo  I'r.  IlfSH'.s  opinion,  gives  the  statistics  from  some  of  on r  Southern  cities,  tiv  wliii-h  it  is  shown  that  211  ileathsfroni  'liph- 
tlieria  were  reported  from  a  poimlation  of  3:11,700  whites  aiel  Tllileaths  from  the  ilisease  among  lTn,(122  colori-.!  iieople.  If  the  latter  had  sutT'reil  .■iinally 
■witli  the  white  ra<e  there  should  have  heen  lOll  deaths  instead  of  To.  Thes<'  nnmherH  show  that  in  ci\il  life,  as  ill  the  army  during  the  war,  the  colored 
men  manifested  a  relative  instisceiitihility  to  the  causes  of  iiseudomemhranons  inllaiiimatioii  of  the  throat. 


736  DirHTIIEIUTIC    IXFLAM>rATTOX   OK   THE    FAI'CE?,  ETC. 

pliaryiigiti>.  ami  in  case  3  dfUth  [irubal'ly  lY'SullcJ  I'lvim  pUfUiaonia  eoiisi'cutive  to  a  catarrhal 
inflaniniatioii  of  tlic  fauces. 

Case  1. — Private  William  CaiiiplK'H,  Co.  IF.  ISth  Conn.:  aj;e  17:  was  admitti-d  .Si'iit.  t),  18(5.",  witli  fi'vcr  anil  tVe- 
(liu'iit  [misc.  swollen  tonsils  anil  diliiciilty  of  Inoatliinu:.  A  solntion  ot' nitrate  of  silver  was  applied  locally  and  elilo- 
rate  of  potash,  in  ten-grain  doses,  fjiveu  every  tliree  lionrs.  There  was  no  improvement  next  day:  tlie  tonsils  were 
covered  with  pnrnlent  matter;  a  thick  tenacious  expectoration  was  hronnht  np:  resi)iiation  was  diliiciilt  and  jiros- 
tration  increasing.  An  emetic  of  ipecacnanha  and  tartar  emetic  was  jinscriUed,  to  be  followed  by  (ininine,  whiskey 
and  beef-tea.  On  the  8th,  after  the  removal  of  membranous  matter,  tli<'  tonsils  were  found  to  have  sloughed  consid- 
erably. t>n  the  ytli  the  patient  was  greatly  prostrati'd :  he  had  not  sle|it  since  Iiis  admission  ;  he  had  much  difticultj' 
in  swallowing  and  urgent  dyspuo'a.  He  becanu'  unconscious  at  5  i".  M.  and  <lied  two  hours  later.  Post-mortem  exam- 
ination: The  tonsils  were  in  a  sloughing  condition  ami  the  fauces  much  inllamed,  but  no  false  membrane  was  discov- 
ered. The  lower  lobe  of  the  left  lung  was  hepatized  and  the  upper  lobe  ciuitained  tubeicular  deposits  :  the  right  lung 
was  normal. — .ht.  A-is't  f<itrijcuit ./.  M.  .Mdtlack,  Ilosjiilitl  -Vc  1.  Aunapolit.  Md. 

C.vSK  2. — Private  Wilson  Weir,  Co.  K.  4tli  Me.;  age  22;  was  admitted  May  7,  1804,  convalescing  from  typhoid 
fever.  On  June  7  while  on  light  duty  he  was  taken  with  diphtheria,  and  on  the  lOth  was  rejiorted  as  improving, 
chlorate  of  potash,  chlorinated  soda  and  solntion  of  nitrate  of  silver  having  been  used  locally  and  neutral  mixture 
with  antimony  and  si)irit  of  nitre  internally.  After  this  the  throat  was  swabbed  with  tincture  of  iodine  and  lauda- 
num, ammonia  and  olive  oil,  and  gargled  with  iodine  and  sulphate  of  zinc  solutions,  while  whiskey-punch  and  tinc- 
ture of  iron  were  employed  internally.  (Mi  the  Itith  the  throat  was  reported  as  being  too  painful  to  admit  of  swab- 
bing, and,  as  the  ingesta  returned  through  the  nostrils,  beef-tea  was  onh'red  by  the  rectum.  On  the  17th  medication 
by  the  mouth  was  resumed,  and  on  the  2lith  a  .Seidlitz  jiowder  was  given  in  the  morning  and  Dover's  powder  at  night, 
alum  gargle  being  used  as  a  local  astringent.  On  tlie  23d  tincture  of  iron  was  prescribed  in  doses  of  fifteen  drops 
three  times  daily.  Next  day  the  patient  was  nnich  debilitated  ;  he  was  unable  to  open  his  mouth  to  permit  of  inspec- 
tion of  the  fauces;  he  drank  two  jiints  of  milk,  and  at  (5  p.  jr.,  having  had  some  milk-pnnch,  he  felt  better;  but  death 
occurred  suddenly  two  hours  later.  I'ost-mortcin  examination:  Considerable  mucus  in  trachea:  sloughing  of  fauces. — 
Motfcr  Ho82>ittil.  I'liiltuMphia,  I'd. 

C'.\.SF.  ^.--Private  Cyrus  G.  Chattertou,  Co.  C,  24th  X.  Y.  Cav.:  age  17:  was  admitted  .Tuly  21.  ISlil,  scorluitic 
and  much  emaciated  from  long-continueil  diarrliica.  On  August  3  the  patient  experienced  ditlicnity  in  opening  his 
mouth  and  complained  of  sore  throat.  The  fauces  were  found  inllamed  and  the  tonsils  covered  with  matter.  Iron 
and  stimulants  were  administered,  with  chlorate  of  i>ot.ash  as  a  gargle  and  counter-irritation  externally.  On  the  5th 
mucous  rales  were  heard  over  the  chest.  An  emetic  was  given  but  without  effect.  He  died  asphyxiated  on  the  6th. 
"The  constitution  of  the  patient  being  scorbutic  anil  his  condition  very  low  there  was  not  a  chance  for  tracheotomy." — 
Fairfax  SemiiKirij  Ilonpita},  Fa. 

But  outside  of  these  exceptional  instances  it  is  of  interest  to  inquire  whether  some  of 
the  recorded  cases  of  diphtheria  were  not  in  reality  inflammations  of  the  fauces  due  to  ordi- 
nary and  non-specific  causes,  such  as  exposure  to  cold  and  dampness.  Some  medical  officers 
have  alluded  to  the  ditficnlty  of  determining  Avith  accuracy  the  true  nature  of  cases  that  were 
called  diphtheritic.'^'  In  the  autumn  of  1S63  diphtheria  was  reported  from  certain  regiments 
near  Xorfolk,  Va.  The  principal  sufterers  were  the  10th  and  13th  X.  11.,  the  latter  having 
had  60  cases  and  10  deaths,  the  former  20  severe  cases,  one  of  whicli  was  fatal,  and  about 
40  or  50  cases  of  sore  throat,  in  six  of  whicli  the  tonsils  suppurated.  Surgeon  X.  P.  Rice, 
U.  S.  Vols.,  who  investigated  these  cases  Sept.  S,  1863,  regarded  them  as  specific  inflam- 
mations of  the  throat  in  men  broken  down  by  excessive  fatigue,  a  deficient  dietarv  and  pre- 
vious sickness. 

From  careful  inquiries  in  these  and  all  the  other  regiments  of  the  division  I  sliould  say  that  there  was  some 
doubt  whether  the  disease  was  idiopathic  diphtheritis.  Enough  material  could  not  be  shown  to  define  this  with  a 
stifficient  degree  of  positiveness.  I  saw  but  one  patient,  a  man  in  the  4th  K.  I.,  who  exhibited  any  serious  trouble  in 
the  throat.  There  was  here  a  distinct  membrane  on  a  raw  bleeding  surface,  but  as  tlie  throat  had  just  lieen  freely 
cauterized  with  nitrate  of  silver  and  the  man  was  using  tincture  of  iron,  the  particular  character  of  the  exudation  was 
much  obscured.  In  a  Connecticut  regiment  three  cases  were  observed  which  showed  great  congestion  and  tumefac- 
tion of  the  tonsils,  with  small  patches  of  pus  immediately  beneath  the  inucous  membrane.  It  was  stated  liy  one  of 
the  medical  ollicers  that  he  had  seen  the  exudation  covering  the  fauces,  the  roof  of  the  mouth  and  the  nasal  passages. 
The  description  of  the  disease,  with  the  manner  of  death,  answers  as  well  for  a  great  de]ircssion  of  the  vital  powers 
due  to  exhaustion  from  the  iiiHaminatory  action  of  the  throat  and  the  inability  to  take  food  as  for  a  true  diphtheria. 
It  is  the  universal  testimony  of  all  the  medical  and  regimental  oHicers  that  the  disease  appeared  shortly  after  the 

*  Thus,  X.  C.  H.VMI.IN,  Ass't  Surgeon  2(1  Me.,  remarliiiig  on  the  Iileinled  and  nuiwkcd  cliaracter  of  disease  as  often  observed  iu  our  armies,  alludes  to 
diphtheria  as  having  ptia.ses  and  coiniilications  tliat  render  its  recojinitiou  Iiy  no  means  easy. — See  Amerk-an  31ed,  Times,  Vol.  IV,  1802,  p.  107.  Tlie  cases 
whieh  he  saw  weretliose  reported  by  Surgeon  S.  It.  JlrnitlsoN,  2d  Me. — See  iii/rn,  page  7;J8. 


DIPHTHKi;rrif    IM--|.A>rMATI(>N    '>[■■   TIIK    KArCKS,   KTC.  ;3( 

return  of  the  regimen  tN  from  t  lie  expnlitioii  up  the  Ten  in  su  hi,  where  i  he  nun  suffered  f;re:itly  from  fatigue  luid  exhaus- 
tion. On  their  return  they  reoeenjiied  their  old  (juarters,  wliieli  had  hi^cn  left  standing.  They  went  into  eainp  after- 
ward in  a  hea  .'y  cold  rain  ujion  grotmd  xvhieh  is  naturally  of  a  coll  character,  with  the  suhsoil  water  but  a  few  feet 
lieloNV  the  surface.  The  cases  occurred  in  nu'n  of  a  dejiraved  and  lirokendown  constitution,  and  esi)ecially  in  those 
who  had  suffered  from  fatigue  on  the  reniusula  or  who  had  lieer.  affected  with  sickness  or  sunstroke.  A  peculiar  fact, 
discovered  in  all  the  regiments,  was  the  existence  in  many  of  tlie  men  of  indolent  ulcerations  of  greater  or  less  size, 
occurring  singly,  in  jiatehes  or  ditfnsed  on  the  legs  and  ankles.  They  are  saic'.  to  have  couimenced  as  slight  pustules 
with  no  i)nri)nric  blotches:  they  are  ditHcnlt  to  treat,  stimulation  seeming  to  increase  their  si/e.  These  cases  aver- 
age 20  to  10  to  a  regiment.  Other  scorbutic  symptoms  do  not  show  themselves.  The  ulcerations  tirst  appeared  on 
the  return  I'nim  the  expedition,  about  the  same  time  as  the  alleged  diphtheriti:;  troulile.  Jlost  of  the  medical  (dliccrs 
asserted  tliat  the  two  numifestations  of  disease  never  existed  in  the  sanu^  jierson.  Xothing  could  be  discovereil  in 
tlu'  neighborhood  to  account  for  these  ulcerations,  nor  was  there  anything  peculiar  in  the  living  or  haljits  of  the  men 
except  the  slight  general  u.se  luade  of  vegetables  and  the  oceuri<'!u.'e  of  the  disease  upon  their  return  from  the  Penin- 
sular expedition,  during  which  it  is  probable  that  they  were  alnu)st  wholly  deprivedof  antiscorbutic  diet.  The  ulcer- 
ations have,  indeed,  th(!  ajjpearance  and  character  of  those  seen  during  the  severe  scorbutic  attack  among  the  troojis 
of  the  Army  of  the  Potomac  at  Harrison's  Landing  iu  July.  \f^62.  The  trouble  iu  the  throat  may  have  lieen  of  the  same 
character,  exhibiting  itself  in  this  more  acute  inflammatory  manner  because  occurring  in  persons  of  broken-down 
constitutions  at  a  time  when  the  vital  force  was  much  low<'red  by  jirevious  fatigue  anil  privation.  The  immediate 
cause  was  probably  the  cold  and  dampiu'ss  of  their  caiu])-siles.  'I'he  disease  is  subsiding  in  both  the  reginu'iits 
because  they  luive  gone  into  dryer  and  more  open  cam]iing-grouiids, — liecause  thi'y  are  rested  and  in  better  i>hysical 
condition,  and  because  the  u.se  of  vegetables  is  now  UH)re  general.  The  ulcerations  have  ceased  to  break  out  afresh 
and  in  most  cases  are  improving.  TJu'  discrei)aney  in  the  niindjer  of  eases  ri'ported  by  the  two  regiments  I  consider 
due  to  the  ditferent  character  of  ground  upon  which  each  was  camped  at  the  time  the  disease  ajipeared,  the  l^ith  being 
on  a  damp,  cold,  thickly  shaded  sit<',  the  10th  close  by  but  on  more  ojieu  ground.  The  ditferent  physical  character- 
istics of  the  men  of  the  two  regiments  nuiy  have  also  liad  an  intiiience,  the  one  least  affected  lieing  of  nnudi  better 
nuiterial  than  the  other. 

Act.  Ass't  Siu'gL'iMi  .Tt)Kf.  St'.AVKN^  iv{iortiMl  that  iiinnyor  liis  ciisL^s  of  iiiHuminatinii  of 
the  throat  assumed  a  diphtheritic  aspect,'-"  and  a  simihti'  [iliraseoloLiA-  is  dccasionallv  eiicnun- 
tered  in  some  oi'  the  rocordetl  cases. 

C.vsK  1. — T.  T.  Koyal.  j>risoner  of  war:  age  11:  was  admitted  May  Si.  ISGt.  with  infliunuat  ion  of  the  tonsils.  \ 
chlorate  of  potash  gargle  was  used  and  tincture  of  iron  given  every  three  hours.  After  a  time  the  throat  assumed  a 
diphtheritic  appearance,  when  cauterization  was  employed  and  stimulants  administered.  Ho  died  on  the  2."itli. 
]'0!it-)noytim  examination  :  The  diphtheritic  exudation  extcmled  as  far  as  the  glottis. which  was  ulcerated:  the  trachea 
was  full  of  pus.     The  pericardium  ciuitained  a  ([iiantity  of  serum. —  Third  DirisiDii  Ilii.ijiital.  AltxiiiKlriii,  I'd. 

C.A.SE  ,"i. — Private  EliC,  Mattson,  Co,  II. 9th  X.  V.  C'av.;  age 22:  was  admitted  from  Augur  hospital.  .Mcxandria. 
Va.,  Feb.  11, 186."),  suffering  from  acute  jdiaryngitis  and  tonsillitis,  with  exudation  and  sthenic  jjy  rexia.  The  disease 
at  tirst  ai)j)eared  to  yield  partially  to  treatment,  Iput  later  it  devoloped  a  distinct  diiditheritic  character:  the  local 
affection  increased  iu  severity,  the  false  membrane  apjieaiing  on  the  wallsof  the  jiharynx  and  gradually  extending. 
About  a  week  after  admissicni  the  patii'Ut's  stomach  bi'canu'  irritable,  and  for  the  last  twodays  bcf'or«'  death  nothing 
was  retained  excejit  a  little  water  froiu  ice  meltitig  in  tin?  mouth.  The  fever  continued  sthenic  in  character  until 
two  days  before  death,  when  the  system  began  to  suffer  from  imperfect  a'rafion  of  the  blood.  From  that  time  the 
ipurple  hue  of  the  skin  becauu-  increasingly  maiked.  Latterly  very  little  urine  was  voided,  but  no  ura^mie  effects 
weic  observable,  the  mind  being  perfectlv  clear  until  death,  whicdi  occurred  on  the  21th.  I'he  case  w;is  treati'd  at 
first  with  saline  laxatives  and  Doser's  ]iowder,  wiih  tiui-tuie  of  inm  internally  iu  doses  of  fifleeu  drops  ri'peat<'d 
every  four  hours, — apidiod  locally  by  sjionge  and  used  diluteil  as  a  gargle.  Nitrate  of  silver  anil  alum  solut  ions  were 
also  employed  as  topical  ajiplicatious,  Afieiwards  lime-water  was  given  with  milk:  sinapisms  and  a  blister  were 
applied  to  the  eiiigastrium  and  nutrient  enemata  administi'red,  I'Dnl-mnrtim  ex:uuin,'ition  :  I'he  tonsils  and  larvnx 
were  uukIi  iufiamed;  the  trachea  lined  throughout  with  a  firm  fal.su  membrane,  which,  ofi  the  left  side,  extended 
into  the  ramifications  of  tlu^  bronchus:  th<^  luonehial  tubes  of  the  right  lung  were  greatly  inflamed  liut  not  lined 
with  membrane;  the  lungs  were  healthy.  The  heart  contained  a  firm  washed  clot  in  each  ventricle,  the  right  clot 
being  larger  and  more  firndy  attached  than  the  other.  The  stomach,  liver,  sjpleen  and  intestines  were  normal. 
[>j)(ci«i(H  .■jl.'i,  Med.  Sec,  Ariu.v  Jledical  Museum,  from  this  ease,  shows  the  e))iglottis  much  thickened  and  the  larynx 
lined  by  a  thick  p.sendomembraue  which  extends  to  tlie  tonsils  and  over  the  sides  of  the  ton.gue.] — .!>.>'/  .^iirijion 
Uan-isoii  Allen,  V.  S.  A.,  Moiitit  J'litisiuil  Hoipilii!.  U'(i«liiii(jluii.  I).  C. 

Soiiiotiines.  iil'ter  tlie  tonsils  ljec:iiiie  iiiji'cted  and  swullrii.  many  d;ivs  ehipsed  before  the 
diphtheritic  character  of  tlio  inllammation  was  evident.  In  cases  (>  tind  7  an  ordinary  or 
non-specitic  iiiflaniination  was  present  i'or  ten  davs  bei'ore  tlie  dij)htheritic  appearances  were 
observed:  tmd  in  the  latter  case  the  attack  \v;ts  apparently  the  result  of  exposure  to  cold 
while  the  individutil  lav  asleep  on  the  hospital  oTounds. 

*.s,ij,,-,f.  iKii;.'  7;i4 

Mki),  Hisr.,  I'r.  Ill— !»3 


-OQ 


/o8  DIPIITHKniTIt;    tXl'LAM.\rATT<)X    OF   THE    FAUCES.   ETC. 

Ca.<f,  6. — I'rivatc  .Iiiiiics  A'andnw  cu  kcr.  Co.  E.  4i>tli  X.  Y.:  ago  IH:  Avas  ailmittfd  Oct.  5,  18C4,  with  a  jjuiishot 
wouud  of  the  linj;i"is.  (_)ii  tlic  iL'th  lio  was  attackcil  with  tonsillitis  and  on  tlu'  1'2<1  diplitheiia  was  developed.  He 
died  on  the  'ICith.  I'dnf-iiioiii m  cxaiiiinatinn  :  A  false  iiienilirane  lined  the  huyux.  trachea  and  l)Vonchial  tulios,  forni- 
ini;  on  the  left  side  a  conii)lete  east  of  tlie  wlioli-  of  the  air-passages  to  the  niiimte.st  ramifications,  bnt  not  extendiiii;; 
into  the  air-vesicles.  The  light  liinir  was  not  invohcd.  A  small  jiortion  of  the  nienilirane  had  been  detached  from 
the  surface  of  the  larynx  and  hung  loosely  in  the  cavit,\  .  Earge  portions  of  it  were  also  detached  from  the  trachea 
and  lost.  In  the  left  hronehus  was  found  a  jierfect  tiihe.  Wlii-n  the  false  nienilirane  had  lieen  detached  the  nincoas 
membrane  was  found  to  be  highly  congest<'d  and  to  have  lost  the  more  snperticial  parts  of  its  epithelium.  [Specimen 
411,  Med.  Sec,  Army  Medical  Museum,  shows  the  left  bronchial  tulie  anil  its  prineijjal  ramifications  occupied  by  a 
tubular  cast  of  iiseudomembrane.] — Ain't  Siinjeon  C.  J.  JfcCnIJ.  I'.  S.  A.,  Moinii  I'kasani  Jloxpitul,  irailiingion,  1).  C. 

C.\SE  7. — Private  Cliarles  A.  (Jreenman.  Co.  C,  :>2d  X.  Y..  was  admitted  Sept.  2.  18lil,  with  typhoid  fever. 
During  convalescence  he  took  cold,  on  the  L'Dth.  while  sleeping  in  the  hospital  garden,  his  tliroat  at  once  swelling 
and  becoming  sore.  On  October  1  a  diphtheritic  membrane  was  observed  in  the  upper  part  of  the  pharynx,  but 
there  was  little  constitutional  disturbance.  A  solution  of  nitrate  of  silver,  forty  grains  to  an  ounce  of  water,  was 
used  locally,  with  chlorate  of  potash  aird  tincture  of  iron  for  internal  use.  On  the  4th  the  membrane  appeared  in 
irregular  patches  about  the  palate  and  tonsils,  interfering  but  little  with  swallowing,  although  the  parts  were  very 
tender:  the  patient  was  anaunic.  On  the  5th  a  ily-blister  was  applied  to  each  side  of  tlie  neck.  On  the  1.5th  the 
false  membranes  were  disappearing. — Hoipitiil,  Ah-xeoidrhi,  Vn. 

Exposure  to  cold  ami  tlanijiness,  especially  at  night,  was  freqiU'Utly  reganletl  as  the 
cause  of  diphtheritic  attacks  as  well  as  of  the  quinsies  and  sori'  fJironfx  that  were  invariably 
associated  with  them  in  a  eoininand.  AVlien  diphtlieria  prevailed  tonsillitis  was  rr.inrnon, 
and  the  latter  was  geiierallv  referreil  to  the  milder  opei-atiou  of  thr  epidemic  cause. 

Surgeon  S.  IS.  MoRUisox,  2d  Mc.  HiiU'a  TTill,  Va.,  Oct.  31.  1801. — Tliere  have  been  many  cases  of  sore  throat  in 
this  regiment  during  the  last  two  mouths.  Most  of  them  appeared  immediately  after  a  storm,  esjiecially  among  those 
who  had  been  on  guard  at  night  or  on  pii'ket  duty  and  exposed  to  the  combined  inlluence  of  cold  and  moisture, 
though  some  occurred  without  any  such  exposure.  At  first  there  would  be  a  slight  ditUculty  of  swallowing,  with  a 
general  tumidity  and  redness  of  the  fauces.  Soon  the  uvula  became  elongated  and  enlarged  and  the  tonsils  highly 
inllamed,  with  aphthous  patches  upon  them  the  size  of  half  a  dime.  These  patches  often  spread  so  rapidly  that,  iu 
the  course  of  twenty-four  hours  from  their  first  aiipearance,  they  would  cover  both  tonsils  and  nearly  the  whole  inter- 
vening space,  and  the  surrounding  parts  would  be  so  much  swollen  as  to  cause  great  dillieulty  in  swallow  iug.  Soon 
afterwards  the  membrane  became  detached,  either  wholly  or  partly,  leaving  the  parts  underneath  of  a  deep-red  or 
almost  purple  color.  The  cervical  glands  were  liable  to  swell  and  the  neck  iu  front  to  become  full  and  (edematous, 
though  this  did  not  usually  occur  until  the  disease  had  lasted  two  or  three  days.  Typhoid  symptoms  appeared 
only  in  severe  or  prolonged  cases.  There  have  been  in  the  regiment  eight  cases  which  I  have  no  hesitation  in  pro- 
nouncing genuine  diphtheria  and  a  large  number  showing  premonitory  indications  of  this  disease,  which  have  been 
speedily  subdued  by  local  applications  of  nitrate  of  silver,  tannic  acid,  chlorate  of  potassa  and  persulphate  of  iron. 
The  same  local  applications  have  been  made  in  more  advanced  stages  of  the  disease,  and  tonics  and  stimulants  have 
been  given  freely  when  typhoid  symptoms  called  for  them.  \o  fatal  case  has  occurred  in  camp,  though  one  patient 
died  at  the  general  hospital  a  day  or  two  after  being  sent  there.  In  that  case  there  was  severe  epistaxis  and  a  large 
abscess  in  the  fauces;  neither  of  these  symptoms  was  present  iu  any  other  case. 

Suvejcon  15.  15.  Br.\siie.vi!,  1C)//(  Ohio,  CtmhcrUnd  Ford,  Kij.,  April  10,  1«(>2.— Biphtheria  made  its  appearance 
among  the  sick  in  quarters  as  well  as  among  those  in  hospital,  luit  only  to  a  limited  extent.  It  attacked  some  of  the 
convalescents  from  continued  fever,  two  of  whom  died.  There  was  a  great  deal  of  sore  throat,  which  was  no  doubt 
referable  to  the  diphtheritic  intluence  and  which  might  have  been  called  diphtheria:  but  no  case  was  so  recorded 
unless  the  characteristic  membrane  was  observed.     Fifty  per  cent,  of  the  cases  of  this  kind  terminated  fatally. 

5Mr(/(;oHT.Hii.DHKTli.3(n/c.,  rr/ii(t'.5/'«r(/,  J/(/.,Xore»i6ir,lS()l.—Intlarnmation  of  the  throat  prevailed, and  we  had 
eight  cases  of  well-marked  diphtheria,  one  of  which  proved  fatal.  All  of  these  cases  occurred  in  company  G,  although 
there  was  nothing  in  its  location  to  account  for  the  disease  prevailing  in  it  more  than  in  the  other  companies.  The 
treatment  in  nearly  all  the  cases  was  tonic  and  sustaining  :  there  was  great  deinession  of  the  vital  powers,  the  patient 
in  the  fatal  case  aiiparently  dying  from  exhaustion.  Local  applications  to  the  throat  were  used  freely,  but  with 
little  or  no  apparent  advantage.  The  causes  of  this  disease  appeared  to  be  exposure  during  cold  damp  weather. 
The  tents  at  this  time  were  old  and  leaked  badly,  and  the  diminution  of  all  inlhimmatory  affections  of  the  throat  after 
the  men  got  into  new  and  comfortable  tents  was  very  apparent. 

But  the  statistics  fail  to  show  that  coincidenee  between  the  prevalence  of  tonsillitis  :ind 
diphtheria  which  should  be  observed  had  the  former  been,  even  in  part,  a  mild  expression 
of  the  epidemicity  of  the  more  dangerous  disease.  Tonsillitis  appeared  among  the  white 
troops  ill  waves  of  prevalence  distributed  over  the  winter  and  spring  months,  December  to 
March,  inclusive.  These  are  illustrated  in  the  diagram  facing  this  page.  Had  diphtheria 
been  connected  with  their  causation  the  line  indicating  its  prevalence  would  probably  have 


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Dli'IirilKRITIO    INFLAMMATION   OK   THE   FAUCES,  ETC.  7o9 

j^-iven  some  evidence  of  the  connection.  But  no  such  distinct  seasonal  infiucneo  is  exhibited 
liy  tlio  record  of  diplitlieria.  Shght  elevations  may  bo  observed  in  the  rate  for  some  of  the 
cold  months,  Imt  these  rarely  coincide  with  the  greatest  prevalence  of  tonsillitis.  In  fact 
die  increased  prevalence  of  diplitlieria  does  not  appear  to  have  exercised  any  effect  in  ele- 
vatiii'^-  tlif  liii':  I'f  tijusillitis.  It  may  be  said  tliat  the  waves  of  prevalence  of  the  non-spe- 
ciilc  intlammatiun  of  the  tln-oat  were  too  high  to  be  materially  affected  by  those  due  to  a 
(li|ihthi'ritic  tendency.  This  may  be  granted;  but  wlien  the  periods  of  infrequency  of  ton- 
silliii-.  fir  instance  the  month  of  August  of  eacli  year,  are  found  to  coincide  with  higli  rates 
us  wi'll  as  witli  low  rates  for  diphtheria,  tlie  latter  disease  cannot  liave  exerted  much  inilu- 
ence  on  the  prevalence  of  the  former.  In  August,  lS6'.->,  when  the  di[)htlieria-rate  was  higli, 
only  2.4  cases  of  tonsillitis  occurred  for  each  reported  case  of  diphtheria,  while  in  August, 
1865,  when  the  diphtheria-rate  was  low,  the  ratio  was  15.9  to  1.  The  same  want  of  relation 
is  observed  in  the  statistics  of  the  colored  troops,  if  the  month  of  Octolter,  1863,  be  excluded. 
L)uring  that  montli  both  diseases  were  of  frequent  occurrence ;  but  as  no  other  analogous  coin- 
cidence appears  tins  must  be  regarded  as  accidental. 

There  is  anotlior  method  of  viewing  the  association  of  diphtheria  and  tonsillitis  which 
is  not  inconsistent  with  a  want  of  relation  between  their  lines  of  prevalence.  The  records 
already  submitted  indicate  that  ordinary  influences,  such  as  exposure  to  cold  wliile  sleeping 
on  the  ground  or  in  the  open  air,  produced  a  disease  which  was  as  much  a  time  diphtheria 
as  if  it  liad  Iteen  pro[iagated  by  specific  infection.  It  had  the  same  local  lesions  which  trom 
peculiarity  of  site  were  prone  to  occasion  sudden  deatli,  and  was  attended  with  the  same 
constitutional  disturbances  and  general  prostration.  Practically  it  was  the  same  disease  as 
that  which  is  usually  considered  a  specific  diphtheria.  If  the  cases  hereafter  presented  be 
examined,  most  of  the  patients  will  be  found  to  have  been  in  a  low  condition  trom  tlie  effects 
ijf  some  antecedent  disease  or  injury.  Thus  many  were  suffering  or  convalescing  from 
typhoid  fever,  some  from  malarial  fever,  pneumonia  or  diarrhoea.  These  were  cases  that 
occurred  in  tlie  general  hospitals,  the  inmates  of  which  had  usually  a  history  of  previous 
sickness.  Taken  alone  they  would  therefore  have  no  weight  in  the  argument;  but  when 
it  is  remembered  that  in  the  field  the  men  attacked  were  those  that  had  just  been  exposed 
to  tlie  depressing  yet  actively  injurious  influences  of  guard  and  picket  tluty  at  night,  or,  as 
in  the  experience  of  Surgeon  Brashear,  the  sick  in  quarters  and  the  convalescents  from 
fever  in  the  regimental  hospital,  a  condition  of  lowered  vitality  may  be  readily  allowed  as 
one  predisposing  to  the  diphtheritic  attack.  But  it  is  not  found  that  tonsillitis  selected  its 
subjects  from  among  the  convalescents.  "Whence  it  may  be  inferred  that  while  the  iVequent 
and  sometimes  inevitable  exposures  of  military  life  induced  tonsillitis  or  catharriial  pharyn- 
gitis in  the  robust  and  healthy,  their  effect  on  the  weakly  or  ])rostrated  was  a  pseudo- 
membranous inflannnation;  and  that  in  our  camps  the  conversion  of  the  milder  into  the 
more  dangerous  disease,  l)y  the  presence  of  unwholesome  conditions  in  the  system  of  the 
individual,  was  the  true  explanation  of  the  association  of  sore  throat  with  epidemics  of  diph- 
theria, although  that  usually  accepted  regarded  the  diphtheria  as  the  primary  disease  and 
the  milder  cases  as  an  extended  expression  of  its  endemicity.  This  explanation  does  not 
involve  a  tendency  to  imrallelism  in  the  prevalence  of  the  two  diseases.  Ex^wsure  to  cold 
and  damjwess  produced  tonsillitis;  hence  the  prominences  in  the  line  expressing  its  preva- 
lence during  the  winter  and  spring  months, — but  something  more  was  required  tor  the  pro- 
duction of  diphtheria,  ajiparently  a  broken  down  condition  of  the  system.     During  the  war 


e 


740  DIPIITHKIUTIC    INKLA.MMATIUX    uK    TIIK    FAUCK.--,   KTC. 

tlu'  wintri"  was  for  a  l-.W'jr  ]r,\vt  of  tlu'  ni'inv  ;i  season  of  rest,  ivcnjioratioii  ami  airi])li'  sup 
pliL'.s,  whicii  w'nulJ  ()Iivioii>!\'  have  toiulctl  to  couiitcraL't  i\  (lispositKMi  to  jisoUiloiiifialu'aiioU: 
inflammation.  Tlir  somewhat  o'l'catei'  juvvaloiu'c  of  diplitheria  among  tho  ( 'oiifeilcrat 
prisoners,  o.*>  cases  annualK'  prr  tiiousaml  oi'  sti'engtli,  as  compareil  with  3.0  cases  amoni;; 
our  white  troops,  is  of  interest  in  view  o(  tlie  u'cnerally  deteriorated  condition  of  those  men. 
Tliis  view  linds  material  support  in  the  fa<'t  tliat  tho  fever  of  diphtheria  is  a  symptomatic 
fever  wliich  keeps  pace  with  the  local  inflammation  and  subsides  on  its  cessation.'-' 

Moreover,  the  inflammation  of  the  fauces  associated  with  and  dependent  on  the  speciflc 
jioisons  of  the  eruptive  fevers  sometimes  assumed  a  dijihtheritic  character.  In  erysipelas 
of  the  head  and  face  there  was  at  the  outset  an  inflammation  of  the  moutli  ami  throat  in  so 
manv  instances  that  its  dependence  on  the  erysipelatous  poison  is  strongly  suggested. f  In 
some  it  was  merely  erytliematous,  but  in  others  tlie  tissues  became  largely  infiltrated; 
sloughs  were  occasionally  cast  oft'  and  at  times  a  pseudomembrane  was  developed.  These 
diphtheritic  cases  can  bo  se[>arated  from  theii'  ervsipelatous  connections  and  attributed  to  a 
specific  diphtheritic  poison  only  by  faith  in  a  doctrine  and  not  l.)v  tlie  authorization  of  facts. 

Tlie  records  of  diphtheritic  dysentery  must  not  be  forgotten  in  this  connection.  In  the 
raajoi'itv  of  these  there  was  nothing  to  suggest  a  specific  infectious  disease  with  its  primary 
disorder  of  the  blood  and  its  subsecjuent  local  lesions. J  On  tlie  contrary,  the  disease  was 
generallv  not  oidv  a  local  bmt  a  simple  iiiflammatoi'v  atleclion  at  the  outset.  I)iplitlieritic 
dvsenterv  began  with  a  simple  inflammalorv  stage  either  developed  indcjiendently  or  super- 
vening oit  an  acute  diarrhu'a.  In  othor  instam/es  it  appeared  in  tho  progr(>s.s  ol  a  cln-onic 
flux,  when  tho  vitalitv  (>f  the  patient  liad  bcrii  miidi  I'educed.  and,  indeed,  it  was  a  commou 
mode  of  fatal  termination  in  disorders  of  that  class.  (.)nly  occasiomdiy  was  its  attaek  so  aln'upt 
and  intense  as  to  countenance  the  assumption  "f  iri:fi'.NKii  that  it  luay  occur  without  any 
preliminarv  catarrhal  stase.  An  acute  diari'licea  or  dvsenterv  lasted  days  or  wet'ks  betore 
it  assumed  the  diphtheritic  character.  The  prevalence  of  diphtheritic  inflammation  can  only 
be  approximated.  It  was  present  in  12.7  }>er  cent,  of  905  post-mortem  observations  in  cases 
of  diarrhoea  and  dysentery.  Applying  this  rate  to  tho  total  number  of  deaths  from  these 
diseases,  no  less  than  4,800  deaths  among  white  troops  must  be  atti'ibuted  to  diphtheritic 
inflannnatioii  of  the  intestinal  lining,  although  only  716  deaths  are  reported  as  due  to  the 
same  pathological  jirocess  affecting  the  mucous  membrane  of  the  throat. § 

Either  there  was  no  specific  diphtheria  in  our  camps  or  the  specific  cause  was  subordi- 


*  In  till-  liit".st  iiutlMiritiltivc  |>iilili™tiii:i  ii:i  111  ■  suLjci  t  nl  ili|ililhrri;i  CkriiaiiiiTciI' Wurtzburi;  >ti  rcpiirtcil  :iM  s]ii'ilkiiig  of  tlii'  fi'ViT  ill  tlif  f.pllciwilij; 

tfiiiis:— ''Diiilitlii-ria  m;i,vlif  r^iud  to  Iii-  iihvii,vs  a. jiipani'-d  li,v  f-vi!-,  -n'  at  li-ast  tlioM-  ca-scs  ia  wliirh  no  fi-v.T  is  pri-scnt  art'  oxpci'din;,:!}-  ran-.     Tliis  fever 

difttTs  ill  maii,v  respects  fruni  that  aeroiiipan.viti.;'  othei-  infections  (]i>'a>es.  Thus  we  fiiiil  that  in  iiian,v  iufeetioiis  iliseascs,  as  in  variola,  measles,  ete., 
the  original  fever  is  eaiise<i  ],y  a  peculiar  pm  i  <-  of  inie.  tion  wliieli  takc^  place  in  the  blootl  and  which  is  the  characteristic  of  tlii'se  diseases  ;  and  that, 
on  the  contrary,  ci'rtaiu  periods  of  fever  wliich  Mip-rveiie  later  ou,  as  fur  instJince  the  fever  of  suppuration,  the  fever  of  decrustation  in  variola,  thos^ 

forms  of  high  fever  occurring  in  parotitis  wlcn  the  testicles  \>'-t le  implicated,  are  inde].cndent  of  the  original  fever.     It  is  very  (litlcreiit  with  diph- 

tticria.  Here  the  fever  is  ilirectl,v  dependent  upon  the  local  a  fleet  loll,  and  the  rule  nia.v  as  well  Iv  stated  hi*re,  that  as  long  as  the  local  affection  keeps  on 
increasing  the  fever  will  also  im-rease,  and  that  so  suou  a>  this  ceases  the  f.'ver  will  also  ceasi'."— Dr.  Ukvku's  Ir.inslation  of  Hkiiinku's  j'ri/.e  Essay— 
Ejrperiiitrtilal Diphtlifrhi,  Detroit,  l^!>-">.  p.  .'i  '. 

f  See  sjijjre,  pag(!  fili-'i.  ^  See  Part  Tl  of  tilis  work,  pag<'  :loi'. 

f.  The  transmission  of  diphtheritic  intlanuuafion  from  lie'  fhl"af  to  the  intestine  aiel  ricf  rersii  is  suggested  l.y  an  editorial  in  the  M''<!irttl  Tiotea, 
Philadidphia,  I'a.,  Vol.  XII,  1««1-8L%  ]».  -I'.iT.  In  rclerririg  to  the  expei-iineiital  reseurches  of  Drs.  M'non  and  FollMAli  on  pseuilomcinhranes  from  a  diph- 
theritic epidemic  at  Lakeview,  Mich.,  the  following  st;iteiienit  is  inadi':— '-.V  very  important  and  curious  ohservatioii  was  made  hy  l»r.  Fok.maii  at  the 
spot  of  the  I'pidcniic.  The  pigs  r»f  a  family  living  iu  an  isolated  po>itii>n  in  the  forest  were  fed  with  slops  from  a  room  where  three  or  ftair  children  were 
sick  with  the  disease.  Several  of  the  pigs  sickened  and  one  died.  At  the  autopsy,  made  hy  Dr.  Vokmap,  the  laryii.x  and  respinitory  passages  were  found 
entirely  free  fiMin  disea>c,  whilst  the  lower  end  of  the  cesojihagns,  the  stomach  and  tie'  upper  duodenum  were  coated  with  a  very  thick  false  memhrane 
load,  d  with  niicrococci  and  containing  the  other  anatomical  elements  of  I  rue  diphtheritic  memhrane.  I'nderiieath  this  false  niemlirane  the  mucous  mem- 
brane was  inflamed  and  in  numerous  jdaces  ulcerated,  in  the  Mood  of  the  jiig,  as  well  as  in  tho  spleen  .iiid  the  hone-marrow,  the  niicriH-occi  were  exceed- 
ingly inunerons.  They  were  seen  attacking  the  leucocytes  an<l  in  other  jiarticulars  conforming  with  the  action  of  the  plant  in  malignant  human  diph- 
theria. Inoculation  of  rahhits  with  the  membrune  from  the  stomach  of  the  pig  produced  sickness  and  death,  with  symptoms  ami  local  ami  general  lesions 
similar  to  those  caused  hy  the  human  menihranc.  This  oh.servation  is  very  important  im  show  ing  the  local  nature  of  diphtheria  i:i  its  fir>t  oti-il,  ami 
especially  as  raising  the  su.spicion  that  the  Kwiue-plague  of  the  "West  has  close  relations  with  human  diphtheria." 


DtPIITJIKKiric    INKl.AMMAlIdN    i^V    TWE    KArcKS,    KTr.  741 

natp  to  and  obscured  liy  otlirr  iiilhu'iiiTs.  Tlir  iv|icii-icd  (•a>(s  dri-ivcd  llicir  origin  I'roiii  llie 
ordinary  causes  of  intlainiriatii")n  of  tlie  faiici's  in  individuals  |ii'cdisj)osod  d.)  iisi.'udoineni- 
liranous  developnients,  or  tlioy  wore  the  }>rodnct  <>(  u  specific  canse  wliicli  wa<  ronlrolled  I'V 
the  vitality  <jf  the  individual  exposed  to  its  intlnonci;'.  ( >n  the  latter  supposition,  with  tli" 
system  in  a  normal  or  liealtliy  state,  the  speciric  germ,  poison,  agem-v  er  intliience  had  iio 
more  })o\ver  than  an  ordinary  irritant  and  its  results  were  local, — a  snhsiding  or  suppurative 
tonsillitis  or  a  catarrhal  pharyngitis  controlled  by  the  vitality  of  the  sulFerer;  Imt  with  the 
system  in  a  condition  of  depression  the  inilaminatoi'v  prodnets  passed  bevond  the  cr)ntr<jl  of 
the  vitality  of  the  individual  and  weri^  given  uji  to  putrefactive  agem-ies  by  which  the  >vstem 
became  exposed  to  septic  infection. 

Since  Oertkl  called  attention  to  the  presence  of  micrococci  in  dijilitherilic  pseiido- 
membraue'-"  tnany  observers  have  urged  the  germ  theorv  of  this  disease;  but  (his  theorv  has 
not  been  established,  and  indeed  the  latest  observations  do  not  subvert  the  conclusion  I'eached 
liy  Dr.  AVoODWAKl)  in  his  investigation  of  this  subject  in  cennectinn  wilh  diphllieriti('  dys- 
entery,— that  the  micrococci  naturally  jireseiit  in  the  locality  lound  tavorabh.'  conditions  lor 
their  development  in  the  uecroseil  tissues,  and  that  their  inultiplicalion  is  not  a  cause  but  a 
result  of  the  diseased  action. f 

In  the  liealthv  buccal  cavitx  are  manv  species  of  micro-organisms  which  vary  in  ilill'er- 
ent  individuals,  and  in  the  same  individual  at  ditferent  times,  as  well  m  shajie  as  in  u\ode  of 
action.  These  bacteria  have  a  septic  influence  when  introduced  into  the  cn-<-ulation  ol  certain 
animals,  as  the  rabbit,  luit  so  lar  as  the  ordinary  state  of  the  human  organization  is  conciu-ned 
tliev  have  no  pathological  siguiilcance.  When,  however,  the  vitality  ol  a.  tissue  ceases,  its 
orii'anic  elements  are  given  up  to  the  fermentative  or  putrefactive  action  ol  just  such  micro- 
oro-anisms  as  are  found  at  all  times  in  the  mouth.  AVhen  vitality  is  impaired,  as  in  the 
psettdomembrane  of  a  diphtheritic  inflammation,  it  may  reasoiutbly  bi.^  assumed  that  tlio 
diseased  tissues  afford  a  more  congenial  niiliis  for  bacterial  development  tiian  the  healthy 
epithelial  surface.  The  micrococci  i\ro  therefore  ti)  be  regarded,  in  the  alisi'iu-e  of  atlirma- 
tive  testimony  to  the  conti'arv,  rather  as  a  result  than  a  cause  of  the  disea-c.  The  manifest 
iuetHcieucy  of  all  attempts  to  disinfect  tin'  tln'oat,  and  the  aggravation  of  the  <liseasc  wliicli 
follows  such  attempts  when  of  an  irritant  character,  seem  also  to  indicate  that  the  inllamma- 
tion  is  not  due  to  the  micrococci,  which  tnust  therefore' be  considei'ed  as  accidental.  I5ut 
althouii-h  nnconuected  with  the  causa.tion  of  the  |irimaiy  inflammation,  they  maybe  pLuisifily 
reo-arded  as  productive  of  septic  results  in  the  individual  by  abs..rpiion  ol  the  necrotic  i^vu- 
ducts  associated  with  their  growth  and  multiplication,  and  if  these  products  be  considi/red 
possessed  of  infectious  qualities  the  jiathology  of  the  disease  is  complete  until  a  stronger 
lio-ht  is  thrown  on  tliis  subject  l>y  the  progress  of  investigation. 

Drs.  "Wood  and  FoiniAD  of  Philadelphia  have  presented  I'esults  of  much  intenst.;!; 
Accordiuu  to  these  observers  th-c  micrococci  of  dijihlheria  do  not  dilb.-r  from  those  ordinarily 
found  in  the  mouth  except  in  their  tendency  to  grow  in  culture-fiuids.  The  rapidity  of  growth 
of  the  micrococci  is  in  direct  proportion  to  the  malignancy  of  th.'  diphtheritic  case  which 
fttrnished  them.     Every  grade  of  case  may  be  found  in  man,  fi'om  an  (^-dinary  sore  thnjat, 

s  An-l:.H<h(S  I,ilrlli'jtii:-Uhil,  XV,  Jiullicll,  ISIS,  I>aj.'e  40"  ('(  k..;. 

t  \iii.iiliiig  to  IlEViiXKii,  if  tlii-si'  iiiiinnoici  wcr.-  tlic  i:iuso  of  tlif  disc.isn  llio  Mo.idv.-ssils  ..f  tli.'  clisi-H»,..l  niucous  in.  nil.raiio  iiii.l  tli.-  Oii|.!llari.-^  ..f 
til.' id.liievs,  liwr,  i-tc,  ouirlit  tc.  )«■  lillfl  witli  l..i.tiriii,  l.ut  ■'.ntiro  s.<ti.jTis  c.f  tlu-  iiviila.  "f  tli.'  tlirfat.  ki.lii.ys.  A.-.,  ..f  liiiti<>iit.s  .l.ad  ,.f  .li]ilitli.-ritii- 
in'cJti.inlii'iVL'  I'f™  ti'ratrf  ivitli  pntiiin-viuiit,  fii.lir'iii  in  liisnnirk  l.rown  (iil:^..  in  aniline  dy^l  \vitli..nt  fn.-.cclinj.'  in  'iisrovcrinK  ii  sin-l.  l,a.  tirintn, 
whicli  in  tlif  aiscasc.l  siivface  of  tlic  miico.is  nnniliram-arr  ."  .  asii.v  Tna.l.-  out."  11  •  ll.-r.-f..r.-  concln.l.-  tliat  tli.-  ilisoaw-j.uisou  is  as y-t  nnlino"  n.-Pago 
44  uf  Dr   l!r.VKi;'s  translation,  alrca(!y  citnl. 

Xl!,p„rlu,i  I.k,l,lh,ri,i,  in  t!io  .1. „1  !!■  ,:rt  ..J  tj,.^  S..i: (  P....,,-.!  .■/ II. 'M,  1.->1.  lia..-  Jl  .(.r.y 


'  ^'-  liII'IITIIEKITU;    IXKI.A.MMATTON    OF   THK    l-'Al'i  Es.   KTr. 

tlirougli  siiiiplo  }i>euJi'iii(_.iribraiii,iis  aiiL!'iii;i.  ainl  tradiritis  ii|i  tu  iiiaiiuiiaiLt  iliiilithi'i'ia.  The 
micrococci,  altliouuli  {irimarily  ariMdciital.  lu'coiii.>.  liv  u-mwlli  uihUt  lavMraliJi'  cniiJitions. 
iiivcstfil  with  sjiccitic  jn'oportics.  TliC'  ilici.iy  df  iji,.  disi-asr.  ilcilucfil  IrMin  ijirsr  uliscrva- 
tioiis,  is  that  certain  circumstances  ontsiilc  ol'  the  human  IkkIv  are  ca|ialjle  of  throwing  tliis 
common  micrococcus  into  its  coinlition  of  active  n-rowth  aial  ongendorinL;-  an  epidemic  of 
diphtlieria.  Latei-  oliservations  l,v  t]ie  sana^  authors  h:ad  to  tlio  conclusion  tliat  tlio  septic 
and  diplitluu'itic  micrococci  are  specifically  one,  aial  that  dijihtheria  is  a  se])tic  sore  throat. 
or  "IS  s  mi  ply  what  it  was  called  a  centur\'  ago.  jinJriil  .-^nrr  t  Jin  mi  w'lfJi  i>r  wit  In  ml  u  sri-oiulun/ 
const itlit II inal  srj/ticd'iiiiii."''^' 

E.xperienct'  ot  diphtheria  in  civil  life  indicates  tin.'  existence  of  an  infectious  qualitv  con- 
nected probably  with  tlie  [iroducts  of  bacterial  growth  in  necrosed  tissue's,  oi',  ac<-ording  to 
the  views  of  A\  ueui  and  Fokmad.  with  the  increased  vital  activities  of  an  ordinarv  sejitic 
micrococcus.  The  .lisease  mav  thus  1)e  jurijiagated  in  favorable  cii'cnmstaiices  iiidt'pendent 
of  the  constiliiiioiial  state:  Init  there  is  little  evidence  of  its  sjiread  in  this  wav  during  the 
war.  Surgeon  Thavkii  speaks  of  its  prevah'nce  in  hi.s  regimental  hospital;  the  statement 
in  the  case  of  Sergeant  George  W.  Ilougii.  that  the  patient  was  taken  with  the  ward  sore 
throat,  indicates  a  local  ])revalcnce  in  one  of  the  wards  of  the  Satterlee  hospital,  Philadelphia; 
and  Ih'igade  Siu'geon  ^b;IU'ER  rep(.)rted  s<.)me  cases  that  were  suggestive  of  contagion. 

Sinvjeoii  W'm.  H.  Tii.vyki!,  iilh  X.  If.,  CitrrolUoii,  La.,  ilinj  \.  1SIJ4. — Diplidioiia  av:is  first  so<-n  in  .Tiiiif,  lsti:i.  iiiul 
tlie  i-i'i;iiiR'iitaI  li(i.s|iitiil  wius  not  without  it  iiftcrwuril.s  for  8i.\  inontli.s;  but  it  did  not  cxti'iid  in  tlii'  liosi]it,-il  to  any 
otlicr  jiationt.s  until  Xovoniber,  when  tluco  inniati-'S  were  suddenly  attuelied.  All  otlii'r  iiatii-nts  cxceiit  those  with 
diphtlieria  were  at  once  ri'iiioved  to  general  hosjiital  and  tliere  was  no  further  extension. 

Ser^'t  Oeor,!,'e  W.  Hoiij;h.  Co.  Y,.  lltli  Mieh.:  agi'  20:  was  admitted  Dee.  12.  1S(I2.  This  palieiil  had  heeii  sent 
to  lio-spinil  at  Washington,  1).  (',,  Septeiiiher.  l!SU2.  on  aeeouiit  ol'great  debility,  the  result  of  constant  exposure  and  fre- 
quent attacks  of  rheuniatisin.  He  has  at  ]ireseiit  a  slight  cougli  witli  pain  in  the  left  breast  and  rheumatic  pains  in 
the  ankle-joints  and  the  muscdes  of  his  legs  and  lumliar  region:  he  slcep.s  well,  has  a  good  ajipetite,  and  for  the  last 
two  weeks  has  had  no  diarrlnea.  He  has  been  taking  cod-liver  oil  and  li(juorice  mixture.  On  December  28  the  cod- 
liver  oil  w-a.s  omitted  and  wine  of  eidcliieum  substitute<l.  At  this  time  he  was  taken  with  -'ward"  sore  throat,  for 
which  an  alum  gargle  xvas  used.  On  Jan.  7,  18G3,  acetate  of  pota.s.sa  was  added  to  the  colchicuin,  and  a  drachm  of 
iodine  tincture  in  an  ounce  of  camphorated  oil  was  us<'(l  as  an  external  application,  lie  was  discharged  February 
14. — Satterlee  Ho-fpif ill,  I'hilddelphia,  Pa. 

Surgeon  D.  MeRUEli,  Seilfiwicli's  Tlriijade,  Arinii  nj'  llir  I'liiomac.  I)cce)iilii  r,  ISGl. — During  the  last  1  wo  months  diph- 
theria has  prevailed  in  the  M  and  -ttli  Jle.,  and  from  the  manner  of  it.s  introduction  as  well  as  its  mode  of  progress 
through  the  camps  it  might  be  inferred  to  be  contagious.  It  was  tirst  ob.served  in  the  families  of  three  civilians  who 
lived  ill  the  vii-inity  of  the  Itli  JFe.:  live  (  hildreu  died  of  the  disease.  The  soldier.s  of  the  4th,  who  had  free  inter- 
course with  these  families,  were  tirst  attacked :  fourteen  cases  occurred,  three  fatal.  The  troojis  of  the  8d,  hiiviug 
free  eomuiunicat  ion  with  the  Itli,  were  next  seized:  seven  cases,  two  fattil.  'J'lie  other  regiuients,  the  38th  and  40th 
N.  Y.,  have  not  siiffere<l,  although  only  separated  from  the  5Ie.  regiiiii'iits  by  a  jiublic  highway:  and  as  this  inimnnity 
might  be  attributed  to  the  fact  that  the  \.  Y.  and  Mc.  troojis  lia\c  but  littU'  intimacy  it  atford.s  another  iMjim  of 
su.spiciou  in  favor  of  contagion. 

Clinical  Kecokds. — The  general  character  ol  the  clinical  records  of  diphthei'ia  may 
be  gathered  from  the  following  examples:  ,S-1  /  trom  the  records  of  the  hospitals  at  Alex- 
andria. Va.;  LS  and  10  from  the  tSatrerlee  and  20-22  from  the  ]\[ower  hospittds  of  Phila- 
delphiti.  Pa.,  tind  23  from  the  Field  hospital  of  the  Fifth  A^-my  Corps. 

Cask  8. — I'rivatc  L.  W.  DolotV,  Co.  I,  otli  JIc,  was  admitled  .Sept.  2,  1801,  with  tyjihoid  fever.  lie  was  conva- 
lescent when,  on  October  2."),  he  was  taken  with  .sore  throat :  pulse  !S8:  skin  hot :  slight  exudation  witli  swelling  of  left 
tonsil :  no  external  swelling.  Applied  nitrate  of  silver  S(diitioii,  ten  grains  to  an  ounce  of  water,  morning  and  even- 
ing: jirescribed  tincture  of  iron  in  water  as  ji  gargle  and  live  grains  of  chlorate  of  potash  every  four  hours  for 
internal  use.  On  the  2Ttli  the  pulse  was  78;  skin  cool:  bowels  constipated,  and  the  exudation  spreading  over  the 
tonsils.  I!y  November  2  the  exudation  had  disapjieared.  The  ]iati<'iit  was  returned  to  duty  December  14.  He  occu- 
pied a  bed  in  a  large,  well-lighted  and  ventilated  ward.     His  was  the  third  case  of  diplitheria  iu  this  ward. 

C'.vSE  it. — Private  Jacob  Cunningham,  Co.  A,  4th  Me.,  was  admitted  Sept.  1,  ISGl,  with  typhoid  fever,  from  wliich 
he  recovered.     On  Xovember  o  his  skin  became  hot  and  dry;  pulso  'JO  and  full:  tonsils  much  swollen  and  covi-ied 

*  Meiwirull  the  Xalnre  of  Hipkllirriu,  Ainii'.tl  y/.j.-)/ o/  (//(■  .\itlwual  Board  of  llnnlUi,  IS^li,  jage  133. 


DII'nTHKKITK'    I.N  I'l.AMMATK '.N    t'V   •|"11K    I-'AlTlvS.   KTC.  74;-) 

X. 'th  pxiulatidii.  A  sola  til  ill  of  uitiatc  of  silvi  r  w  ii>  iiiijpliiMl :  i  iuci  me  nl'  iion.  ililiiti-d.  «  m>  ummI  :i>  a  ,L;int;lr  and  livo 
jjnii.-iS  ol' ohlorate  of  jiotash  ,i;iv('U  every  tliici'  1ic)ur>.  Illi:  I'lil.-e  !Ki:  >lcin  Imi  :  swelliii;;  stationary:  exudation 
Jiniinislied.  "■Ili:  l'iilse«0;  skineool:  liowels  open  :  swelling  diniini>licd  ;  l>iil  lit  t  le  exudation  and  I'onliued  to  the 
.eft  tonsil,      litli:   ^>ittinjf  i;p  r„!l  f'ay:  appetite  jrood.      IHtli:    K'etuiued  to  duty. 

Casi-:  111. — Private  Lyn^an  llowanl.  Kith  X.  V.:  admitted  .Sept.  :i.  18lil.  witli  typhoiil  fever.  He  eoiivalesoed. 
liiit  on  Xovenilier  ij  had  a  sliijtht  iuliaiuniation  of  the  tonsils  and  soft  palate.  Alnni  was  used  as  a  K'HHl^'  "'"1  ^  ^^i"- 
apisui  wa.s  applied.  Ttli.  Sli<;hr  ileposits  of  white  exudation  on  the  inllanied  jiarts.  Applied  s(did  nitrate  of  silver: 
gave  twenty  drops  of  tincture  of  iron,  one  draehiu  of  a  saturated  solution  of  ehlorate  of  jiotash  aiul  one  jrrain  of 
sulphate  of  ipiinia  three  time.s  daily.  8th:  White  exudation  eoverin;;  intlamed  surface  of  hd't  tonsil,  edse  of  soft 
tialatc  and  left  side  of  inula.  Keapplied  nitrate  id'  silver:  repeated  sinaiiisni:  used  tiiietiiie  of  iron  and  solution  of 
'■lihiiate  (d'  Jiotash  as  a  j;ai;;lc.  I'th:  Exudation  st.itionary :  juilse  110:  l.owiOs  regular,  l.'epeated  iiiliate  of  siher: 
towards  evening  exndat  ion  heeanie  detached.  1  Itli:  Patient  iiniiroviiig.  A]i]died  a  solution  id'  ten  grains  of  nitrate 
of  silver  in  cuie  ounce  of  water.      I:2tli:  Kxudat  ion  thinner  and  less  I'X  tensive.      L'lth  :   licturned  to  duty. 

Casi-:  II. — Corporal  Charles  Wickwiie,  Co.  (J.  llith  X.  V.;  age  21:  was  admitted  Sejit.  I'L'.  IStil.  with  int.iuiiiit- 
tent  fever,  for  which  Fowler's  .solution  was  administered.  On  <  lct<ilier  (!  he  was  returned  to  duty,  but  was  readmitted 
on  the  14th  with  a  recurrence  of  the  disea.se.  On  the  afternoon  of  the  21th  hi'  had  fever  not  ])ree<'(led  by  a  rigor: 
iml.se  90;  skin  hot;  throat  sore  and  right  tonsil  covered  with  an  c'xndation.  On  the  evening  of  thc>  Ibllowiiig  day 
the  left  tonsil  also  becaino  coated.  The  tliroal  was  swabbed  with  a  solution  of  nit  rate  of  silver:  tincture  (d'  iron. 
ilihitetl,  was  used  as  a  gargle,  ami  live  grains  i>l'  ehlorati-  of  )iotasli  were  given  every  four  Inuirs:  castor  oil  was 
employed  to  move  the  bowels.  The  exudation  did  not  iiitirely  disaiijicar  until  XoNeuiber  '<.  Sugar  w.is  found  in 
the  patient's  urine  some  time  afterwards.  He  was  placed  on  duty  as  nurse  on  the  'Jlst.  This  was  the  lirst  case  cd' 
diphtheria  which  occurred  in  the  Fairfax  street  ward. — one  (d'  the  best  w.mkIs  of  the  lios]iital.  Proper  ]iiceaut  ions 
were  taken  to  prevent  contact  with  the  other  jialieuts. 

('a.sk  12. — Private  Jloses  Patdiard,  Co,  K,  ."itli  Me.,  while  convalescing  from  ty|ilioid  fever  w  as  taken,  ( lei .  21. 
1851.  with  sore  throat :  jmlse  il."i:  skin  hot :  tonsils  mmdi  swollen  :  exudation  on  right  tonsil.  Used  nitrate  of  silver 
solution  and  iron  gargle:  chlorate  of  potash  internally.  2."uli:  Pulse  00:  skin  hot  :  bowels  costive:  tonsils  swollen  : 
exudation  extending  towards  the  right :  snlnuaxillary  glands  ,swidlen,  (iave  an  ounce  (d' cast  or  idl.  2dth  :  Pulse  IK  i: 
skin  hot:  swelling  and  exuilation  unchanged  :  bowels  moved.  27th:  Pulse  s.">:  skin  hot  :  exudation  extendeil  to  the 
lefttonsil:  bowelsojien.  2lhh:  PulseTO:  skineool:  .'welling  uiindi  diminislied  and  exudation  lesseiieil.  Xoveiiiber.">; 
Steadily  ini]iroviiig:  but  little  swelling;  slight  exudation  on  left  tonsil.      i:!i  h  :   li'ctnrned  to  duty. 

Cask  IM. — loliu  Adams,  Co.  G,  10th  X',  V,;  age  2."i:  was  admitted  X(>\  .  S.  ISfil,  having  snlieic-d  for  two  weeks 
with  headache,  umch  lassitude  and  jiain  in  the  baik  ami  bones.  His  pulse  wasiHl  nuil  full,  skin  hot.  tongue  dry  and 
brow  11  in  the  centre,  right  iliac  region  tender  but  the  bowels  cjiiiet.  He  became  ilidiiiiuis  ou  the  loth  and  for  some  days 
had  more  or  less  diarrhiea.  On  the  18th  he  felt  chilly  and  afterwards  feverish  :  his  tlimat  became  sore  in  the  e\ cning, 
and  next  day  a  patch  of  exudation  about  the  size  id'  a  three-cent  jiiece  was  t'oiiud  on  tlii'  letl  toii>il.  This  extended 
rapidly,  einering  tlu'  fauces  and  interfeiiiig  with  res]iirat  iiui.     lb'  died  on  tin'  22d. 

Casi-:  11. — Private  .1.  AV.  .lohnson.  Co.  li,  H2d  Pa,,  w.-is  admitted  Xov.  il,  ISlil,  with  tyidioiil  lever.  He  im]i  roved, 
and  ou  the  Kith  all  incilieiiie  was  stopped  exccjit  turpentine  emulsion,  and  he  was  jdaced  on  milk  iliet.  (In  the  2(ith 
oyster  soup  was  periiiitted.  <  In  the  2Jth  hi- became  feverish,  had  ]>ain  in  the  tliioat  .ind  an  exudation  on  thi'  left 
tonsil,  which  continued  to  extend  until  the  2l!tli,  and  thereafter  gradually  dis,'i]ipeared.  .Nitrate  of  silver,  tiiu'lure 
of  iron,  elihu-ate  of  Jiotash  and  whiskey-Jiiiueh  weri'  used  in  the  trealmeiit.      He  was  returned  to  duly  .Ian,  22,  lMi2. 

('.\sr:  l.~i. — Private  Lewis  Lamon.  Co.  II,  :!2d  Pa.,  w  us  admitted  No\  .  11,  ISIil.  Iiaviiig  bei'ii  sick  for  two  w  eeks 
with  chills  and  fever,  which  had  assumed  latterly  a  tyjiiioid  tyjie.  His  tongue,  was  dry  and  fissured  and  he  had 
great  a  bdoiuiual  tenderness,  diarrhiea  and  much  cough,  1  lei  ilium  sujiervened  on  the  Pitli :  sordes  aiijieared  ou  the  ti'cth 
Jill  the  20th  and  there  was  mi'teorism  with  iiiucli  ejiigastiic  tenderness.  Dijilit  heritic  exudation  was  found  in  the 
throat  on  the  21st,  when  the  breathing  becanii'  laboreil  and  the  fei't  and  hands  jiiiiph'.     He  died  at  noon  id'  the  22d. 

Ca.se  Ki. — Hecruit  .TaniesMclJowan.  :!Otli  Me.:  age  2d:  was  admitted  .Ian.  ."i.  l.Mi."i,  from  Washington  st  reel  ini-on. 
Alexandria,  \;)..  with  jiueiimoiiia.  He  convalesced:  but  suddenly  tin'  tongue  and  snbliiign.il  glamls  became  miirh 
swollen  and  the  tonsils  and  Jiharynx  covered  with  an  ashy-white  nii'iiibrane  easily  removed  by  means  of  nitrati'of 
silver:  it  came  away  in  Hakes  half  an  inch  si|nare.  but  it  foniied  anew  vitv  rajddly.  Chlorinated  soda  solution  was 
used  as  a  gargle  and  stimulants,  tonics  and  nutrients  were  administered.     The  jiatient  died  on  the  2Sth. 

Casi;  17. — Private  Ailaui  Hull'.  Illli  X.  ,1.;  a^'e  21:  was  admitted  .March  22.  Isid,  with  dijilithei  ia  :  Tonsils 
enlarged  :  sjieech  iiidistinet  :  skin  hut  and  dry:  jiiilse  fr<'(|iieut  :  seNcre  ji.-iiii  in  t  he  head  and  ii)i|n'i  jiart  of  chest.  I'sed 
a  saturated  solution  of  chlorate  of  jmtash  in  hoi  w  ater  as  a  gargle:  1  lo\  ei  's  jiow  der.  2:'.il :  Pulse  luo.  Ii.ard  :  skin  hot 
and  dry:  tonsils  much  swollen,  covi.'red  thickly  with  exndat  ion  :  breath  a  cry  (di'ens;\  e.  (,;i\  f  twenty  diojis  of  tinc- 
ture of  iron  every  three  hours.     21th;   Pulse  NO.  full.     Ajiril  2(i:   K'etiiined  to  dut\ . 

Cask  is. — Corjioral  John  1 1,  Tiiell.  Co.  F.  til  h  Me.,  w  as  admitted  Awj;.  lo.  l.si;2.  wit  li  eh  ionic  diariliiea,  hyjier- 
trojihy  of  the  heart  and  general  debility.  In  a  few  weeks  he  was  able  to  iiio\e  about  the  ward  with  other  convales- 
eeiits.  On  the  luorniiig  of  October  10  he  was  found  in  l>e(l  suil'ering  I'rcun  severe  headache,  with  furred  tougue,  (juick 
juilse  and  hot  skin.  In  the  afteruoou  lie  took  three  compound  cathartic  jiills,  which  inoveil  his  bowels  freely  and  to 
some  extent  checked  the  fever.  In  the  evening  he  comidained  of  sore  throat,  and  next  day  the  fauces  and  part  of 
the  tongue  were  covered  with  a  diphtheritic  niembraiie.  The  throat  was  toiu'hed  four  times  a  day  with  hydrochloric 
acid  and  water,  the  internal  treatment  consisting  of  twenty  drojis  of  muriated  tincture  of  iron  every  three  hours. 


744  PiPirniKFJTir'  ixflammatiox  of  tiiI':  fafcfs,  ktc. 

On  tlic  llith  tlic  |i;iliciit  scciiird  soiiiculiat  licttcr.  his  .skin  iiKiist  and  imlsc  less  lVci|Uiiit .  In  tlir  at'lriniiiin  clilniati' 
(if  [icitash  was  incscrilicd  almm'  wil  li  tlic  iioii  in  dciscs  of  ten  ;;  rains  (•\  (  i  v  lliiii'  linuis,  <  In  t  hi'  Filli  tlu'  fi'\  ri'  and 
swelling  liacFsuMifwhat  diminislicd  and  ilr,nlutitii)n  w  as  less  dil'lir'ilt.  Ticatnicnt  \v;is  i-ont  in nrd.  and  on  llii-  ITlli  tlic 
thrnrit  was  lu-uily  frcr  frnin  diplitlu'iit  ic  di'iKisit.s  and  tlii'  paticnl  ir(ij\  ci  in^'  lapiillx  .  1  li'  liad  dniini;  1  hr  attai  1<  as 
inuoli  lii'uf-tea  and  otlioi'  nntritlnus  aitielos  as  lu'  coulil  rake. 

Cask  Ul. —  ]'ii\  ate  TiiiHithy  |l<iuo\an.  1st  X.  V.  Cav.:  a^i'li:!:  was  sci/rd  wit  h  sore  throat  (Ict.S.  ISili'.  Al  this 
tiir.e  he  had  just  liru'iin  to  vecover  iVoni  a  sc\  ere  attaek  of  janndii-e.  with  olist  iiiate  co  list  i  pat  ion  and  faintiiif;'  tits.  He 
had  thus  lieeii  for  some  time  in  feeble  Iiealth.  'I'he  sore  throat  was  aeeompaniid  with  extreme  iirostriltiou,  dysphagia 
and  severe  pain  in  the  ear  and  ri^ht  side  of  tlie  faee  :  his  ]Milse  wa-~  upwards  of  liiil  and  feehh'.  ( )ii  tlio  right  side  of 
the  fauces  and  imsterior  wall  of  the  pharynx  were  thin  grayish-white  cMidations:  the  \  <iicc  was  souiewhat  husky; 
there  was  slight  cough .  and  soiiiet lines,  in  swallowing,  lliiids  returned  1  h rough  the  nose.  Tincture  of  chloride  of  iron 
was  given  every  fourth  hour,  and  a  .strong  solution  of  suljiliate  of  cojiiier  was  applieil  on  and  around  the  exudation 
every  four  or  tivi;  hours.  The  membranes  did  not  spread  after  this  and  hy  the  lilth  they  had  disaiipeared.  liy 
Xovcniber  1  the  patient  was  well,  though  still  very  weak. 

C'.\SK  20. — Private  .James  Jf.  (ireer.  Co.  I),  .jtli  Mich,  Cuv.:  age  /i.">:  was  admitted  May  li.  IStil.  as  a  eoiivaleseent 
from  typhoid  fever.  lie  was  weak  and  niiudi  emaciated.  Iron,  (niinine  and  extra  <liet  were  prescrilied.  ITtli:  Sore 
throat ;  diphtlieritic  p.ati-hcs  on  fauces.  Oavi'  tincture  of  muriate  of  iron  and  chlorate  of  potash.  18th  :  Very  weak. 
19tli :  Dark-colored  otiensivc  stools,  (iave  beef-tea  and  iiiilk-pumdi  every  lioiir.  20th:  Heef-tea  and  punch  every  half 
hour:  five  grains  of  carbonate  of  aininonia  every  two  hours.     Failing  rapidly.     21.st :  Died  at  1  .\.  .M. 

C-vsE  21. — Private  Truman  li.  Kichardson,  Co.  K,  2(1  X.  Y.  Cav.:  age  19:  was  admitted  from  City  Point,  Va., 
July  Hi,  l<St3-l,mucli  prostrated  by  severe  diarrlueal  attacks.  22d:  Inflammation  of  throat,  (jave  astringent  gargle; 
applied  tincture  of  iodine.  24th:  Tliroat  and  fauces  much  worse:  no  diarrhiea.  Used  nitrate  of  silver  solution  ;  gave 
tonics.  2Gth:  Uvula,  tonsils  and  palatine  arch  covered  with  diphtheritic  membranes.  Cairterized  with  strong  solu- 
tion of  nitrate  of  silver:  ajiplied  saturated  solution  of  chlorate  of  potash  and  tincture  of  iron  to  throat  every  half 
hour.  28th:  Profuse  expectoration;  throat  gangrenous.  Cauterized  every  si.x  hours  with  eighty  grains  of  nitrate 
of  silver  in  one  ounce  of  water:  gave  a  gargle  of  alum  tiiul  chlorate  of  potash;  ice  freely;  beef-essence  and  inilk- 
imiich  every  half  hour:  applied  tincture  of  iodine  externally  three  times  a  day.  29th:  Conijilete  aphonia:  tongne 
swollen:  diiihtheritic  membrane  extending  below  posterior  arch;  dysphagia  extreme.     I:i0th:  Died  at  4  i'.  M. 

Cask  22. — Private  John  Parmenter,  Co.  K,  2d  Pa.  Provisional  Art'y:  iige  20:  was  admitted  .July  20,  18G4.  with 
diphtheria.  .\p|die(l  \dlatile  liniment  and  flaxseed  poirltioes  to  throat;  ga\e  ten  grains  of  chlorate  of  potash,  lifteen 
drops  of  tincture  of  iron,  two  grains  of  sulphate  of  <|uiniii  and  one-fourth  of  a  grain  of  extract  of  belladonna  every 
four  hours:  extra  diet.  27tli:  Tonsils,  uvula  and  soft  palate  covered  with  a  dark  asliy  deposit.  Sponged  with  tinc- 
ture of  muriate  of  iron  morning  and  evening:  gave  twelve  drops  of  tincture  of  opium  in  half  an  ounce  of  spirit  of 
Miudererus  every  four  hours;  used  a  gargle  of  muriatic  acid  in  sweetened  water:  applied  powdered  alum:  gave  milk- 
liunidi,  whiskey  and  porter.  28tli :  High  fever:  pulse  98.  29th:  Tonsils  cleaning;  ate  a  little  toast  and  ice-cream. 
3Uth:  Died  at  U.l.j  p.  M. 

Ca.se  23. — Private  A.  C.  Wentz,  Co.  F,  83d  Pa.,  was  admitted  Juno  7,  1864,  suffering  with  sore  throat.  The 
patient  came  on  foot  to  the  hospital  and  seemed  in  fair  condition:  but  a  membrane  was  observed  covering  the  fauces. 
C^uiniiie  in  whiskej'  -was  given  every  two  hours  and  tincture  of  iron  applied  every  half  hour  to  the  fauces.  On  the 
9th.  after  a  hard  spell  of  coughing,  the  memlirane  was  ejected  [see  Sjn'ciiniii  391,  Med.  Sec,  Army  Medical  Museum], 
and  for  tliirty  hours  the  ]iatient  aiijieared  in  good  condition  and  likidy  to  do  well;  but  at  the  end  of  that  time  dysp- 
ucea  came  on,  and  he  died  in  three  hours,     yo  jmst-nwrtiin  examination  was  held. 

In  case  24,  reported  Ijv  Sui'u-im.hi  ,Johx  A.  Lidkll,  U.  h^.  Vols.,  an  ojiening  tlirougli  tlie 
crico-tlivroii.l  ineinliraiio  gave  re'liet'  but  failecl  to  save  the  patient.  Failure  also  attenJei.! 
the  only  other  recorded  eflbrts  to  save  the  .patient  hy  surgical  interference."' 

Ca.sk  24. — Private  D.  M.  Brimmer,  Co.  H,  169th  X.  Y.,  a  young  soldier  of  good  eonstitutioi),  was  admitted  Feb. 
20,  1803,  with  typhoid  fever.  He  was  treated  by  the  tonic  and  expectant  method,  and  did  so  well  that  on  March  l.j 
he  was  out  of  bedmost  of  the  time,  though  still  i)alo,thin  and  weak.  On  the  16th  he  was  attacked  with  sore  throat. 
Xext  day,  his  case  having  assumed  an  unfavorable  appearance,  my  attention  was  called  to  him  by  the  attending  sur- 
geon. Dr.  C.  H.  Usnoi;NK.  His  throat  was  swollen  externally  a  good  deal:  counteiianc(i  anxious  and  dusky;  respira- 
tion hurried  and  rather  diflicult ;  pulse  weak  and  about  120,  and  he  complained  of  great  debility.  On  depressing  his 
tongue  to  examine  the  fauces  a  very  offensive  odor  was  exhaled.  The  tonsils,  )ialatine  arches  and  posterior  fauces 
were  covered  with  diphtheritic  membrane  of  moderate  thickness  and  dirty-gray  color.  Dr.  OsiKiuxK  Inid  already 
cauterized  the  throat  with  a  strong  solution  of  nitrate  of  silver,  and  was  administering  (|uiiiine  and  iron,  whiskey 
freely,  along  with  beef-tea  and  any  other  nutrient  that  the  patient  could  swallow.  1  ordered  this  treatment  to  be 
continued.  Xext  morning  he  was  decidedly  worse:  his  iie(k  was  more  swollen;  ho  had  greater  difficulty  in  swal- 
lowing and  the  respiratiow  was  cr()U]iy  to  a  marked  degree;  his  imlse  was  weaker  and  more  fre(iuent  and  other  evi- 
dences of  debility  were  increased.  As  the  moriiiug  wore  away  he  lost  the  jiower  of  deglutition;  he  became  more 
stupid:  his  countenance  grew  darker  in  hue  and  death  by  sutfocation  seemed  to  be  clo.se  at  hand.  Under  these  cir- 
cumstances, and  as  a  remedy  of  last  resort,  I  performed  laryngotomy  at  noon.  His  neck  was  swelled  so  much  that 
I  waa  unwilling  to  attemi^t  tracheotomy.     As  it  was,  the  swelling  einbarrasaed  me  a  good  deal  by  obliterating  the 


*"  Sre  c.THi-s  t  iiii'ltil  "f  t\u.'  jitj^f-'tiorfini  rec<:iril:^. 


DIl'UTIIKl'.ITU'   T.M-l.AMMATIuX    I'F   TlIK    KAUCK-.   KTC.  il> 

l;iii(liii:uUs  l.y  i-1kui,uC(1  cciliii-  ol'  tissur.  Iiy  iiicii'ascil  thirUnoss  ol'  soil  |i;ni>  i.i  It  rut  tliKm^h  a)i(l  li.v  llu'  cinislMiH 
(lO/.iiig  of  a  liliKjily  liiiiiid  iVoiu  tlic>  siul'aco  dl'  tin-  iioi'cssaiy  iiicisicm.  llius  dliscMriiiu;  ami  at  tinii's  lii<lii]Lr  ihc  iiaits 
I'l'om  view:  ii<i  artery  riM|uiri-il  to  1ii'  tied.  On  cuttiiij;  throiij,'!!  tin-  criio-i  liyroiil  iiniiiliraiu-  I  was  i-iialilcd  to  witli- 
draw  from  tlie  larynx  a  coiisidcralilo  ijuaiitity  of  false  iiiemliraiie  stained  wiih  l.Inod.  Thi^  jiatieiit  breatlu'd  easily 
tlirimuli  the  artificial  opeiiiiiK  and  ilireetly  afterwards  was  able  to  swallow  aL;aiii  ;  and  an  assistant,  whose  linjrers 
were  on  tlir  ladial  pulse,  lold  me  tliat  tlie  circulation  rallii'd  ileeidedly  at  the  same  moment.  Not  iiioru  than  anonnc<' 
of  lilood  was  l(]st  liy  the  operation.  Tlie  ]iatient  niipeared  to  tie  nearly  if  not  (|iiite  inseiisildi'  to  jiain  liy  reason  of 
the  inereasinii;  eoina  of  suffocation.  Ills  lirenthini,'  seemed  to  continue  free  and  easy.  Inn  he  died,  ajiparcntly  from 
exhaustion,  font  hours  after  the  operation. 

rusT-MOHT!-;M    I'lKCOEDS. 01  i.scVVat  ic  HIS   WdV    mail'   lllnl    I'lT.ir.li'il    ill    (WcUty-livo    (--asi-.s, 

which  are  lion-wilh  siibiaittcil.  In  1-:)  tin.'  iiiucoiis  iiu'iiilu-aia^  "f  \\\>'  laryi;.\  \va<  swultc^u 
ami  (udciiuitous,  Imt  not  eovcreil  with  |isi'Uilonirniliraiu'.  ihc  iliiihllirrilie-  inlilti'alicii  huiiig 
confined  to  tho  tonsils  or  to  the  fauces  ami  cpi^nltis.  in  4-7  iiM'tulnincinhfatio  cxtriidril 
from  the  fauces  anJ  pluuynx  into  the  larvnural  passairi';  tlif  last-iiKtr/Kdird  case  was  rom- 
plicated  with  swelling  of  tlie  parotid  glamls  and  an  ahscess  in  tla'  mM-k  nii  the  Icll  sidccil  the 
larvnx.  In  S-lSthe  larvn.\  was  aH'ceti'd  and  the  trachea  in\adid:  swelling  ol  the  jiarofids 
was  noted  also  in  the  last  of  these  cases.  In  li)-2-")  the  exudation  extended  inti)  the  lifnii- 
cliiul  tulii's,  ])lugging  in  sotne  instances  their  smaller  ramihcaticdis.  In  2i)  the  cnndilinii  cd 
the  ]diar\'iix  ami  air-[iassages  was  not  stated. 

C.\SE  1. — I'rivati'  Pavid  Late,  Co.  K.  1st  \'t.  ('a\ .:  ai;e  i;i:  was  admitted  Dec.  L'!!.  ISdl.  coin|dainin,i;  of  lassit  nde, 
chilliness,  pain  in  the  limtis,  anorexia  and  jaundice.  On  tlie  LWth  his  tliroat  tieeame  soie.  liotli  tonsils  and  ]ialatine 
arches,  the  soft  and  part  of  the  hard  palate  ]iartiei])atin^  in  the  inllaniniatory  process;  dysjuHea  was  a]i])ari'nt  next 
day.  On  Jan.  1,  IXfio,  a  membranons  exudation  of  scmie  consistence!  hniif,'  from  tlie  n\  iila  ami  on  lieiiij;  denudied  left 
a  clean,  red,  hijihly  inilamed  surface.  The  expi'ctorated  matters  were  very  olVeiisive.  coiisisiinj;  <d'  f^laiiy  ninciis, 
lilood  and  particles  of  membrane.  The  patient  beeaiiie  asphyxiated  on  tlie  L'll  dm  in  ;^  a  sudden  jiaroxysm  of  dyspno'a. 
Tracheotomy  was  porfoiined  but  failed  to  resuscitate  liim.  I'lixl-mDrlnn  examination:  The  Sp(<iiiini  (."iL'S.  Med.  Sec., 
Army  iledieal  Jliisenm],  eoiisistiiif;  of  the  tongue,  ]ialate,  pharynx,  larynx  and  one  imli  and  a  half  of  the  tiac  hea, 
was  removed  cii  iiKixm'.  The  velum  palati  was  covered  with  a  partially  dcta(died  membranous  exudation  of  some 
consistence,  blackened  exti'tnally  liy  the  preparations  of  iron  which  had  tn'cn  n.sed  medicinally  and  ha\  inn  beneath 
it  some  effusion